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MANAGEMENT OF

Vertical Discrepancies –
Deep Bite

Presented by,
Dr. Shreyank G
Post Graduate Student
Department of Orthodontics
CONTENTS
Introduction
Development of a vertical problem
Etiology of vertical problems
Diagnosis of vertical problems
Deep bite
- Classification
- Etiology
- Diagnosis
- Management
- Conclusion
References

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INTRODUCTION
 The vertical dimension of face is often altered, either
intentionally or non intentionally, during orthodontic
treatment
 These changes have a great impact on the way the
mandible rotates and changes are seen in the facial
esthetics.

Therefore, before the initiation of orthodontic therapy, it is


vital for the clinician to clearly define the treatment goals
related to the vertical dimension of face and design a
detailed individualized treatment strategy and mechanics
plan based on sound biomechanical principles .

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DEVELOPMENT OF VERTICAL PROBLEM

Facial growth in relation to the cranial base proceeds


along a vector with variable amounts of horizontal and
vertical growth.
It is important to consider , understand
and appreciate the value of the vertical
growth, as it relates to the antero-posterior
growth.
 Vertical growth carries the chin
downward, while the antero-posterior
growth carries it forward.

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The major sites of bony additions contributing to the
facial growth are :
- Facial sutures
- Maxillary and mandibular alveolar processes
- Mandibular condyle

This alters the lower facial height and chin position


horizontally and vertically.

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GROWTH
After the cessation of the anterior cranial base growth at
an early age , the anterior half of the cranio-maxillary
complex is displaced in antero-superior direction by
the growth at the spheno-occipital suture until the
suture closes after puberty.
The spatial position of the maxillary dentition is
influenced by the eruption pattern of the teeth and the
growth of the maxilla and the anterior cranial base
whereas the spatial position of the mandibular dentition
is determined by the growth of the mandible and it’s
relationship to the temporal bone .
Condylar head , being the primary growth centre of the
mandible grows in upward and backward directions with
the resultant downward and forward displacements of
the mandible and carries the mandibular dentition away
from the vertebral column and cranial base.
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Therefore , the growth at the spheno-occipital
synchondrosis displaces the maxillary complex antero
superiorly, while the growth at the mandibular condyle
displaces the mandible downward and
forward,ie,anteroinferiorly.
These two diverging growth vectors create a space for
vertical facial growth, alveolar growth and tooth
eruption.

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The mandible demonstrates a great degree of variation
in the direction of its growth in the normal population as
shown in studies on facial growth by Bjork and Skieller
using metallic implants.

The most common direction of condylar growth is


vertical with some anterior component however, the
posterior growth is less frequently observed.

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- It is important for the clinician to consider, understand
and recognize the importance of mandibular growth
rotation as it relates to anterior facial height (AFH) and
overbite relationship.

Bjork suggested 3 types of mandibular rotations based on


fulcrum points of rotation

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In addition to condylar growth direction, differences in
the AFH and PFH development play an important role in
development of vertical discrepancies.

These differences significantly contribute to rotational


growth or to changes in the mandibular position,
influencing the position of the chin.
Research findings show that the dentoalveolar heights
are significantly greater in long AFH patients and smaller
in short lower AFH group.

The excessive maxillary posterior dentoalveolar


development may be associated with weaker
masticatory musculature in high-angle patients
compared with stronger musculature associated with
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low-angle patients.
ROLE OF ENVIRONMENTAL FACTORS IN
THE DEVELOPMENT OF VERTICAL DISCREPANCIES

 The role of environmental factors like swallowing, breathing and


tongue
posture in altered vertical dimension continues to be the subject of
debate.
 However breathing due to large adenoids, tonsils and deviated nasal
septum are frequently associated with high angle patients which alter
mandibular posture, creating more room for posterior teeth eruption.
Removal of adenoids or tonsillectomy have resulted in closing of the
mandibular plane angle and reduction in the anterior facial height.
 Abnormal tongue posture and tongue thrust habit is a causative
factor in
the development of malocclusions.

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DIAGNOSIS OF VERTICAL DISCREPANCIES

Vertical discrepancies consist of various components


of the craniofacial complex and are often associated
with abnormalities in other planes of space.

Their accurate diagnosis is a key element in the


design of any successful treatment plan.

In order to plan an appropriate treatment strategy, the


clinician should localize and quantify any skeletal and
dental contributions, vertical and sagittal variations
and the role of abnormal function to the development
of vertical problems.
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Clinical evaluation :

1. Facial evaluation
 Facial assessment begins with a three dimensional
assessment of the frontal and profile views in the
vertical, sagittal and transverse planes. The goal of
this assessment is to establish an accurate
description of the esthetic, skeletal and occlusal
abnormalities as well as functional disorders.

 Based on extra-oral features, patients with vertical


discrepancies may be broadly classified as long-
face and short-face patients.

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LONG FACE PATIENTS SHORT-FACE PATIENTS

1. Leptoprosopic facial form 1.Euryprosopic facial form


Dolicocephalic head form Brachycephalic head form
2. Increased lower facial height 2.Decreased lower facial height
3. Class II malocclusion 3. Class II
- Mandibular deficiency - Normal upper lip length
- Orthognathic or prognathic maxilla - Obtuse naso-labial angle
- flattened or recessive chin - Acute mento labial sulcus
- Retruded mandible
- Excessive soft tissue chin

4. Class III 4.Class III


Narrow alar base -Short upper lip
- Prominent nasal dorsum - Acute naso-labial angle
Incompetent lips with mentalis strain -Obtuse mento labial sulcus
- Shallow mento-labial sulcus -Prognathic mandible

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LONG FACE PATIENTS SHORT FACE PATIENTS

Maxillary-mandibular Maxillary and mandibular


dentoalveolar protrusion bidentoalveolar retrusion
Upright and supraerupted Upright incisors
maxillary and mandibular
incisors
Excessive eruption of Deep curve of spee
posterior teeth
Anterior open bite and Excessive deep bite
posterior crossbite

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2. Functional assessment
An assessment of function is a very important part of the
clinical examination for planning treatment of vertical
discrepancies. Associated disorders involving airway,
speech and tongue function should be carefully
evaluated.

It has been generally recognized that environmental


factors that are responsible for keeping the maxillary and
mandibular teeth apart promote elongation of the
posterior teeth leading to increase in the lower facial
height.

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3. Morphologic characteristics

 Classifying patients into long or short face patients is just a broad

understanding of vertical discrepancies.

 Patients with vertical problems should be further analysed

cephalometrically to identify and locate the structures at fault,


which mainly contribute to the development of a problem .

 Vertical discrepancies can be divided into those that are


dentoalveolar in nature and into those that are predominantly
skeletal as a result of the growth patterns of the jaws.
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2.Cephalometric assessment

BJORK ANALYSIS
• The cranial flexure angle(N-
S-Ar),articulare angle and
gonial angle(Ar-Go-Me) are
used to determine the
growth pattern of an
individual.
• The mean value of sum of
these angles is 396°+/-
4°,higher values are
suggestive of vertical growth
pattern, whereas low values
indicate horizontal growth
pattern

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• The gonial angle having a mean value
of 130°+/-7° is a good indicator of
vertical or horizontal growth pattern.

• An increased value shows that the


individual is backward growth rotator,
while a decreased value indicates a
forward rotator.

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• Mandibular plane angle(Go-Me-true horizontal)
have a mean value of 27°+/-5° is one of the most
commonly used parameters.
• It is increased in patients with a vertical growth
pattern while horizontally growing patients exhibit
low angle

• Width of the symphysis measured at pogonion(Pg)


parallel to true horizontal has a mean value of
16.5+/-3mm with greater values in horizontally
growing patients and smaller values in vertically
growing patients

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Jarabak’s proportions

Posterior facial height : Sella (S) –


Gonion (Go)

Anterior facial height : Nasion (N) –


Menton (Me)

Jarabak Ratio : Posterior facial height ×


100
Anterior facial height
54-58% - HYPER DIVERGENT
59-63 %- NEUTRAL
64-80 %- HYPODIVERGENT
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R – Angle
- Nasion (N)
- Center of the condyle (C)
- Menton (Me)
-
-The angle formed at center of
the condyle (C) by the
intersection of C-N axis and C-
Me axis represents the R angle.
R angle below 70.5 ⁰ - low
angle,
70.5 ⁰ -75.5 ⁰ - average angle
above 75.5 ⁰ - high angle
cases.
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High – angle patients Low – angle patients
1. Steep MP angle. 1. Decreased MP angle

2. Rotation of palatal plane down posteriorly. 2. Decreased lower facial height

3. Large gonial angle. 3. Normal or long posterior facial height

4. Short ramus height or decreased 4. Reduced maxillary molar height - the strongest
posterior face height. measure of vertical maxillary deficiency

5. Increased maxillary and mandibular 5. Reduced incisor height maybe associated with
dentoalveolar height. deficient incisor
display.

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Bjork described morphologic method of predicting growth rotation
from a
single cephalogram and found seven structural signs for predicting
forward or backward growth rotation.
1. Inclination of the condylar head : Curved forward - forward
rotator
Straight or slopes up or back –
backward rotator
2. Curvature of the mandibular canal : curved – forward rotator
straight – backward rotator
3. Shape of mandibular lower border : Curved downwards –
forward rotator
notched – backward rotator
4. Inclination of the symphysis : Slopes backward - forward
rotator
Slopes forward – backward
rotator
Prediction of mandibular growth rotation evaluated from a
longitudinal
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implant 102 26
sample – Bjork, Skieller and Hansen, AJO, Nov 1984, pg. 359-370.
5. Inter-incisal angle : Vertical /obtuse - forward rotator
Acute – backward rotator
6. Inter- premolar/molar angle : Vertical /obtuse - forward
rotator
Acute – backward rotator
7. Anterior lower facial height : Short - forward rotator
Long – backward rotator

Of the 7 original signs, 4 of the variables when combined give


the best
prognostic estimate of mandibular growth rotations.
1.Mandibular inclination
2.Shape of the lower border
3. Inclination of the symphysis
4. Inter-molar angle

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DEEP BITE
Definition :
Graber has defined deep bite as a condition of excessive
overbite, where the vertical measurement between the
maxillary and mandibular incisor margins is excessive when
the mandible is brought into habitual or centric occlusion.

Etiology of deep bite


The etiology of deep overbite is a complex problem
and may include one or more of the following;

1. Hereditary and may follow a genetic pattern or familial


condition

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2. Skeletal

a. An overgrowth or undergrowth of one or more alveolar


segments.
b. An excess of growth of the ramus and posterior cranial
base permits the mandible to rotate upward. Thus Long
ramus and short body with decreased gonial angle is
characterstic feature
c. Convergent upper and lower jaw bases
d. Horizontal growth pattern or forward rotation or anticlock
wise rotation of the lower jaw
e. The four planes of the face (infraorbital ( FH Plane),
palatal, occlusal, and mandibular) as seen from lateral
roentgenograms are horizontal and nearly parallel to each
other
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3. Dental

a. Loss and/or mesial tipping of posterior teeth( diminished


posterior dental height)
b. Early loss of teeth and lingual collapse of the anterior teeth
c. Overeruption of the incisor teeth, infraocclusion of the
buccal segment or a combination of both.
d. Overbite may be accentuated by an aberration in the tooth
morphology.
.

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• 4. Muscular
The posterior vertical chain of muscles (masseter,
internal pterygoid, temporal) is strong and attached
anteriorly on the mandible and stretches in nearly a
straight line vertically. The molars are directly under the
impact of the masticatory forces of this chain.

• When the posterior vertical chain of muscles is


strong and anteriorly positioned, a greater depressive
action is transmitted to the dentition
• 5. Habits
a. Lateral Tongue thrust swallow
b. Finger sucking,
c. Lip sucking

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•Classification
1. According to its origin;
a) Dental deep bites
b) Skeletal deep bite
2. According to functional classification;
a) True deep bite.
b) Pseudo deep bite.
3. Depending on the extent of deep bite
a)incomplete over bite
b)complete over bite
4. According to dentition;
a) Primary dentition deep bite.
b) Mixed dentition deep bite.
c) Permanent dentition deep bite

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DENTOALVEOLAR DEEP
BITE
SKELETAL DEEP-BITE Due to infra-occlusion of molars(true)
1. Molars partially erupted
1. Horizontal growth
2. Large inter-occlusal space
pattern
3. Lateral tongue posture or
2. Convergence of
thrust
skeletal jaw bases
4. Distances between
3. Short LAFH
maxillary and mandibular
4. Long post. facial height.
basal planes and occlusal
5. The horizontal
plane are short.
cephalometric
planes (SN, PP, OP and Due to supra eruption of
MP) are approximately incisors(pseudo)
parallel or convergent 1. Incisal margins of incisors
to each other. extend beyond the functional
occlusal plane.
2. Molars are fully erupted.
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3. Excessive curve of spee.
3.Incomplete and complete deep bite
Incomplete over bite is an incisor relationship in which
the lower incisors fail to occlude with either the upper
incisors or the mucous of the palate when the teeth are
occluded
Complete over bite on the other hand is a relationship
in which the lower incisors contact the palatal surface of
the upper incisors or the palatal tissue when the teeth
are in centric occlusion . This kind of deep bite often
results in trauma of the mucous palatal to the maxillary
incisors

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V. Features and Effect of deep over bite
Extraoral features
1. Brachycephalic and europroscopic face. Strong contractions of
the masseter muscle can be seen in the face by clenching the
teeth
2. Straight to Mild convex profile
3. Short anterior face height as measured from nasion to menton
4. Diminished anterior lower face height. Short nose-chin
distance
5. The lips are thin and with an excess of lip height relative to
face height. This gives a curled appearance of the lips .
6. Mento labial sulcus :There is usually deep furrow, or sulcus,
between the prominent chin and the lower lip
7. Mandibular deficiency characterized by long mandibular ramus
and short body, Square gonial angle, flat mandibular plane,
prominent zygoma and prominent chin. Many of these features
are common to class II div II
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• Intra oral features
1. The maxillary dental arch is broad, with often a maxillary buccal
cross-bite
2. May involve a group of teeth or whole dentition.
3. In skeletal deep bites the patient may exhibit gummy smile if there is
clockwise rotation of maxilla . When the problem is in the anterior
maxillary region, the patients often show excessive gingival tissue
during smiling or even while speaking even when the upper lip is of
adequate length
4. The palatal vault is flat. The presence of deep bite may cause palatal
grooving by the indentations caused by lower anteriors.
5. The dentition exhibits a tendency to small teeth prone to abrasion and
a high increased percentage of congenitally missing teeth.
6. Although teeth tend to spaced, a crowding of lower incisors may be
present as a result of the deep bite.
7. A deep curve of Spee in lower arch or a reverse curve of spee in the
maxillary dentition
8. Occlusal functions become impaired.
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9. Often the maxillary incisors are tipped lingually in Angle's Class II, 39
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• Other features
1. The mandible cannot be opened to an appreciable
degree in skeletal cases.
2. Temporomandibular joint dysfunction due to
overclosure of the mandible characterized by clicking
sensation of the joint.
3. Periodontal conditions may be found as a result of
such occlusion.

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TREATMENT OF DEEP BITE

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Flat or near flat
curve of Spee

Why is Normal overlap


Overjet reduction
and class I interarch
deepbite for functional
occlusion,ie
relation cannot be incisal guidance
achieved correction &canine
guidance
important?
Normal overjet,overbite &
interincisal angle helps
withstand occlusal
stresses,promoting stability
of incisor positions

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Various options in the treatment of
deepbite
• Deep anterior overbite can be
opened using
 extruding the posteriors
by intruding the anteriors
by correcting the inclinations of
the retroclined anteriors
By uprighting or distalizing the
molars(which rotates the
mandible downward by
increasing the ‘wedge effect’)
 By a combination of any of
these
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• Intrusion is defined by Nicolai as “A transitional form of the
tooth movement directed apically and parallel to the long
axis.”
• Burstone defined intrusion as, “Apical movement of the
geometric center of root (centroid) in respect to the occlusal
plane or a plane based on long axis of the tooth.”
• Intrusion of incisors is commonly indicated in pseudo deep
bite cases or the cases with increased anterior face height.
• It is also indicated in cases where there is an excessive
gingival display during speaking or smiling.
• Pure incisor intrusion is not possible with removable
appliances.
• Fixed appliance therapy is probably the best to intrude the
teeth for correction of deep bite in children as well as
adults.

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True/absolute intrusion : Achieved
by moving the root apices of the
anteriors closer to the bony base.

Relative intrusion : preventing the


eruption of the incisors and the
growth of the mandible will allow
the posteriors to erupt.

Apparent intrusion: Is achieved by


extrusion of the posterior teeth.
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Treatment planning in primary
dentition

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1.Primary dentition period
- In early stages of development of
occlusion,deep bite exists as a self
correcting anomaly.
-The initial eruption of the permanent
molars,growth of the jaw bases and
transition of incisors help in deep bite
correction.
- They may be associated with the
presence of developing class II
malocclusion
- As with class II malocclusions, treatment
decisions are typically postponed until the
mixed dentition period.

-Treatment is indicated if there is


impingement on the palatal mucosa
excessive grinding, clenching and
headaches if they are believed to be
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secondary to the deep bite.
a. Anterior bite plane
- In growing patient an efficient method of overbite
reduction is the use of an anterior bite plane.
-Anterior plane inhibits the vertical development of the
lower incisors and allows differential eruption of the
posterior teeth to take place.
-The anterior bite plane should be just thick enough to
disengage the posterior teeth by 2-3 mm.

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Treatment in mixed and
Early permanent dentition

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a. Orthopedic appliance
1. Cervical headgears
• Very effective in extruding and
distalising the upper molars
• It exerts a vertically downward
component of force with the potential
for extrusion of the molars.
• So with the cervical pull headgear the
molars get distalized and extruded
and the mandible rotates downward
and backward and deep overbite gets
corrected.
• For extrusion and distalization of
molars 200-300 gm of force per side
is applied. The force duration should
be 14 to 16 hours per day or more
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- Another application of headgear is to apply the
intrusive force on the upper incisors directly by
using the J hook to the archwire as was described
by Terrel Root.

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Asher headgear
• Recommended by Dr.Cetlin and
Roth ,the Asher lasher facebow
is the facebow of choice for
intrusion and retraction.
• With a high pull cap,it retracts
and intrudes
• The bow is hooked to the
archwire mesial to the cuspid
against a keyhole loop or a hook
attached to the wire

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Correction of deep overbite and gummy smile by
using a mini-implant with a segmented wire in a
growing Class II Division 2 patient

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Kim, Kim, and Lee
American Journal of Orthodontics and Dentofacial Orthopedics Volume 130,
Number 5
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Correction of deep bite with
fixed appliance therapy

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•Reverse curve wires
• The archwires with reverse curve of
spee(RCS) made of superelastic alloys
such as NiTi are used to actively open
the bite.

• These preformed wires made of shape


memory alloy deliver gentle intrusive
forces on the incisors and extrusion of
buccal segment and arch form.

• The unwanted effects include difficulties


in control of proclination of anterior teeth
and poor control on extrusion of buccal
segment
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Bite plate
Bite opening in deep bite cases
is enhanced in 3 ways by
using a bite plate
• Allows for early placement of
brackets on the lower incisors
which begin their movement
simultaneously with the upper
teeth
• Anterior bite plates can
produce an intrusive force on
the anterior teeth thereby
preventing further eruption of
these teeth
• Anterior bite plates allow for
eruption,extrusion and
uprighting of posterior teeth.

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• Acrylic extensions are bonded to the lingual
surfaces of the maxillary incisors, producing an
intrusive effect or growth restrain on the
incisors while allowing the extrusion of the
posterior teeth. It is also called as lingual bite
steps or bite turbos.

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INCLUSION OF SECOND MOLARS

• Banding of the lower


second molars in early
stages of treatment will
favour bite opening.
• Inclusion of second
molars provides an
excellent lever arm for the
eruption of premolars as
well as uprighting of molar
itself

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UTILITY ARCH
 This auxiliary archwire was developed according to the
biomechanical principles developed by Burstone and
refined by Ricketts for bioprogressive therapy
Material used :
Although stainless steel can be used, blue elgiloy of
0.016″ x 0.016″ or 0.016″X 0.022″ dimension in an
0.022″ slot is the material of choice

PARTS OF A UTILITY ARCH


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Parts of Ricketts utility arch

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Typically when activated ,Ricketts
utility arch produces 40-80 gm of
force,which is sufficient to intrude
four incisors

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Burstone’s Three piece intrusion arch

• The Three piece intrusion arch was introduced in 1995


by Bhavana Shroff, Charles Burstone and Leiss for the
purpose of simultaneous intrusion and retraction of flared
anterior teeth as well as correction of their axial
inclinations with good anchorage control
• The three piece utility arch is advantageous for it shifts the
point of application of force more distal, close to the lateral
incisors which is the anticipated centre of resistance.

Simultaneous
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intrusion and retraction using a102three piece base arch .Bhavana Shroff, 66
Charles J Burstone, Won M Yoon. Angle orthod 1997;7(6);455-462
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Burstone ‘s continuous intrusion
arch

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Charles J. Burstone “ Biomechanics of deep overbite correction” semin orthod


2001: 7: 26-33 102 68
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K- SIR ARCH
Dr. Varun Kalra introduced the K-SIR (Kalra
Simultaneous Intrusion and Retraction) archwire,
which is a modification of the segmented loop
mechanics of Burstone and Nanda
K-SIR archwire: .019 " x.025" TMA archwire with closed
U-loops 7mm long and 2mm wide.

Kalra V. Simultaneous Intrusion and Retraction of the Anterior Teeth. JCO 1998 ;35:535 –
540 6/30/2019 102 71
- A 90° V-bend is placed in the
archwire at the level of each U-
loop to create equal moments
that counteract tipping
moments produced by
activation forces.

- A 60 ° off centre bend placed


2mm distal to U-loop to create
greater moment on molar and
increase anchorage to
intrudeanteriors.

- A 20° antirotation bend is


placed in the archwire just
distal to each U-loop to
prevent molar mesio-lingual
roll in.
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Activation :
-After the trial activation, the neutral position of the each
loop is determined with the legs extended horizontally .
In neutral position, the U-loop will be about 3.5mm wide.
The archwire is inserted into the auxiliary tubes of the
first molars and engaged in the six anterior brackets . It is
activated about 3mm, so that the mesial and distal legs
of the loops are barely apart . Reactivation every 6-8
weeks till the extraction spaces close.

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Translation Arch
• Translation Arch was given by Martina & Paduano in
1997
• Translation Arch has anterior segment inserted into
incisor brackets and two buccal segments inserted into
gingival first molar tubes.
• Vertical loops between segments extend as far as
possible. Palatal root torque given in the anterior
segment of the arch .
• An arc—should be bent into each buccal segment to
produce an intrusive force of 40g on the incisors..

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MULLIGAN’S 2X4
appliance
•The archwire used is round 0.016”
stainless steel archwires with tip back
ends.
•The tipback bends or ‘V’ bend given to
the arch wire for intrusive action on
incisors and extrusive action on molars.
•Since the canines and premolars are
not bracketed when this mechanism is
used,it is another way of applying a
bypass arch for incisor intrusion
•Though the anterior segment of the
wire is engaged in the incisor bracket, it
doesnot create a labiolingual moment
since a round wire is used.
•A helix is provided at the tip back bend
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for ligating to the molar tube,to resist
MODIFICATION OF LINGUAL ARCH
FOR DEEP BITE
• This technique was introduced by WINSTON
SENIOR.
• An .036" lower lingual arch is soldered to first molar
bands.
• Distal extensions form occlusal rests on the second
molars to prevent distal tipping of the first molars
as the incisors are intruded.
• Four elastic chains are attached to the anterior
bridge of the lingual arch.
• After cementation of the arch, the elastics are
stretched to four lingual buttons on the lower
incisors
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. A lingual arch for intruding and uprighting lower incisors. J
W Senior. 102 77

Clin Orthod. 2003 Jun;37(6):302-6.


6/30/2019 W Senior. A lingual arch for intruding
102 and uprighting lower incisors. J 78

Clin Orthod. 2003 Jun;37(6):302-6.


Intrusion with anchorage derived from
mini screws
BILATERAL IMPLANTS FOR EN-MASSE INTRUSION OF
ANTERIORS
 To intrude the upper incisors the implant is placed between
the upper lateral incisors and the canines. The placement of
the mini-screws should be done after leveling and alignment,
in order to maximize the inter-radicular space at the
placement site.

 In order to avoid tipping the upper incisors buccally during


the intrusion, the end of the archwire should be cinched back

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Placement Site:
For enmasse intrusion of the maxillary anterior teeth the
most suitable site for the placement of implant selected
is the alveolar bone between lateral incisor and canine
bilaterally at the level of attached gingiva.

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2) Mid-implant For Intrusion Of Maxillary
Incisors

The implants used are 1.3 mm in diameter and 8 mm


in length.
A stainless steel archwire with utility design engaging
four incisors and two molar, bypassing the canine and
premolar is used made of 0.017x0.025
Passive segmented posterior stabilizing unit
(0.019x0.025 SS)
A closed coil spring or a E-chain can be used to
deliver force of around 60-70 grams

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SURGICAL TREATMENT

 Surgery will be needed if there is a severe skeletal or very


severe
dentoalveolar problem , too severe to correct with
orthodontics alone.
 There are limits on how far the jaws can be moved
surgically, but these limits are larger than the limits of
camouflage and growth modification.
 In patients with vertical maxillary deficiency, the maxilla can
be repositioned inferiorly by a Le Fort I down grafting
procedure.
 This is the least stable of all surgical procedures and rigid
fixation must be employed to improve the stability.
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MAXILLARY SURGERY

LEFORT I OSTEOTOMY
ANTERIOR SUB-APICAL
OSTEOTOMY

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Maxillary Intrusion Splint
•Maxillary Intrusion Splint (M.I.S.) system which
incorporates a near vertical pull headgear, is used in the
management of severe 'gummy' Class II division 1
malocclusion
•M.I.S. is a full coverage, acrylic palatal plate with both
anterior and posterior capping carried round and onto labial
surfaces of the incisor teeth and extra-oral traction tubes
incorporated in the base plate mesially to the cusp tip of
the first premolar.
•M.I.S reduces the visibility of the maxillary incisors by the
intrusion of maxillary teeth, restraining maxillary growth, and
encouraging an element of subsequent forward mandibular
rotation.
•Indicated in “gummy smile” patients.
The treatment of severe 'gummy' Class II division 1 malocclusion using the
maxillary
6/30/2019 intrusion splint. Eur J Orthod. 1992
102 Jun;14(3):216-23 84
Acrylic capping for the incisors and
canines should cover the incisal third of
the crown.

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•Vertical pull to the bow at about 60 degrees to
the occlusal plane is given.

•The outer arm was shortened so that traction


could be applied through the centre of resistance
of the maxillary dentition.– dental and skeletal
effects can be achieved with good vertical
control.

•A force of 500 g and upwards was applied


bilaterally depending upon the patient tolerance.

•worn for up to 14 hours per day

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Orthodontic treatment of gummy smile by maxillary
total intrusion with a midpalatal absolute anchorage
system

• A gummy smile of skeletal origin requires orthognathic


surgery for correction.
• Dentoalveolar gummy smiles caused by over-eruption
of the maxillary incisors can be corrected by intruding
the extruded maxillary incisors.
• The dentogingival type of gummy smile is related to
abnormal dental eruption or lack of gingival recession
and requires lengthening of the anatomic crown.
• The neuromuscular type of gummy smile is caused by
hypercontractibility or excessive muscle contraction and
can be improved temporarily by injecting botulinum
toxin type A.
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[Korean J Orthod 2013;43(3):147-158]
• The use of screw mechanics for achieving the
effect of a Le Fort I impaction of the maxilla was
proposed by Lin et al.
• MAAS (Midpalatal absolute anchorage
system)using an implant accomplished the effect
of a Le Fort I impaction of the maxilla with the
aid of a modified lingual arch.
• The screw withstood quite heavy orthodontic
forces. An appropriately formed 0.032- × 0.032-
inch stainless steel power arm was fixed to the
head of the screw and provided the force
application points for the required absolute
anchorage without using multiple screws.

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Early vs late orthodontic treatment of deepbite: a
prospective clinical trial in growing subjects.
• The aim of this prospective clinical trial was to compare the
outcomes of prepubertal vs pubertal treatment of deepbite
patients with a protocol including biteplane and fixed appliances.
• METHODS:
• A sample of 58 subjects with deepbite completed the study. A
total of 34 subjects received treatment with removable biteplane
appliances in the mixed dentition at a prepubertal stage of
skeletal maturation (early treatment group), and 24 subjects
were treated at a pubertal stage of skeletal maturation in the
permanent dentition (late treatment group).
• All subjects of both groups were reevaluated after an average
period of 15 months after the completion of fixed appliance
therapy. Treatment outcomes were assessed statistically after a
phase with removable biteplane appliances and at the
posttreatment observation.

Am J Orthod Dentofacial Orthop. 2012 Jul;142(1):75-82


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• They found:-
• Treatment duration was significantly shorter in the
early treatment group.
• Overbite reduction was significantly greater in the
late treatment group (-3.1 mm) than in the early
treatment group (-1.4 mm).
• In the late treatment group, 92% of the patients
had a corrected overbite 1 year after therapy
compared with 65% in the early group.
• The authors concluded that:-
• Treatment of deepbite at puberty in the permanent
dentition leads to significantly more favorable
outcomes than treatment before puberty in the
mixed dentition.
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CONCLUSION

All vertical discrepancy cases cannot be treated in a


similar manner due to extreme variation in the facial
pattern and morphological characteristics.
Therefore in patients with compromised AFH’S , various
treatment methods of mandibular rotation opening
versus closure-as part of orthodontic treatment should
be recognized as either desirable or undesirable.
Thus the primary goal in patients with hyper-divergent
malocclusions should be to autorotate the mandible to
decrease the lower facial height, in patients with
average facial height vertical dental problems should be
corrected while simultaneously maintaining the vertical
dimension and in low angle cases various treatment
procedures should contribute to the downward and
backward rotation of mandible resulting into an
increased lower facial height.
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REFERENCES
1. Contemporary Orthodontics.Proffit, Fields,Sarver 5th edition.
2. Graber T.M., Vanarsdall R. Orthodontics: Current Principles and
Techniques
3.Dentofacial Orthopedics with functional appliances by Graber, Petrovic
and
Rakosi.
4.Orthodontic diagnosis and management of malocclusion and dentofacial
deformities. 2nd edition, O.P.Kharbanda
5.Biomechanics in clinical orthodontics-Ravindra nanda
6.Orthodontic and orthopedic treatment in the mixed dentition-J.A.
McNamara
7.Biomechanics in orthodontics- Michael R.Marcotte
8. Essential of orthodontic biomechanics. Vijay P.Jayade and Chetan
Jayade
9. A new parameter for assessing vertical skeletal discrepancies: The R
angle.
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11. Prediction of mandibular growth rotation evaluated from a longitudinal
implant
sample – Bjork, Skieller and Hansen, AJO, Nov 1984, pg. 359-370.
12. A Lingual Arch for Intruding and Uprighting Lower Incisors. JCO volume 37 :
number 06 : (302-306) 2003 winston senior.
13. Simultaneous intrusion and retraction using a three piece base arch
.Bhavana
Shroff, Charles J Burstone, Won M Yoon. Angle orthod 1997;7(6);455-462
14. Techniques For Intrusion In Deep Bite Cases-A Review Article.Chirag
Panchasara, Muralidhar, R Sastri,Krishna Nayak
15Kim, Kim, and Lee American Journal of Orthodontics and Dentofacial Orthopedics
Volume 130, Number 5

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