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Márcio Antonio de
Figueiredo, MSc1
Danilo Furquim Siqueira, PhD2
Silvana Bommarito, PhD3
EARLY TOOTH EXTRACTION IN THE
TREATMENT OF ANTERIOR OPEN BITE IN
HYPERDIVERGENT PATIENTS
Eduardo Kazuo Sannomiya, PhD4
Aim: To describe the treatment of a 7-year-old patient with a hyperdivergent (dolichofacial) pattern, Class II Division 1 malocclusion, and anterior
open bite. Methods: Treatment was performed in 2 stages following the
principles of the Ricketts bioprogressive technique and comprised early
extraction of the maxillary permanent first molars and primary second
molars. Results: The treatment plan established for correction of the initial
malocclusion reached the orthodontic goals, providing optimal esthetics
and normal function. Conclusion: Posterior dentoalveolar height, which is
fundamental in diagnosis and treatment planning, should be investigated
in cases with excessive vertical dimension. In addition, extraction of permanent or primary maxillary posterior teeth at an early age may be a good
option for hyperdivergent patients with excessive posterior dentoalveolar
height. World J Orthod 2007;8:249–260.
Larry W. White, DDS, MSC5
1Postgraduate
Resident, Program in
Dentistry, Area of Concentration in
Orthodontics, Methodist University,
São Paulo, Brazil.
2Professor, Postgraduate Program in
Dentistry, Area of Concentration in
Orthodontics, and Professor, Discipline of Child Clinic (Undergraduate),
Dental School, Methodist University,
São Paulo, Brazil.
3Professor, Human Communication
Disturbances by UNIFESP, and
Chairman and Professor, Postgraduate Program in Dentistry, Area of
Concentration in Orthodontics, Dental School, Methodist University, São
Paulo, Brazil.
4Professor, Postgraduate Program in
Dentistry, Area of Concentration in
Orthodontics, Dental School,
Methodist University, São Paulo,
Brazil.
5Private practice of Orthodontics,
Dallas, Texas, USA.
CORRESPONDENCE
Dr Márcio Antonio De Figueiredo
Rua Capitão Nascimento Filho,
131 – Vergueiro
Cep.18030-123
Sorocaba, SP
Brazil
E-mail:
[email protected]
ccording to Epker and Fish,1 the diagnosis, treatment, and stability of
open-bite treatment has been confounding and frustrating clinicians more than
any other malocclusion. Schulz et al 2
considered the treatment of patients
with increased vertical dimension as
one of the greatest challenges of orthodontic/facial orthopedic treatment; difficulty also applies to maintenance of
results achieved. Gavito-Lopes and
Little3 observed more than 35% relapse
in anterior open bite cases. Huang,4 in
2002, reviewing the literature on the
treatment stability of anterior open bite
with or without aid of or thognathic
surgery, found 20% relapse for both
methods, yet the author reported that
the current level of evidence is not conclusive because many studies are characterized by small samples and selection problems.
Schudy5 was one of the first to assign
importance to vertical facial relationships and their interrelation with antero-
A
posterior problems. The author classified patients with imbalance between
condylar growth and posterior dentoalveolar development as hyperdivergent; ie, these patients presented a dentoalveolar increase at the molar region
that was not followed by condylar
growth.
As mentioned by Schendel et al,6 the
long-face syndrome is the most adequate name to describe all aspects
involved in this dentofacial deformity.
According to the authors, the common
aspect of this type of deformity is the
maxillary vertical excess.
In the opinion of Proffit et al, 7 the
main cephalometric indicators of a
skeletal relationship predisposing to
open bite are short mandibular ramus
and excessive maxillar y ver tical
increase. These alterations tend to produce downward and backward mandibular rotation, with consequent increase in
lower anterior facial height and anterior
open bite.
249
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According to Proffit and Ackerman,8
anterior open bite might be related to
inadequate eruption of anterior teeth
and normal eruption of posterior teeth,
even though there is a higher frequency
of normal or even increased eruption of
anterior teeth and excessive eruption of
posterior teeth.
Other authors 9,10 have agreed with
Proffit and Ackerman8 in that the anterior teeth (both maxillary and mandibular) present extrusion in patients with
open bite, whereas the posterior teeth,
especially the maxillary molars, present
increased eruption.5,9
Ceylan and Eröz 10 investigated the
effect of overbite on the morphology of
the maxilla and mandible. The result of
their study revealed that both maxillary
and mandibular dentoalveolar height
were larger for the group with open bite
and long and narrow symphysis. The
most significant change in mandibular
morphology was observed for the gonial
angle, which was larger in the group with
open bite. The authors concluded that
evaluation of maxillary and mandibular
dentoalveolar height, symphyseal shape,
and gonial angle may be useful in the
diagnosis and successful treatment of
open bite.
Riolo et al,11 in their atlas on craniofacial growth, presented guidelines that
might be used for the dentoalveolar
height of maxillary and mandibular first
molars. Using the same methodology of
Riolo et al11 to measure the maxillary dentoalveolar height and a similar methodology for mandibular height, Langlade9 conducted a study on 65 cases with anterior
vertical excess and concluded that the
vertical dysplasia was located at the maxilla, due to its increased dentoalveolar
process, and that the mandibular dentoalveolar process was often reduced,
indicating a natural attempt of vertical
compensation by mechanisms of growth
and development.
In 1994, Janson et al12 demonstrated
a correlation between dentoalveolar
height and the ratio between maxillary
anterior facial height and lower anterior
facial height. The dentoalveolar height is
significantly different between patients
with excessive, normal, or reduced verti-
cal dimension; the dentoalveolar height
was significantly larger in individuals with
vertical excess compared to the normal
patterns. The difference in dentoalveolar
development, particularly on the maxilla,
significantly influenced the anterior facial
height in orthodontic patients.
TREATMENT OF ANTERIOR
OPEN BITE
Many cases of anterior open bite characterized by a remarkable vertical imbalance between the bone bases (maxilla
and mandible) are treated with orthognathic surgery. For more severe cases,
compensatory orthodontic treatment
including extractions may not provide
pleasant facial esthetics,13 and orthognathic surgery with Le Fort I osteotomy of
the maxilla in isolation or combined with
sagittal surgery of the ramus is the most
indicated treatment.
Many methods are available in the literature for cases with anterior open bite
submitted to orthodontic treatment without orthognathic surgery, most of which
emphasize the need to reduce the vertical dimension of the maxillary posterior
segments by intrusion of molars, or at
least attempting to prevent their extrusion during orthodontic treatment.2,14–16
Extraction mechanics are also frequently used for patients with anterior
open bite. Freitas et al17 performed a retrospective study of 31 patients treated
with extraction of first or second premolars and observed that 74.2% of cases
were clinically stable with respect to correction of the open bite. Langlade9 has
written that the best option for correction
of open bite is extraction of the mandibular second molars and maxillary first
molars; the author’s explanation for this
was the reduced dentoalveolar height of
mandibular first molars and increased
dentoalveolar height of maxillary first
molars.
For successful orthodontic treatment,
it is fundamental to investigate possible
environmental influences present in
patients with anterior open bite, such as
airway obstruction, oral habits, and
altered tongue posture and function.
250
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Fig 1 Extraoral photographs taken at treatment onset of patient with long face (effort of the orbicularis oris muscle for lip
sealing).
Fig 2 Intraoral photographs
taken at treatment onset.
Cases presenting some of these etiologic
factors should receive special attention
and a treatment protocol to remove
these interferences.
CASE REPORT
The patient, MCC, a female 7 years of
age, had a dolichofacial pattern. Anam-
nesis revealed typical signs and symptoms of mouth breathing, which was confirmed after an ear-nose-throat (ENT)
evaluation. The extraoral clinical examination (Fig 1) demonstrated that the
patient had a long face with a convex
facial profile and excessive contraction
of the mentalis muscle during lip sealing.
The intraoral clinical examination (Fig
2) revealed that the patient was in the
251
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Fig 3 (above) Initial lateral cephalogram.
Fig 4 (right) Ricketts cephalometric
analysis.
Fig 5 Transpalatal distance according to
Spillane and McNamara.18
Table 1
Fig 6 Distance between mandibular
teeth, according to Ricketts.
Pretreatment cephalometric analysis
Table 2
Measurement
Patient
Normal
value
SNA (degrees)
85
82
SNB (degrees)
ANB (degrees)
Sella-Nasion to Gonion-Gnathion (degrees)
Mandibular plane to Frankfort (degrees)
Facial axis (degrees)
Convexity (mm)
Maxillary depth (degrees)
Maxillary height (degrees)
Facial depth (degrees)
Lower facial height (degrees)
Mandibular corpus length (mm)
Interincisal angle (degrees)
Maxillary incisor to Plane 1Apo (mm)
Mandibular incisor to Plane 1Apo (mm)
Dentoalveolar height; maxillary first molar (mm)
Dentoalveolar height; mandibular first molar (mm)
Growth pattern
81
4
42
33
87
4
94
55
89
53
62
124
8
2
22
28
Dolichofacial
80
2
34
26
90
3
90
53
86
45
62
132
4
1
18
28
Analysis of dental measurements
Mandible
Arch depth (mm)
Intermolar distance (mm)
IV/IV distance (mm)
Intercanine distance (mm)
Measurement
Normal value
24
48
33
23
26
55
38
25
252
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Fig 7 (a) Occlusal view of fitted
quad-helix after placement. (b)
Occlusal view of fitted bi-helix soon
after placement. (c) Dentoalveolar
expansion achieved by quad-helix. (d)
Dentoalveolar expansion achieved by
bi-helix.
a
b
c
d
mixed-dentition stage and had a Class II
Division 1 malocclusion with anterior
open bite, reduced transverse dimension,
and lack of space for eruption of the maxillary and mandibular lateral incisors.
Initial radiographic examinations (Fig
3) and cephalometric analysis (Fig 4,
Table 1) confirmed the presence of a
skeletal Class II malocclusion with anterior open bite and revealed excessive
posterior dentoalveolar height located on
the maxilla, according to Langlade.9
Analysis of the transpalatal dimension, according to Spillane and McNamara18 (Fig 5), revealed a transpalatal
distance of 29 mm, whereas the normal
value of this distance during this stage of
mixed dentition is 36 mm.
According to the same authors, 18
when a child in the stage of early mixed
dentition presents a transpalatal dimension smaller than 31 mm, achievement
of adequate arch dimensions by normal
growth mechanisms is not likely. Thus,
dental arch expansion at an early age is
favorable for skeletal, dentoalveolar, and
muscular adaptation before eruption of
all permanent teeth.
Figure 6 illustrates the analysis of
dental measurements according to Ricketts.19 All values observed are less than
normal values (Table 2).
Treatment plan
The treatment plan was discussed with
the patient and parents, and followed
pre-established objectives to: (1) normalize the maxillary and mandibular transverse diameters, allowing more space for
tongue function and posture; and (2) correct the skeletal Class II malocclusion
and anterior open bite. The permanent
maxillary first molars and primary maxillar y second molars were extracted
because of the excessive maxillary dentoalveolar height, thus removing posterior
dental support and allowing upward and
forward rotation of the mandible. The
mandibular dentoalveolar height was
within the normal pattern and without the
need for extraction of mandibular teeth.
Treatment
Treatment was performed in 2 stages,
following the principles of the Ricketts
bioprogressive technique.19
Stage 1. This stage comprised maxillary and mandibular dentoalveolar expansion with the quad-helix and bi-helix (Fig
7) and extraction of the permanent maxillary first molars and primary maxillary
second molars. Af ter maxillar y and
253
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Fig 8 (a) Maxillary occlusal view after
slow expansion. (b) Maxillary occlusal
view after extraction of primary second
molars and permanent first molars.
a
b
Fig 9
Intraoral photographs showing upward and forward rotation of the mandible.
Fig 10
Extraoral photographs at onset of the second stage of orthodontic treatment.
mandibular dentoalveolar expansion, the
primary maxillary second molars and permanent maxillar y first molars were
extracted (Fig 8). The immediate effect
was upward and forward rotation of the
mandible, which can be seen on the
intraoral photographs (Fig 9).
The first stage of orthodontic treatment
achieved the desired goals: Correction of
Class II malocclusion and anterior open
bite. The perioral and facial muscular
function was also improved, demonstrating better balance at onset of the second
stage (Figs 10 and 11), intermediate radiographic examinations (Fig 12), and
cephalometric analysis (Fig 13, Table 3).
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Fig 11 Intraoral photographs at onset
of the second stage of orthodontic treatment.
Fig 12
gram.
Intermediate lateral cephaloFig 13 Intermediate Ricketts cephalometric
analysis.
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Table 3
Cephalometric analysis at the start of stage 2 treatment
Measurement
SNA (degrees)
SNB (degrees)
ANB (degrees)
Sella-Nasion to Gonion-Gnathion (degrees)
Mandibular plane to Frankfort (degrees)
Facial axis (degrees)
Convexity (mm)
Maxillary depth (degrees)
Maxillary height (degrees)
Facial depth (degrees)
Lower facial height (degrees)
Mandibular corpus length (mm)
Interincisal angle (degrees)
Maxillary incisor to Plane 1Apo (mm)
Mandibular incisor to Plane 1Apo (mm)
Dentoalveolar height; maxillary first molar (mm)
Dentoalveolar height; mandibular first molar (mm)
Growth pattern
Fig 14
Patient
Normal value
80
80
0
40
29
89
0
91
58
91
50
66
118
10
4
18
30
Dolichofacial
82
80
2
33
26
90
2
90
54
87
45
67
130
4
1
20
30
Extraoral photographs taken at completion of the second stage of facial orthodontic-orthopedic treatment.
Stage 2. The second stage of treatment (fixed orthodontics) was performed
following the principles of the Ricketts
bioprogressive technique, with utilization
of brackets with a 0.018-inch slot. The
final result achieved all orthodontic
goals: (1) ideal occlusion with satisfactory overjet and overbite; and (2) adequate perioral muscular function and
facial esthetics (Figs 14 and 15). The
treatment results are observable on the
final radiographs and final cephalometric
tracing (Figs 16 and 17, Table 4).
DISCUSSION
Analysis of the initial, intermediate, and
final radiographs and cephalometric tracings reveal that the upward and forward
mandibular rotation achieved soon after
tooth extraction was not maintained at
treatment completion. The facial axis was
87 degrees at treatment onset and 84
degrees at treatment completion. This
demonstrates that the dolichofacial pattern was not affected by extractions and
the orthodontic mechanics applied, even
256
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Fig 15 Intraoral photographs taken at
completion of facial orthodontic-orthopedic treatment.
a
Fig 16 (a) Panoramic radiograph taken at treatment completion. (b) Final cephalogram.
b
Fig 17
Final Ricketts cephalometric analysis.
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Table 4
Posttreatment cephalometric analysis
Measurement
SNA (degrees)
SNB (degrees)
ANB (degrees)
Sella-Nasion to Gonion-Gnathion (degrees)
Mandibular plane to Frankfort (degrees)
Facial axis (degrees)
Convexity (mm)
Maxillary depth (degrees)
Maxillary height (degrees)
Facial depth (degrees)
Lower facial height (degrees)
Mandibular corpus length (mm)
Interincisal angle (degrees)
Maxillary incisor to Plane 1Apo (mm)
Mandibular incisor to Plane 1Apo (mm)
Dentoalveolar height; maxillary first molar (mm)
Dentoalveolar height; mandibular first molar (mm)
Growth pattern
Fig 18
Patient
Normal value
77
74
3
46
31
84
2
92
59
89
54
70
123
9
5
21
33
Dolichofacial
82
80
2
33
25
88
2
90
54
88
45
71
130
4
1
22
32
Extraoral photographs taken 3 years posttreatment.
though the extraoral and intraoral photographs (Figs 18 and 19) obtained 3
years after treatment completion reveal
stability of the permanent teeth, demonstrating that the pre-established treatment plan was adequate.
The panoramic radiograph obtained 3
years posttreatment (Fig 20) shows all
permanent teeth, except the permanent
maxillary first molars that had been
extracted at an early stage. The maxillary
right third molar occupied the position of
the second molar, providing normal
occlusion, and the left maxillary third
molar is currently erupting and presents
a normal aspect.
Oral habits are etiologic factors frequently related with anterior open bite,
since they can affect tongue posture and
function. These habits should be eliminated during the period of mixed dentition, to avoid establishment of severe
dentoskeletal alterations. Removable
appliances with tongue crib, as well as
speech therapy, should be used for treatment and should be presented to the
child as an aid rather than a punishment.
According to Gugino and Ivan,20 there is
a close relationship between shape and
function in the oral cavity and any other
area of the human body, which leads to
the assumption that normal oral function
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Fig 19 Intraoral photographs taken 3
years posttreatment.
Fig 20
Panoramic radiograph taken 3 years posttreatment.
is easier to achieve if oral anatomy is
within the normal limits. On this basis,
expansion of the atresic dental arches
restored functional orthodontic occlusion
and yielded a wider smile with balance
with the remaining parts of the face,
which may provide spontaneous correction of the inadequate tongue posture.
Some options for nonsurgical correction of anterior open bite in the period of
mixed dentition include high-pull headgear, high-pull chin cap, and posterior
bite block. The main objective of these
mechanics is to avoid extrusion or even
achieve intrusion of posterior teeth. Early
extraction of the permanent maxillary
first molars in well-indicated cases with
increased dentoalveolar height and presence of the third molars may effectively
achieve the same objectives, with no
need for patient compliance.
CONCLUSION
The treatment plan established allowed
correction of a Class II malocclusion with
anterior open bite, promoting optimal
function and facial esthetics. In cases
with vertical excess, the posterior dentoalveolar height should be investigated
and extraction may be a good option for
hyperdivergent patients with dentoalveolar height above the normal values.
259
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