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Treatment of skeletal open bite

with a device for rapid molar


intrusion

ANGLE ORTHODONTIST-sept 2005; vol 75



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INDIAN DENTAL ACADEMY

Leader in continuing dental education
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A rapid molar intruder for non-
compliance treatment


JCO March 2002 ;volume 36


Aldo Carano DO,MS
William C Machata DDS
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Various modalities for intrusion-
Coronal reduction
Subapical osteotomy
Full coverage splints with fixed appliances
High pull headgear with functional appliances
Magnets
Miniplates and screws
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it has been shown that 25gm of force is
sufficient for intrusion of a single tooth along
with significant gain of attachment and the
max sinus is not an obstacle to intrusion.
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Appliance design
modification of jasper jumper

flexible fixed appliance that delivers light
continous forces and can be used to move
single teeth,units of teeth,or an entire arch

Delivers functional;bite jumping;headgear like
and elastic like forces or a combination of
these
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Modules



L shaped pins
Guide the modules into positions
parallel to the occlusal plane
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During occlusion the modules flex and deliver a
force upto 900gms against the molars.

Adverse movt-buccal crown tipping
Control-use upper and lower lingual arches
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Case report
11yr old male
Chief complaint-anterior open bite
difficulty to close lip

Clinically- long face
open bite 5mm
bilateral posterior crossbite


Cephalometric analysis- straight profile
vertical growth pattern
mand rotated clockwise
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Upper arch - Spring Jet palatal expander
Lower arch soldered lingual arch
RMI
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Post Rx-
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M-B inclination of molars - controlled by
palatal/lingual arches
Molar intrusion and counter clockwise rotation
of mandible achieved -6months
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Discussion-

Although promising a more long term research
project needs to be done

Relapse ?

Periodontal status and pseudo pockets ?
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Treatment of skeletal open bite
with a device for rapid molar
intrusion

ANGLE ORTHODONTIST-sept 2005; vol 75

Aldo Carno
Giuseppe Siciliani
S.Jay Bowman


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Open bite is one of the most difficult malocclusions
to treat

Features-
Vertical max excess
Backward rotation of mandible
Supra eruption of post teeth

Vertical control - directed against posterior maxilla
corrections obtained here are
relatively stable
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Design

Elastic modules attached to
bands
End caps-
Straight-maxillary tube
Angulated-mandibular tube
L shaped annealed ball pins-
placed into buccal tubes


Force - 600 900 gms
Buccal tipping-always use TPA
or lingual arch
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Clinical application
Attach modules to TPA/lingual arch while in
attached to plaster models
Modifications- with tongue crib
with expansion screw
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Construction-
place pin into hole of angulated end of elastic
module of lower arch
Insert pin through convex side of metal cap with
ball end directed buccogingivally
Then insert it in the mesial opening of buccal
tube.the annealed portion is bent gingivally.
Terminal 2mm is bent mesially.

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Put other ball pin through the hole in flat end of
force module

Then insert pin into mesial of buccal tube of the
maxillary band

Ball end of pin at mesial side is bent gingivally
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Class II-attach max end of force module to
distal of buccal tube



Class III- mand end of force module to distal
of buccal tube
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Appliance is most suitable for growing patients
showing excessive vertical growth

More intrusion in maxillary molars
Deciduous molars if hypererupt-serial extraction


If 2
nd
molars erupt-include using sectional rectangular
wire
Avg Rx time-5 7 months
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Case report-

12 yr old female
Chief complaint lack of contact bet upper and lower incisors
and diff in closing lips
Clinical examination-class Imalocclusion
open bite 3.6mm
moderate posterior contraction
Ceph analysis-
obtuse mand plane angle
vert excess of maxilla and lower 1/3 of face


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Rx time- 4months
Open bite reduced to 0mm
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Results
Moderate intrusion of 1
st
molars
Anterior rotation of mandible
Anterior facial height
Counter rotation of occlusal plane


relapse of skeletal correction was seen-
Cause
Normal growth
Return to excessive vertical pattern
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adult patients

skeletal open bites with class I and II patterns are
treated better

Additional anchorage-TPA/lingual arches

Modules need to be replaced as they deform with
time causing decay in force level
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Case report

22yr female
Chief complaint-lack of contact bet anterior teeth and
poor esthetic appearance of smile

Clinical examination-
class II malocclusion
1.9mm openbite
posterior cross bite

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Ceph analysis-obtuse mand plane angle
excess vert dev of maxilla
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4months- levelling and alignment
Molar rotation and counter clockwise rotation
of mandible -5months

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Conclusions
Force 600 900 gms on each side
Rx time 4 6 months

Adverse buccal tipping
Incisor position appears stable
TMDs ?

during growth -limits normal eruption of molar and
induces change of mand plane
Adults-molar intrusion and anterotation of mandible
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Noncompliant treatment of
skeletal open bite

AJODO December 2005 Volume 128
Number 6

Aldo Carano
William Machata
Giuseppe Siciliani
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AIM

to illustrate the effects of the rapid molar
intrusion appliance, a treatment alternative
that does not require patient compliance,
for counteracting excessive vertical
dimensions in growing patients and adults.
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Anterior dental open bite
backward-rotation mandible
Overeruption of molars


passive system -relative intrusion
potential of molar eruption during growth
active system -physically intrude the
molars into their bony support
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Appliance design





intrusive force - 800 g each side
450 g - end of 1
st
week
250 g - end of 2
nd
week

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Material and methods
19 patients
11 - mixed dentition; 7 girls, 4 boys; avg age, 11.9 yrs, SD
1.8 years
8 - permanent dentition; 5 women, 3 men; avg age, 19.9
years, SD 3.9 year
criteria
S-N Go-Gn > 37
palatal plane Go-Gn > 32
UFH/LFH < 0.70
ODI < 68
1-mm opening when the incisal edges were projected
perpendicularly the facial plane (N-Me).


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growing patients
maxillary and mandibular soldered
stabilization arches were used
8 pts-spring jet appliance -maxillary
expansion with a force of 470 g
9 pts,deciduous teeth interfered-the teeth
were extracted
If 2
nd
molars erupted- banded and connected
with the 1
st
molars by a full-size rectangular
wire
Rx time -4 to 5 months

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adult patients
No anterior vertical elastics
6 pts-RMI + stabilization arches +fixed
appliances
variation -some pts,1
st
and 2
nd
molars - only
contacting teeth,
other patients, when the premolars were also
in contact
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guidelines in the clinical management of
patients

1
st
molars were stabilized with soldered palatal
and lingual arches (1 mm diameter).
ball stops of the pins did not impinge on the
gingival tissues.
Patients were recalled at 4-week intervals.
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The RMI intruded only the molars to which
it was attached.

Occlusal contacts, other than the first
molars, were eliminated to allow for the
intrusive effects of the RMI
deciduous tooth extraction,
leveling of the occlusal plane
extraction of the maxillary 2
nd
molars in
difficult adult cases,
extraction of the 3
rd
molars when erupted
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Lingual arches were adjusted every 2
months to compensate for compression of
the gingival tissue as the molars intruded.
After the intrusion was completed and the
open bite closed, the palatal and lingual
stabilization arches were left in place for
retention.
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Results

Mean closure at the
incisors - 5.15 mm
range 3.1-6.21 mm

Rx time- 5.45 months

Avg rate of 0.94
mm/month of open-
bite correction


Measurement T1 SD T2 SD T2-T1 SD
Skeletal
SNA 79.60 2.20 80.02 2.35 0.41 0.64
SNB 75.08 2.23 77.25 2.16 2.16
*
1.13
SN^ANS-PNS 2.06 7.84 2.28 7.52 0.22 1.84
S-N-Pg (angle) 75.40 2.66 77.44 2.26 2.04
*
0.26
SN^Go-Gn 40.48 4.09 38.14 4.23 2.34
*
1.04
ANS-Me 75.22 8.15 71.97 7.96 3.15
*
1.98
Dental
SN^occl plane 20.60 2.70 18.75 2.58 1.85
*
0.82
Upper1^lower 1 123.52 5.95 124.88 6.88 1.36
*
1.89
Lower1^GoGn 87.75 5.26 89.66 7.31 1.83
*
1.24
Open bite 3.98 1.05 1.17 1.35 5.15
*
0.56
Max 6-palat plane 18.32 1.70 15.89 1.11 2.42
*
0.37
Max 7-palat plane Not erupted Not erupted
Mand 6-mandible 26.12 1.62 24.60 1.43 1.52
*
0.31
Mand 7-mandible Not erupted Not erupted
T1, Pretreatment; T2, posttreatment; T2-T1, treatment changes (Mann-Whitney U test
for independent samples).

*
P < .01.
Table I. Pre- and posttreatment measurement
of growing group with skeletal open bite

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Table II. Pre- and posttreatment measurements of adult
group with skeletal open bite

Measurement T1 SD T2 SD T2-T1 SD
Skeletal
SNA 76.61 6.46 76.68 6.17 0.08 0.66
SNB 70.60 4.14 72.92 3.80 2.02
*
0.62
SN^ANS-PNS 10.96 6.27 10.31 6.23 0.65 0.62
S-N-Pg (angle) 72.71 2.13 74.95 2.26 2.22
*
0.48
SN^Go-Gn 47.07 8.55 44.71 8.04 2.36
*
0.92
ANS-Me 84.02 4.69 81.26 4.50 2.65
*
0.57
Dental
SN^occl plane 26.82 10.01 27.30 10.34 0.39 1.01
Upper1^lower 1 123.54 10.26 125.15 7.38 1.60 0.66
Lower1^GoGn 89.59 10.43 92.41 8.95 2.82 0.94
Open bite 3.44 1.36 0.47 0.53 2.86
*
0.21
Max 6-palat plane 25.07 3.37 22.63 3.19 2.40
*
0.45
Max 7-palat plane 21.37 3.66 19.49 3.91 1.43
*
0.38
Mand 6-mandible 32.42 2.75 29.50 3.64 2.92
*
0.36
Mand 7-mandible 28.21 2.46 26.14 3.45 2.01
*
0.32
T1, Pretreatment; T2, posttreatment; T2-T1, treatment changes (Mann-Whitney U
test for independent samples).

*
P < .01.
Mean closure -3.80mm
range 3.11-7.00 mm


Rx time-5.01 months



average rate of 0.75
mm/month of open-bite
correction


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Case study
18-year-old man
anterior open-bite and occlusal
disturbance

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mandibular 2
nd
molars - extracted

RMI modules attached

maxillary 2
nd
molars - banded and consolidated

utility arch was used to disocclude the incisors and
allow the mandible to autorotate

Molar intrusion - 5 months

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occlusion -Class III

lip bumper - move teeth into the extraction
sites of the mandibular 2
nd
molars.
Class III elastics - maxillary 1
st
molars to
lip bumper
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counterclockwise
rotation of
mandible and
decrease in
anterior facial
height.


more mandibular
molar intrusion
than maxillary
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Discussion

intrusive force simultaneously to the maxillary and
mandibular molars
No patient compliance
buccal crown tipping

skeletal vertical dimension is accompanied with
advancement of the chin; suited for treating Class I
and Class II skeletal open bites

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Conclusions

Initial experiences with the RMI are
promising, but a more structured research
project is needed to demonstrate the long-
term stability of the results


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