Anteroposterior problems

Usually manifest as an increased or reverse

overjet, where there is a discrepancy between
the dental arches. Protrusion of both upper
and lower dentitions will result in bimaxillary
protrusion or proclination. Conversely,
retroclination of the dentition can result in
bimaxillary retrusion, development of a class II
division 2 incisor relationship and an increased
overbite (discussed in vertical problems).
 Increased overjet

An increased overjet is associated with a class II malocclusion and there are

essentially two options for its reduction:
● Retraction of the upper labial segment; and
● Advancement of the lower labial segment.
Which option is chosen will depend on a number of factors, which
relate primarily to the skeletal and soft tissue pattern, and patient age:
● Skeletal relationship — a class II malocclusion is usually associated with a
class II dental base relationship and where this is the case, the majority of
patients will have a degree of mandibular retrognathia ( McNamara, 1981
). The more severe the skeletal discrepancy, the more diffi cult it will be to
reduce the overjet by orthodontic tooth movement alone and the greater
potential compromise to the soft tissue profi le. Treatment aimed at
encouraging favourable growth should always be considered in a growing
child with a skeletal discrepancy either using functional appliances or
headgear.
● Soft tissue profile
The drape of the upper lip is in part determined by the
position of the upper incisors. If these teeth are retracted the
upper lip will follow, although it will not move as far as the
teeth. If the upper incisors are proclined and the upper lip
protrusive, as can occur when the lower lip rests behind the
upper labial segment, retraction of the upper incisors will be
benefi cial particularly as the lower lip will tend to uncurl and
lengthen, adopting a more favourable position in front instead
of behind the upper incisors. If the upper incisors are upright
or retroclined, excessive retraction of the upper labial
segment may result in flattening of the upper lip and
excessive opening of the nasolabial angle, which can
compromise the soft tissue profile.
• Age of the patient
In an adolescent patient mandibular growth can be
utilized to reduce an increased overjet, especially during
the pubertal growth spurt. Functional appliances can
achieve this and are described in Chapter 8. In adult
patients facial growth has essentially stopped and
orthodontic correction of an increased overjet can only be
achieved by tooth movement, either retraction of the
upper labial segment or proclination of the lower. There is
an anatomical limit to how far the upper labial segment can
be retracted and proclination of the lower labial segment is
prone to relapse. Therefore in certain cases, especially
those with a severe underlying skeletal discrepancy,
orthodontics combined with orthognathic surgery will be
the treatment of choice.
 Mechanotherapy for reducing an overjet
The options for reducing an increased overjet range from simple incisor
tipping mediated by a removable appliance, functional appliances that attempt
alteration of dental and skeletal relationships, fixed appliances to tip and move
teeth bodily or orthognathic surgery to reposition the jaws.
 Removable appliances—
If the upper labial segment is proclined and spaced, particularly when the
lower lip rests behind it, an increased overjet can be reduced by simply tipping the
upper incisors back. A removable appliance with an activated labial bow is an
effective way of doing this (see Fig. 8.13).
 Functional appliances
In a growing patient, growth can be utilized to reduce an overjet and an
effective way of doing this is the use of a functional appliance. Although there is
little evidence that this will result in significantly increased mandibular growth
beyond what might be expected naturally, this approach can utilize growth early
on in treatment. These appliances are most effective during the pubertal growth
spurt and, if successful, will result in effective overjet correction and reduced
anchorage demand later on in treatment because there is no longer an overjet to
reduce. However, this must be offset by the greater compliance required and the
overall extension of treatment time (see Chapter 8).
 Fixed appliances
if bodily retraction of the upper labial segment is
required, it necessitates the use of fixed appliances. Space will
need to be created by either distal movement of the buccal
segments or mid-arch extractions. Once space is available, the
labial segment can be retracted to reduce the overjet.
Treatment aims can be facilitated by the following:
 If extractions are required in both arches to relieve crowding,
extract further forward in the upper arch than the lower arch
(Fig. 11.8).
 If the lower arch is well aligned or treatment is planned
without extraction, consider loss of upper premolars and treat
to a class II molar relationship (Fig. 11.9).
 Use class II intermaxillary elastics to support anchorage.
 When using an edgewise bracket system the incisors
are moved backwards bodily on a heavy rectangular wire.
This can be done using space closing loops, although when
using a preadjusted system, sliding mechanics are generally
used. A stretched elastomeric module or nickel titanium
coil spring is connected between the terminal molar and
hooks situated on the archwire in the labial segment ( Fig.
11.10 ).
This will result in the archwire shortening as it slides
through the brackets in the buccal segment and is often
facilitated by the use of class II elastics. If anchorage has
been correctly planned, bodily retraction of the incisors and
a reduction in the overjet will take place. When using the
Begg or Tip-Edge appliance the overjet is reduced early in
treatment by tipping the teeth with light class II elastics (
Fig. 11.10 ). The teeth are later uprighted using auxiliary
springs.
● Orthognathic surgery
Once growth has ceased the only way to reduce an
overjet is by orthodontic tooth movement. If there is a
signifi cant skeletal discrepancy tooth movement alone
may result in an unacceptable compromise to the
patient’s soft tissue profile. Therefore a combined
orthodontic–orthognathic solution may have to be
considered. Considering that mandibular retrognathia
is a common aetiological factor in many significant
class II malocclusions and that surgical setback of the
maxilla to any great extent is difficult to achieve, this
usually consists of mandibular advancement (see
Chapter 12).
 Reduced or reverse overjet

A reduced or reverse overjet is associated with a class III

malocclusion and the options for correction include: l
 Advancement of the upper labial segment
 Retraction of the lower labial segment.
Anatomical limitations mean that there is less scope for the
retraction of lower incisors and advancement of the uppers using
orthodontic mechanics. Therefore, the more severe class III cases
are more reliant on surgical intervention. Whether a class III case
can be treated by orthodontic tooth movement alone will depend
significantly on the degree of existing incisor compensation for the
skeletal pattern (Table 11.3). The upper incisors are often already
proclined and the lowers retroclined and for orthodontic treatment
to be successful it is important that this is minimal; otherwise, it
limits the potential for further movement of these teeth aimed at
correcting the class III incisor relationship.
 The stability of incisor
correction will depend in
part on whether a positive
overbite can be achieved at
the end of treatment.
Stability will also depend on
future adolescent growth
because any increase in
mandibular prognathism will
tend to worsen the class III
incisor relationship. If there
is any doubt, it is better to
monitor growth in patients
with a class III malocclusion
before final treatment
decisions are made, which
can be done using serial
cephalometric lateral skull
radiographs taken a year
apart (Table 11.4).
 Mechanotherapy for correcting a class III incisor
relationship
Correcting a reduced or reverse overjet with simple upper incisor
tipping can be mediated by a removable appliance, whilst bodily tooth
movement or lower incisor retraction will require fixed appliances. In
more severe cases, orthognathic surgery to reposition the jaws will be
required in combination with orthodontic treatment. The adverse nature
of facial growth and difficulty in addressing the reduced maxillary or
increased mandibular growth seen in many class III cases means the use of
growth modification is more problematic in these patients. Functional
appliances and protraction headgear, if used, are usually commenced in
the mixed dentition. Options in the permanent dentition include:
 Removable appliances—a removable appliance can be used to push one
or two maxillary incisors over the bite to correct an anterior crossbite if
they are retroclined and a positive overbite can be achieved at the end of
treatment to hold the corrected position (see Fig. 8.15).
 Fixed appliances—comprehensive treatment usually involves bodily
movement of the incisors in both arches and therefore fixed appliances
are more appropriate.
 The aim is to create a
positive overjet and overbite at
the end of treatment and this
can be facilitated by the
following:
 If extractions are required in
both arches to relieve crowding,
extract further forward in the
lower than in the upper arch
(Fig. 11.11).
 If the upper arch is well-aligned
but space is required to align
and retrocline the lower
incisors, extraction of a single
lower incisor can be an option
(see Fig. 7.12).
 Closing space on a round wire in
the lower arch will facilitate
retroclination of the lower
incisors. L
 Use of class III intermaxillary
elastics will help procline the
upper incisors and retrocline
the lowers