Orthodontics in the Vertical Dimension E-Book

Thomas E. Southard

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1261

Veröffentlichungsjahr: 2015

Beschreibung

This case-based clinical text is an exhaustive review of orthodontic problems in the vertical dimension, with evidence-based guidelines for successful diagnosis and treatment. A total of 21 cases address dental deep bites, skeletal deep bites, dental open bites, skeletal open bites, and posterior open bites. Each case includes pretreatment, interim, and posttreatment orthodontic records, as well as references to provide a solid evidence base for decision making. Written with a clinical focus, Orthodontics in the Vertical Dimension is ideal for the practicing orthodontist and makes an excellent resource for residents in pursuit of board certification. Key Features * Detailed case-based scenarios for treatment of the spectrum of open bites and deep bites * Cases presented in question and answer format to encourage thought * 2500 clinical photographs and illustrations. "This is a great textbook, and I will use it in my classes. Highly organized and elaborately illustrated, the authors' work is inspired by problem-based learning and stimulates cognitive processes by encouraging critical thinking. Their text deserves a 'must read' category for orthodontic professionals of all ages." Dr. Jeryl D. English DDS, MS, Chairman and Graduate Program Director, Department of Orthodontics, The University of Texas Health Science Center at Houston "A terrific book for students of orthodontics and dentofacial orthopedics, covering the vertical dimension and much more. A wide range of cases are presented, treatment plans are realistic, and the authors openly discuss complications encountered during treatment." Dr. Greg J. Huang, DMD, MSD, MPH Professor and Chair Department of Orthodontics, The University of Washington School of Dentistry "This comprehensive text prepares the reader in the context of a mini-residency with a question answer teaching style. Resident and experienced orthodontists can match their cases with fully worked up patients and alternative treatment options. Well written." Dr. Katherine L. Vig, BDS, MS, FDS, D.Orth Professor Emeritus and Former Head of Orthodontics, The Ohio State University College of Dentistry

Leseprobe

CONTENTS

Cover

Title page

Preface

CHAPTER 1: Foundations

The Spectrum of Vertical

Growth Foundations

Diagnosis and Treatment Planning Principles

References

CHAPTER 2: Dental Deep Bites

Introduction

Case Andrew

Case Emma

References

CHAPTER 3: Skeletal Deep Bites

Introduction

Case Adam

Case Valerie

Case Shawn

Case Megan

Case Connie

References

CHAPTER 4: Dental Anterior Open Bites

Introduction

Case Sasha

Case Derrick

Case Steven

References

CHAPTER 5: Skeletal Anterior Open Bites

Introduction

Case Emma

Case Rachael

Case Kaylee

Case Greg

Case Ashley

Case Alyson

References

CHAPTER 6: Posterior Open Bites

Introduction

Case Mark

Case George

Case Kreslyn

References

APPENDIX

Cephalometrics Primer

Iowa AP Classification Primer

Tables for Reference

Abbreviations

Appendix References

Index

End User License Agreement

List of Tables

bapp

Table A.1  Template: Diagnostic findings and problems list.

Table A.2 Template: Primary problems list.

Table A.3 Checklist to follow for surgical patients.

Table A.4 Limits of orthognathic surgical movements.

Table A.5  Guidelines for post-surgical biomechanics if occlusal discrepancies exist (i.e., not fully corrected or overcorrected).

Chapter 01

Table 1.1 Dental and skeletal features of Brad (Figure 1.28).

Table 1.2 Skeletal and dental features of Robert (Figure 1.29).

Table 1.3 Skeletal and dental features of Kelly (Figure 1.31).

Table 1.4 Skeletal and dental features of Owen (Figure 1.32).

Table 1.5 Diagnostic findings and problem list with some common features to examine.

Table 1.6 Diagnostic findings and problem list for Monica (Figure 1.40).

Table 1.7 Diagnostic findings and problem list for Corey (Figure 1.43).

Table 1.8 Primary problems list for Corey

(apical base/skeletal discrepancies italicized).

Table 1.9 Primary problems list for Monica.

Table 1.10 Primary problems list for Jackie

(apical base/skeletal discrepancies italicized).

Table 1.11 Primary problems list for Phoebe (Figure 1.56).

Table 1.12 Diagnostic findings and problem list for Lauris (Figure 1.59).

Table 1.13 Primary problems list for Lauris

(apical base/skeletal discrepancies italicized).

Chapter 02

Table 2.1 Diagnostic findings and problems list for Jane (vertical dimension only).

Table 2.2 Diagnostic findings and problem list for Andrew.

Table 2.3 Primary problems list for Andrew

(apical base/skeletal discrepancies italicized).

Table 2.4 Diagnostic findings and problem list for Emma.

Table 2.5 Primary problems list for Emma

(apical base/skeletal discrepancies italicized).

Chapter 03

Table 3.1 Diagnostic findings and problem list for Adam.

Table 3.2 Primary problems list for Adam

(apical base/skeletal discrepancies italicized).

Table 3.3 Diagnostic findings and problem list for Valerie.

Table 3.4 Primary problems list for Valerie

(apical base/skeletal discrepancies italicized).

Table 3.5 Diagnostic findings and problem list for Shawn.

Table 3.6 Primary problems list for Shawn

(apical base/skeletal discrepancies italicized).

Table 3.7 Diagnostic findings and problem list for Megan.

Table 3.8 Possible reasons for excessive or inadequate incisal/gingival display.

Table 3.9 Primary problems list for Megan

(apical base/skeletal discrepancies italicized).

Table 3.10 Limits of orthognathic surgical movements.

Table 3.11 Checklist to follow for surgical patients.

Table 3.12 Guidelines for postsurgical biomechanics if occlusal discrepancies exist (i.e., not fully corrected or overcorrected).

Table 3.13 Diagnostic findings and problem list for Connie.

Table 3.14 Primary problems list for Connie

(apical base/skeletal discrepancies italicized).

Chapter 04

Table 4.1 Diagnostic findings and problem list for Sasha.

Table 4.2 Primary problems list for Sasha.

Table 4.3 Diagnostic findings and problem list for Derrick.

Table 4.4 Primary problems list for Derrick

(apical base/skeletal discrepancies italicized).

Table 4.5 Diagnostic findings and problem list for Steven.

Table 4.6 Primary problems list for Steven

(apical base/skeletal discrepancies italicized).

Chapter 05

Table 5.1 Diagnostic findings and problem list for Emma.

Table 5.2 Primary problems list for Emma

(apical base/skeletal discrepancies italicized).

Table 5.3 Diagnostic findings and problem list for Rachael.

Table 5.4 Primary problems list for Rachael

(apical base/skeletal discrepancies italicized).

Table 5.5 Diagnostic findings and problem list for Kaylee.

Table 5.6 Primary problems list for Kaylee

(apical base/skeletal discrepancies italicized).

Table 5.7 Diagnostic findings and problem list for Greg.

Table 5.8 Primary problems list for Greg

(apical base/skeletal discrepancies italicized).

Table 5.9 Checklist to follow for surgical patients.

Table 5.10 Diagnostic findings and problem list for Ashley.

Table 5.11 Primary problems list for Ashley

(apical base/skeletal discrepancies italicized).

Table 5.12 Diagnostic findings and problem list for Alyson.

Table 5.13 Possible reasons for inadequate or excessive incisal display.

Table 5.14 Primary problems list for Alyson

(apical base/skeletal discrepancies italicized)

.

Table 5.15 Checklist to follow for surgical patients.

Table 5.16 Limits of orthognathic surgical movements.

Table 5.17 Guidelines for post-surgical biomechanics if occlusal discrepancies exist (i.e., not fully corrected or overcorrected).

Chapter 06

Table 6.1 Diagnostic findings and problem list for Mark.

Table 6.2 Primary problems list for Mark.

Table 6.3 Primary problems list for Mark after 3 Years in retention.

Table 6.4 Diagnostic findings and problem list for George.

Table 6.5 Primary problems list for George.

Table 6.6 Diagnostic findings and problem list for Kreslyn.

Table 6.7 Primary problems list for Kreslyn

(apical base/skeletal discrepancies italicized)

List of Illustrations

Chapter 01

Figure 1.1 (a, b) Emily’s facial photographs. (c, d) Soft tissue midface height (vertical distance from supraorbital ridges/soft tissue Glabella to Subnasale) is compared to LAFH (vertical distance from Subnasale to soft tissue Menton). Abbreviations used in this book are defined in the Appendix.

Figure 1.2 (a) Emily’s lateral cephalometric tracing. (b) Skeletal TAFH is the distance Nasion–Menton. Skeletal LAFH is the distance measured from Menton along a Nasion–Menton line to a point where ANS projects perpendicularly to the Nasion–Menton line. A primer on the determination of facial height and other cephalometric measurements used in this book can be found in the Appendix.

Figure 1.3 (a) Frontal intraoral view of Emily with (b) approximately 20% central incisor overbite measured relative to mandibular central incisor crown length.

Figure 1.4 Illustration of maxillary and mandibular central incisors in the sagittal view depicting incisor overbite, ranging from deep (left) to open (right).

Figure 1.5 The spectrum of vertical facial development depicted on the right ranges from deficient (top, usually associated with deep bite) to excessive (bottom, usually associated with open bite). Emily is located in the center of this range and exhibits normal vertical facial development.

Figure 1.6 Variation of vertical soft tissue proportions: (a, d) Kelly, (b, e) Ashley, and (c, f) Alexis.

Figure 1.7 Variation of vertical skeletal and dental features: (a, d) Kelly, (b, e) Ashley, and (c, f) Alexis.

Figure 1.8 Variation of intraoral vertical dental features for the subjects shown in Figure 1.6: (a) Kelly, (b) Ashley, and (c) Alexis.

Figure 1.9 Kelly, Emily, and Alexis plotted on the spectrum of vertical facial development.

Figure 1.10 Variation of vertical soft tissue proportions: (a, d) Cassie, (b, e) Grace, and (c, f) Adair.

Figure 1.11 Variation of vertical skeletal and dental features: (a, d) Cassie, (b, e) Grace, and (c, f) Adair.

Figure 1.12 Variation of intraoral vertical dental features for the subjects shown in Figure 1.10: (a) Cassie, (b) Grace, and (c) Adair.

Figure 1.13 Example individuals representing the complete spectrum of vertical facial development.

Figure 1.14 Initial records of Mitchell (a) lips straining to close, (b) smile, (c) profile with lips straining to close, (d) lips relaxed revealing an ILG, (e) intraoral photo, (f, g) lateral cephalograph and tracing.

Figure 1.15 Incisal display: (a, c) an adolescent girl, (b, d) a young man.

Figure 1.16 Steps in the anterior portion of the maxillary occlusal plane affect the amount of incisal display at rest: (a) anterior teeth stepped down and (b) stepped up relative to the maxillary occlusal plane, which is defined by the occlusal surfaces of the posterior maxillary teeth bilaterally (red line).

Figure 1.17 (a) Effect of philtrum length (red arrow)–commissure height (yellow arrow) difference on incisal display. (b) Matt has a small, 3–4 mm philtrum length–commissure height difference and exhibits 1 mm incisal display at rest. (c) John has a much larger philtrum length–commissure height difference and exhibits 10 mm of incisal display at rest.

Figure 1.18 Smile arcs during a posed smile: (a) ideal smile arc, (b) reverse smile arc, (c) same patient, improved smile arc following treatment.

Figure 1.19 Chris: (a) at rest, (b) smiling in a posed smile, and (c) smiling in an unposed smile.

Figures 1.20 Patients with asymmetrical smiles due to structural maxillary occlusal cants: (a, d) Tanner, (b, e) Olivia, and (c, f) Trevor.

Figure 1.21 (a, b) Patient with an asymmetrical smile due to unbalanced smile musculature function.

Figure 1.22 Christina presents with an asymmetrical smile.

Figure 1.23 Patients with varying thicknesses of lip vermillion.

Figure 1.24 Incisor midline positions: (a) ideal, (b) 2 mm right deviation, (c) 3–4 mm right deviation.

Figure 1.25 Buccal corridors: (a) initially large, (b) reduced following SARME

Figure 1.26 Dental features impacting esthetics: (a–b) well-finished occlusions, (c) a malocclusion possessing many unesthetic features.

Figure 1.27 (a–o) Unesthetic dental features.

Figure 1.28 Initial records of Brad: (a–c) composite facial photographs, (d) lateral cephalograph, (e) cephalometric tracing, (f–h) intraoral photographs, and (i) models separated.

Figure 1.29 Initial records of Robert.

Figure 1.30 Robert: (a) initial photo again, in maximal intercuspation; (b) with jaws separated until lips relaxed and just touching; (c) opened until lips relaxed and parted to demonstrate degree of incisal display at rest.

Figure 1.31 Initial records of Kelly.

Figure 1.32 Initial records of Owen.

Figure 1.33 Tongue interposition habit of Owen.

Figure 1.34 (a) Changes in size, shape, and position of the major skeletal components contributing to the growth of the face as viewed in the sagittal. Approximate outline of the cranial base (gray), the maxilla (green), and the mandible (blue) as seen on a lateral cephalogram. Darker shades of color indicate the approximate location and direction of changes in size and shape due to drift and displacement of the cranial base, maxilla, mandible, and teeth during growth (Duterloo HS, Planche PG. Handbook of Cephalometric Superimposition. Hanover Park: Quintessence, 2001. Figure 3.23. Reprinted with permission from Quintessence Publishing Company Inc, Chicago.) (b) The location of the cranial base (gray), maxilla (green), and mandible (blue) on a lateral cephalogram.

Figure 1.35 Changes in size, shape, and position of the cranial base during growth—as viewed in the sagittal. The intersection of the white lines indicates Sella point. Darker gray and dark arrows indicate approximate magnitude and direction of changes due to growth-driven drift and displacement.

Figure 1.36 Changes in size, shape, and position of the maxilla and maxillary teeth during growth—as viewed in the sagittal. Darker color and dark arrows indicate approximate magnitude and direction of changes due to growth-driven drift and displacement.

Figure 1.37 The mandible consists of five regions: 1, condyle; 2, coronoid process; 3, ramus; 4, corpus; 5, alveolar process.

Figure 1.38 Plot of change in growth velocity with age.

Figure 1.39 Overall superimposition of cephalometric tracings depicting 2 years of growth in a young male. Black dots indicate location of implant markers. Numbers 1, 2, and 3 indicate maxillary implant markers. Numbers 4, 5, and 6 indicate mandibular implant markers. Black lines bisecting dot pairs indicate the direction of implant marker displacement during growth. Note the equivalence in magnitude and direction of maxillary implant displacement indicating nominal true rotation. In contrast, the pattern of changes in magnitude and direction of the mandibular implants indicates true mandibular anterior rotation. The pattern of inferior mandibular border change suggests nominal apparent mandibular rotation due to angular remodeling.

Figure 1.40 Initial records of Monica: (a–c) facial photographs, (d) lateral cephalograph, (e) cephalometric tracing, (f) pantomograph, (g–k) intraoral photographs, (l–q) model photographs.

Figure 1.41 Lingual view of Monica’s occlusion: (a) left, (b) right.

Figure 1.42 Separated models view of Monica.

Figure 1.43 Initial records of Corey.

Figure 1.44 Progress records of Corey.

Figure 1.45 Deband records of Corey.

Figure 1.46 Initial records of Martin.

Figure 1.47 Deband records of Martin.

Figure 1.48 Initial records of Jackie.

Figure 1.49 Initial records of Jesse.

Figure 1.50 Deband records of Jesse. Note the additional growth he had.

Figure 1.51 Panoramic and complete mouth series radiographs for an 11-year-old female presenting for orthodontic evaluation.

Figure 1.52 Posttreatment panoramic radiograph of the patient presented in Figure 1.51.

Figure 1.53 Initial records of Connie.

Figure 1.54 By proclining initially upright mandibular incisors (top) additional arch length can be gained (bottom).

Figure 1.55 Deband records of Connie.

Figure 1.56 Initial records of Phoebe.

Figure 1.57 Illustration of the effect of (a) second premolar, (b) first premolar, or (c) incisor extraction on movement of teeth (red arrows) adjacent to mandibular extraction sites using conventional orthodontic mechanics without the aid of supplemental anchorage. Yellow lines in (a) and (b) indicate approximate location where translation of tooth segments will stop when extraction spaces are completely closed, reciprocally. Note in (c), protraction of posterior teeth is not seen.

Figure 1.58 Deband records of Phoebe.

Figure 1.59 Initial records of Lauris.

Figure 1.60 Progress records of Lauris.

Figure 1.61 Deband records of Lauris.

Figure 1.62 Progress records of Monica.

Figure 1.63 Deband records of Monica.

Chapter 02

Figure 2.1 Initial records of Jane: (a–c) facial photographs, (d) lateral cephalograph, (e) cephalometric tracing, (f) pantomograph, and (g–k) intraoral photographs.

Figure 2.2 Initial records of Jane: (a) incisal display with lips at rest and (b) intraoral view with teeth apart.

Figure 2.3 (a–l) Deband records of Jane.

Figure 2.4 Deep bite correction example: (a) initial OB of 70–80% and (b) following treatment OB of 10%.

Figure 2.5 Opening a deep bite to permit bonding of mandibular anterior teeth: (a) initial deep bite with inadequate room for mandibular brackets, (b) deep bite corrected, and (c) mandibular brackets placed.

Figure 2.6 Opening a deep bite to create OJ for maxillary incisor retraction: (a) deep bite with inadequate OJ to retract maxillary incisors and (b) deep bite correction creates OJ for maxillary incisor retraction.

Figure 2.7 Opening a deep bite to create space for restoring badly worn teeth: (a) left-to-right normal OB, deep bite with badly worn maxillary incisors, deep bite corrected with maxillary incisor restored; (b–d) example of patient’s initial intraoral photos showing severe wear and deep bite—there is no room on the lingual of the maxillary incisors to restore these teeth; (e) same patient following bite opening; and (f) and following deband/restoration.

Figure 2.8 Deep bites can affect soft tissue: (a–c) mandibular incisors can bite into palate and (d and e) maxillary incisors can strip mandibular incisor labial gingiva.

Figure 2.9 Deep bite resulting in lip “trapping” and a deep labiomental sulcus.

Figure 2.10 (a, b) Measurement of the curve of Spee depth.

Figure 2.11 Depth of curve of Spee deepens with eruption of permanent mandibular first molars/central incisors and with eruption of permanent mandibular second molars [7]. ()

Figure 2.12 An exaggerated curve of Spee (3–4 mm deep).

Figure 2.13 Incisor vertical movement during arch leveling: (a and b) if incisor brackets are positioned

incisal

to posterior brackets, then incisors will be intruded by the archwire; and (c and d) if incisor brackets are positioned apical to posterior brackets, then incisors will be extruded.

Figure 2.14 Second molars should be banded in deep bite patients: (a) mandibular second molars erupt higher on the ramus than first molars and (b) when second molars are banded, the archwire (solid line) must be deflected further to engage the premolars than if only the first molars are banded (dotted line archwire). So, a deep bite will open more readily if second molars are banded.

Figure 2.15 Uprighting mesially tipped mandibular molars results in their eruption.

Figure 2.16 Leveling the curve of Spee using second

and

third molars: (a) before and (b) after.

Figure 2.17 Another example of a curve of Spee that was leveled: (a) before and (b) after.

Figure 2.18 (a–c) Deep-bite patient with inadequate OJ to bond mandibular incisors.

Figure 2.19 (a–c) Overjet created by proclining maxillary incisors (opening spaces distal to the maxillary lateral incisors), which then allows bonding of mandibular incisors.

Figure 2.20 Overjet created by placement of anterior biteplates: (a and b) commercially available biteplates and (c) “poor man’s” anterior biteplate formed using composite resin.

Figure 2.21 Overjet created by placement of orthodontic banding cement on posterior teeth: (a) inadequate OJ to bond mandibular incisors due to a deep bite, (b) banding cement placed on maxillary second molars to open bite, and (c) results in adequate OJ created to bond mandibular incisors.

Figure 2.22 (a) Placement of excessively thick banding cement on mandibular first molars permits bonding mandibular incisors but (b) resulted in a posterior open bite.

Figure 2.23 Orthodontic cement placed on canines to open the bite and permit bonding of mandibular incisors.

Figure 2.24 Anterior biteplate used to open the bite for mandibular incisor bonding. Vertical elastics are being used to erupt the posterior teeth.

Figure 2.25 Guray “bite raisers”: (a) placed on maxillary first molar bands and (b) patient biting on “bite raisers” that open the bite and allow bonding of mandibular incisors.

Figure 2.26 Leveling the mandibular arch using segmental archwires: (a–c) curve of Spee initially leveled using mandibular segmental wires from canines to molars, (d–f) as the bite is opened OJ is created permitting mandibular incisor bonding, and (g–i) final overbite and occlusion.

Figure 2.27 Patient presents in treatment with a deep bite and maxillary left central incisor edge hitting a lower bracket.

Figure 2.28 Whenever you are faced, in treatment, with a deep bite: (a) check the mandibular incisor to canine relationship. The incisors should be stepped down slightly from the canines; (b) mandibular arch of patient in Figure 2.27; (c) check the mandibular canine to posterior teeth relationship. The occlusal plane should be flat; (d) check the maxillary incisor to canine relationship. The incisors should be stepped up slightly from the canines; (e) maxillary arch of the patient in Figure 2.27; and (f) check the maxillary canine to posterior teeth relationship. The occlusal plane should be flat.

Figure 2.29 Patient presents with maxillary incisor edges hitting lower brackets.

Figure 2.30 With the jaws separated, examine relationships between anterior teeth and between anterior and posterior teeth to help determine the cause of the deep bite (and how to correct it).

Figure 2.31 Determining the cause of a dental deep bite: (a) Patient presents with maxillary incisors hitting the mandibular brackets and (b) examining the lower arch to look for factors contributing to the deep bite.

Figure 2.32 Determining the causes of a dental deep bite: (a) patient presents with maxillary incisors overlapping lower brackets and (b) have the patient open to look for factors contributing to the deep bite.

Figure 2.33 Determining the cause of a deep bite: (a) the maxillary incisal edges contact the mandibular brackets during retraction/space closure and (b) the patient opens.

Figure 2.34 Correcting the deep bite in Figure 2.33: (a) a larger/stiffer mandibular archwire was placed together with maxillary central incisor and mandibular incisor intrusion steps and (b) which opened the bite and create OJ. Central incisor retraction can now continue.

Figure 2.35 Correction of a deep bite (and curve of Spee) by placement of

reverse

curve of Spee and compensating curve: (a and b) patient presents with a deep bite and upright incisors, (c) reverse curve of Spee is placed in the mandibular archwire and compensating curve is placed in the maxillary archwire, (d) the deep bite is corrected by, and (e and f) mandibular and maxillary incisor proclination/intrusion.

Figure 2.36 Pearl to help level an intractable curve of Spee: (a) placing the archwire under brackets increases the wire deflection/eruptive force and (b) results in the mandibular occlusal plane leveling (at this time, the wire can be placed

in

the bracket slots).

Figure 2.37 For the same amount of bite opening (vertical yellow arrow), B-point and Pogonion will move back less in a short LAFH patient (left, horizontal yellow arrow) than in a long LAFH patient (right).

Figure 2.38 Overerupted incisors in a mixed dentition patient.

Figure 2.39 Effects of a “V bend” utility archwire: (a) bend placed just mesial to the first molar, (b–d) analysis of resulting forces acting on the molar and incisor, and (e) net result is a distal tipping moment on the molar, eruptive force on the molar, and intrusive force on the incisor.

Figure 2.40 Effects of a “V bend” archwire: (a and b) incisors and

primary

second molars bonded and (c–e) incisors intruded, primary second molars tipped distally. Note “V bend” mesial to molars under the open-coil spring.

Figure 2.41 (a–h) Effects of reciprocal space closure following extraction of first premolars. As teeth tip into the extraction spaces, the mandibular curve of Spee deepens, the maxillary compensating curve reverses, OB deepens, and a posterior open bite can develop.

Figure 2.42 (a–i) The undesirable effects of space closure previously shown can be corrected by increasing archwire size, decreasing space closure force, and allowing adequate time for teeth roots to move through bone.

Figure 2.43 A deep bite retention protocol: (a) vacuum-formed retainers are initially worn during the day, (b–f) Hawley retainers, with maxillary anterior biteplate to disclude the posterior teeth, are worn at night for life.

Figure 2.44 Long-term deep bite correction stability: (a) cephalometric superimposition of deep bite correction, (b) initial deep bite, (c) OB correction at deband, and (d) 10–20% OB increase 10 years later.

Figure 2.45 Initial records of Andrew: (a–c) initial facial photographs, (d) lateral cephalograph, (e) cephalometric tracing, (f) pantomograph, (g–k) intraoral photographs, (l–p) model photographs, and (q–u) separated model views.

Figure 2.46 (a, b) Andrew’s models as viewed from the lingual.

Figure 2.47 (a, c, and e) Skeletal and dental effects of high-pull headgears (HPHG) and (b, d, and f) cervical-pull headgears (CPHG) compared to controls.

Figure 2.48 Effects of Class II functional appliances, such as a (a) twin block or (b) bionator, as the mandible is held forward (c).

Figure 2.49 (a–t) Correction of a 3–4 mm Class II malocclusion, using a Herbst appliance, in an adolescent.

Figure 2.50 Masking, or camouflage, of a Class II (mandibular deficient) patient by extraction of maxillary first premolars: (a) initial Class II relationship, (b) extraction of maxillary first premolars and retraction of maxillary anterior teeth using TADs as anchorage, and (c) final Class I relationship.

Figure 2.51 Tendency for maxillary incisors to upright during retraction: (top left) maxillary incisors to be retracted using a closing loop archwire, (top center left) opening the closing loop results in a retraction force being applied against the maxillary incisor brackets, (top center right) at the center of resistance (CR) this retraction force is equivalent to the same retraction force translating the incisors distally plus a CCW moment tending to upright the incisors, (top right) uprighted maxillary incisors, (bottom) this tendency for maxillary incisors to upright can be reduced by filling the incisor edgewise bracket slots with a large rectangular archwire, adding CW archwire lingual root torque to overcome the retraction force CCW moment, decreasing the retraction force magnitude so its CCW moment is reduced, and providing adequate time for the incisor roots to move through the maxillary alveolar process bone.

Figure 2.52 Masking, or camouflage, of a Class II (mandibular deficient) patient by retracting the entire maxillary arch: (a) initial Class II relationship, (b and c) distalization of maxillary molars to Class III with an open-coil spring—the more anterior teeth are held in place with a steel ligature to a left buccal TAD, and (d) following TAD removal and reciprocal space closure, a Class I relationship was achieved.

Figure 2.53 Masking, or camouflage, of a Class II (mandibular deficient) patient by use of interarch Class II mechanics: (a) elastic and (b) spring.

Figure 2.54 Surgical correction of a Class II (mandibular deficient) patient with a BSSO mandibular advancement osteotomy: (a) initial relationship and (b) final relationship.

Figure 2.55 Before (left) and after (right) silhouettes of patients having average profile improvements when using headgear (top) and Herbst (bottom) appliances.

Figure 2.56 Maxillary incisor eruption and lingual tipping, mandibular molar eruption, mandibular molar mesial movement, and CW (down and back) rotation of mandible following heavy Class II elastic use for an extended period of time.

Figure 2.57 Spontaneous alignment of mandibular anterior teeth following exfoliation of mandibular primary second molars with a LLHA in place: (a) before loss of mandibular primary second molars and (b) after loss of mandibular primary second molars.

Figure 2.58 Why we need to correct Andrew’s deep bite: with a deep bite (left), Andrew lacks the OJ to correct his Class II relationship; by opening his bite (center), OJ is created to allow his maxillary teeth to move distally and/or his mandibular teeth to move mesially—resulting in (right) a Class I occlusion with ideal overbite.

Figure 2.59 Tooth movements to correct Andrew’s deep bite include leveling his maxillary arch (top, left to right) by intruding/proclining his maxillary incisors and erupting posterior teeth; leveling his mandibular curve of Spee (bottom, left to right) by intruding/proclining his mandibular incisors, and erupting his mandibular premolars and uprighting/erupting his mandibular molars. Any posterior tooth eruption will rotate his mandible CW, worsening his Class II relationship.

Figure 2.60 A “tip back” or “V” bend placed in the archwire, just mesial to the maxillary molar bracket, results in an intrusive force against the incisors, an extrusive force against the molars, and a CCW moment (as shown in this view) against the molars.

Figure 2.61 (a–h) Progress records of Andrew.

Figure 2.62 Evaluation of some frontal features important to finishing: (a) at rest with lips slightly parted and (b) in a posed smile.

Figure 2.63 Evaluation of dental features viewed from (a) the right, (b) front, and (c) left.

Figure 2.64 (a, b) Evaluation of dental features viewed from occlusal.

Figure 2.65 Evaluation of dental features (a) when closed and (b) open.

Figure 2.66 Determining the magnitude of OJ.

Figure 2.67 The importance of examining the patient for a CR—CO shift at every appointment cannot be overstated. (a) Here a CR—CO shift went undetected for many months. (b) The discovery of this shift completely changed the treatment plan.

Figure 2.68 Inadequate lingual root torque of the maxillary left central incisor. Not only should buccal-lingual crown torque of posterior teeth be checked, but buccal-lingual crown torque of anterior teeth must also be checked.

Figure 2.69 Evaluating esthetic features of the maxillary anterior teeth. Ideal shade is probably the most important of all features.

Figure 2.70 (a) Maxillary and mandibular midlines should be coincident and (b) the maxillary central incisor widths should be equal.

Figure 2.71 (a) Width/length ratio of the maxillary incisors should be 4/5, and (b) tooth widths from central incisor to canine should be follow the golden proportion.

Figure 2.72 (a) Proper mesio-distal long axis alignment should exist. (b) Gingival margins of the maxillary central incisors should be even, the maxillary lateral incisor gingival margins should be slightly more incisal, and the canine gingival margins should be at the same level as the central incisors.

Figure 2.73 (a–e) Progress intraoral photographs of Andrew.

Figure 2.74 (a, b) Initial records of a Class II adolescent patient treated nonextraction with orthopedics and fixed orthodontic appliances.

Figure 2.75 Deband records of the same patient. (a) Note the upright maxillary incisors, the very proclined mandibular incisors, and (b–e) the spacing distal to the maxillary lateral incisors.

Figure 2.76 (a–d) Example of a patient with small maxillary lateral incisors who chose to be left slightly Class II in order to avoid anterior spacing.

Figure 2.77 Opening a deep bite (left) can create OJ (right) for maxillary incisor retraction (anterior space closure).

Figure 2.78 Creating OJ for space closure: (a and b) placing anterior labial crown torque (lingual root torque) in the maxillary archwire can create OJ (c), which can be used for space closure (d).

Figure 2.79 (a–d) Clinical examination of Andrew’s gingival sulcus depths.

Figure 2.80 (a–c) Periapical radiographs of Andrew’s maxillary incisors to compare CEJ levels.

Figure 2.81 Because Andrew has a low smile line, you could choose to leave his central incisor gingival margins uneven.

Figure 2.82 (a–e) Progress intraoral photographs of Andrew while his maxillary lateral incisors are being centered in the anterior spaces.

Figure 2.83 Andrew had significant OJ in CR which should have been eliminated before dealing with any residual spaces.

Figure 2.84 (a, b) If you have 2 mm of bilateral maxillary spaces to close, then you need 2 mm of OJ to close the spaces entirely.

Figure 2.85 (a–e) Progress intraoral photographs of Andrew after his OJ has been eliminated and his maxillary anterior spaces reduced.

Figure 2.86 (a–p) Deband records of Andrew.

Figure 2.87 (a–g) Because Andrew’s right central incisor and right lateral incisor gingival sulci were deep, laser gingivoplasty was used to improve his gingival margin positions.

Figure 2.88 (a–f) Placement of direct composite veneers permitted closure of remaining anterior spaces.

Figure 2.89 (a–l) Andrew’s final records.

Figure 2.90 Initial records of Emma: (a–c) facial photographs, (d) lateral cephalograph, (e) cephalometric tracing, (f) pantomograph, (g–k) intraoral photographs, (l–p) model photographs, and (q–t) separated model views.

Figure 2.91 (a) If a mandibular primary second molar is ankylosed, then (b) a vertical bone defect will develop during adolescence as the second premolar and permanent first molar continue to erupt. (c) However, if the ankylosed primary second molar is extracted, then the alveolar ridge crest should move occlusally to a satisfactory level for later bone grafting.

Figure 2.92 Adolescent with a deeply impacted mandibular left canine: (a) initial panoramic image, (b) surgical exposure of the mandibular canine, and (c) eruption of the mandibular canine was unsuccessfully attempted for 1 year and the canine was subsequently extracted.

Figure 2.93 The wrong and right ways to initially move a palatally impacted maxillary canine crown: (a) the wrong way, dragging the canine crown across the lateral incisor root and potentially resorbing the root, (b) the right way, moving the canine crown initially

away

from the incisor roots until they are clear of the roots, (c) and then moving the canine crowns buccally into position.

Figure 2.94 Forced eruption of a buccally impacted canine: (a) panoramic image reveals a high impaction of the maxillary left permanent canine which is resorbing the central incisor root; (b and c) a bracket is attached to the canine crown and a segmental wire used to initially move the canine crown

buccally

—away from the incisor roots; and (d–f) later, the left primary canine is extracted and the permanent canine erupted and moved distally into its correct position.

Figure 2.95 (a) Open surgical exposure and (b–f) initial orthodontic movement of Emma’s impacted mandibular canines. To avoid incisor root resorption, the canine crowns were first moved toward the lip bumper (away from the incisor roots) before being moved distally. Also note reciprocal proclination of the incisor crowns by the LLHA (which is moving mesially) as the canines are retracted distally.

Figure 2.96 (a–f) Progress records of Emma.

Figure 2.97 (a–u) Deband records of Emma.

Figure 2.98 (a–k) Final records of Emma.

Chapter 03

Figure 3.1 Initial records of Haley: (a–c) initial facial photographs, (d) lateral cephalograph, (e) cephalometric tracing, (f) pantomograph, (g–k) intraoral photographs, and (l–m) right buccal view of maxillary and mandibular models.

Figure 3.2 Close-up of Haley’s maxillary incisal display with (a) lip relaxed and (b) in a posed smile.

Figure 3.3 The growth pattern of (a) skeletal open bite patients contrasts with (b) the skeletal growth pattern of skeletal deep bite patients in terms of magnitude and direction of condylar growth, maxillary, and mandibular bony surface apposition/resorption (mandibular internal/true rotation), vertical descent of the maxillary corpus, and molar eruption.

Figure 3.4 Orthopedic correction of a skeletal deep bite is aimed at enhancing maxillary corpus downward growth and molar eruption—resulting in downward/backward mandibular rotation, increased LAFH, and bite opening.

Figure 3.5 Cervical-pull headgears tend to rotate the anterior palatal plane downward and backward, increasing LAFH and gingival display, plus erupting maxillary first molars slightly (less than 1 mm, on average).

Figure 3.6 (a–c) By separating posterior teeth slightly, anterior biteplates remove posterior occlusal forces and assist in the eruption of posterior teeth during curve of Spee leveling.

Figure 3.7 Favorable mandibular growth can improve LAFH/TAFH in skeletal deep bite patients: (a–c) Vaughn, a skeletal deep bite patient treated with a cervical-pull headgear and (d) Margaret, a skeletal deep bite patient treated with an LSU activator and bionator. Both had favorable mandibular growth with LAFH increasing more than midface height. Of course, unfavorable adolescent growth can worsen LAFH.

Figure 3.8 Masking a skeletal deep bite consists of reducing the overbite without addressing the short LAFH—and is therefore equivalent to dental deep bite correction. Overbite may be reduced by (a and b) intruding anterior teeth relative to posterior teeth using fixed orthodontic appliances and increasingly stiffer archwires; (c, left to right) using fixed appliances, enhancing this bite opening by bonding anterior teeth more incisally; or (d, left to right) enhancing this bite opening by placing “steps” in the archwire. (e) Example of mandibular incisors stepped down by placing archwire “steps” distal to the mandibular lateral incisors (to open the bite in preparation for maxillary incisor restorative treatment).

Figure 3.9 (a–c) Overbite reduction by intruding mandibular anterior teeth with clear aligners and TADs.

Figure 3.10 (a, b) Overbite reduction by proclination of anterior teeth during alignment.

Figure 3.11 (a–i) Following curve of Spee leveling using an anterior biteplate plus posterior vertical elastics, this adult Class III patient’s mandibular molars erupted, rotating the mandible down and back, improving his AP relationship, increasing his LAFH, and helping to correct his deep bite (under bite). Excessive maxillary incisor proclination also helped open his bite.

Figure 3.12 (a–e) The Le Fort I maxillary downgraft osteotomy is the surgical procedure traditionally used to treat vertically deficient LAFH (skeletal deep bite) patients. The patient illustrated here also underwent maxillary advancement, mandibular setback, and genioplasty advancment osteotomies.

Figure 3.13 A tripod mandibular advancement (top left to top right) increases LAFH slightly as the mandible is advanced. It does this because the curve of Spee is

not

leveled before surgery. Therefore, the mandibular incisors are left stepped up (bottom), and they “ride down” the lingual surfaces of the maxillary incisors as the mandible is advanced—increasing the LAFH.

Figure 3.14 (a–j) Initial records of Michael.

Figure 3.15 Profile photos of Michael: (a) initial and (b) postured forward into a Class I canine relationship.

Figure 3.16 (a–h) Michael’s presurgical records.

Figure 3.17 Presurgical models mounted on a Galetti articulator.

Figure 3.18 (a–c) Michael’s presurgical articulated models.

Figure 3.19 (a–b) Michael’s presurgical maxillary and mandibular models.

Figure 3.20 (a) Initial, (b) presurgery, and (c) deband profile photos of Michael. (d–h) Deband intraoral photos.

Figure 3.21 (a–c) Initial records of Karina.

Figure 3.22 (a–c) Postsurgical records of Karina (BSSO advancement). Note the improved canine relationship. Postsurgically, she complained of bilateral TMJ pain.

Figure 3.23 (a–c) Records of Karina 1 year post surgery. She had missed all appointments since her postsurgical visit (Figure 3.22) and requested that her braces come off.

Figure 3.24 Judging the impact of a mandibular advancement osteotomy on Haley’s profile: (a) initial photo of Haley in CR and (b) postured forward until canines are Class I.

Figure 3.25 (a) Right and (b) left three-quarter facial views of Haley (45° views).

Figure 3.26 Initial lateral cephalometric radiographs of a skeletal deep bite patient: (a) in maximum intercuspation, (b) with her teeth separated to where her relaxed lips are just touching. The interocclusal gap created provides a guide as to how much the maxilla will needed to come down (or the maxillary/mandibular teeth erupted) to support the facial soft tissue drape adequately.

Figure 3.27 Judging maxillary incisal display: (a) initial frontal photo, (b) initial relaxed lip position, (c) initial posed smile, (d) postleveling of arches frontal photo, (e) postleveling relaxed lip position, (f) postleveling posed smile. Note that her incisal display was reduced following maxillary arch leveling because her maxillary central incisors were initially stepped down.

Figure 3.28 Restorative treatment to increase incisal display: (a and c) initial photos of Justin who was finished with minimal OB but was concerned with his lack of incisal display, (b and d) improvement in his incisal display by lengthening his maxillary incisors (but deepening his bite), restoratively.

Figure 3.29 Retention of a skeletal deep bite patient should include a maxillary Hawley retainer incorporating an anterior bite plate (“bite-raising” design) which slightly discludes the posterior occlusion when the patient wears it at night.

Figure 3.30 A patient whose dental deep bite was opened to make room for restorative material: (a) initial deep bite, due to overerupted maxillary and mandibular incisors, (b) bite opened, and (c) restorative material placed. (d) Poor retainer wear resulted in deepening of his bite.

Figure 3.31 Initial records for Adam: (a–c) initial facial photographs, (d) lateral cephalograph, (e) cephalometric tracing, (f) pantomograph, (g–k) intraoral photographs, (l–p) models, and (q) articulated models tipped up.

Figure 3.32 Adam’s separated models viewed from the front.

Figure 3.33 Adam probably illustrates the classic growth features found in a skeletal deep bite patient: condyles growing more vertically than normal, mandible rotating forward (internally, true rotation) more excessively than normal (blue arrows), maxilla descending less than normal, and molars erupting less than normal. His skeletal deep bite resulted as his mandible rotated upward and forward (yellow arrow) producing excessive incisal vertical overlap. Excessive eruption of his mandibular incisors contributed to this deep bite as a dental deep bite component.

Figure 3.34 Noncompliance Class II molar distalizers, such as the Pendulum appliance (a), are capable of driving the maxillary molars distally when activated (b, red arrows). However, this effect comes at the expense of reciprocal mesial anchorage loss of the anterior teeth (b, yellow arrows). To prevent such anchorage loss, TADs must be placed in the palate and secured to the palatal acrylic of the appliance.

Figure 3.35 Orthopedic changes to improve Adam’s short skeletal LAFH would include enhancing maxillary corpus downward growth and increasing molar eruption. As a result, his mandible would tend to rotate down (and back), thereby increasing his LAFH.

Figure 3.36 Potential vertical effects of cervical-pull headgears include rotating the anterior palatal plane downward and backward, increasing lower anterior facial height and gingival display, plus erupting maxillary first molars slightly (less than 1 mm, on average).

Figure 3.37 (a–n) Use of vertical elastics to assist leveling the curve of Spee. Eruption of posterior teeth potentially increases the vertical facial dimension.

Figure 3.38 The dilemma of trying to achieve correction in

both

the anteroposterior and vertical dimensions for Class II skeletal deep bite adolescent patients, like Adam. If you attempt to lengthen Adam’s LAFH (top, left-to-right), then his mandible will rotate CW (down and back), worsening his Class II. If you attempt to maximize his Class II correction, say by preventing eruption of his posterior teeth (bottom, left-to-right), then his growing mandible will tend to rotate CCW, worsening his LAFH.

Figure 3.39 (a–q) Adam’s deband records.

Figure 3.40 (a–d) Adam was placed in maxillary and mandibular Hawley retainers to be worn at night. His maxillary retainer includes an anterior biteplate that discludes his posterior teeth slightly when worn—improving his chances of maintaining OB correction.

Figure 3.41 Initial records for Valerie: (a and b) facial photographs, (c) close-up posed smile, (d) profile, (e) lateral cephalograph, (f) cephalometric tracing, (g) pantomograph, (h–l) intraoral photographs, (m–q) model photographs, (r and s) occlusal view with lines to determine arch symmetry, and (t) overjet assessment.

Figure 3.42 Valerie’s separated models from the front.

Figure 3.43 Valerie with her relaxed lips and teeth/lips parted slightly.

Figure 3.44 Classic patterns of growth which result in skeletal deep bites, like Valerie’s: condyles growing more vertically than normal, mandible rotating forward (internally, true rotation) more excessively than normal (blue arrows), maxilla descending less than normal, and molars erupting less than normal. As a result, Valerie’s mandible rotates upward and forward (yellow arrow), resulting in a skeletal deep bite (excessive incisor vertical overlap). Her excess maxillary and mandibular incisor eruption added a dental deep bite component.

Figure 3.45 Valerie’s brow, nose, philtrum, lips, and chin are all symmetric. She is skeletally symmetric.

Figure 3.46 (a–h) Initial records of Marissa.

Figure 3.47 Marissa’s excessive right mandibular condylar growth produced a Class III dental relationship on her right, deviation of her chin to the left, and a left posterior cross bite.

Figure 3.48 (a–k) Taylor’s initial records. Taylor is skeletally symmetric, lacks a CR–CO shift, and has an identical dental arch asymmetry in the maxilla and mandible (right posterior slightly ahead of left), resulting in matching right and left first molar relationships (Class II by 1–2 mm) when viewed from the buccal.

Figure 3.49 (a) Initially mild mandibular arch asymmetry, right posterior ahead, (b and c) improved by using Class II elastics or other Class II interarch force systems to advance the mandibular left posterior teeth.

Figure 3.50 (a) An asymmetric left facebow headgear is created by bending the left arm of the facebow laterally. (b) The resultant force vector is brought closer to the left molar—loading and distalizing it more.

Figure 3.51 TADs can useful in correcting dental asymmetries: (a) in this case, a slight maxillary (right posterior ahead) asymmetry exists and the maxillary left lateral incisor plus left first molar were deemed hopeless and extracted; (b–d) a palatal TAD was used to move the left canine and premolars forward into symmetry with the right—and to move the maxillary left second molar forward to replace the extracted left first molar.

Figure 3.52 (a) In extraction cases, if a left-to-right dental arch asymmetry less than or equal to ½ a premolar width exists, then (b and c) it is generally best to extract symmetrically and improve the arch asymmetry using biomechanics.

Figure 3.53 (a) In extraction cases, if a left-to-right arch dental asymmetry greater than or equal to ½ a premolar width exists, then (b and c) asymmetric extractions may help improve arch symmetry following space closure.

Figure 3.54 Single premolar extractions should be reserved for severe arch asymmetries (e.g., a left-to-right full premolar width asymmetry): (a and b) a single premolar extraction in a case less than a full premolar width asymmetry can create (c) a reversed arch asymmetry following space closure.

Figure 3.55 (a–h) Initial records of a four-premolar extraction patient with a symmetric mandibular arch and an asymmetric maxillary arch (patient’s right posterior ahead).

Figure 3.56 (a–b) Progress records of the patient in Figure 3.55. The maxillary right first premolar, maxillary left second premolar, and mandibular first premolars were extracted. Reciprocal space closure is proceeding.

Figure 3.57 (a–h) Final records of the patient from Figure 3.55.

Figure 3.58 Zero meridian line is drawn perpendicular to FH at soft tissue Nasion. The chin should lie on or just short of zero meridian line to be considered effective.

Figure 3.59 Orthopedically increasing maxillary corpus downward growth and increasing molar eruption would improve Valerie’s short skeletal LAFH, but her mandible would tend to rotate down (and back) worsening her Class II relationship.

Figure 3.60 (a) During initial opening, B-point moves in a direction (blue arrow) perpendicular to a line drawn from the condyle to B-point. For this reason, the vertical and horizontal distances from the condyle to B-point determine the direction B-point moves if molars are erupted; (b) in short face patients, molar eruption results in greater downward movement of B-point (bite opening) and less backward movement of B-point (Class II worsening). In long-face patients (c), molar eruption results in less bite opening and greater Class II worsening.

Figure 3.61 (a–q) Deband records of Valerie.

Figure 3.62 Initial records of Shawn: (a–c) facial photographs, (d) lateral cephalograph, (e) cephalometric tracing, (f) pantomograph, (g) complete mouth series of dental radiographs, (h–l) intraoral photographs, and (m–r) model photographs.

Figure 3.63 When Shawn was re-examined, he displayed a sizable CR–CO shift. In CR, his left central incisors contacted. Note that his mandibular incisors appear overerupted but that his maxillary incisors do not.

Figure 3.64 (a, b) Separated models view of Shawn.

Figure 3.65 Shawn’s models viewed from the lingual: (a) left side and (b) right side

Figure 3.66 Borderline skeletal deep bites, like Shawn’s, result from the same underlying growth patterns as more severe skeletal deep bites: condyles growing more vertically than normal, the mandible rotating forward (internally, true rotation) more than normal (blue arrows), the maxilla descending less than normal, and/or molars erupting less than normal. As a result, the mandible rotates upward and forward (yellow arrow), deepening the bite.

Figure 3.67 (a, b) If you could (stably) erupt Shawn’s posterior teeth, Shawn’s mandible would rotate down and back—improving his Class III relationship, LAFH, and underbite.

Figure 3.68 (a–e) Allison is a 7-year-old Class III patient (deficient maxilla, normal mandible), initially treated with RME and RPHG (elastics running between the RPHG and attachments on the RME) which corrected her anterior cross bite.

Figure 3.69 (a–c) Marc is a 12-year-old Class III patient (deficient maxilla, normal mandible), initially treated with RPHG (elastics running between the RPHG and maxillary anterior miniplates) which corrected his anterior cross bite.

Figure 3.70 (a–h) After his anterior cross bite was corrected using a mandibular biteplate and fixed orthodontic appliances, this Class III adolescent (maxillary AP deficiency, mandibular AP excess) patient was placed on a high-pull chin cup until growth was complete. No additional treatment was requested or instituted. Note the dramatic improvement with this treatment.

Figure 3.71 Orthopedic Class III treatment consisting of Class III elastics worn between TADs.

Figure 3.72 Class III elastics (a, c) tend to protract maxillary teeth, retract mandibular teeth, erupt maxillary molars, erupt mandibular anterior teeth, rotate the mandibular plane CW, and rotate the occlusal plane CCW. Class II elastics (b, d) tend to retract maxillary teeth, protract mandibular teeth, erupt mandibular molars, erupt maxillary anterior teeth, rotate the mandibular plane CW, and rotate the occlusal plane CW.

Figure 3.73 The zygomatic buttress—considered the primary skeletal resistance site to RME.

Figure 3.74 Maxillary expander cemented in Shawn.

Figure 3.75 Deband records of Shawn: (a, c, e) initial facial photographs and (b, d, f) final facial photographs. (g–w) final records.

Figure 3.76 Initial records for Megan: (a–c) initial facial photographs, (d) lateral cephalograph, (e) cephalometric tracing, (f) pantomograph, (g–i) intraoral photographs, and (l–n) models.

Figure 3.77 (a–e) Additional model views for Megan: (d) left molar relationship viewed from the lingual and (e) right molar relationship viewed from the lingual.

Figure 3.78 Additional helpful images: (a) teeth separated until Megan’s lips are just touching, (b) biting a tongue blade on the posterior teeth, (c and d) right and left ¾ facial views, (e and f) posteroanterior radiograph and tracing, and (g–j) profile and lateral cephalometric radiographs when closed and with teeth separated until the lips are just touching.

Figure 3.79 (a–c) Christy presents with a significant maxillary occlusal cant.

Figure 3.80 Christy’s radiographs demonstrate the skeletal nature of her asymmetry: (a) her pantomograph shows a longer left condyle and greater distance from the left inferior border of her mandible to left root apices (red arrows) than on the right (yellow arrows); (b) notice the discrepancy in right-to-left inferior mandibular borders (red arrow) on the lateral cephalograph.

Figure 3.81 (a–f) Iatrogenic right-to-left occlusal cant resulting from prolonged attempted eruption of an ankylosed maxillary right canine. Attempting to erupt the ankylosed canine with fixed appliances and vertical elastics resulted in intrusion of the maxillary right incisors and maxillary right premolars and eruption of the mandibular right incisors, canines, and premolars.

Figure 3.82 Correction of an occlusal cant. Inadequately erupted maxillary right teeth are erupted (left, yellow line) or excessively erupted maxillary left teeth are intruded (left, red line), resulting in an occlusal plane parallel to the interpupillary line (right), ideal LAFH, ideal maxillary incisal display in relaxed lip position, and absence of an ILG. These movements are accomplished orthodontically or surgically. Mandibular teeth must follow their maxillary counterparts in order to maintain correct interdigitation.

Figure 3.83 TADs used to intrude excessively erupted maxillary right teeth and correct an occlusal cant: (a) patient presents with a right-to-left occlusal cant, (b and c) elastomeric chains stretched between the maxillary right posterior teeth and TADs inserted into the buccal and palatal alveolar processes, (d) posteroanterior initial-to-final cephalometric superimposition showing leveling of the occlusal plane by intrusion of the maxillary right teeth plus eruption of the mandibular right teeth (using vertical elastics), (e) initial frontal photo showing canted occlusal relationship, and (f) final corrected occlusal relationship.

Figure 3.84 Orthognathic surgery used to correct an occlusal cant: (a–f) patient presents with a right-to-left occlusal cant of approximately 3 mm. Her right maxillary dentition appears to have erupted normally. Her left dentition appears undererupted. Note (e) the difference in height between her left and right mandibular skeletal border, (f) the shorter left condylar length, the shorter left ramal height, and the shorter distance between the left posterior teeth apicies and the mandibular border then, the right; (g–j) surgical correction consisted of a Le Fort I differential maxillary downgraft osteotomy with her left side inferiorly repositioned, (i) a mandibular BSSO to articulate the mandibular occlusion into the newly positioned maxillary occlusion, and (j) a differential downgraft genioplasty to enhance her chin symmetry. (i) Note improved coincidence of Kim’s mandibular lower borders postsurgically; (l–m) initial and final posteroanterior radiographs illustrating surgical correction of her occlusal cant; and (n–p) final facial photographs demonstrating cant improvement (a very slight right-to-left occlusal cant is still evident).

Figure 3.85 (a–d) Adolescent patient exhibiting excessive incisal and gingival display.

Figure 3.86 Megan represents a classic skeletal deep bite growth pattern: condyles growing more vertically than normal, mandible rotating forward (internally, true rotation) more than normal (blue arrows), maxilla descending less, and (mandibular) molars erupting less than normal. Consequently, her mandible rotated upward and forward (yellow arrow), resulting in excessive incisal overlap (a skeletal deep bite).

Figure 3.87 Two general approaches to correcting deep bites: (a)

erupting posterior teeth

opens the bite by increasing LAFH, and is performed either orthodontically or surgically (with a Le Fort I maxillary downgraft, b–d); (e)

Intruding/proclining anterior teeth

does not affect the LAFH.

Figure 3.88 Maxillary

intra-arch

mechanics (a) to correct Megan’s Class II canine and molar relationship results in identical maxillary canine retraction/maxillary incisor retraction, regardless of the specific technique used (headgear, TADs, premolar extractions). Why? Because there is no movement of mandibular teeth.

Inter-arch

mechanics, on the other hand (b), results in dental movement in both arches. With interarch mechanics, the distance maxillary canines and maxillary incisors retract is reduced by the amount the mandibular teeth move forward.

Figure 3.89 Signs of successful maxillary skeletal expansion with RME include (a–c) the formation of a midline diastema and/or (d) presence of a clear widening of the midpalatal suture on an occlusal radiograph.

Figure 3.90 (a–g) Megan’s presurgical records.

Figure 3.91 (a–s) Deband records of Megan.

Figure 3.92 Skeletal and dental movements correcting Megan’s deep bite.

Figure 3.93 Genioplasties considered for Megan: (a and b) genioplasty downgraft and setback—actually performed on Megan, (c) genioplasty with anteriorly tapered ostectomy, and (d) sliding setback genioplasty.

Figure 3.94 Initial records of Connie: (a–c) facial photographs, (d) posed smile, (e) lateral cephalograph, (f) cephalometric tracing, (g–k) intraoral photographs, (l) pantomograph, and (m–q) model photographs.

Figure 3.95 (a, b) TMJ arthrocentesis.

Figure 3.96 Autologous blood injection of TMJ.

Figure 3.97 (a–f) Initial records of Jackie.

Figure 3.98 (a–f) Initial records of Julian.

Figure 3.99 CBCT scan of Julian: (a) right condyle and (b) left condyle.

Figure 3.100 Connie’s separated models.

Figure 3.101 (a–c) Examination of maxillary anterior periodontal tissues.

Figure 3.102 (a–c) Periodontal surgery to modify thick, fibrotic gingival tissues resulting from delayed apical migration (d) into periodontal tissue having improved architecture (e).

Figure 3.103 A skeletal deep bite growth pattern, like Connie’s, includes: mandibular condyles growing more vertically, the maxilla descending less, the mandible rotating forward (internally, true rotation) more excessively, and/or molars erupting less than normal. As a result, the mandible rotates upward and forward increasing vertical overlap of the incisors (a skeletal deep bite).

Figure 3.104 (a–i) Presurgical records and (j) postsurgical lateral cephalometric radiograph of Connie. Note that her articulated models (i) are positioned with canines Class I and contacting only at three points (anterior teeth and the most posterior tooth of each side, “tripod advancement”) and that this relationship is reflected in her immediate postsurgical radiograph (j).

Figure 3.105 (a–e) Posttrauma records of Connie two days after her accident. She had been debanded shortly before.

Figure 3.106 (a–p) Final records of Connie.

Chapter 04

Figure 4.1 Initial records of Connor: (a–c) initial facial photographs, (d) lateral cephalograph, (e) cephalometric tracing, (f) pantomograph, and (g–k) intraoral photographs.

Figure 4.2 Habits that can cause dental (functional) open bites include (a) anterior resting tongue or tongue sucking, (b) lip biting, and (c) and digit sucking.

Figure 4.3 Dental (functional) open bites due to a (a–c) anterior tongue interposition habit, (d–f) lip-biting habit, and (g–h) thumb-sucking habit.

Figure 4.4 (a–c) Adolescent with an anterior open bite.

Figure 4.5 (a–c) Etiologic factors contributing to his anterior open bite included both a digit-sucking habit and an anterior tongue interpositional habit.

Figure 4.6 (a, b) Kolbe presented with a finger sucking habit and a corresponding dental open bite. Using the psychological approach, he stopped the habit, which allowed the dental open bite to spontaneously close (c) in 3 months.

Figure 4.7 Options for correcting a digit-sucking habit: (a, b) a thumb crib appliance, (c, d) a crib with the addition of spurs, and (e, f) a thumb guard appliance.

Figure 4.8 (a) Blunted spurs soldered to an LLHA, (b, c) blunted spurs embedded in a mandibular Hawley retainer to correct an anterior interpositional tongue habit.

Figure 4.9 Interpositional tongue habit correction using blunted spurs: (a) initial open bite, (b) blunted spurs soldered to an LLHA, and (c) with tongue habit corrected, the anterior teeth erupted, and the open bite closed (brackets placed to align the maxillary incisors, only).

Figure 4.10 Blunted spurs soldered to a TPA to correct an anterior interpositional tongue habit.

Figure 4.11 (a) Bondable spurs or (b) orthodontic bondable buttons can also be used to remind patients to stop their interpositional tongue habit. The “poor man’s” anterior tongue habit reminder (c) is simply composite resin squirted to a point on the mandibular incisor lingual surfaces.

Figure 4.12 (a, b) The Bluegrass appliance uses a plastic roller to draw the tongue away from anterior teeth. The same principle is employed during retention by placing a hole through the anterior palate plastic of the maxillary retainer.

Figure 4.13 (a) Example of a patient with an anterior tongue interposition habit causing a dental open bite. The open bite was closed using fixed orthodontic appliances and vertical elastics alone—without any adjunctive aides to correct her tongue habit. Fortunately, closing the open bite must have corrected her habit (trained her tongue), because the closure was stable 5 years later (b).

Figure 4.14 (a–d) Myofunctional exercises.

Figure 4.15 (a, b) Illustrations of partial glossectomy surgeries used to decrease tongue volume. (c) Crenations, or scalloping, of the tongue border.

Figure 4.16 Treatment of anterior open bites by erupting anterior teeth: (a) is appropriate for dental open bites; (b) is often inappropriate for skeletal open bites as it does not address the underlying long LAFH/ILG, and can create excessive incisal display.

Figure 4.17 (a) Example of open bite (b) closure by anterior tooth eruption during arch leveling with fixed orthodontic appliances. (c) Note at deband the presence of minimal OB with incisal embrasures. Ideally, this patient should have been finished with greater OB in anticipation of some relapse.

Figure 4.18 (a–c) Triangle vertical elastics used to close an open bite. Elastics can also be worn between maxillary and mandibular incisors.

Figure 4.19 Enhancement of anterior open bite closure occurs by: (top left to right) bonding incisors more gingivally than normal and (bottom left to right) placing “steps” in the archwire (“step ups” in the mandibular archwire shown). Note that such techniques are exactly opposite to those used to open dental

deep

bites.

Figure 4.20 Mandibular incisors can be erupted by adding curve of Spee to the archwire.

Figure 4.21 (a, b) Retracting proclined incisors rotates them around their root apicies, thereby erupting them and helping to close the open bite.

Figure 4.22 Triangle elastics failed to close this isolated open bite.

Figure 4.23 (a, b) The isolated open bite was closed by sectioning the archwires plus triangle elastic wear.

Figure 4.24 In retention, aides for controlling an anterior interpositional tongue habit include (a) placing a hole in the anterior of the retainer to draw the tongue away from the teeth and (b) wearing a tooth positioner to block the tongue from the anterior teeth.

Figure 4.25 Retention aid for a skeletal open bite patient who desired only alignment of her anterior teeth: (a) initial frontal intraoral photograph; (b, c) mild eruption of her maxillary anterior teeth occurred during alignment and was retained using a vacuum-formed retainer. The retainer snapped over small composite “dots” placed on the labial surfaces of her maxillary anterior teeth.

Figure 4.26 (a, b) Composite “dots” placed on the labial surfaces of maxillary and mandibular teeth to retain closure of an anterior open bite. Vacuum-formed retainers snap over these dots during wear.

Figure 4.27 Initial records of Sasha: (a–c) initial facial photographs, (d) lateral cephalograph, (e) cephalometric tracing, (f) pantomograph, and (g–k) intraoral photographs.

Figure 4.28 Dental open-bite patients present with normal vertical facial growth.

Figure 4.29 Once the habit is eliminated, the dental open bite is closed by erupting anterior teeth.

Figure 4.30 Thumb crib similar to Sasha’s.

Figure 4.31 (a–e) Deband intra-oral photos of Sasha.

Figure 4.32 (a–l) Final records for Sasha.

Figure 4.33 Initial records of Derrick: (a–c) initial facial photographs, (d) lateral cephalograph, (e) cephalometric tracing, (f) pantomograph, (g) complete mouth series of dental radiographs, (h–l) intraoral photographs, (m–q) model photographs, and (r, s) separated model views.

Figure 4.34 Principal difference between a dental and skeletal open bite? A dental (functional) open bite will present with a normal LAFH, while a skeletal open bite presents with a long LAFH. Of course, a skeletal open bite can also have a dental (functional) component.

Figure 4.35 Treatment of a dental open bite consists of eliminating the habit and erupting the anterior teeth. Orthopedic or surgical treatment of a skeletal open bite consists of intruding the maxillary corpus and molars (masking a skeletal open bite consists of erupting anterior teeth).

Figure 4.36 Diastema formation during RME: (a) initial maxillary posterior transverse discrepancy; (b) during RME, the formation of a midline diastema indicates that the midpalatal suture has separated.

Figure 4.37 (a–i) Progress records of Derrick following RME.

Figure 4.38 Comparison of Derrick’s cephalometric radiographs: (a) initial and (b) progress. Note the slight increase in open bite at the central incisors following RME.

Figure 4.39 (a) During RME, buccal movement of the maxillary molars forces the mandible down. As a result, the molars occlude cusp-to-cusp (b), and the bite opens in the anterior.

Figure 4.40 (a–v) Derrick’s deband records (including juxtaposed initial facial photographs for comparison).

Figure 4.41 (a–h) Derrick’s 2-year post-treatment records.

Figure 4.42 Initial records of Steven: (a–c) initial facial photographs, (d) lateral cephalograph, (e) cephalometric tracing, (f) pantomograph, (g–k) intraoral photographs, (l–p) model photographs, and (q–r) separated model views from front.

Figure 4.43 Judging maxillary incisal display with a relaxed lip.

Figure 4.44 Two general approaches to consider when treating Steven’s anterior open bite. (Left) treating Steven as a dental open bite (erupting “stepped up” maxillary incisors) by eliminating the tongue interposition habit and leveling the maxillary arch. (Right) treating Steven as a skeletal open bite by impacting the maxillary corpus, slowing descent of the maxillary corpus during growth, intruding (slowing eruption of) maxillary molars, and intruding (slowing eruption of) mandibular molars. As a result, the mandible autorotates closed (curved yellow arrow).

Figure 4.45 (a–e) Steven’s progress records.

Figure 4.46 (a–u) Steven’s final records (including juxtaposed initial facial photographs and initial cephalometric tracing for comparison).

Chapter 05

Figure 5.1 Initial records of Allison: (a–c) initial facial photographs, (d) lateral cephalograph, (e) cephalometric tracing, (f) pantomograph, and (g–k) intraoral photographs.

Figure 5.2 The magnitude and direction of condylar growth, mandibular internal (true) rotation, maxillary corpus descent, and molar eruption combine to create (a) a skeletal deep bite or (b) a skeletal open bite.

Figure 5.3 Allison’s incisal display judged at rest with lips relaxed.

Figure 5.4 Orthopedic treatment of skeletal open bites reduces maxillary corpus descent, reduces molar eruption, or intrudes molars (resulting in mandibular autorotation and bite closure, yellow arrow). Treatment is opposed by continuing unfavorable condylar posterior–superior growth and backward mandibular internal (true) rotation.

Figure 5.5 (a) HPHG and (b) the resulting force vector (red arrow) in relation to the centers of resistance of the maxilla (yellow cross) and maxillary first molar (green cross). Compared to normal growth, a high-pull headgear reduces forward maxillary growth and may reduce vertical maxillary growth. A HPHG distalizes maxillary molars and may reduce maxillary molar eruption.

Figure 5.6 (a) Vertical-pull chin cup and (b) the resulting force vector (red arrow) in relation to the centers of resistance of the maxilla (yellow cross) and maxillary first molar (green cross). Vertical-pull chin cups can reduce the MPA, compared to controls, by inhibition of posterior tooth eruption.

Figure 5.7 (a) High-pull chin cup and (b) the resulting force vector (red arrow) in relation to the centers of resistance of the maxilla (yellow cross) and maxillary first molar (green cross). High-pull chin cups can inhibit ramus height, inhibit mandibular body length, close the gonial angle, and flatten FMA without increasing LAFH, but the force vector must be kept high.