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New Concepts and Treatment Approach to

the Different Types of Malocclusions

Preface
Sadao Sato 4#

Development and Orthodontic Treatment of Skeletal Class III Malocclusion


without Surgical Intervention
Sadao Sato, Susutmt Akinioto, Hisaaki Shinji, Eiiana Midori Tanaka and Ales Celar 51

Different Mechanics for Orthodontic Correction of Class II Openbite


and Class III Openbite Malocclusions
Sadao Sato, Masaaki Kaneko, Kenichi Sasaguri, Eiiana Midori Tanaka and Ales Celar 65

Orthodontic Reconstruction of Occlusion in Class III Malocclusion


with Low Mandibular Plane Angle
Akiyoshi Shimsu, Eiiana Midori Tanaka and Sadao Sato yg

Application of MEAW Mechanics to the Treatment of Class III Malocclusion


with Dental Mid-Line Discrepancy
Kenichi Sasaguri, Susiunu Akinioto, Hisaaki Shinji, Eiiana Midori Tanaka and Sadao Sato 87

Orthodontic Treatment of Class III Malocclusions Associated


with Mandibular Lateral Deviation
Susinmt Akinioto, Mitsmjoshi Kubota, Atsushi Matsnmoto, Sadao Sato,
Eiiana Midori Tanaka and Ales Celar 95

Interception of Decompensated Class III Malocclusions in Early Mixed Dentition


Hisaaki Shinji, Takehiko Hiyama, Mina Yamaguchi, Kanji Onodera and Sadao Sato W5

Interdisciplinary Treatment Approach to a Patient with Severe Mandibular


Displacement and Dysfunction of Craniomandibular System
Katsushi Tantaki, Ales G. Celar, Rudolf Slavicek and Sadao Sato U3
Preface

New Concepts and Treatment Approach to the Different Types of Malocclusions

Dental medicine revolves around the study of occlusion. The basis of occlusion is not simply the

interdigitation of the aligned teeth in both the upper and lower jaws, but a combination of their positional
relationship and the functional movement of the mandible. This is controlled by a complex system of
functional elements, i.e. the masticatory muscles, neuromuscular system, TMJ function etc., which serve
as the basis of dental treatment. Orthodontics, a branch of dental medicine, constructs an occlusion by
correcting misaligned teeth. In Prosthodontics, the recontouring of tooth crowns, as the primary measure
in bite construction, is an important approach in improving malocclusion. Therefore, in clinical practice,
especially in orthodontics, it is essential to fully understand the physiology of occlusal function and the
biology of tooth movement.

However, so far, these important topics have not been satisfactorily dealt with in orthodontics. Looking

at the history of the subject, the development of orthodontics has tended to focus more on orthodontic
appliances and their improvement. With continuous technology as the focal point of therapeutic
advancement, the treatment effects on malocclusion have certainly improved and clinical application

has expanded. Nevertheless, numerous contradictions have come about as a result of mere technological

advancement. The orthodontic approach seems have become isolated from dental medicine and to have
enclosed itself in a specialized field.

Orthodontic advances in the past failed to give pertinent attention to the etiology of malocclusion and

mechanism of its development. The introduction of cephalometric radiography in orthodontic diagnosis


has definitely played a significant role in understanding malocclusion. However, this does not clearly
show the cause of malocclusion. It only localizes the site of skeletal malocclusion and shows the degree
of deviation. Elimination of the cause is an indispensable factor in a radical treatment method and enables
stable results to be obtained. This only means that current orthodontics simply identifies and treats
symptoms rather than targeting the cause.

Moreover, current orthodontic therapy has insufficient therapeutic objectives. To improve the facial
profile as a treatment objective, orthodontics can obtain results as if it were a section of cosmetic orthopedic
surgery. Of course, in managing the maxillofacial area, the relevance in the improvement of facial profile
must not be neglected, but this should not be the ultimate treatment objective in orthodontics. As
previously mentioned, orthodontic therapy is one of the effective approaches in occlusal construction.
However, as a treatment objective, there are still no basic guidelines or established therapeutic techniques

for each particular type of occlusion to be managed. Now the time has come to re-evaluate orthodontic
therapy.

Since the arrival of the Angle expansion arch appliance, several improvements have been introduced
in the evolution of the current full bracket system. From a mechanical standpoint that constitutes,
apparently, a satisfactory accomplishment. However, there is the question of why there are still a number
of patients who are difficult to treat. Why does malocclusion recur after treatment? Does this mean that
serious errors were committed in the planning and development of occlusal treatment? As numerous
improvements are being made, the current treatment approach has become too complicated. This is
perhaps, due to the unpredictable results obtained by palliative treatment based on a less accurate diagnosis
only through the identification of symptoms.

Orthodontic occlusal construction should be widely applied in dental medicine. However, this does
not reconcile the concerns of present orthodontics, as the contradiction is evident from its new standpoint.
Hence, there is a need for the introduction of a new treatment philosophy based on the functional rather
than esthetic necessary requirements according to the health and well being of the patient.

In this BKDC topic, the dynamic mechanism of the development of malocclusion will be clearly
discussed. On this basis, the diagnosis, treatment objectives, and treatment techniques for orthodontic
occlusal construction will also be explained.

Finally, it must be mentioned that the articles appearing here were previously published in the Journal
of Informationen aus Orthodontie und Kieferorthopadie, Volume 37 July 2005 issue, in the German
language. Members of our Department of Craniofacial Growth and Development Dentistry were kindly
invited to publish our approach to the various malocclusions by Professor H.P. Bantleon, Orthodontic
Department, University of Vienna, Austria. Therefore these English translation issues are presented here
in their secondary publication with copyright permission from Thieme, Stuttgart, Germany.

Sadao Sato D.D.S.,D.D.Sc.


Department of Craniofacial Growth and Development Dentistry,
Division of Orthodontics,
Kanagawa Dental College, Yokosuka, Japan

March 2007
Bulletin of Kanagavva Dental College
Vol. 35, No. 1, March, PP. 51-63, 2007

Development and Orthodontic Treatment of


Skeletal Class III Malocclusion without
Surgical Intervention

Sadao Sato, Susumu Akimoto, Hisaaki Shinji,


Eliana Midori Tanaka, and Ales Celar*

Department of Craniofacial Growth and Development Dentistry,


Kanagawa Dental College

Department of Orthodontics, Medical University of Vienna, Bemhard Gottlieb


Dental Clinic, Vienna, Austria

Abstract

In this article, the development of Class III open bite malocclusion is explained from a
human evolutional perspective. The authors focus on vertical development of the craniofa-
cial complex with its hyperdivergent tendency. The position and inclination of the occlusal
plane are affected primarily by the posterior occlusal vertical dimension. On the basis of this
principle, steepening of the occlusal plane (inclined postero-superiorly) causes the develop
ment of a Class II malocclusion and concomitantly the mandible adopts a retruded position.
Particularly, the cant of the upper posterior occlusal plane - upper second premolar to upper
second molar at the occlusal surface - is considered one of the most important determinants
for the antero-posterior position of the mandible. On the other hand, when the occlusal plane
is oriented almost horizontally or becomes abruptly flatter, a Class III malocclusion will de
velop as a result of the inducing anterior rotational adaptation of the mandible. Depending on
the skeletal and neuromuscular adaptation capacity, an open bite malocclusion may also
appear if there is an imbalance in the functional adaptation of the mandible to maxillary
occlusal surfaces that continuously descend during vertical growth in order to achieve proper
functional occlusion, which also induces excess or less hyperdivergency of the lower face.

Key words: Human crattiofacial skeleton I Basicranial flexion I Occlusal


vertical dimension I Class III malocclusion I Open bite

Evolutional background of Viscerocranium to 180, however, in man, this decreases to approximately


and Class III malocclusion 125 (Fig. 2).
Observations made on human skeletal evolution re This postural change of the skeleton also affects the
veal that the most significant morphologic change of the facial morphology in terms of hyperdivergence of the
facial skeleton has occurred over the last four to five lower face. Subsequently, the dentition has been ren
million years. Bipedalism and erect posture of the en dered susceptible to an anterior openbite, which is a
tire human body have caused an uprighting of the skull malocclusion exclusive to the human specie. The adop
(Fig. 1). The human craniofacial skeleton underwent an tion of an upright posture of the body has caused the
almost rectangular flexion. Also the cranial base assumed growth pattern to be vertical rather than horizontal. This
a larger bend and the foramen occipitalc magnum was vertical facial development has given us some difficulty
displaced anterior-inferiorly. Therefore, in contrast to in properly fitting the upper and lower dentition, be
humans, primates have a large cranial base angle close cause a descending spatial positioning of the maxillary
occlusal plane may easily create an anterior opening of
Accepted for publication on October 5,2006. the upper and lower jaws if there is no continuous man-
Address for correspondence: Sadao Sato, Department of dibular rotational adaptation. Also, the neuromuscular
Craniofacial Growth and Development, Kanagawa Dental College,
82 Inaoka-cho, Yokosuka, Kanagawa, 238-8580, Japan. system must work against this hyperdivergent tendency
Tel: +81-46-822-8880 (ex. 2381) Fax: +81-46-822-8844 in order to maintain full occlusal contacts. Thus, the
S. Sato etui. Bull. Kanagawa Dent. Col. 35 (2007)

adaptation of occlusion against the vertical growth of Therefore, during this growing process, a gradual
the facial skeleton is possible through a serial functional flattening of the occlusal plane occurs (Table 1) (1-3) and
adaptation of the mandible. consequently the mandible can adapt by way of rota
During human ontogenesis, the viscerocranium, es tion by anterior repositioning to achieve a proper func
pecially the maxillary complex, mainly grows in a down tional occlusion - full intercuspation -. This type of
ward direction as the posterior vertical dimension adaptation may induce secondary condylar growth
increases, due to the vertical growth of alveolar bone, which provides a decrease in the mandibular plane angle
which is a consequence of tooth eruption. (Fig. 3).

Fig. 1: Evolution and morphology of the human craniofa-


cial skeleton. Morphologic changes during evolution ac
company the upright posture of body and skull. The flex

ion of the cranial base greatly influences the facial profile


and the growth direction of the maxillary complex.

Table 1: Alteration of Occlusal Plane and Mandibular Plane during Growth


Development and Orthodontic Treatment of Class III Malocclusion

Fig. 2: Comparison of craniofacial skeleton in human and primates. The human cranial base assumes a larger
bend, thereby reducing the degree of flexion (N-S-Ba) in contrast to primates. Flexion of the cranial base
causes maxillary vertical elongation while extension causes anterior rotation of the maxillary complex.

Mandibular rotational adaptation is a primary and


important process of the natural growth of the face, and
failure of this process creates a skeletal type of maloc
clusion. The functions of the anterior mimic and bucci
nator muscles include closing and helping the mandible
to adapt by rotational movement, so that the upper and
lower surfaces fit. Patients with weak mimic muscle ac
tivity develop an anterior openbite malocclusion, as the
mandible cannot adapt through rotation. It can be said
that the openbite in modern humans originates from the
inability to balance vertical dimensions of occlusion.
The degree of basicranial flexion differs in the vari
ous types of malocclusions (Table 2) (4). The cranial base
angle (N-S-Ar) comes to approximately 124,25,2 in class
I patterns. Prom this average value, a more obtuse (ex
tension) angle indicates skeletal class II and a more acute
(flexion) angle means skeletal class III. The more pro
nounced the class [II pattern, the higher the flexion of
the cranial base and the greater the tendency of the cran
iofacial complex to hyperdivergence (Fig, 4). The devel
opmental process of skeletal class TIT malocclusions Fig. 3: Concept regarding occlusal plane changes and man

includes vertical elongation of the maxilla and an in dibular adaptation. Eruption of the maxillary molars creates
crease in the occlusal vertical dimension of the poste a flat occlusal plane, which induces anterior mandibular ro
rior molar segment. Subsequently, the mandible rotates tational adaptation and consequently allows forward man
forward in order to maintain anterior occlusal contacts dibular growth followed by secondary condylar growth and
(Fig, 5). Because of its appearance, class III malocclu- the mandible can reach a skeletal class I.
S. Sato et a\. Bull. Kanagawa Dent. Col. 35 (2007)

Table 2: Cranial Base Angle Associated with sion has been considered an anterior-posterior or trans
verse deviation. However, from a developmental view
the Various Types of Malocclusion
point, class III malocclusion certainly deals with a
Malocclusions N-S-Ar vertical component. In the past, this aspect was ne

Class III 122.2 4.7


glected and orthodontists struggled to correct the an-
teroposterior dentoalveolar relationship in class III
Class 1 124.2 + 5.2

ClassII, Div.2 125.5 + 4.8


pa tients. Trea tmen t options such as chin cups, long class

Class II, Div. 1 128.9 4.5


III elastics, premolar extraction, orthognathic surgery,
etc. are all based upon the idea of correcting the class III
Hopkin GB sl.nl, 1968, Angle Orthod 38; 250
malocclusion in the anterior-posterior direction. Further
more, understanding this malocclusion as a vertical

Class III Class II


Fig. 4: Comparison of typical skeletal class
III and class II malocclusions. Differences in
basicranial length and angle, position and in
clination of the occlusal plane, maxillary and
mandibular position and posture, and den
toalveolar vertical height are seen.

Fig. 5: Developmental process of skeletal class III malocclusion. The posterior occlusal vertical dimension is considerably enlarged.
The mandible adapts through forward rotation resulting in mandibular prognathism. Also in class I, an increment in molar and
premolar occlusal vertical dimension occurs (a), but in class III the posterior discrepancy causes an excessive increase in posterior
occlusal vertical dimension and more pronounced flattening of the occlusal plane. Functional mandibular adaptation is necessary for
occliisat compensation (intercuspation) with subsequent mandibular prognathism (b. c).
Development and Orthodontic Treatment of Class UI Malocclusion

problem and targeting and treating its real cause will riorly and therefore the maxillary occlusal plane tends
prevent post-treatment relapse. to displace downward in space. Insufficient mandibular
adaptation to maxillary vertical elongation constitutes a
Adaptation of the viscerocranium and class key factor in mandibular hyperdivergency (5, 6).
III malocclusion Another aspect to take into consideration is the max
The flexure of the cranial base angle is related to illary growth, and eruption of the posterior teeth. Most
changes in. the craniofacial skeleton. In other words, the of the growth in the anteroposterior dimensions origi
more developed the class III, the more accentuated the nates through bone apposition from the posterior aspect
flexion of the cranial base and the greater the tendency to the maxillary tuberosity. The initial appositional
of the orofacial complex to grow vertically. In skeletal growth at the tuberosity arises with the forward transla
class II, the length and angle of the cranial base are large tion of the maxillary complex. Lack of maxillary transla
and the facial morphology is oriented horizontally. The tion makes it difficult to provide an eruption space for
extent of the basicranial flexion greatly influences the the posterior molars. In primates, the maxillary forward
facial profile and the growth direction of the maxillary growth supports the tuberosity growth and increases the
complex (5,6). Longitudinal observations on growth and anteroposterior orofacial dimension. This horizontal
orientation of the cranial base in skeletal Class III mal- maxillary growth creates a space for the eruption of the
occlusions clearly show why the mandible is becoming second and third molars. In modern man, the primary
prognathic or retrognathic. This verticalized orofacial vertical maxillary growth does not allow sufficient hori
growth induces serious problems in the development zontal space to develop in the molar segment. Lack of
of malocclusions such as mandibular hyperdivergency eruption space In the posterior molar region has been
and posterior discrepancy, which will be discussed be termed posterior discrepancy (Fig. 6) (7-14).
low.
The main reason for the vertical development of the Posterior discrepancy and occlusal plane
orofacial complex is the flexion of the cranial base. The Posterior discrepancy denotes the difference between
dynamic connection, of the sphenoid, vomer and maxil molar tooth size and denture base size in the posterior
lary bones transfers the basicranial motion causing the segment distal to the first permanent molar. Basically, a
maxillary complex to grow in a mainly downward di negative discrepancy is assumed to refer to the lack of
rection. In primates, the maxilla moves anteriorly or ro space in the dentition. Posterior discrepancy is associ
tates forward during growth and consequently, the ated with molar crowd ing in extreme spatial deficiency
maxillary dentition may attain a sufficiently large an (Fig. 6).
teroposterior dimension. Dynamic motion of the primate Posterior discrepancy significantly increases the prob
sphenoid vomer maxilla complex enlarges the anterior- ability of third molar impaction. Wisdom teeth repre
posterior distance of the dentition (Fig. 2). In man, this sent a serious dental problem that is frequently
anteroposterior distance is reduced due to the flexed encountered. Once third molar impaction occurs, poste
cranial base and the orofacial skeleton displaces verti rior discrepancy may cause an over-eruption of the ad
cally downward. In particular, the maxilla moves infe- jacent teeth due to the "squeezing-out" effect. The

c bfi

Fig. 6: Relation among maxillary growth, eruption space, posterior discrepancy and occlusal vertical dimension. Most of the
growth in the maxillary anteroposterior dimension originates through bone apposition from the posterior aspect to the max
illary tuberosity. Lack of maxillary translation makes it difficult to provide eruption space for the posterior molars; this creates
posterior discrepancy that causes an over-eruption of the adjacent teeth and changes the inclination of the occlusal plane.
S. Sato et si. Bull. Kanagawa Dent. Col. 35 (2007)

over-erupted molars produce occlusal interferences that


act as a fulcrum causing functional mandibular transla
tion with subluxation of the mandibular condyles and
consequently, the active transformation of the condylar
cartilage. This then results in mandibular forward dis
placement that either adapts through and/or develops
an anterior openbite. [f the interference emerges con
tinuously during growth, the mandible will be forced
to permanently adapt to this new occlusal configuration.
Such morphologic alterations resulting from functional
mandibular adaptation influence the development of
skeletal malocclusion.
As mentioned previously, the orofacial skeleton in
Homo sapiens is susceptible to hyperdivergence because
Fig. 7: Treatment mechanics in class III malocclusion:
of the postural change during evolution. The over-erup
uprighting and intrusion of upper and lower molars by tip
tion of molars increases the posterior vertical dimension
back bends in both multiloop edgewise arch wires and use
of the dentition and facilitates the tendency toward skel
of vertical elastics or short class III elastics at the anterior
etal hyperdivergency (Fig. 6).
loops. Treatment objectives are decreasing the posterior oc
However, the process of mandibular hyperdiver
clusal vertical dimension and steeper orientation of the oc
gency is a very complex one. An increase in the poste
rior occlusal vertical dimension is followed by an clusal plane.

anterior mandibular rotational adaptation where the


anterior mimic muscles and perioral soft tissues play an
important role in closing and helping to adapt the man cal dimension. When treating such patients, the orth
dible by rotational movement resulting in a balanced odontist should not only aim to improve the dentoal-
occlusion, with proper occlusal contacts. Patients with veolar relationship but should also consider the dynamic
inherent mouth breathing or weak muscle tone show a system of skeletal balance with its cycle reactions that
higher prevalence for anterior openbites. take place during the malocclusion development pro
On the other hand, the rotational forward movement cess. The substantial changes occurring in the develop
of the mandible indicates the mechanism for develop ment of a Class HI high angle are forward mandibular
ing mandibular pro- gnathism. In normal growth sub rotation and the subsequent orofacial compensation. In
jects, the occlusal plane gradually flattens slightly due this sense, posterior occlusal vertical dimension consti
to the increment in the posterior vertical dimension of tutes an. important parameter that influences the entire
occlusion. During the development of a class HI maloc orofacial balance.
clusion, the mandibular adaptation that occurs is char The active phase of orthodontic treatment has been
acterized by a marked forward rotation in response to to focus on correcting the inclination of the posterior
the excessive increase in the posterior occlusal vertical occlusal plane associated with the control of the occlusal
dimension (caused by the "squeezing out effect" of pos vertical dimension, i.e. an increase in the existing verti
terior discrepancy) that leads to mandibular pro- cal dimension must be corrected at the occlusion by the
gnathisrn. Under these considerations, orthodontic treat intrusion of the upper and lower molars as a method of
ment of skeletal class 1TI maiocclusions must be accom steepening the occlusal plane (tipping the occlusal plane
plished by the elimination of posterior d iscrepancy and posterosuperiorly and decreasing the vertical dimension
reconstruction of the posterior occlusal plane to re-es in the molar area). In order to reconstruct the occlusal
tablish the proper vertical dimension. plane, a multiloop edgewise arch wire (MEAW) is placed
in both dental arches (Fig. 7) (15,16). The MEAWs con
Treatment mechanics for correction of class tain progressive tip-back bend from the premolar to the
III malocclusion molar area. Anterior loops are used to support vertical
The treatment mechanics used in the orthodontic cor or short class III elastics (3/16" in., 6 oz.). Conventional
rection of Class IIL maiocclusions are not difficult to ap use of long Class III elastics must be avoided because
ply. The treatment objectives for a Class III high angle further upper molar extrusion may aggravate the mal
should be clearly established for the correction of reverse occlusion. By this approach, the mandible is able to adapt
overbite - openbite that has resulted from a poor for posteriorly with a subsequent change in the entire
ward mandibular adaptation, i.e. the sequelae of basic- orofacial complex. It has become possible to bring about
ranial flexion; posterior discrepancy with molar an improvement in the occlusion (6,17).
over-eruption, and therefore, increased posterior verti-
Development and Orthodontic Treatment of Class III Malocclusion

Patient 1
This patient consulted the dental clinic at the age of
eight years in the period of mixed dentition. He pre
sented a reverse overjet. Orthodontic treatment was con
tinuously carried out until age 13 with no good result.
At that time, the patient was recommended for
orthognathic surgery, but he refused it. The treatment
was discontinued. At age 19, the patient complained of
his facial appearance with a reverse overbite as well as
impaired mastication (Fig. 8, 9).
The patient records show the skeletal changes from
age 8 to 19 years: the occlusal plane became very flat, an
anterior openbite developed and the mandibular plane
angle decreased (Fig. 10). Superimposition of lateral
cephalometric radiographs indicates an extremely in-
Fig. 8: Patient 1: Pre-treatment frontal and profile views.

Fig. 9: Pre-treatment Intraoral views.

Fig. 10: Cephalometric superimposition to visualize growth changes. Cephaiograms at age 8 years (a), 19 years (b), and superimpo
sition of the tracings showing the increase in occlusal vertical dimension at the molars and the flattening of the occlusal plane, i.e. a
forward mandibular rotational adaptation during the development of skeletal class III maiocclusion with mandibular prognathism.
S. Sato et al.
Bull. Kanagawa Dent. Col. 35 (2007)

creased vertical occlusal dimension in the molar area


and the flattened occlusal plane. Panoramic radiograph
reveal impacted third molars with a low potential of
eruption (Fig. 11). This case was diagnosed as having a
skeletal prognathism with a reverse overbite caused by
mandibular forward rotation, which resulted from an
increased vertical occlusal diinension due to posterior
discrepancy.
The treatment objectives were to provide a steep oc
clusal plane for the posterior adaptive repositioning of
the mandible, to correct the crowding and improve the
occlusion by uprighting and alignment the dentition.
First, the impacted upper and lower third molars were
Fig. 11: Pre-treatrnent Panoramic radiograph showing in
removed in order to eliminate the posterior discrepancy.
creased molar vertical dimension caused by posterior crowd
Then standard edgewise appliances were bonded to all
ing (posterior discrepancy) due to form, growth, and erup teeth and the levelling and alignment stage was started
tion of second and third molars. using 0.014-inch Australian wire. Three months later,
maxillary and mandibular MEAWs were engaged for
occlusal plane control with vertical short class III elas
tics in the anterior area (Fig. 12). Eight months after the

Fig. 12: Follow-up intraoral views (a)


after three months, (b) after 10

months, (c) after 20 months, and (d)


two years post-treatment,
Development and Orthodontic Treatment of Class III Malocclusion

onset of treatment an overlay expansion wire made of 0.7


mm stainless steel was additionally used on the maxil
lary dental arch for its expansion. Class III elastics were
continuously worn until the achievement of optimal and
stable occlusion. After 17 months the active treatment
was completed. The occlusion accomplished tended to
ward class ITT but the cephalometric super imposition
substantiated a mandibular posterior shift and a steep
ened occiusal plane (Fig. 13).

Patient 2
This patient was also brought to the clinic at 8 years
old and orthodontic treatment was performed to elimi
nate crowding. At age 13 treatment finished but the pa
tient returned at age 23 years. His chief complaint was
Fig. 13: Pre and post-treatment cephalometric superimposi-
inverse overjet (Pig. 14, 15). Between the ages of eight
tion: steeper occiusal plane and mandibular posterior posi
and 22 years, the occiusal plane had become flatter and
tion with less hyperdivergence are obvious.
the mandibular plane angle had decreased (.Fig. 16).
Cephalometric tracing super imposition of ages 13 and
22 revealed the descent of the posterior occiusal plane
(Fig. 17). The panoramic radiograph showed impacted
upper and lower third molars with an unfavorable in
clination and low eruption potential (Fig. 18). At age 23,
a skeletal reverse occlusion and a high angle character
were diagnosed in spite of a low value for the mandibu
lar plane angle (FH-MP 23). Other characteristics were
found, such as retroclination of lower incisors, exces
sive functional anterior rotation of the mandible that
resulted from the increased vertical height of the denti
tion, dysfunctional mandibular position and imbalance
of the whole orofacial. complex.
The treatment objectives consisted in achieving a
posterior adaptive repositioning of the mandible and

Fig. 14: Patient 2: Pre-treatment frontal and profile views.

Fig. 15: Pre-treatment intraoral views.


S. Sato et a]. Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 16: Follow-up facial profile views dur


ing growth course. Class III facial appear
ance worsened affer age 12.

Fig. 17: Cephalometric superirnpositions of


growth course at age 12 years (a) and 23
years (b) indicating the flattening of the oc-
clusal plane after increasing the posterior
occlusal vertical dimension and the signifi
cant forward mandibular rotation.

establishing a proper functional occlusion. At tine begin


ning of treatment, all third molars were extracted to
eliminate the posterior discrepancy. Standard edgewise
brackets and. tubes were bonded to all teeth. Levelling
was performed using 0.014-inch Australian wire arches.
One month later, MEAWs were incorporated in both
dental arches and the occlusal plane was corrected with
short class III elastics {Fig. 19). After four months of treat
ment, the upper dental arch was expanded with an over
lay wire (0.7 mm stainless steel). Nine months later a
0.016"x0.022" ideal arch wire was placed in the maxil
lary arch and the class III elastics remained in use. After
12 months the active treatment was finished (Fig. 19,20).
The therapeutic occlusion showed a tendency to class
III. However, cephalometric superimposition demon
strated a mandibular backward position with a slight
hyperdivergence resulting from the steeper occlusal
plane (Fig, 21).

Discussion
It has been generally accepted that mandibular de
velopment depends on the direction of condylar growth
and the difference in growth between anterior and pos
terior facial height. If vertical condylar growth exceeds
Fig. 18: Panoramic radiograph: (a) Pre-treatment and (b) the vertical growth at the sutural-alveolar process area,
Post-treatment. a forward or closing mandibular rotation occurs and vice
Development and Orthodontic Treatment of Class III Malocclusion

a Fig. 19: Foliow-up intraora! views dur


ing and post-treatment: fa) beginning of

treatment, (b) after two months, fc) end


of treatment after 12 months, and fd)

two years post-treatment.

Fig. 21: Pre-treatment and post-treatment cephalometric superim-


position shows backward repositioning of the mandible,
Fig. 20: Post-treatment frontal and profile views. hyperdivergence, and a slightly steeper occlusal plane.
S. Sato ct al. Bull. Kanagawa Dent. Col. 35 (2007)

versa (18-21). Molar over-eruption occurs in individu From this point of view, no retainer provides the effect
als with reduced functional biting force caused by mus of keeping vertical distances. Vertical stability is attained
cular weakness. Mouth breathing constitutes an by the final adjusted occlusion and occlusal function.
additional problem displacing the mandible downward For this reason, the careful establishment of a proper
while the dentition gains in height secondarily. These dental occlusion is the key point in post-orthodontic sta
statements rest upon the genetic determination of bility. It is incorrect to attempt to maintain an occlusion
growth potential and direction which are both influ without perfect finishing according to each individual
enced by dentition and alveolar growth. The develop case. However, retention for a limited period of time is
ment of an openbite malocclusion has been attributed indispensable in preventing horizontal problems as
mainly to these factors but mandibular growth is also crowding.
influenced by environmental factors (22-26). Many re The patients cited in this article wore Hawley retain
searchers report an increment in mandibular condylar ers day and night for approximately five months after
growth and mandibular angle alteration caused by man removal of the fixed appliances. Later on the same re
dibular anterior shift. McNamara and Bryan (26) ob tainers were used for another three to four months only
served a considerable increase in mandibular growth at night and then the retention was ceased. The post-
following artificial protrusion in rhesus monkeys over retention occlusion remained stable. Both patients re
a period of 144 weeks. Also Petrovic (27) found adap port exemplified occlusal stability once posterior
tive changes in mandibular morphology as well as in discrepancy had been removed with the inclination of
the temporomandibular joint. It was concluded that the occlusal plane. Thus, posterior discrepancy is con
adaptive changes in mandibular corpus represent the sidered an important pathogenic factor. Even in severe
type and character of a malocclusion. skeletal Class III cases, a correction of the malocclusion
On the other hand Sato ct al. (7-14) demonstrated that can now be achieved solely by orthodontic treatment
a space deficiency in the posterior region (posterior dis without the need for orthognathic surgery in a relatively
crepancy) has a pathological effect that exerts squeez- short amount of time.
ing-out forces and produces not only mesial drifting but
also over-eruption of molars, causing an increment in
posterior occlusal vertical dimension with a subsequent Acknowledgements
flattening of the occlusal plane and forward mandibu This work was performed in Kanagawa Dental College,
lar rotational displacement. If there is no continuous Research Institute of Occlusion Medicine and supported by a
functional mandibular adaptation, this will result in the grant-in-aid for open research from the Japanese Ministry of
Education, Culture, Sports, Science and Technology. The content
development of a class III openbite malocclusion.
of this article was originally published in the journal Information
The previous hypothesis that an openbite results from Orthodontic und Kieferorthopadie (IOK) in German. This issue
mandibular hyperdivergence was abandoned as evi in BKDC topics is a secondary publication after translation into
dence emerged that an increase in occlusal vertical di English with copyright permission from IOK (Thieme).

mension influences the continuous process of forward


mandibular rotational adaptation, which is essential for
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overbite malocclusions with the multiloop edgewise archvvire
Bulletin of Kanagawa Dental College
Vol. 35, No. 1, March, PP. 65-77,2007

Different Mechanics for Orthodontic Correction


of Class II Openbite and Class III
Openbite Malocclusions

Sadao Sato, Masaaki Kaneko, Kenichi Sasaguri,


Eliana Midori Tanaka and Ales Cefar*

Department of Cmniofacial Growth and Development Dentistry,


Kanagawa Dental College
Department of Orthodontics, Medical University of Vienna, Bernhard Gottlieb
Dental Clinic, Vienna, Austria

Abstract

In most cases, diagnosis and treatment planning tor skeletal openbite malocclusions can
I be complex and constitutes a real challenge particularly in those accompanied by antero-
postenor maxillo-mandibular discrepancies.
The present paper deals with high angle and low angle Class III malocclusions as well as
with Class II openbites. Utilization of MEAWs (multiloop edgewise arch wires) with different
tip back mechanics and short vertical elastics can be effective in reconstructing the occlusal
plane inclination, and so allow the repositioning of the mandible. Tooth alignment with cor
rected occlusal plane inclination can lead to a physiological mandibular position which is the
key to stability of the properly adjusted occlusion.

Keywords: Class II malocclusion I Class III malocclusion I Openbite

Introduction
activity. In this regard, restoration of function achieved
The reason why openbites and mandibular only by extraction or surgical correction of patient's
hyperdivergence are quite often seen in human beings morphology is questionable. In addition, surgical cor
is not just a dental problem but also one of the topics in rection is a treatment option with associated risks. Most
human evolution. Through the years, orthodontic his patients prefer not to have surgical intervention and in
tory has faced this question but actually has still no clear
deed, many patients refuse it. High angle openbites de
answer. Therefore, an accurate treatment plan cannot note the malocclusion with the highest frequency of
be established and palliative therapies are still carried surgical intervention. Until now, there are no definite
out including unnecessary extractions or combined treat guidelines on how to treat openbites according to the
ment with orthognathic surgery. state of the art.
The condition high angle indicates mandibular Twenty years ago, Ellis et nl. (1, 2) studied the char
hyperdivergence and involves functional problems re acteristics of maxillary and mandibular occlusal planes
lated to the maxillary position, temporomandibular joint as well as the anterior-posterior mandibular position in
function, balance of the maxillo-mandibular complex class II and class III openbite subjects. They concluded
and the facial skeleton as well as the skull, and muscle that the problem was caused by anteroposterior devia
tions of the maxilla and the mandible and that this should
Accepted for publication on October 5,2006. be treated by surgical correction. On the other hand, Kim
Address for correspondence: Masato Matsuo, Tissue Engineering
Division, Institute for Frontier Oral Science, Kanagawa Dental Y.H. (3-5) has treated numerous patients with openbite
College, 82 Inaoka-cho, Yokosuka, Kanagawa, 238-8580, Japan malocclusion with no surgical intervention. Kim's or
Tel: +81-46-822-8880 (ex. 2381) Fax: +81-46-822-8844
thopedic correction was successfully carried out by
S.Sato etal. Bull. Kanagawa Dent. Col. 35 (2007)

changing the occlusal plane using a product of his own Pi'


development, the multiloop edgewise arch wire
(MEAW). According to our experience, MEAW treat
FH'OPtQ
ment for occlusal plane correction is not Limited to VOP(A)
FH-OP(A)
openbite malocclusions but is very effective in correct FU-OP(P)
*UOP(C)
ing the occlusal plane in any malocclusion with no sur UOP(C)
VOP(A)
gical intervention (6-1.3). In our practice, we sometimes ~* UOP(P)
UOP(P)
have to deal with openbite malocclusions that are very MP'OP(C)
difficult to treat. Most of them consist of a class U high MP-OP(A)
MP-OP(P)
angle with an openbite. Still, there are no contemporary
LOP(B)
clinical guidelines for effectively treating openbite mal LOP(Pog)
OP(A-P)
occlusion with class II or class III that use an exclusively
orthodontic approach. Pog

Our duty as doctors of dental medicine is to find the


cause of this malocclusion and to define accurate treat Fig. 1: Cephalometric measurements regarding occlusal
ment methods. The aim of this article is to present an planes. OP(C) conventional occlusal plane, OP(A) anterior
orthodontic approach to the treatment of different types occlusal plane, OP(P) posterior occlusal plane, UOP upper
(maxillary) occlusal plane, LOP lower (mandibular) occlusal
of high angle openbite malocclusions. This contribution
plane, OP (A-P) the difference between anterior and poste
should be considered helpful for further research in this
rior occlusal planes.
field.

Developmental characterization of openbite 11=0.5860


malocclusion P<0.0001

Many skeletal malocclusions are considered as


openbite even those including mandibular prognatbism
as well as retrognathism. Treatment guidelines and clini
cal procedures depend on skeletal conditions. A precise
description of the character of the openbite is indispens
able for correct diagnosis.
High angle morphology indicates the posterior man
60 70 80 90 100
dibular rotation in hyperdivcrgent skeletal patterns. A
APDI (Anfero posterior DispJasiu [mik'utur, l'l'-AH)
close evaluation of the development of openbites reveals
that what has occurred is not just a simple rotation. De Fig. 2: Correlation between upper (maxillary) posterior oc
clusal plane, UOP(P) and anterior-posterior maxillomandibu-
pending on the occlusal plane, the mandible rotates for
lar relationship (PP-AB). A flat maxillary posterior occlusal
ward or backward. According to our findings (14-20),
plane UOP(P) creates a skeletal class III, a steep maxillary
the most determinant factor in mandibular
posterior occlusal plane UOP(P) a skeletal class II.
hyperdivergence has been the inclination of the maxil
lary posterior occlusal plane (upper occlusal plane - pos
terior, LJOP-P; Fig. 1, 2, 3). The steeper the posterior
segment of the occlusion, the greater the posterior rota
tion of the mandible will be, creating a class 11 openbite
malocclusion. The flatter the occlusal plane, the more so-
the mandible will rotate forward and a class III openbite
may develop (Pig. 2). Furthermore, it should be kept in
mind that a steeper cant of the occlusal plane induces 70-
greater mandibular hyperdivergence and that a flatter
inclination of the occlusal plane decreases the mandibu
lar plane angle (Fig. 3). (.(I
2(1 3(1 411 5(1
Longitudinal growth studies in subjects with a class 10
PP-MP
11 high angle openbite only show a slight increment in
Fig. 3: Correlation between upper posterior occlusal plane
posterior occlusal vertical height and a steeper orienta
UOP(P) and lower facial hyperdivergency (PP-MP). Leveling
tion of the occlusal plane. Subsequently, an anterior the cant of the posterior occlusal plane UOP(P) to an almost
openbite develops because of mandibular posterior ro horizontal orientation is related to the closure of the lower
tation (Fig. 4). Class II and class III openbites differ in face. A steeply inclined cant of the posterior occlusal plane
the vertical height of the molar occlusion, inclination of UOP(P) is associated with hyperdivergence of the lower face.
Different Mechanics for Treatment of Class II and Class III Openbite

Fig. 4: Development of a class II openbite


in longitudinal growth observation. During
normal growth the mandible rotates for
ward in response to the increasing molar
vertical dimension and the mandibular
plane angle remains stable (a). If the cant
of the occlusal plane becomes so steep that
the mandible cannot rotate forward (insuf
ficient eruption of maxillary molars, over-
eruption of mandibular molars), then a
retrognathic openbite appears (b).

Fig. 5: Concept regarding occlusal plane


changes and mandibular adaptation. A flat
occlusal plane due to the eruption ot upper
molars induces the mandibular forward
rotation. This forward mandibular growth
is accompanied by secondary condylar
growth. Molar over-eruption causes the oc
clusal plane to be too flat and subsequently
gives an excessive mandibular forward
thrust, i.e. a tendency toward class III
openbite (a). Insufficient eruption of the
posterior molars creates a steep occlusal
plane; posterior rotational mandibular dis
placement produces a tendency toward
class II openbite (b).

the occlusal plane, and adaptive movement of the man Denture Frame Analysis (Fig. 6)
dible (Fig. 5). For the correction of a class III openbite, The relationship between the occlusal plane and the
the mandible should be repositioned posteriorly, by shape of the orofacial skeleton can be evaluated using
steepening of the occlusal plane (i.e. a posterior-supe the simple cephalometric method introduced by Sato (21,
rior orientation). In order to close a class TI openbite mal- 22), i.e. the Denture Frame Analysis. The four horizontal
occlusion the flattening of the steep occlusal plane will planes used in the construction of a denture frame are:
provide a forward adaptation of the mandible. So dif the Frankfort horizontal (FH), the palatal plane (PP), the
ferent dynamic systems are needed in the therapy of class mandibular plane (MP), the AB-line (AB), and the oc
I] openbite and class III openbite malocclusions. clusal plane (OP). The adaptive movements of the max
illa and the mandible are evaluated against the functional
Diagnostic approach to the high angle - planes, particularly the occlusal plane. The cant of the
"long face syndrome" occlusal plane related to the intersection with PP and
In the treatment of patients with a high angle MP indicates the relative incline of an occlusal plane
dysgnathia, the characterization of the inherent maloc- orientation that is either too steep or too flat.
clusion is the most important issue. Skeletal patterns are In the diagnosis and treatment plan of high angle
generally evaluated by cephalometric analysis. We will malocclusions, the dynamic mechanism that occurs due
limit this analysis to a method that is easy to handle. to an altered occlusal vertical dimension and the subse
Such an analysis is necessaiy to understand the relation quent skeletal adaptation must be taken into consider
ship between occlusal vertical dimension and mandibu ation. Very often in class IT openbite malocclusion, the
lar adaptation. posterior occlusal plane (UOP-P) is steeply oriented at
the molars and the mandible rotates backward, i.e. the
mandible cannot functionally adapt forward against the
S. Sato et at. Bull. Kanagawa Dent. Col. 35 (2007)

FH-lllF ODI: 3+4


PP-KP APDI: 1+2+3
OP-HP CF: ODI+APO)

Fig. 6: Denture Frame Analysis. The relationship between Fig. 7: Kim's analysis evaluates vertical and anterior-poste
occlusal plane and orofacial structures is analyzed by appli rior components of malocclusion: ODI, APDI, and CF. The
cation of Frankfort horizontal (FH), palatal plane (PP), man- ODI is associated with the overbite and the normal ODI value
dibular plane (MP), AB-line (AB), and the occlusal plane (OP). averages 72 in Asians (approximately 75 in Caucasians).
The type of maxillary and mandibular adaptation is analysed Lower values indicate an openbite, higher values a skeletal
facing functional cephalometric planes, particularly the oc deep bite. The APDI describes skeletal anterior-posterior re
clusal plane. lationships (mean 81; higher values indicate class 111, smaller
values class II). The smaller the CF value, the more the high
angle tendency prevails, and extractions become more likely.

steepening of the occlusal plane. This causes an anterior MP is small relative to the anterior mandibular adapta
openbite. During growth, this event Inhibits condylar tion. In this case the ODI value is small.
growth (compression of the condyle) and the high angle The APDI consists of three angular measurements
condition is aggravated. (FH-PP, AB-NPg, FH-NPg) but corresponds to the angle
In the case of posterior discrepancy, an overeruption PP-AB. The APDI evaluates the skeletal classes I, IT, and
of the upper molars occurs and the posterior occlusal 111 of the lower face. The average APDI-value for class J
plane inclination flattens. The mandible is displaced for is 81; higher values indicate class 111, lower values class
ward with anterior rotation in response to the increase II.
in posterior vertical dimension and consequently, the Small CF-values represent a high angle tendency.
orofacial skeleton becomes a class III. This is why the CF is used in determining the necessity
The orthodontic treatment approach must realize this for tooth extraction in orthodontic therapy: the lower
developmental background and the outcome of the high the CF, the higher the necessity for extraction. Extrac
angle morphology, either class II or class III. This view tion of teeth does not refer to the exclusive extraction of
discloses the morphologic structures, the functional ad premolars. An evaluation of which teeth need to be ex
aptation of the orofacial skeleton, and the character of tracted will be performed depending on each individual
the malocclusion. case.

Analysis of malocclusion by Kim's ODI and Treatment objectives for class III openbite
APDI (Fig. 7) (23, 24) In the development of a class III openbite, the key
Kim described compound cephalometric measure point is the increment in the occlusal vertical dimension
ments for the analysis of vertical and anterior-posterior of the posterior teeth. In the case of molar over-erup
components of malocclusion, He named them overbite tion, the occlusal plane will become flatter and the man
depth indicator ODI and anterior-posterior dysphsin indica dible will adapt by forward rotation in order to attain
tor APDI. Their mathematical sum represents the combi occlusal contacts. In other words, the mandible rotates
nation factor CF. forward and reaches a class III relationship. Whenever
The ODI consists of two angles, i.e. (1) the angle be the forward mandibular rotational adaptation is insuf
tween FH and PP and (2) the angle between AB and MP. ficient m the vertical direction, a class III openbite will
Among various cephalometric measurements the ODI arise. The basic problem behind this development origi
shows the highest statistical correlations with dental nates from a posterior discrepancy and the subsequent
overbite. An anterior openbite results from an increased alteration of the cant of the occlusal plane as well as
posterior occlusal vertical dimension and the angle AB- mandibular adaptation.
Different Meciianics for Treatment of Class II and Class III Openbite

Fig. 8: Orthodontic mechanics for correction of class 111 and class II openbite malocclusions. Class 111 openbite malocclusion requires
a steeper occlusal plane for backward adaptation of the mandible. Tip back bends of the MEAW correct the post-canine teeth to an
upright position and intrude the molars. Short class III elastics are used on the front teeth. In class II with an openbite the mandible
rotates and is displaced posteriorly. These patients will benefit from a flatter occlusal plane by elimination of the molar interferences,
which will then allow a physiologic mandibular forward rotation. This goal is reached by using moderate tip back bends in the
maxillary MEAW, strong tip back bends in the mandibular MEAW, and short anterior class II elastics.

With reference to its development, class 111 openbite Treatment objectives for class II openbite
malocclusion will benefit from steepening of the occlusal According to morphologic studies on class II openbite
plane, which induces mandibular backward adaptation. malocclusion, the maxillary occlusal plane is inclined
The orthodontic correction must aim at uprighting the too steeply at the posterior segment. As a consequence,
posterior teeth and any additional intrusion of the mo the physiologic forward adaptation and the mandibu
lars. This approach will steepen the occlusal plane with lar growth are often restricted. Furthermore in class II,
a concomitant release of the squeezing-out effect at the the mandibular posterior discrepancy promotes man
molars. The convenient treatment mechanics used are dibular molar over-eruption. This elevation of the oc
tip back bend activations of the multiloop edgewise arch clusal surfaces is followed by a posterior rotation of the
wires and vertical or short class III elastics on the ante mandible. In other words, the mandible in class II
rior teeth (Fig. 8). openbite malocclusion is displaced by a backward rota
During the reconstruction of the occlusal plane, one tion because of less-erupted maxillary molars with over-
limitation can be the occurrence of molar crowding, erupted mandibular molars. In addition, the steep
which is followed by an increase in the vertical height occlusal plane interferes with mandibular movement
of the molar dentition during uprighting, and a subse and forward rotation does not take place. Therefore, the
quent forward rotation of the mandible. Therefore, in occlusal plane must be flattened in order to eliminate
most cases, priority is given to a solving the posterior the molar interference and initiation of the physiologic
discrepancy problem, usually by extraction of the third forward adaptation. The orthodontic treatment of class
molars. In some cases, the extraction of the upper third II openbite malocclusion focuses on the extrusion of the
molar may be very difficult and the surgery carries with maxillary molars and the intrusion of the mandibular
it a high risk. Following this, the second molar may be molars in order to flatten the occlusal plane. The me
extracted if the inclination of the third molar has been chanics for this correction consist of moderate tip back
assessed as being favourably positioned for eruption into bends in the maxillary MEAW and strong tip back bends
occlusion later on. in the mand ibular MEAW. Vertical or short class II elas
Figures 9-14 show a class Til openbite malocclusion tics are used at the anterior loops (Fig. 8).
in an 18-year-old patient. The diagnosis includes molar Figures 15-20 show an 18-year-old female patient
over-eruption in posterior discrepancy and class III with class TI openbite and cranio- mandibular dysfunc
openbite due to a flat occlusal plane. Orthodontic treat tion. She complained of a shooting pain in the temporo-
ment was started after extraction of the upper and lower mandibular joints. The class II openbite malocclusion
third molars. After seven months of active treatment, was associated with mandibular backward rotation and
the anterior openbite was corrected and the treatment a very steep posterior occlusal plane. In prior orthodon
ended. The patient wore a retainer for six months. The tic treatment, all third molars were removed and the
occlusion remained stably visible during the two years occlusal plane was flattened by MEAW mechanics. The
and five month follow up period. oiLtcome of active treatment over a period of 19 months
S. Sato etal Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 9: Class 111 with openbite.

Pre-treatment frontal and profile views.

Fig. 10: Pre-treatment intraoral views.

Fig. 11: Pre-treatment cephalogram and panoramic radiograph.

,-
Different Mechanics for Treatment of Class II and Class III Openbite

Fig. 12: Intraoral views during treatment; (a) at onset of treatment, (Id) after two months,

(c) after four months, (d) after seven months, and (e) two years after finishing treat
ment.
S. Sato etal Bull. Kanagawa Dent. Col. 35 (2007}

Fig. 13: Post-treatment frontal and profile views.

a Fig. 14: Cephaiometric tracing before

treatment (a) and superimposition of trac


ings before and after treatment (b).

Table 1. Denture Frame Analysys


Different Mechanics for Treatment of Class TI and Class III Openbite

Fig. 15: Class II with openbite. Pre-treatment frontal and profile views.

Fig. 16: Pre-treatment Intraoral views.

Fig. 17: Panoramic radiograph before and after treatment.


S. Sato et nl. Bull. Kanagawa Dent Col. 35 (2007)

Fig. 13: Intraoral views during treatment: (a) at


onset of treatment, (b) after one month, (c) after
seven months, (d) after 19 months, (e) one year
later, and two years five months after the end of
treatment.
Different Mechanics for Treatment of Class II and Class III Openbite

Fig. 19: Post-treatment frontal and profile views.

Fig. 20: Cephaiometric tracing before


treatment (a) and superimposition of
tracings before and after treatment, (b)
Orthodontic treatment flattened the
steep posterior occlusal plane and a
slight forward mandibular displace
ment is visible.

was the correction of the anterior openbite and the elimi occlusal dimension in the posterior part of the dentition
nation of temporomandibular joint pain and dysfunc because of the squeezing out effects of molar crowding
tion. Two years and five months after finishing (posterior discrepancy). The subsequent flat occlusal
orthodontics., the dentition remained stable without plane conditioned the mandibular adaptation in terms
major alterations. of a forward rotation, which again created a class III
The cephaiometric changes of both patients presented openbite malocclusion (6, 7, 10-13,16-19, 21). Previous
in this article are described in Table 1. hypotheses stated that the increase in the molar vertical
height of the occlusion had affected the hyperdivergence
Discussion of the inandible and the openbite. Later on, it was con
Generally, openbite malocclusion has been consid cluded that the increased posterior occlusal vertical di
ered a vertical anomaly in the relationship between mension had been actually followed by a mandibular
maxillary and mandibular arches or between the max adaptation with forward rotation. This mechanism has
illa and mandible as in deep bite. The development of an important influence on orofacial growth and agrees
openbite has been interpreted from various aspects such with descriptive studies of normal individual orofacial
as developmental disharmony of the jaws, abnormal growth in different populations. These studies also sub
habits related to lip and tongue function, excessive erup stantiate the forward rotation of the mandible, an in
tion, etc. The direction of mandibular growth and con crease of the posterior height of the occlusion, and
comitant functional factors have been considered, to be flattening of the occlusal plane's orientation (29,30). Dur
an important factor in aggravating the openbifce (25-28). ing growth, the angle between the Frankfort horizontal
Sato et al. emphasized the increment in the vertical and occlusal plane (FH-OP) has become continuously
S. Sato el al. Bull. Kanagawa Dent. Col. 35 (2007)

smaller and more horizontal, and the mandibular plane grant-in-aid for open research from the Japanese Ministry of
Education, Culture, Sports, Science and Technology. The content
angle (FH-MP) has shown a decrease without hyperdi-
of this article was originally published in the journal Information
vergence.
Orthodontie und Kieferorthopadie (IOK) in German. This issue
Clinical observations of openbite malocclusion do not in BKDC topics is a secondary publication after translation into
show molar over-eruption and flattening of the occlusal English with copyright permission from IOK (Thieme).

plane. Subjects with a steep occlusal plane and decreased


occlusal vertical dimension may bring etiologic insight
References
and diagnosis into confusion. This is why orthodontists
1. Ellis, E. III. and McNamara, J. A. Jr. (1984). Components of adult
consider a surgical correction the only achievable treat
Class III openbite malocclusion. American journal of
ment option. Openbite has been viewed as a difficult Orthodontics. 86: 277-290.
malocclusion for orthodontic treatment and corrections 2. Ellis, E. III., McNamara, J.A. Jr. and Lawrence, T.M. (1985).
have been carried out with concomitant orthognathic Components of adult Class II open-bite malocclusion. journal
of Oral and Maxillofacial Surgery. 43:92-105.
surgery.
3. Kim,Y.H. (1987). Anterior openbite and its treatment with
Difficulties in treating openbites probably arise from multiloop edgewise arch wire. Angle Orthod. 57: 290-321.
palliative treatment options without etiological consid 4. Kim, Y.I 1. (1999). Treatment of severe openbite malocclusions
eration of the malocclusion. The body's adaptive re without surgical intervention. In: McNamara, J.A. Jr. (Ed).
Growth modification: what works, what doesn't, and why.
sponse will only fulfil the requirements if correct
Craniofacial Growth Series, vol. 35, Ann Arbor: Center for
treatment has been applied. In suitable compensatory Human Growth and Development. The University of
function, the occlusion will remain stable. Orthodontic Michigan, pp. 193-212.
treatment has the potential to use inherent adaptive 5. Kim, Y.H. (2000). Treatment of anterior openbite and deep
overbite malocclusions with the multiloop edgewise archwire
properties and promote proper individual function. The
(MEAW) therapy. In: The Enigma of the Vertical Dimension.
most important treatment objectives are the control of Craniofacial Growth Series, vol. 36, Ann Arbor: Center for
the vertical dimension and the reconstruction of the oc Human Growth and Development, McNamara J.A. Jr, (Ed.),
clusal plane. The University of Michigan, pp. 175-202.
6. Sato, S.A. (2001). Treatment approach to malocclusions under
In high angle class II openbite malocclusion there is
the consideration of craniofacial dynamics. Grace Printing
insufficient occlusal contact because of the low occlusal Press Inc. (Philippines).
vertical dimension at the molars and the steep posterior 7. Sato, S., Akimoto, S., Matsumoto, A., Shirasu, A. Yoshida, J.
occlusal plane. In the case of adaptive mandibular pos and Sato, S. (2002). MEAW - Manual for the clinical application
of MEAVV technique. Printing Press Inc. (Philippines).
terior rotation, a class II openbite will develop. Along
8. Fujita, A., Ono, K., Maruta,Y. and Sato, S. (1995). New approach
with this background, there is still another problem, to the treatment of Class II malocclusion with high mandibular
namely the dynamic skeletal balance in the openbite. plane angle based on occlusal plane control. Bull Kanagauui
The treatment should not only correct the den to- alveo Dent Col. 23: 63-68.
9. Sagara, N., Takahashi, S., Lin, J-M. and Sato, S. (1995).
lar situation but also make use of the dynamic system
Orthodontic treatment of Class II malocclusion with
with its supporting skeletal balance. In the development
temporomandibular joint dysfunction. Bull Kanagaxi'ii Dent Col.
of skeletal class III openbite, an inverse adaptation takes 23: 55-62.
place, i.e. the background of the skeletal class III con 10. Sato, S. (1994). Case report: Developmental characterization
of skeletal Class III malocclusion. Angle Orthod. 64:105-112.
sists of a flexion of the skeleton, a hyperdivergent face
11. Protacio, C. and Sato, S. (1995). The role of posterior
due to maxillary downward growth, and an increased discrepancy on the development of skeletal Class III
occlusal vertical dimension. In addition, the occlusal malocclusion - Its clinical importance, hit J. MEAW Tech Res
plane levels posteriorly (Fig. 5). That is why an inverse Found. 2: 5-18.
12. Sato, S., Dennis, C.L., Miyakawa, Y. and Kim, R.I I. (1998). The
curve of Spec is generated in class III. Under these cir
development of openbite as a result of posterior discrepancy
cumstances, the mandible responds in terms of a for and its treatment approach using mutiloop edgewise arch wire.
ward rotation. //// /. MEAW Tech Res Found. 5: 5-15.
The most important functional determinants for the 13. Sato, S., Takamoto, K. and Suzuki, Y. (1988). Posterior
discrepancy and development of skeletal Class HI
orofacial balance are the occlusal vertical dimension and
malocclusion. Orthodontic Revieio. Nov/Dec: 16-29.
the posterior occlusal plane inclination (31). Thus, in the
14. Hwang, D.H., Akimoto, S. and Sato, S. Relationship Between
orthodontic treatment of skeletal Class II or III openbite the Occlusal Plane Inclination and Mandibular Posture in the
malocclusions, successful results are obtained when con Hyperdivergent Type of Skeletal Frame.
15. Hwang, D.H., Akimoto, S. and Sato, S. Occlusal Plane and
trolling the posterior vertical dimension and posterior
Mandibular Posture in the Hyperdivergent Type of
occlusal plane inclination. Malocclusion in Mixed Dentition Subjects.
16. Sato, S., Motoyanagi, K., Suzuki, T., Imasaka, S. and Suzuki,
Y. (1988). Longitudinal study of the development of skeletal
malocclusions. J.jpn Orthod Soc. 47: 186-196.
Acknowledgements
17. Sato, S., Suzuki, N. and Suzuki, Y. (1988). Longitudinal study
This work was performed in Kanagawa Dental College, of the cant of occlusal plane and denture frame in cases with
Research Institute of Occlusion Medicine and supported by a congenitally missing third molars. Further evidence for the
Different Mechanics for Treatment of Class II and Class III Openbite

occlusal plane change related to posterior discrepancy. /. //;// 24. Kim, Y.I I. and Vietas, J.J. (1978). Anteroposterior dysplasia
Orlhod Soc. 47: 517-525. indicator. An adjunct to cephalometric differential diagnosis.
18. Sato, S., Sakai, H., Sugishita, T., Matsumoto, A., Kubota, M. Am J. Orlhod. 73: 719-733.
and Suzuki, Y. (1994). Developmental alteration of the form 25. Lowe, A.A. (1980). Correlations between orofacial muscle
of denture frame in skeletal Class III malocclusion and its activity and craniofacial morphology in a sample of control
significance in orthodontic diagnosis and treatment, bit }. and anterior openbite subjects. Am J. Orthod. 78: 89-9.
MEAW Tech Res Found. 1: 33-46. 26. Prof fit, VV.R. (1978). Equilibrium theory revisited: factors
19. Sato, S. and Suzuki, Y. (1988). Relationship between the influencing position of the teeth. Angle Orthod. 48: 175-18.
development of skeletal mesio-occlusion and posterior tooth- 27. Subtelny, J.I:, and Sakuta, M. (1964). Open-bite: diagnosis and
to- denture base discrepancy - Its significance in the treatment. Am J. Orthod. 50: 337-358.
orthodontic reconstruction of skeletal class III malocclusion. 28. Mizrahi, E. (1978). A review of anterior open-bite. Brit J. Orthod.
journal of Japanese Orthodontic Society. 47: 796-810. 5: 21-27.
20. Fushima, K., Kitamura, Y., Mita, H., Sato, S., Suzuki, Y. and 29. Richardson, E.R. (1991). Atlas of craniofacial growth in
Kim, Y.H. (1996). Significance of the cant of occlusal plane in Americans of African Descent, Center for Human Growth and
Class 11 division 1 malocclusion. Eur J. Orthodonl. 18: 27-40. Development, Craniofacial Growth Monograph Series.
21. Sato, S. (1987). Alteration of occlusal plane due to posterior 30. Bhatia, S.N. and Leighton, B.C. (1993). A manual of facial
discrepancy related to development of malocclusion - growth, A computer analysis of longitudinal cephalometric
Introduction to denture frame analysis. Bull Kanngawa Dent growth data. Oxford Univ. Press.
Coll. 15: 115-123. 31. Slavicek, R. and Sato, S. (2001). The dynamic functional
22. Freudenthaler, J.W., Celar, A.G. and Celar, R.M. (1994). anatomy of craniofacial complex and its relation to the
Denture Frame Analysis- I'osteriore Diskrepanz Funktionelles articulation of the dentitions (pp. 482-514). Das Kauorgan
Konzept nach S. Sato. Informational. 3: 359-370. Funktione und Dysfunktionen. Gamma Dental Edition,
23. Kim, Y.I I. (1974). Overbite depth indicator with particular (Austria).
reference to anterior open-bite. Am / Orlhod. 65: 586-610.
Bulletin of Kanagawa Dental College
Vol. 35, No. 1, March, PP. 79-86, 2007

Orthodontic Reconstruction of Occlusion


in Class III Malocclusion with Low
Mandibular Plane Angle

Akiyoshi Shirasu, Eliana Midori Tanaka and Sadao Sato

Department of Craniofaeial Growth and Development Dentistry, Kanagawa Dental College

Abstract

In orthodontics, occlusal reconstruction should be one of the ultimate goals in the achieve
ment of both aesthetically satisfactory and functionally effective treatment. The establish
ment of a proper vertical dimension of occlusion through occlusal plane control will provide a
balance for the maxillofacial complex. A skeletal Class III low angle malocclusion case in
early permanent dentition accompanied by an anterior cross bite, decreased vertical dimen
sion and mandibular midline deviation to the right is presented and a report given on a treat
ment plan accomplished by extracting the upper second molars to facilitate the reconstruc
tion of the occlusal plane by uprighting the mandibular posterior teeth with the concomitant
use of MEAWs (Multiloop Edgewise Arch Wire).

Key words: Class III Low angle I Occlusal plane I Vertical dimension I
MEAW technique

Introduction mony with vertical condylar growth. Although antero


The basic objective of orthodontic treatment is to re posterior growth of the maxilla does not present much
store the harmony of the maxillofacial skeleton through of a problem, the anterior crossbite is associated with a
the control of occlusion with appropriate vertical dimen deep overbite due to the excessive forward rotation of
sion. In other words, the restoration of the harmony of the mandible.
the maxillofacial complex through occlusal treatment is Orthodontic reconstruction of occlusion in this type
the responsibility of every orthodontist in daily prac of malocclusion requires an increase in occlusal vertical
tice. In the treatment of malocclusion associated with dimension. Even though ME AW mechanics (6-9) is gen
skeletal symptoms, occlusal reconstruction is difficult, erally considered to be an effective treatment modality
especially in patients with a Class III malocclusion. There for an openbite condition, this technique can also be uti
are different types of Class III malocclusion, high angle lized to correct the occlusal vertical dimension in a Class
and low angle (1-6). In these types of cases, the vertical III case with a low mandibular plane angle. A case is
and anteroposterior problems of the jaw are complicated, presented to show how the MEAW technique was uti
and difficulty in the diagnosis and occlusal reconstruc lized to correct such a malocclusion.
tion is due to the absence of a standardized procedure
on which force system to apply. Case Description
A Class III malocclusion with an anterior openbite The patient, a girl, 12 years and nine months old,
and a low mandibular plane angle is often termed a func complained mainly of mandibular prognathism. Her
tionally shifted crossbite, and is skeletally characterized face appeared almost symmetrical and oval in shape
by poor vertical growth of the upper face resulting in a frontally with a prognathic profile of the lower face (Fig.
lack of posterior occlusal vertical dimension and dishar- 1-A). The molar relationship was in Class III with a stron
ger tendency toward the left, causing the mandibular
Accepted for publication on October 5, 2006. midline to shift to the right by half a tooth. The overjet
Address for correspondence: Akiyoshi Shirasu, Department of and overbite were -3.3 and 2.7mm, respectively. No
Craniofaeial Growth and Development Dentistry, Kanagawa Dental
College, 82 Inaoka-cho, Yokosuka, Kanagawa, 238-8580, Japan.
crowding was observed (Fig. 1-B).
Tel: +81-46-822-8880 (ex. 2381) Fax: +81-46-822-8844 Cephalometric analysis indicated a mandibular prog-
A. Shirasuef al. Bull. Kanagawa Dent. Col. 35 (2007)

A: Pretreatment facial views and cephalometric tracing.

B: Pre-treatment intraoral views.

Fig. 1: Facial views, cephalometric tracing and intraoral views in pre-treatment.

nathism with SNA = 82.9, SNB = 83.7, and ANB differ Diagnosis
ence of -0.8. The mandibular plane showed a low angle The case was diagnosed as having an anterior
with FH-MP of 22.0 and PP-MP of 22.4s. The A'-P' dis crossbite with a low angle tendency, lack of occlusal
tance was 48.8mm and showed no anteroposterior dis vertical dimension in the molar area, and excessive for
crepancy of the maxilla. The occlusal plane was slightly ward rotation of the mandible.
inclined with an OP-MP of 11.3 and OP-MP/PP-MP of
50.6%. Kim' s analysis (10-11) showed OD1 = 62.2% APDI Treatment Objective
- 95. J and CF = 157.2, indicating a Class III malocclu- The objectives of treatment were to upright the me
sion with a low angle tendency (Table 1). Panoramic sially inclined mandibular molars, to reconstruct the
radiography revealed mesially inclined molars and miss occlusal plane by increasing the occlusal vertical di
ing mandibular third molars that had been extracted mension and to readapt the mandible to a more distal
previously. The maxillary third molars were present (Fig. position.
10).
Orthodontic Treatment of Low Angle Class III Malocclusion

Table 1: Cephalometric analysis ot pre-treatment to two years post-treatment

Treatment 16inch, 6 oz.) in the anterior area (Fig. 3).


The treatment plan was to extract both maxillary sec Because the anterior overbite and overjet improved
ond molars to facilitate the reconstruction of the occlusal two months later, the tip-back activation was reduced
plane and to upright the mandibular posterior teeth. to zero degrees. Instead, step-up bends were incorpo
Standard edgewise appliances were placed on the max rated into the posterior sections of the MEAWs to in
illary and mandibular teeth to initiate leveling with crease the vertical dimension (Fig. 4).
0.014-inch super-elastic wires (Fig. 2). The initial wires Five months later, a short Class II elastic on the right
were replaced with iMEAWs (0.016 x 0.022 inch Elgiloy and a short Class III elastic on the left were placed to
wire) that were kept in place until the end of treatment. improve the midline (Fig. 5).
Approximately twenty-five degrees of continuous tip- With the achievement of the desired position of the
back bends were placed in the MEAWs initially to start mandible seven months after the onset of treatment, the
uprighting the posterior teeth to correct the occlusal step-up bends in the posterior sections were gradually
plane by utilizing vertical and short Class III elastics (3/ reduced (Fig. 6).
A. Shirasu ct til. Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 2: Intraoral views at onset of treatment.

Fig. 3: Ten days after beginning treatment. The MEAW therapy began with short Class III elastics.

Fig. 4: Four months after beginning treatment. Step-up bends were added on the posterior dentition.

Fig. 5: Five months after beginning treatment. To correct the midline, Class II elastic was used on the right and Class III elastics
on the left.
Orthodontic Treatment of Low Angle Class III Malocclusion

Fig. 6: Seven months after beginning treatment. Step-up bends were gradually reduced in the posterior dentition.

Fig. 7: Ten months after beginning treatment. The malocclusion showed improvement.

Fig. 8; Ten months after beginning treatment. Tooth positioner is used for retention.

Since a normal occlusion was obtained ten months to a more downward and backward position due to the
later, all the brackets and the bands were removed to increment of 2.8C of FH-MP, 2.6 of PP-MP and a flatten
start the retention with a tooth positioner (Fig. 7, Fig. 8). ing of OP-MP by approximately 5 (Table 1). The har
mony of the skeletal jaw relationship was restored with
Treatment Results the achievement of the treatment goals.
The post-treatment profile showed an improvement
in the patient's prognathic lower face with the molar Discussion
relationship in Class I and no midline deviation. The In a reversed malocclusion with a low mandibular
overjet and overbite were improved to 4.2 and 1.1 mm, plane angle, there is insufficient vertical growth of the
respectively (Fig. 9-A, B); however, a slight midline de dento.fad.al complex, and because of this, the vertical
viation to the right was noted two years after treatment dimension in the posterior dentition is insufficient, cre
(Fig. 11). ating a discrepancy in its relationship to the vertical
growth of the mandibular condyle. Normally, though
Superimposition of pre- and post-treatment there is less of a problem in the antero- posterior growth
cephalograms showed a clockwise rotation of the man of the maxilla, this usually manifests a symptom of over-
dible as a result of an occlusal plane change and an in bite of deep reversed occlusion due to the
creased vertical dimension caused by the up righting of hyperprotrusion of the mandible. The treatment objec
the posterior teeth (Fig. 12). The mandible was readapted tive in this type of patient is to improve the functional
A. Shirasu ct al.
Bull. Kanagawa Dent. Col. 35 (2007)

A: Post-treatment facial views and cephalometric tracing.

B: Post-treatment intraoral views.

Fig. 9: Facial views, cephalometric tracing and intraoral views in post-treatment.

Fig. 10: Panoramic radiographs. A, pre-treatment (13 yrs nine months) and B, post-treatment (14 yrs eight months).
Orthodontic Treatment of Low Angle Class III Malocclusion

Fig. 11: Two year post-treatment intraoral views.

Fig. 12: Evaluation of treatment results.


A, post-treatment cephalometric superimposition and B, pre-, post-, and two years post-treatment

excessive rotation of the mandible by increasing the ver The treatment method described here made it possible
tical dimension. to achieve the goals of orthodontic occlusal reconstruc
Conventional orthodontic treatment for a functional tion in a relatively short term by restoring the closed
cross bite has been based, on growth control and devel vertical dimension that forms the skeletal characteris
opment with a functional appliance and/or a chin cap tics of a functional anterior crossbite. MEAW (7-11) is
therapy. Subsequent reconstruction of the occlusion by an arch wire developed by Kim Y.H. in which horizon
moving the teeth within the alveolus bones imposes a tal loops are bent from the contact point of the distal
great burden on the patient by causing a treatment of part of the lateral incisors to the posterior part of the
long duration and results that are less than satisfactory. entire teeth. Tooth alignment from the premolars to
A. Shirasu et al. Bull. Kanagawa Dent. Col. 35 (2007)

molars is possible with the continuous tip back bend of 4. Sato, S. and Suzuki, Y. (1988). Relationship between the
development of skeletal mesio-occlusion and posterior tooth-
MEAW. Moreover, reconstruction of the occlusal plane
to-denture base discrepancy - Its significance in the
can be performed with the force system coming from orthodontic reconstruction of skeletal class III malocclusion.
the tip back bend and the vertical elastics. Therefore, journal of Japanese Orthodontic Society. 47: 796-810.
MEAW mechanics provides a very effective means for 5. Sato, S., Sakai, H., Sugishita, T., Matsumoto, A., Kubota, M.
and Suzuki, Y. (1994). Developmental alteration of the form
accomplishing the treatment goals.
of denture frame in skeletal Class III malocclusion and its
significance in orthodontic diagnosis and treatment.
International journal of MEAW Technic and Research Foundation.
Acknowledgements 1: 33-46.
6. Sato, S.A. (2001). Treatment approach to malocclusions under
This work was performed in Kanagawa Dental College,
the consideration of craniofacial dynamics. Grace Printing
Research Institute of Occlusion Medicine and supported by a
Press Inc. (Philippines).
grant-in-aid for open research from the Japanese Ministry of
7. Kim, Y.H., (1987). Anterior openbite and its treatment with
Education, Culture, Sports, Science and Technology. The content
multiloop edgewise arch wire. Angle Orthodontist. 57: 290-321.
of this article was originally published in the journal Information
8. Kim, Y.II. (1999). Treatment of severe openbite malocclusions
Orthodontie und Kieferorthopadie (IOK) in German. This issue
without surgical intervention. In: Growth modification: what
in BKDC topics is a secondary publication after translation into
works, what doesn't, and why, Craniofacial Growth Series,
English with copyright permission from IOK (Thieme).
vol. 35, Ann Arbor: Center for Human Growth and
Development, McNamara, J.A. Jr., (Ed.), The University of
Michigan, pp. 193-212.
9. Kim, Y.H. (2000). Treatment of anterior openbite and deep
References overbite malocclusions with the multiloop edgewise archwire
1. Protacio, C. and Sato, S. (1995). The role of posterior (MEAW) therapy. In: The Enigma of the Vertical Dimension.
discrepancy on the development of skeletal Class III Craniofacial Growth Series, vol. 36, Ann Arbor: Center for
malocclusion - Its clinical importance. International journal of Human Growth and Development, McNamara, J.A. Jr., (Ed.),
MEAW Technic and Research Foundation. 2: 5-18. The University of Michigan, pp. 175-202.
2. Sato, S., Takamoto, K. and Suzuki, Y. (1988). Posterior 10. Kim, Y.H. (1974). Overbite Depth Indicator with particular
discrepancy and development of skeletal Class III reference to anterior openbite. American journal of Orthodontics.
malocclusion. Orthodontic Review. Nov/Dec: 16-29. 65: 586-611.

3. Sato, S. (1994). Case report: Developmental characterization 11. Kim, Y. H. and Vietas, J. J. (1978). Anteroposterior Dysplasia
of skeletal Class III malocclusion. Angle Orthodontist. 64:105- Indicator: an adjunct to cephalometric differential diagnosis.
112. American journal of Orthodontics. 73: 619-635.
Bulletin of Kanagawa Dental College
Vol. 35, No. 1, March, PP. 87-94, 2007

Application of MEAW Mechanics to the


Treatment of Class III Malocclusion with
Dental Mid-Line Discrepancy

Kenichi Sasaguri, Susumu Akimoto, Hisaaki Shinji,


Eliana Midori Tanaka and Sadao Sato

Department ofCraniofacial Growth and Development Dentistry, Kanagawa Dental College

Abstract

Midline discrepancy is considered to be one of the complex issues surrounding the plan
ning of orthodontic treatment. Unusual tooth extraction, such as the unilateral removal
of premolars is sometimes applied in an attempt to correct this problem. A clinical case with
a 4 mm midline discrepancy and an anterior cross bite was treated orthodontically with the
application of a multi-loop edgewise arch wire (MEAW) system and no tooth extraction was
performed. The result of the treatment was quite stable and indicated the necessity of repo
sitioning the mandible in asymmetric patients. Based on the results of the treatment, it can
be concluded that a conservative approach that avoids extraction and that consists of fitting
MEAWs with the appropriate use of elastics is an effective mechanotherapy that allows dif
ferential tooth movement and corrects midline discrepancy.

Key words: MEAW I Midline discrepancy I Class III

Introduction anterior cross bite by counter clockwise rotation of the


In orthodontic practice, the correction of midline dis mandible and the midline discrepancy by uprighting the
crepancies constitutes one of the major concerns and un buccal segment of the displaced side of the mandible.
usual solutions, such as unilateral premolar extractions The treatment result was quite stable and indicated that
are sometimes performed in an attempt to correct this the functional reposition of the mandible is indispens
problem. However, orthodontic treatment with such able in asymmetric patients.
dental mutilation involves not only the necessity of the
long-term utilization of asymmetric mechanics, but also Case Presentation
results in an unstable occlusion with unilateral compen A female patient, 17 year 11 months old consulted
sating molar class II or class III interdigitation. The case us, complaining mainly of anterior cross bite and mid
presented here showed a mandibular midline deviation line discrepancy. Her facial appearance was rather sym
of 4 mm to the left from the upper dentition with an metrical in a frontal view with a straight facial profile.
anterior cross bite. This case was treated orthodontically The occlusion findings showed that the mandibular
with no tooth extraction and a multi-loop edgewise arch midline was deviated 4 mm to the left from the upper
wire (MHAYV) system was applied to correct both the dentition with an anterior cross bite, an overjet of 2 mm
and an overbite of 2 mm. The molar relation was Class
Accepted for publication on October 5,2006. III on both sides. The right upper first molar was inter-
Address for correspondence: Kenichi Sasaguri, Department of digitated with the antagonistic lower second molar. The
Craniofacial Growth and Development Dentistry, Kanagawa Dental
College, 82 Inaoka-cho, Yokosuka, Kanagawa, 238-8580, Japan.
calculated arch length discrepancy of the upper and
Tel: +81 -16-822-8880 Fax: +81-46-822-8844 lower dentitions was 2 mm positive and 1 mm positive,
K. Sasaguri et al. Bull. Kanagawa Dent. Col. 35 (2007)

respectively (Fig. 1). Intra-oral examination indicated the Diagnosis and Treatment Planning
impossibility of attaining anterior teeth contact, even This case was diagnosed as a skeletal Class III mal-
though the mandible was manipulated backward. occlusion with anterior cross bite and midline discrep
The cephalometric measurements of the craniofacial ancy. The orthodontic treatment plan called for the
complex revealed a skeletal Class III with ANB of -2 installation of 0.01.8 standard edgewise appliances with
degrees, ODI 70, and APD1100 (Fig. 2, Table 1). Frontal MEAWs following third molar extraction, in order to
cephalogram analysis did not show an obvious man produce an improvement of the anterior cross bite by
dibular lateral displacement and the upper dental mid- raising the bite and uprighting the right buccal teeth to
line was coincident with the facial midline, while the correct the midline shifting.
lower dental midline had shifted 4 mm to the left. A
panoramic radiograph displayed the presence of right Treatment Sequence
upper and lower third molars. Upper and lower edgewise brackets were bonded
Mandibular position analysis using the mandibular after third molar extraction. Leveling was started with a
position indicator (MPL SAM articulator) did not indi 0.014 round NiTi plane arch wire. An upper MEAW with
cate a major deviation of the mandible between the man a contraction combination loop and a lower MEAW were
dibular reference position (RP) and intercuspal position inserted and their tip back bends and crown lingual
(ICP). torque were accentuated during the progression of treat-

Fig. 1: Pre-treatment intraoral and extraoral views.

Mandibular position indicator (MPI) did not show significant difference between reference position (RP) and intercuspal position
(ICP).
Application of MEAW to Treatment of Class III with Mid-line Discrepancy

ment. intermaxillary elastics of 3/16 inches 6 oz between


the upper second loop and the lower first loop (short
Class 111 elastics) were used continuously on both sides.
Since the molar overjet decreased with the uprighting
of the lower buccal teeth, enlargement of the upper den
tition was achieved by applying an overlay expansion
wire (Mulligan). Moreover, for the purposes of closing
the gaps, which had appeared due to the flaring of the
upper front teeth; short Class HI elastics with posterior
cinch back activation were used (Fig. 4, a-f). The total
active treatment was 24 months and the retention pe
riod was 12 months.
Comparing the conditions immediately following
orthodontic treatment and those prevailing 16 months
later, there was no difference between the panoramic
radiograph and the MPI findings (Fig. 3, b, c and Fig. 5-
7).

Fig. 2: Pre-treatment cephalometric analysis Treatment Results and Discussion


, Left| Right The case presented here was diagnosed as skeletal
Class III malocclusion without functional mandibular
shift based on an analysis of the following data; an ar
ticular diagnostic mounted cast, axiographic records of

Table 1: Comparison of cephalometric measurements


K. Sasaguri et al. Bull. Kanagawa Dent. Col. 35 (2007)

crown lingual torque in the MEAW to prevent any un


favorable inclination of the buccal teeth (Fig. 4d). Even
though axis control of the buccal teeth was performed,
the scissor-bite tendency affecting the upper and lower
second molars was not avoided (Fig. 4e). Therefore, great
care should be taken when using this mechanics espe
cially in the combination of MEAW and overlay expan
sion devices.
In order to obtain the Class I molar relationship, an
upper MEAW was fitted that had a contraction loop built
into it, while at the same time, the lower buccal teeth
were in the process of uprighting. When Class III elas
tics were used, the upper anterior teeth began to flare
out, and the advantage of the contraction loop was not
only to prevent anterior spacing, but also to provide a
molar Class I relation due to the molar mesial move
ment arising from the cinch back activation at the termi
nal loops (Fig. 4e). The superimposition of cephalometric
tracings revealed a molar mesial movement with no
unfavorable mesial inclination. The labial inclination of
the upper incisors, the lingual inclination of the lower
incisors and a mandibular clockwise rotation due to the
extrusion of the upper molars contributed to correcting
this malocclusion.
The superimposition of cephalograms taken before
and after orthodontic treatment indicates that the labial
Fig. 3: Panoramic radiographs: (a) pre-treaiment, (b) post- inclination of the upper front teeth, the lingual inclina
treatment, (c) sixteen months after treatment tion of the lower front teeth and mandibular clockwise
rotation due to upper molar extrusion contributed to the
correction of the anterior cross bite. There was no sig
mandibular movement, and frontal and lateral nificant difference in the lower left first molar position
cephalograms. This case was considered a midline shift between before and after orthodontic treatment, while
due to the influence of the lower right third molar, be the position of the lower right first molar was corrected
cause there was no significant difference between the 4 mm distally and the position of the right upper first
anteroposterior position of the right and left upper first molar was corrected 2 mm mesially. These changes in
molars, while the right lower first molar was positioned the position of the upper and lower first molars greatly
anteriorly compared to the left first molar (Fig. 4a). contributed to an improved molar relation (Fig. 8). Based
After three months of leveling, MEAWs with pas on these observations, it can be concluded that MEAW
sive crown lingual torque was applied using short Class with appropriate elastic use was effective on the differ
III elastics full time. A moderate tip back bend was built ential tooth movement on the right and the left. How
into the upper ME AW. Since the lower right buccal teeth ever, because at 14 months after orthodontic treatment
needed more uprighting than in the left; the tip back there was a relapse and the right molar relation had re
bend of the lower right buccal segment was more ac turned 2 mm (Fig. 9), it is necessary to consider how to
centuated than that on the left (Fig. 4 b and c). Due to bring about a stabilized occlusion.
the right-left difference of the molar relationship, greater
active elastic forces were exerted on the right side than
in the left, although the same short Class III elastics were Acknowledgements
used on both sides. This was effective to bring about This work was performed in Kanagawa Dental College,
differential tooth movement in the case of the midline Research Institute of Occlusion Medicine and supported by grant-
shift. in-aid for open research from the Japanese Ministry of Education,
Culture, Sports, Science and Technology. The content of this article
During progression of molar uprighting, the overjet
was originally published in the journal Information Orthodontie
of the buccal segments gradually decreased due to the und Kieferoi thopadie (IOK) in German. This issue in BKDC topics
buccal uprighting of the lower premolars and molars. is a secondary publication after translation into English with
Thus, enlargement (expansion) of the upper dentition copyright permission from IOK (Thieme).

by overlay wire (Mulligan) was carried out with strong


Application of ME AW to Treatment of Class III with Mid-line Discrepancy

Fig. 4: Intraoral views (a to f) showing the progression of the orthodontic treatment within a total period of 24 months.
K. Sasaguri et al. Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 5: Intraoral and extraoral views and mandibular position record by MPI after orthodontic treatment.
Application of MEAW to Treatment of Class III with Mid-line Discrepancy

vs. X-

Z _o. R n

z
Fig. 6: Intraoral views and mandibular position record (MPI) sixteen months after treatment.

Fig. 7: Cephalometric analysis: (a) post-treatment, (b) sixteen months after orthodontic treatment
K. Sasaguri et al. Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 8: Superimposition of tracings pre and post treatment.

Fig. 9: Superimposition of tracings pre-treatment and sixteen months later.

References 4. I'iehslinger, E., Celar, A., Celar, R., Jager, VV. and Slavicek, R.
1. Kim, Y.H. (1987). Anterior open bite and its treatment with (1993). Reproducibility of the condylar reference position. /.
multiloop edgewise arch wire. Angle Orlhod. 57: 290-321. Orofac. Pain. 7: 68-75.
2. Kim, Y.H. (1974). Overbite depth indicator with particular 5. Slavicek, R. (1988). Clinical and instrumental functional
reference to anterior open-bite. Am.}. Orthod. 65: 586-610. analysis and treatment planning. Part 4. Instrumental analysis
3. Kim, Y.I I. and Vietas, J.J. (1978). Anteroposterior dysplasia of mandibular casts using the mandibular position indicator.
indicator. An adjunct to cephalometric differential diagnosis. /. Clin. Orthod. 22: 566-575.
Am. j. Orthod. 73: 719-733.
Bulletin of Kanagawa Dental College

Vol. 35, No. 1, March, PI3. 95-104, 2007

Orthodontic Treatment of Class III


Malocclusions Associated with
Mandibular Lateral Deviation

Susumu Akimoto, Mitsuyoshi Kubota, Atsushi Matsumoto, Sadao Sato,


Eliana Midori Tanaka and Ales Celar*

Department of Craniofacial Growth and Development Dentistry,


Kanagawa Dental College
* Department of Orthodontics, Medical University of Vienna, Bernhard Gottlieb
Dental Clinic, Vienna, Austria

Abstract

A Skeletal Class III reversed occlusion morphologically defined by mandibular prognathism,


maxillary retrognatism or a combination of the two is often accompanied by mandibular
lateral deviation (MLD) and in most cases is considered an indication for orthognatic sur
gery. Posterior discrepancy, i.e. tooth-to-denture base discrepancy in the posterior area
resulting in crowding distal to the first molars, has not been regarded as an etiological factor
causing lateral mandibular displacement. In this respect, it is important to recognize the
effects of the flattening of the occlusal plane (OP) as well as variations in the vertical dimen
sion on both sides due to the unilateral over-eruption of the molars caused by the squeez-
ing-out effect of posterior discrepancy. This affects the vertical relationship of the dentition
providing interferences in occlusal function and contributes to the malposition of the man
dible, associated with a decreased vertical dimension and higher positioning of the man
dibular condyle on the displaced side. Therefore, it should be emphasized that elimination of
the posterior discrepancy prior to the differential vertical dimension control of the occlusal
planes is of paramount importance in the planning of any treatment of Class III malocclu
sions with MLD. Two clinical case examples will illustrate how premature occlusal contacts
have resulted in lateral mandibular deviation in dentitions showing posterior discrepancy.
Orthodontic treatment was achieved with the reconstruction of the deviant occlusal planes
using multiloop edgewise arch wires subsequent to the extraction of the third molars to
eliminate the posterior discrepancy in order to reestablish the appropriate mandibular posi
tion and to improve the lateral mandibular displacement and associated symptoms relating
to temporomandibular joint dysfunction with no surgical intervention.

Key words: Class HI malocclusioti I Lateral mandibular deviation I Posterior


discrepancy I Occlusal Plane I Multiloop edgewise arch wire

Introduction purely orthodontic approach (1-9). The current situation


A skeletal configuration characterized by a reverse is predominantly suggestive of surgical correction as the
overjet-overbite and mandibular lateral deviation in only treatment option for the management of many MLD
volves a combination of different three-dimensional adult cases.
dental and skeletal components (anterior-posterior, Treatment of malocclusion can be roughly divided
transverse and vertical) causing the development of the into two groups based on the treatment prognosis: pal
malocclusion. This MLD malocclusion is a complex clini liative or curative therapy. Where the cause is unknown,
cal entity assessed as unlikely for correction with a palliative therapy is carried out. If the cause can be sus
pected or identified, an etiology-oriented treatment is
Accepted for publication on October 5, 2006.
Address for correspondence: Susunui Akimoto, Department of
preferable because a relapse will be more likely to occur
Craniofacial Growth and Development, Kanagawa Dental College, after palliative treatment that does not correct or eradi
82 Inaoka-cho, Yokosuka, Kanagawa, 238-8580, Japan. cate the cause of the problem.
Tel: +81-46-822-8880 (ex. 2381) l:ax: +81-46-822-8844
S. Akimoto et al. Bull. Kanagawa Dent. Col. 35 (2007)

The etiological factors in the development of MLD and reestablish the differences in the occlusal vertical
malocclusions have been claimed to originate from ge dimensions on both sides.
netic backgrounds, mal- formations, abnormal habits, In the pathogenesis of MLD, posterior discrepancy
growth anomalies, external injuries, etc. Most of the MLD has been considered to be an underlying factor. For this
conditions are treated in a palliative way. If the devia reason, extraction of the upper third molars had been
tion exceeds a certain limit as judged by the individual performed before the placement of the multi-bracket
orthodontist, the correction of the malocclusion is often appliance in both arches. The engaged multiloop edge
considered to be too difficult to treat without surgical wise arch wires (15) were activated and heat-treated to
intervention. produce the subsequent movements; 1) uprighting and
However, irregularities in tooth position are fre intrusion of mandibular molars, 2) intrusion of the max
quently encountered in different types of malocclusion illary molars, 3) a marked intrusion on the right com
and it is not particularly unusual to be confronted with pared to the left side. At the same time, short class III
MLD in orthodontic patients. No claim for the above- elastics (3/16 inch, 6 oz.) were used in the anterior loops.
mentioned etiology can be made for the majority of pa Three months after starting orthodontic treatment, a
tients but rather a small minority. A discussion of dental significant improvement in the occlusion had occurred
positional irregularities follows. (Fig. 5). The above-mentioned mechanics enabled the
Deviation from the ideal dental position, so called, transverse correction of the occlusal plane inclination
dental malposition or misalignment of the teeth impairs by controlling the differences of vertical dimension on
the dental arch form, generates occlusal premature con both left and right sides - a key feature in the treatment
tacts, and the position of the mandible is highly affected of MLD (15). The duration of active treatment was ap
(2, 3). Minor or major MLD malocclusions result from proximately one year. Intraoral photographs taken af
transversely different degrees of deviation from the den ter bracket removal (Fig. 6) show that the stability of the
tal position (10) (see patient 1). MLD malocclusion shows occlusion after one month is the same as after five months
a transverse inclination of the occlusal plane as well as and 20 months of the retention phase (Fig. 7). A slight
different muscle activity on both sides because of dis class III tendency persisted in the first molar.
parities between the left and right occlusal vertical di In spite of the short treatment length, the stability of
mensions (11). From this point of view, many MLD cases the occlusion was accomplished by eliminating the di
can be treated using orthodontics by eliminating the etio agnosed cause even in MLD combined with anterior
logical factor, i.e. the discrepancy in tooth position. In openbite and reversed occlusion. In this sense, the cor
fact, surgical correction is not a consideration. The fol rection of the posterior discrepancy represents a signifi
lowing clinical cases document non-surgical orthodon cant treatment objective although the lack of posterior
tic therapy with elimination of the MLD associated cause, space for the eruption of third molars has often been
particularly the posterior discrepancy (1,4, 5,12-14). neglected. In this exemplary patient we may assume that
the MLD would not have been able to develop if the
Patient 1 third molars had been extracted earlier in the initial treat
An 18-year-old female patient consulted the dental ment approach. A current extraction option is the re
clinic again with a jaw deviation as her chief complaint moval of the maxillary second molars instead of the third
(Fig. 1). At age 11, the previous orthodontist had diag molars to relieve posterior discrepancy, namely before
nosed a slight tendency toward an inverse overbite and age 15. This prompt intervention helps avoid the prob
had applied a multi-bracket treatment for approximately lem of time until the third molars can be removed.
six months (Figs. 2, 3). Following this, a chin cup was
used and the lower third molars were extracted to pre Patient 2
vent the anterior cross bite. In Fig. 4, a mandibular posi A woman aged 24 years who was attending a dental
tion with a coincidence of dental maxillary and clinic requested surgical correction for her facial asym
mandibular midlines can be seen accompanied by a uni metry (MLD). Her main concerns were occlusal dishar
lateral occlusal contact at the right molars, whereas an mony, a prominent chin, and a crooked facial
openbite and inverse over jet prevail anteriorly. appearance. Her mandible had shifted to the left and
The displacement of the mandible to the left resulted her right cheek was straight while the left cheek was
from the occlusal interference on the right side where rather round (Fig. 8). The intraoral photographs showed
the second molar had been squeezed out and had over- that all third molars had erupted, furthermore there was
erupted due to the abnormal high position of the right an anterior openbite, a crossbite of the left canines, a ten
upper third molar (see panoramic radiograph in Fig. 1). dency toward inverse overjet, and the lower midline had
Considering a therapeutic position with coincident mid- shifted 5.5 mm to the left (Fig. 9).
lines (Fig. 4), the treatment mechanics was focused on According to the patient's history, all previous con
designing a force system to correct the anterior crossbite sultations in Yokohama and Tokyo at age 13 had con-
Orthodontic Treatment of Class 111 Malocclusion with Mandibular Lateral Deviation

Fig. 1: Patient 1. Facial (frontal and profile views) and intraoral (anterior, occlusal and lateral views) photographs and panoramic
radiograph at age 18. Head posture tends to turn toward to the left, differences in vertical position between the left and right eyes and
shoulders, lower midline discrepancy to the left 3 mm, overbite and overjet 1 mm each (almost edge-to-edge), mandibular third
molars extracted, different direction of left and right maxillary third molars: the mesial inclination of the right third molar caused the
squeeze-out of the right second molar creating occlusal interference on the right side which produced the mandibular shifting to the
left and the class III tendency increased.
S. Akimoto et ah Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 2: Frontal and profile views at initial consultation at age 11 yrs, four months.

Fig. 3: Facial (frontal and profile) and intraoral views during six months treatment and after bracket removal. A chin cup was
used for a further six months, whereupon both mandibular third molars were extracted.
Orthodontic Treatment of Class Ul Malocdusion with Mandibular Lateral Deviation

Fig. 4: Intraoral views of second consultation at the dental clinic show coincident midlines whereas coincidence of the midlines from
the actual position show a negative overbite and overjet, occiusal contact at the right premolars but no occlusal contact on the left
side. Therefore the right vertical occlusal dimension is longer than that on the left.

Fig. 5: Intraoral views three months after the beginning of treatment: canine relationship almost reaches class I. Improvement of the
midlines, overjet and overbite is observed.

Fig. 6: Intraoral views one month after orthodontic appliance removal.


S. Akimoto et ah Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 7: Post-treatment frontal and profile views after five months and post-treatment intraoral views after 20 months.

eluded that an improvement of her occlusion could only (Fig. 12). Seven months after the beginning of treatment,
be achieved through surgical intervention. So she waited the overjet and overbite had turned into positive values
to reach the age possible for operation and as a conse (Fig. 13).
quence, came to our institute. In addition, from age 17 The active orthodontic treatment lasted approxi
onward, the facial asymmetry had become more pro mately 16 months (Fig. 14). The correction of the maloc-
nounced in concordance with the eruption of the third clusion was achieved only by orthodontic therapy
molars. Moreover the patient preference was for non- although the patient had been advised to undergo
surgical treatment, if possible. orthognathic surgery at other medical institutions. Pos
The removal of all third molars was considered cru terior discrepancy was regarded as the cause of the MLD
cial owing to their association with MLD. Then orth and its elimination, was accompanied by the correction
odontic therapy was carried out without surgery (Fig. of the openbite and the skeletal reverse occlusion.
10). The inherent trend toward skeletal inverse overbite
made it necessary to upright and intrude the mandibu- Discussion
lar posterior teeth. This is why a plain arch wire (.016 Orthodontic diagnosis and treatment of skeletal re
inch round) was used on the maxillary dentition while versed occlusion with MLD should find and correct the
an MEAW with a reverse curve of Spee (.016 x .022 inch) etiology of the present symptoms. Many of these are
was engaged in the mandibular arch. Vertical short class slight deviations from a normal tooth position. The dif
III elastics (3/16 inch, 6 oz.) were used at the anterior L- ferences iii the extent of symptoms depend on the per
loops. As shown in the figures, class III elastics were sistence of the causative factor. Some symptoms remain
used at the same corresponding spots on the left and minor while the pathogenic impact lasts longer in other
right. As a result, the elastics generated a higher force patients. Then the necessity for surgical correction may
on the right side due to the MLD (Fig. 11). Improvement erroneously appear unavoidable. However, dental po
in the midline had already become visible after six weeks sitional deviations have not been taken into sufficient
Orthodontic Treatment of Class III Malocclusion with Mandibular Lateral Deviation

Fig. 8: Patient 2. Facial (frontal and profile) views. The


patient was worried about her occlusion, a prominent
chin, an oblique face with the mandible shifted to the
left, the right cheek being straight and the left cheek
round.

Fig. 9: Pre-treatment intraoral views. All third molars had erupted. Viewed from the frontal aspect, a correct intercuspation
disclosed the mandibular midline deviation of about one lower incisor width and an anterior openbite. From a lateral view,
the overjet was 0 mm.

consideration as the cause of developing MLD. It still 9). Both patients in this article suffered from temporo-
could happen that MLD patients, who might be success mandibular dysfunction symptoms, which were relieved
fully corrected by a pure orthodontic approach, are still by orthodontic therapy. From this point of view, maloc
eligible and need to undergo orthognathic surgery. clusion has been strongly associated with temporoman-
MLD does not occur exclusively in skeletal reversed dibular dysfunction and many patients have also shown
occlusion but also in mandibular retrognathia. In MLD an association with posterior discrepancy.
malocclusion there is a higher probability of temporo-
mandibular dysfunction than in other malocclusions (8,
S. Akimoto et si. Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 10: Intraoral views after third molar extractions, just before bracketing.

Fig. 11: intraoral views at the beginning of treatment.

Fig. 12: Above: Lateral view with coin

cident midlines at the time of bracket


fixation showed a skeletal openbite.
Below: Lateral view with coincident mid-
lines six weeks after starting treatment.
The direction and orientation of the oc-
clusal plane movement was visible.
Orthodontic Treatment of Class 111 Ma I occlusion with Mandibular Lateral Deviation

Fig. 13: After seven months, overjet and overbite have become positive - initially overjet and
overbite were negative when the midlines coincided.

Fig. 14: Intraoral views at the end of treatment. After 16 months, the appliances were removed. The midlines

coincided and the openbite was corrected.

and Suzuki, Y. (1994). Developmental alteration of the form


Acknowledgements
of denture frame in skeletal Class TTI malocclusion and its
This work was perforated in Kanagawa Dental College, significance in orthodontic diagnosis and treatment hit j.
Research Institute of Occlusion Medicine and supported by a MEAW Tech Res Found. 1: 33-46.
grant-in-aid for open research from the Japanese Ministry of 4. Sato, S., Takamoto, K. and Suzuki, ,1988), Posterior
Education, Culture, Sports, Science and Technology. The content discrepancy and development of skeletal Class III
of this article was originally published in the journal Information malocclusion. Orthodontic Review. Nov/Dec: 16-29.
Orthodontie und Kieferorthopadie (IOK) in German. This issue 5. Sato, S. and Suzuki, Y. (1988). Relationship between the
in BKDC topics is a secondary publication after translation into development of skeletal mesio-occlusion and posterior tooth-
English with copyright permission from IOK (Thieme). to-denture base discrepancy - Its significance in the
orthodontic reconstruction of skeletal class III malocclusion.
journal of Japanese Orthodontic Society. 47: 796-810.
6. Sato, S., Takamoto, K., Fushima, K.., Akimoto, S. and Suzuki,
References
Y. (1989). A new orthodontic approach to mandibular lateral
1. Sato, S. (1987). Alteration of occlusal plane due to posterior
displacement malocclusion - Importance of occlusal plane
discrepancy related to development of malocclusion -
reconstruction -. Dentistry in japan. 26: 81-85,
Introduction to denture frame analysis. Bull Kanagawa Dent
7. Pushima, K., Odaira, Y., Saito, N., Tsurumi, F. and Sato, S.
Coil. 15: 115-123.
(1998). Dental asymmetry in facial asymmetry. Bulletin of
2. Sato, S. (1994). Case report: Developmental characterization
Kanagawa Dental Colleg. 26:15-21.
of skeletal Class III malocclusion. Angle Orthod. 64:105-112.
8. Inui, M., Fushima, K. and Sato, S. (1999). Facial asymmetry in
3. Sato, S., Sakai, H., Sugishita, T., Matsumolo, A., Kubota, M.
S. Akimoto et al. Bull. Kanagawa Dent. Col. 35 (2007)

temporomandibulnr joint disorders. Journal of Oral malocclusion - Its clinical importance, hit J. MEA\N Tech Res
Rehabilitation. 26:402-406. Found. 2: 5-18.
9. Fushima, K., Inui, M. and Sato, S. (1999). Dental asymmetry in 13. Sato, S., Suzuki, N. and Suzuki, Y. (1988). Longitudinal study
temporomandibular disorders, journal of Oral Rehabilitation. 26: of the cant of occlusal plane and denture frame in cases with
752-756. congenitally missing third molars. Further evidence for the
10. Sato, S.A. (2001). Treatment approach to malocclusions under occlusal plane change related to posterior discrepancy. /. jpn
the consideration of craniofacial dynamics. Grace Printing Orthod Soc. 47:517-525.
Press Inc. (Philippines). 14. Sato, S., Dennis, C.L., Miyakawa, Y. and Kim, R.H. (1998). The
11. Akimoto, S., Fushima, K., Sato, S. and Suzuki, Y. (1995). development of openbite as a result of posterior discrepancy
Masticatory muscle activity of the facial asymmetry cases - and its treatment approach using mutiloop edgewise arch wire.
Effects of the different combination of bite blocks -. The journal hit /. MEAW Tech Res Found. 5: 5-15.
of Orthodontic Society. 54(6): 436-440. 15. Sato, S., Akimoto, S., Matsumoto, A., Shirasu, A., Yoshida, J.
12. Protacio, C. and Sato, S. (1995). The role of posterior and Sato, S. (2002). MEAW - Manual for the clinical application
discrepancy on the development of skeletal Class III of MEAW technique. Printing Press Inc. (Philippines).
Bulletin of Kanagawa Dental College
Vol. 35, No. 1, March, PP. 105-111, 2007

Interception of Decompensated Class III


Malocclusions in Early Mixed Dentition

Hisaaki Shinji, Takehiko Hiyama, Mina Yamaguchi,


Kanji Onodera and Sadao Sato

Department of Craniofacial Growth and Development Dentistry, Kanagawa Dental College

Abstract

In the early period of mixed dentition, various malocclusions may potentially occur that can
manifest themselves clinically. Preventive and interceptive treatment must be given prior
ity in order to avoid the risk of developing a skeletal malocclusion in the future. During the
development of the dentition, a deficiency in the vertical dimension of occlusion may result in
a Class III malocclusion with a closed mandibular rotation as a sign of the vertical decom
pensation. The correction of the occlusal vertical dimension with the use of simple treatment
procedures such as supra-occlusal surfaces normalizes the occlusion during the later devel
opment as well as possible. This article describes an early treatment of the Class III maloc
clusion caused by decompensation, where the vertical dimension was raised by using supra-
occlusal surfaces. Due to bite raising, the mandible adapts to a posterior position and the
dentition continues to erupt into a Class I relationship. The correction of the occlusal vertical
dimension can reorient the developmental direction abnormal tendency from the early mixed
dentition period.

Key words: Class III I Interceptive treatment I Early treatment I


Vertical dimension

Introduction malocclusion in the permanent dentition. If malocclu


In the early period of mixed dentition, various mal sion is detected in the early developmental stage and
occlusions such as crowding, deep bite, cross bite and when the mandibular and facial growth patterns are
openbite may occur that can manifest themselves clini properly controlled, the number of cases needing surgi
cally. For this reason, priority must be given to preven cal intervention for the treatment of skeletal dysgnathias
tive and interceptive treatment in order to avoid the risk will be reduced. The relevant steps to prevent maloc
of a skeletal malocclusion developing in the future. Con clusion are considered to be: to more clearly understand
sidering malocclusions, there is a tendency to focus only the growth and developmental changes in the craniofa
on the dentition and to overlook the developmental cial complex, as well as the occlusion, and to correct the
changes in the facial complex, the mandible, as well as developing malocclusion at the earliest possible stage.
the maxilla. A treatment approach for the correction of
malocclusions without regard to growth and develop Relationship between cranio-facial complex
mental changes can lead to a lack of stability and an in and the mandible
crement in relapse risk. Under certain circumstances, Since the origin of bipedalism with an upright body
surgical correction is likely to be needed when treating posture, the cranial base angle has slowly become
smaller. Concomitantly, the growth direction of the
Accepted for publication on October 5,2006. maxillary complex bordering the cranial base has
Address for correspondence: Hisaaki Shinji,Department of changed to predominantly downward instead of for
Craniofacial Growth and Development Dentistry, Kanagawa Dental
College, 82 Inaoka-cho, Yokosuka, Kanagawa, 238-8580, Japan. ward, and the head has adopted an erect and upright
Tel: +81-46-822-8880 (ex. 2381) Fax: +81-46-822-8844 posture. Additionally, the antero-posterior dimension
1. Shinji et ah Bull. Kanagawa Dent. Col. 35 (2007)

of the maxilla has reduced and the space available for the later regular occlusion development. If the develop
the molars has correspondingly decreased. This explains ing malocclusion is influenced therapeutically, it is nec
the high frequency of third molar impaction in modern essary to keep in mind that the nialocclusion seems to
man. Such a discrepancy in the molar area (posterior be dependent on the occlusal plane and the occlusal ver
discrepancy) can cause an over-eruption of the poste tical dimension.
rior teeth and several unfavorable changes in occlusion This article proposes early treatment of the Class III
take place (1-6). This explains how a hyper divergent malocclusion caused by decompensation, where verti
(high angle) Class III nialocclusion with anterior cal dimension is raised by using supra-occlusal surfaces.
openbite develops. The flattening of the occlusal plane Two patient treatment plans arc presented as an ex
as a result of the increment of the posterior vertical di ample.
mension is due to posterior discrepancy. The mandible
adapts functionally to this by rotating forward to main Treatment
tain the occlusion, using the over-erupted molar area as At the initial examination, there is an evaluation of
a fulcrum of rotational axis. Simultaneously, the man the patient's chief complaint, the anamnesis, and the
dible also moves forward. A hyper divergent Class III initial findings. Articulator-mounted models (Fig. la),
nialocclusion is therefore understood to be the result of MPI (Mandible Position Indicator), panoramic radio
a forward positioning of the mandible opposed to the graph (Fig. 2a) and cephalograms (Figs. 2b and c), ex
enlarging of the posterior occlusal vertical dimension. tra-oral/ intra-oral pictures, and a functional analysis
On the other hand, a hypo-divergent (low angle) Class in the articulator (vertical dimension, occlusal plane,
III nialocclusion can also occur during the development mandibular position, and TMJ) are used for the diagno
of dentition, in addition to a hyper divergent nialocclu sis and treatment plan. After a thorough explanation to
sion. This develops through decompensation caused by the patient, treatment begins with his/her consent.
a reduced posterior occlusal vertical dimension, in other Adjusting the occlusion position of the model at the
words insufficient posterior vertical support. MPI, waxing of the new supra-occlusal surfaces of the
lower deciduous molars is performed in order to estab
Class III malocclusion caused by lish the new corrected mandibular position. The waxed
decompensation occlusive surfaces are formed from the Kerr impression
Homo sapiens, with its varying types of skeletal compound. The hardened Kerr silicone impression is
frame has a tendency to reach Class I occlusion despite used as a mold (matrix) for the later added acrylic resin
the existing skeletal deviations. This means that the func (fill in and repositioning onto the non-waxed up/off
tional development and the consequent structural ad model). The manufactured supra-occlusal surfaces will
aptation show a somatic response to constantly attain a be cemented to the occlusal surfaces of the deciduous
normal function, to stabilize, and to maintain it. But molars and are to be regularly checked. Fig. lb shows
reaching the ortho-function is only possible through the the supra-occlusal surfaces formed by acrylic resin.
compensation of skeletal shifting. When the adaptation
reaches its limit, the body uses a compensatory mecha Patient 1
nism to achieve a more efficient function. Compensa A seven-year-old boy visited the pediatric depart
tory mechanisms appear in all varieties of skeletal ment of the Kanagawa Dental College Hospital com
alterations especially during the period of dentition de plaining chiefly of a nialocclusion. He exhibited early
velopmental in order to accomplish the ortho-function. mixed dentition with an anterior cross bite. The normal
Where there is insufficient compensation, a skeletal number of teeth was presented and no abnormal find
alteration caused by decompensation develops. In such ings appeared on panoramic radiograph examination,
a case, early occlusion treatment is important because as shown in Fig. 2a. The results of the cephalometric
decompensation is the factor that has the greatest influ analysis of the lateral cephalogram are shown in Tables
ence on functional malocclusion during dentition devel 1 and 2. The overjet and overbite were 1.0 mm and 0.0
opment later on. A Class III malocclusion develops due mm respectively. The terminal plane was a mesial step
to the simple forward rotation of the mandible as a re type on both the right and the left side. A pointed den
sult of an insufficient occlusal vertical dimension (dec tal arch form in the maxilla and squared in the man
ompensation) or due to a forward rotation of the dible were observed at the dental cast analysis. Also,
mandible as a result of an excessive occlusal vertical di the upper right and left first molars were erupting. In-
mension (adaptation). Most hypo-divergent Class III traoral photographs (Figs. 3a ~ g) show the progress of
malocclusions are accompanied by a vertical decompen this case. The upper central incisors were observed to
sation as a result of a lack of occlusal vertical dimen be erupting with a reversed occlusion (anterior cross bite)
sion. Therefore, any increase in occlusal vertical at the time of the initial examination. The intraoral pho
dimension is appreciated as compensation for reaching tographs taken at the initial examination and after ap-
Interceptive Treatment of Class III Malocclusion

Fig. 1: The establishment of the caps as supra-occlusal surfaces (acrylic resin).

(a) Articulating mounted casts, fb) Supra-occlusal surfaces on the deciduous molars.

Fig. 2: Radiographs at the point of the initial examination (case 1):


(a) Orthopantomograrn, (b) frontal cephalogram, (c) lateral cephalogram.
H. Shinji et al. Bull. Kanagawa Dent. Col. 35 (2007)

Table 1: Analysis of the cephalogram at the time of the initial examination - Cephalometrical analysis

Cephalomelric Analysis

Data Average/mean Standard


deviation

Facial angle 85 83.7 3.3


Convexity 175 163.5 5.3
A-B Plane -4 -6.7 2.4
Mandibular plane 33 31.5 5.1
Y-axis 64 63.8 3.6
Occlusal plane 20 14.4 4
Interincisal angle 134 12.1
L-l to mandibular plane 88 89.5 6.5
FH-SN 8 8 3
SNP 75 76 5.5
SN-GN 74 71.6 1.9
SNA 79 81.4 3.3
SNB 76 76.2 2.9
U-l to I'M 104.8 9
U-l to SN 96.8 8.2
Gonial angle 135 130.1 1.3
GZN 87 89.4 5.3
Kamus inclination 78 81.6 4.4

Table 2: Analysis of the cephalogram at the time of initial examination - Denture frame analysis

Denture Frame Analysis

Standard
deviation

FH-MP 4.3
PP-MP 3.9
OP-MP 3.7
OP-M P/PP-MP
AB-MP 4.4
A'-P' 2.5
A'-6' 2.5
A'6'M'P'
I-AB(o) 4
I-AB (mm) 1.5
l-AB(o) 4.4
1-AB (mm) 1.4
Intermolar angle 3.7
ODI 5.3
APDI 4.4

plying the supra-occlusal surfaces are shown in Figs. 3a edge-to-edge bite is seen to remain after two months (Fig.
and b. At the point of applying the supra-occlusal sur 3d). Fig. 3e shows an occlusal condition after three
faces, an anterior openbite was visible. One month after months. Fig. 3f shows an occlusal condition after seven
the supra-occlusal surfaces had been applied, the over- months. The normal position of the anterior teeth was
bite had become approximately 1.0 mm (Fig. 3c). An gradually reached after nine months (Fig. 3g).
Tnterceptive Treatment of Class III Malocclusion

Fig. 3: Changes in the occlusion (case 1).


(a) Intra-oral pictures at the time of the initial examination (b) At the time of applying the supra-occlusal surfaces
(B) one month later (d) two months later (e) three months later (f) seven months later (g) nine months later.
H. Shinji et a\. Bull. Kanagawa Dent. Col. 35 (2007)

Patient 2 at the time when the supra-occlusal surfaces were ap


An eight-year-old child with reversed occlusion (an plied, there was a slight anterior openbite (Fig. 4b), 11
terior cross bite) received the same treatment as patient months later the bite was corrected (Fig. 4c). The condi
1. Figure 4 shows the occlusion changes from the begin tion after one year and five months is shown in Fig. 4d,
ning of the initial examination. At the time of the initial and two years and five months later, an appropriate
examination an anterior cross bite was present (Fig. 4a), anterior tooth position was reached (Fig. 4e).

Fig. 4: Changes in the occlusion (case 2).


(a) Intra-oral pictures at the time of the initial examination (b) At the time of applying the supra-occlusal surfaces (c) 11
months later (d) one year and five months later (e) two years and five months later.
Interceptive Treatment of Class III Malocclusion

Discussion Acknowledgements
The dento-alveolar growth is tightly correlated with
This work was performed in Kanagawa Dental College,
the maxillo-facial development and should therefore not Research Institute of Occlusion Medicine and supported by a
be considered separately. The same applies for the oc grant-in-aid for open research from the Japanese Ministry of
Education, Culture, Sports, Science and Technology. The content
clusion development. From a functional standpoint, the
of this article was originally published in the journal Information
dento-alveolar growth and the maxillo-facial develop
Orthodontie und Kieferorthopadie (1OK) in German. This issue
ment influence each other. Consequently, it is impor in BKDC topics is a secondary publication after translation into
tant to completely grasp the effects on the occlusion English with copyright permission from IOK (Thieme).

whenever iatrogenic occlusal changes are present dur


ing the developmental period, and furthermore, to cor
rect them accordingly. The occlusal plane and occlusal References

vertical dimension play an extremely important role in 1. Sato, S. (1994). Case report: Developmental characterization
of skeletal Class III malocclusion. Angle Orthod. 64:105-112.
the development of malocclusions and are therefore es
2. Sato, S., Sakai, II., Sugishita, T., Matsumoto, A., Kubota, M.
sential factors to be considered in the planning and treat and Suzuki, Y. (1994). Developmental alteration of the form
ment phase (7, 8). of denture frame in skeletal Class III malocclusion and its
The effectiveness of an early treatment of the ante significance in orthodontic diagnosis and treatment, Int f.
MEAW Tech Res Found. 1: 33-46.
rior cross bite in Class III malocclusions during the de
3. Sato, S., Dennis, C.L., Miyakawa, Y. and Kim, R.H. (1998). The
velopmental phase has already been shown. The development of openbite as a result of posterior discrepancy
advantages of the active control of the occlusal vertical and its treatment approach using mutiloop edgewise arch wire.
dimension have been only reported by Al-Sehaibany et hit}. MEAW Tech Res Found. 5: 5-15.
4. Sato, S., Takamoto, K. and Suzuki, Y. (1988). Posterior
al. (9, 10) and Alexander et a\. (11). As proven in this
discrepancy and development of skeletal Class III
paper, during the development of the dentition, a defi malocclusion. Orthodontic Review. Nov/Dec: 16-29.
cient vertical dimension in the occlusion may result in a 5. Sato, S. and Suzuki, Y. (1988). Relationship between the
Class III malocclusion with a closed mandibular rota development of skeletal mesio-occlusion and posterior tooth-
to-denture base discrepancy - Its significance in the
tion as a sign of the vertical decompensation. Due to bite
orthodontic reconstruction of skeletal Class III malocclusion.
raising, the mandible adapts to a posterior position and journal of Japanese Orthodontic Society. 47: 796-810.
the dentition continues to erupt into a Class I relation 6. Sato, S., Motoyanagi, K., Suzuki, T., Imasaka, S. and Suzuki,
ship. Y. (1988). Longitudinal study of the development of skeletal
malocclusions. /. Jpn Orthod Soc. 47:186-196.
The correction of the occlusal vertical dimension with
7. Sato, S.A. (2001). Treatment approach to malocclusions under
simple treatment procedures such as supra-occlusal sur the consideration of craniofacial dynamics. Grace Printing
faces normalizes the occlusion during the later devel Press Inc. (Philippines).
opment as far as possible. 8. Sato, S., Akimoto, S., Matsumoto, A., Shirasu, A., Yoshida, J.
and Sato, S. (2002). MEAW - Manual for the clinical application
The discrepancy in the vertical dimension that origi
of MEAW technique. Printing Press Inc. (Philippines).
nated in the developmental period of the occlusion can 9. Al-Sehaibany, F., and White, G.E. (1996). Posterior bite raising
exceed the adaptation capacity and lead to functional effect on the length of the ramus of the mandible in primary
anomalies later on. The correction of the occlusal verti anterior crossbite: Case report. /. Clin. Pediatric Dent. 21:21-26.
10. Al-Sehaibany, P., and White, G.E. (1998). A three dimensional
cal dimension can reorient the developmental direction
clinical approach for anterior crossbite treatment in early mixed
abnormal tendency from the early mixed dentition pe dentition using an ultrablock appliance: case report. /. Clin.
riod on. Pediatric Dent. 23:1-8.
11. Alexander, S., Jumlongras, D. and White G.E. (1999).
Perspective in posterior vertical dimension: three case reports.
/. Clin. Pediatric Dent. 23: 301-314.
Bulletin of Kanagawa Dental College

Vol. 35, No. 1, March, PP. 113-125, 2007

Interdisciplinary Treatment Approach to a


Patient with Severe Mandibular Displacement
and Dysfunction of Craniomandibular System

Katsushi Tamaki1, Ales G. Celar2, Rudolf Slavicek3 and Sadao Sato4

1 Department of Oral ami Maxilbfacial Rehabilitation,


Kanagawa Dental College

2 Department of Orthodontics, University of Vienna, Vienna, Austria


3 Department of Environmental and Medical Sciences,
Center for Interdisciplinary Dentistry, Donau Umversitat Krctns
4 Department of Craniofacial Growth and Development Dentistry,
Kanagawa Dental College

Abstract

Mandibular lateral displacement (MLD) malocclusion demands one of the most difficult
treatment modalities, because it can be associated with complex symptoms such as
TMJ pain, head and neck pain, cervical pain, and functional disturbances of the
craniomandibular system (CMS). This report describes an interdisciplinary approach includ
ing endodontic, orthodontic, and prosthodontic treatment of MLD malocclusion with severe
problems in the CMS, head and neck and including other somatic symptoms. Clinical exami
nation and instrumental analysis of the functional condylar paths using computerized
axiographic recordings of hinge axis movement indicated a displaced mandible due to incor
rect articulation of the teeth and lack of posterior occlusal support. Orthodontic correction of
the dentition provided mandibular repositioning and relief from muscle pain and dysfunction.
Prosthodontic occlusal reconstruction provided a stabilization of the corrected mandibular
position, and ensured proper occlusal guidance and occlusal support. Post-treatment exami
nations indicated that most of the pain dysfunction symptoms had disappeared and smooth
condylar movements were observed with no limitation during normal functions. A
multidisciplinary approach combining orthodontics and prosthodontics enhanced the treat
ment of a complex malocclusion and its functional disturbances without need for surgical
intervention.

Key words: CMS I Mandibular displacement I Orthodontics I Prosthodontics

Introduction synovial apparatus, ligaments, retroarticular connective


All phases of restorative dentistry and orthodontics tissues and muscles with neural control networks (1, 2).
are dependent on the position of the mandible relative The system is involved in several physiological func
to the cranium and the functional movements of the tions such as mastication, swallowing, respiration,
mandible. Over the years, emphasis has been placed on speech, head posture, facial expression, and stress man
technical procedures but very often the inability to agement (4).
achieve success in treatment was not due to the incor Tt is important for the progress of the profession that
rect application of any given technique but rather fail dentists have a sound knowledge of the physiologic
ure to comply with certain unalterable biological importance of the CMS and that they undertake clinical
principles in the living individual (1). practice in accordance with a broad physiologic ap
The craniomandibular system (CMS) consists of bony proach. The orthodontic and prosthodontic approach
structures of temporomandibular joints, articular disks, must consider treating functional disturbances of the
CMS, and the mechanical therapy must confirm to the
Accepted for publication on October 5,2006. fundamental physiology of all the parts as they func
Address for correspondence: Katsushi Tamaki, Department of tion collectively and interdependently as a biological
Prosthodontics, Kanagawa Dental College, 82 Inaoka-cho,
Yokosuka, Kanagawa, 238-8580, Japan. unit. Tf any dental procedure violates any of the ana
Tel: +81-46-822-8880 (ex. 2381) Fax: +81-46-822-8844 tomical and physiological principles concerned, it will
K. Tamakia etal. Bull. Kanagawa Dent. Col. 35 (2007)

fail to attain the objective of restoring normal function


and may even further enhance the abnormal function.
Often dental treatment does not consider the CMS
but only the teeth and their occlusion relation. The gen
eral aim, therefore, should be referred to as functionally
optimal occlusion with a physiological mandibular po
sition. This term signifies an occlusion that is in func
tional harmony with the whole masticatory system,
comprising the supporting tissues, the facial skeleton,
the CMS and an occlusion that ensures efficient func
tionality without placing any undue strain on the inte
gral structures (5-7).
In order to properly evaluate abnormal function, it
is necessary to understand the physiology of the CMS.
In this paper, we describe an interdisciplinary approach
involving the functional assessment of condylar move
ment in a patient with severe displacement of the man
Fig. 1: Facial photographs before occlusion treatment. Symp
dible and functional disturbance of the system.
toms regarding CMS dysfunction associated with facial asym
metry.
Clinical Report

Case Preseittation
The patient was a 29-year-old male Japanese male while the left condyle showed a normal position in the
complaining of severe TMJ pain, joint clicking of the right fossa (Fig. 4).
TMJ, headaches, cervical tension, pain in the right eye
ball and further unidentified symptoms such as red heat Cephalometric analysis of craniofacial structures
of the eyelid, shoulder stiffness and lower back pain The morphological measurements of the craniofacial
(lumbago) with facial asymmetry (Fig. 1). In addition, complex taken with a lateral cephalogram revealed a
he complained that his mandible and masticatory decreased vertical jaw relationship with a lower facial
muscles soon became fatigued and that he suffered pain height (LFH) of 40 degrees and retrognathic mandible
after speaking. For this reason, being a teacher in high (Fig. 5). Frontal cephalogram analysis showed asymme
school, he had given up Ms job. try of the dentofacial complex caused by the displace
ment of the mandible.
Intraoral and ocdusal findings
The dental occlusion was compromised with mul Functional analysis of condylar movements
tiple previous prosthodontic treatments showing a com The functional condylar movement was recorded at
plete scissor bite in the left buccal segment. The mandible the hinge axis using a computerized system (CADIAX,
had shifted severely 5 mm to the right and the facial Gamma corp. Klosterneuburg, Austria) (8-11). The
appearance was asymmetrical (Fig. 2). condylar path of the right TMJ showed a typical tracing
of reciprocal clicking with excessive translation move
Clinical examination of the CMS ment, indicating a displacement of the articular disc and
Palpation of the TMJ indicated that the retroarticular loose ligaments (12-17). When the right condyle trans-
region of the right TMJ was painful. The muscles relat la ted forward d uring protrusion and retrusion and open
ing to the head and neck posture and mastication, espe ing/closing movements (Fig. 6), the hinge axis paths
cially the temporalis, masseter, and digastric muscles showed that the condyle had shifted laterally with the
on the right side indicated stiffness accompanying the clicking, then had moved forward smoothly. This sug
pain. gested that once the disc entered a normal position, the
condyle would be able to move regularly. During speak
Panoramic and dental radiogrciphic findings ing, both condyles were working in an approximately 4
Panoramic and dental radiographs photography re to 5 mm forward position from the reference position
vealed that most of the posterior teeth had been given (RP) (18-21). The rest position of the condyle was located
root canal treatment and several teeth showed apical 4 mm and 1.6 mm anterior to the RP on the right and the
lesions. These root canals were treated before any oc left, respectively.
dusal treatment was started (Fig. 3). The lateral TMJ ra
diographs showed a posteriorly displaced right condyle,
Interdisciplinary Treatment of Craniomandibular Dysfunction

Fig. 2: Intraoral photographs before occlusal


treatment. Severe mid-line discrepancy with large
overjet and overbite and scissor bite on the left

side were observed. A severely compromised

occlusion with different prosthodontic restora


tions was clearly evident.

Fig. 3: Panoramic radiograph. Almost all the


teeth had been treated previously in some way.

Fig. 4: TMJ radiographs {Schuller method). The right side of the condyle indicates pos
terior displacement.
K. Tamakia et al. Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 5: Cephalometric tracings before occlusion treatment. The lateral tracing shows a
low vertical dimension with an LFH of 45 degrees. Frontal tracing indicates lateral dis
placement of the mandible to the right.

a Open/Close b Pro/Ret
JT-4L.JJ.J. .!-

i <

c Mediotrusion right Mediotrusion left

.'

d Phonation

Fig. 6: Axiographic tracings of condylar movements us


ing Cadiax program:

a; opening/closing, b; protrusion/retrusion:
c; mediotrusion/medioretrusion right-left, cf; phonation.
Interdisciplinary Treatment of Craniomandibular Dysfunction

Diagnosis and treatment planning reinforced composite material (Targis-Vectris, Ivoclar


The diagnosis was malocclusion with cranioman Corp, Liechtenstein) (25) for the premolar and molar
dibular dysfunction associated with mandibular lateral teeth. Ceramic crowns (IPS Empess, Ivoclar Corp.
displacement. Muscular dysfunction due to mandibu Liechtenstein) (26,27) were placed on the anterior teeth
lar lateral displacement seemed to be the cause of the according to the individual inclinations calculated from
head and neck pain, the dysfunction and other somatic the hinge axis tracing (protrusion movement) (Fig. 12).
symptoms. Primarily, the objectives of the treatment
were to correct the mandibular position. The estimated Results of Occlusion Treatment
therapeutic position (ETP) of the mandible was calcu All the symptoms regarding the CMS including right
lated as 4 mm forward in the right condyle and 2 mm TMJ clicking disappeared after rehabilitation with the
forward in the left condyle from the RP. A splint therapy temporary crowns. It was possible to reconstruct occlu
was initiated with the endodontic treatment simulta sion in the corrected position of the mandible with the
neously. In the ETP, there was no vertical occlusal sup sequentially guided occlusion. The facial asymmetry was
port on both sides of the dentitions. In order to correct reduced. The lower facial height (LFH) increased from
the mandibular position, orthodontic treatment with an 40 to 45 degrees and the mandibular occlusal plane lev
edgewise appliance was planned to improve the tooth eled off with an inclination of 15 degrees to the axis-
position and axial inclination, to correct the occlusal orbital plane. The antero- posterior mandibular position
plane, and to provide vertical occlusal support. moved slightly forward as revealed by the superimpo-
Prosthodontic treatment was also planned to rehabili sition of pre- and post-treatment cephalogram tracings
tate the function with a provisional restoration with an (Fig. 13). After treatment, the movement along the
terior occlusal guidance as the first step, leading to the condylar paths remained smooth with no clicking or
achievement of full mouth reconstruction of the occlu limitation. It is noteworthy that the deviation of the
sion as a result of a sequential guidance scheme. condyle in the horizontal projection disappeared (Fig.
14). The hinge axis position during speech was 1 to 2
Progress of occlusion treatment mm forward from RP (Fig. 15). The distance from RP to
The occlusal splint was constructed in the ETP on a the new ICP was 1.5 mm on the right side and 0.3 mm
SAM2 articulator and was worn throughout the day on the left side. The TMJ lateral X-ray examination of
except during meals. The splint provided a non-click both condyles also showed a normal condylar position.
ing smooth movement of the mandible and a significant Clinical examinations after the treatment indicated that
reduction of pain (Fig. 7). Root canal treatment was car most of the symptoms had disappeared. Facial asym
ried out during splint therapy. metry had significantly improved during the sequence
After the endodontic treatment, orthodontic treat of combined treatment (Fig. 16).
ment was initiated with the standard edgewise appli
ance. After two months, multiloop edgewise arch wires Discussion
(22) (Kim Y.H., 1987) were inserted to upright the pos There are two concepts to be considered in the mat
terior teeth (Fig. 8). After ten months of orthodontic treat ter of occlusion of the teeth. The first is the anatomical
ment, all the metal crowns were replaced with temporary or morphological concept. A matched set of natural teeth
acrylic crowns to stabilize the mandibular position, af could be arranged so as to have proper contact relations
ter which, orthodontic treatment continued. The edge and axial inclinations with the maximum intercuspation
wise appliance was removed after 14 months of of the masticating surfaces, and then, an ideal occlusion
orthodontic treatment (Fig. 9). would exist. The second, and by far the most important,
Immediately following orthodontic treatment, the is the physiological or functional concept of occlusion
hinge axis paths were recorded (Fig. 10). Based on the as it participates in its role as one of the important com
new recordings, the right condylar position was reposi- ponents of the stomatognathic system. Normal function
tioned one more millimeter forward, because the open of the postural muscles and both TM joints are highly
ing/closing movement indicated occasionally clicking. dependent on the articulation of the teeth. Thus, an ana
Individual inclinations for the occlusal guidance were tomically ideal occlusion must coincide with the func
calculated from the tracings (mediotrusion movement) tional concept of occlusion. The muscular function of
to create a so-called "sequential guidance occlusion" (23, the cranio-mandibular hyoid-cervical connection can be
24). The new temporary crowns were made of hard resin influenced by the articulation of the teeth.
(Estenia), Kurare Corp. Japan) to retain the occlusion Lack of proper contact between the upper and lower
and provide more functional occlusal surfaces (Fig. 11). teeth in a physiological position of the mandible induces
No conventional retention was planned. After cementa the mandible to displace into an abnormal position with
tion of the temporary crowns and wearing for ten an accompanying dysfunction of muscular connection.
months, the final restorations were made using fiber- Faulty intercuspation can produce abnormal muscle
K. Tamakia et a!.
Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 7: Occlusal splint fabricated in the esti


mated therapeutic position (ETP)

Fig. 8: Orthodontic treatment with standard


edgewise appliance. Multi-loop edgewise
archwire (MEAW) applied to upright poste
rior segment After ten months of orthodon
tic treatment, temporary acrylic crowns were
placed on the posterior teeth to establish
posterior occlusal support.
Interdisciplinary Treatment of Craniomandibular Dysfunction

Fig. 9: Intra-oral photographs after


orthodontic treatment.

Oben/Close

Phonation
g B !'J in 9

Fig. 10: Axiographic tracing of condylar movement immediately af


ter orthodontic treatment. The clicking movement of the right condyie

.
V-T has disappeared.
K. Tamakia et al. Bull. Kanagawa Dent. Col, 35 (2007)

Fig 11: Diagnostic waxing with sequential guidance occlusion concept.

Fig. 12: Provisional restoration after orthodontic treatment. The guidance inclination of
each tooth was calculated from axiographic tracings. Acrylic provisional crowns with
functional guiding planes were placed instead of conventional retention procedures.
Interdisciplinary Treatment of Craniomandibular Dysfunction

Fig. 13: Final reconstruction achieved after ten months provisional restoration. The grinding movement of the mandible offers poste
rior clisocclusion.

Fig. 14: Cephalometric superimposition of pre~ and post occlusion treatment. The mandibu-
lar posture had improved not only as for vertical height, but also transverse dimension.
K. Tamakia et al. Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 15: TMJ radiographs (Schiiller method). Position of right side of the condyle im
proved and central part ot glenoid fossae positioned.

a Open/Close b Pro/Ret

Fig. 16: Axiographic tracings of condylar movements.


a; opening/closing, b; protrusion/retrusion, c; phonatlon, d; bruxism (grinding movement).
Interdisciplinary Treatment of Craniomandibular DystLinction

Fig. 17: Facial frontal views comparing pre- and post-treatment.

functions expressed as facial pain, headaches, cervical A combination of orthodontic and prosthodontic cor
pain and emotional stress. And likewise, faulty rection of an MLD malocclusion associated with com
intercuspation can produce an abnorma] TMJ function plex symptoms of the CMS is one of the significant
expressed as clicking, crepitus and restricted and pain procedures to improve states of dysfunction. Orthodon
ful condylar movement. The patient presented here was tic treatment provides gradual alteration of the func
a typical case who had severe problems due to man- tional surfaces of the occlusion, enabling the mandible
dibular lateral displacement caused by failure of the to adapt to a new position, while prosthodontic treat
proper articulation of the teeth. Clinical and instrumen ment provides proper support and occlusal guidance
tal examination revealed that the cranial-mandibular- for each tooth.
hyoid-cervical muscular connection was affected by the Condylar position, vertical dimension and occlusal
dysfunctional movement of the mandible not only in plane are compensation factors of the occlusion for each
movements such as protrusion/retrusion and opening/ skeletal pattern. "Compensation" refers to the capacity
closing, but also during speech. of the teeth, the dentoalveolar process and the facial skel
MLD ma [occlusion is one of the most difficult condi eton to cope with structural variations in the mastica
tions to treat, because it is accompanied by problems tory organs (31).
such as condylar displacement to abnormal positions, Condylar positions must be respected in occlusal re
asymmetrical muscular function/ dysfunction, occlusal constructions, especially in subjects with a displaced
plane deviation, and head-neck pain syndromes. The mandibular position. Therefore the treatment mandibu
independent therapeutic approaches of orthodontics and lar position has to be recognized at the stage of plan
prosthodontics tend to result in a compromised correc ning occlusal treatment by means of an estimated
tion of the MLD malocclusion because the orthodontic therapeutic position. An estimated therapeutic position
vertical] zation of occlusal height is limited without sur is successful when it obtains the physiological mandibu
gery and the prosthodontic correction of axial tooth in lar position. Anterior positioning of the mandible was
clinations is also limited. Therefore, many cases with intended not only to correct the mandibular position but
MLD have been treated by orthognathic surgery (28). also to compensate for the skeletal pattern in this Class
Surgical procedures, however, may be limited in the U case. In the treatment of case presented here, although
correct repositioning of a displaced condyle. A surgical the right and left condyles were repositioned 5 mm and
separation between the mandibular body and the ramus- 2 mm forward, the distance between the RP and the ICP
condyle part followed by repositioning the mandibular after treatment was only 1.5 mm and 0.3 mm, respec
body can retain the condyle in. its abnormal position. tively. Therefore, it can be concluded that condylar re
Owen reported that it is not uncommon for either positioning therapy in dysfunction cases with
anterior and posterior condylar displacement or both mandibu lar displacement provides healing and remod
on patients with a posterior crossbite (6, 7). Many re eling processes in the joint structure, and consequently
ports show functional disturbances of masticatory reduces the RP-ICP distance. The combination of orth
muscle activity (29,30) and condylar paths (12,17), and odontic and prosthodontic procedures provides a favor
a high incidence of TMJ disorder (14,15) in subjects with able approach to a complex case with CMS dysfunction.
facial asymmetry. The patient presented in this article The vertical jaw relationship and the inclination of
had obvious TMJ disturbance with clicking. the occlusal plane were corrected taking into consider-
K. Tamakia el a\. Bull. Kanagawa Dent. Col. 35 (2007)

ation compensation for the skeletal pattern. Therefore, 5. Sato, S., Tamaki, K., Sakakibara, K., Ishii, Y. and Slavicek, R.
(1994). Diagnosis and treatment of the mandibular position of
the lower facial height increased to 45 degrees and the
a case associated with temporomandibuJar joint dysfunction
inclination of the mandibular occlusal plane to axis-or that employed the computerized axiographic system. J.fap
bital plane increased to 15 degrees according to the den- Gnathologi/. 15: 205-15. (in Japanese)
toalveolar compensation of the Class II skeletal pattern, 6. Owen, A.M. III. (1984). Orthodontic/ orthopedic treatment of
cranio-mandibular pain dysfunction. Part 2: Posterior condylar
and as a result, the posterior disocclusion was achieved
displacement. /. Craniommui. Pracl. 2:334-49.
with little effort. 7. Owen, A.M. III. (1988). Orthodontic/orthopedic therapy for
Anterior guidance has to be performed in coordina craniomandibular pain dysfunction Part B. Treatment flow
tion with posterior guidance. Sequential guidance oc sheet, anterior disk displacement, and case history, /.
Craniomand. Pracl. 6:48-63.
clusion with canine dominance (24, 27) was applied in
8. Slavicek, R. (1988). Clinical and instrumental functional
order to accomplish stress management with low muscle analysis for diagnosis and treatment planning. Part 3: Clinical
activity, which showed disocclusion in the premolar and functional analysis. /. Gin Orthoii. 22: 498-508.
molar parts during excentric mandibular movement. 9. Slavicek, R. (1988). Clinical and instrumental functional
analysis for diagnosis and treatment planning. Part 5:
Axiography. /. Clin Orlhod. 22: 656-67.
Summary 10. Piehslinger, E., Celar, A.G., Celar, R.M. and Slavicek, R. (1991).
This article presents an interdisciplinary approach Computerized axiography: principles and methods. /.
to an MLD malocclusion with severe dysfunction of the Cratiiomand Pracl. 9: 344-55.
11. Ino, S., Tamaki, K., Aoki, II., et al. (1995). An experimental
CMS. In the first stage, the large lateral displacement of
study on the measurement accuracy of the computerized
the mandible was corrected by orthodontic treatment axiography. Bull Kanagawa Dent Col. 23: 93-7.
to the estimated therapeutic position. The diagnosis of 12. Earrar, VV.B. (1978). Characteristics of the condylar path in
the displaced mandibular position was the key to suc internal derangements of the TMJ /. Prosthel.Dent. 39: 319-23.
13. Earrar, VV.B. and McCarty, W.L. (1979). Inferior joint space
cessful treatment of the MLD malocclusion. Correct
arthrography and characteristics of condylar paths in internal
molar occlusal support and occlusal guidance in the derangements of the TMJ. /. Prosthet Dent. 41: 548-55.
anterior teeth were established in the final stage of oc 14. Gibbs, CM. and Lundeen, H.C. (1982). Jaw movements and
clusal therapy. After this correction, the clinical exami forces during chewing and swallowing and their clinical
significance. In Gibbs, C.H., Lunddeen, H.C. (eds), Advances
nation and functional analysis of the CMS indicated that
in occlusion. Massachusetts: John Wright 2-32.
the management of the pain dysfunction symptoms had 15. Eushima, K., Sato, S., Suzuki, Y. and Kashima, I. (1994).
resulted in a subjective state with no pain symptoms and Horizontal condylar path in patients with disk displacement
no TMJ clicking. The condylar movements were smooth with reduction. /. Cranioniand Pracl. 12: 78-87.
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