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Treatment of Class II Open Bite in the Mixed Dentition with a Removable

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Treatment of Class II Open Bite in the Mixed Dentition with a Removable Orthodontics Treatment of Class II open bite in the mixed dentition with a removable functional appliance and headgear Peter Ngan* / Stephen Wilson"' "^ / Michael Florman^' '^ '•" I Stephen H, Y. Wei* * * * Early diagno.ús of patients exhibiting open bites that are complicated by skeletal Class ¡I and vertical growth problems can facilitale subsequent treatment. Eight patients with Class 11 skeletal open bite were treated with the high-pull activator appliance and compared to reasonably matched controls to determine the effects of the appliance. The high-pull activator was found to reduce forward growth of the maxilla and increase mandibular alveolar height, transforming the Class II molar relationship into a Class ! molar relationship. The overjet atid open bite were decreased, and, in addition, the appliance reduced the amount of forward and downward movement of the maxillary molars, providing vertical control of the maxilla during Class II ortho- pedic correction. These results demonstrated that open bite complicated by a Class 11 vertical growth pattern can be treated during the mixed dentition with favorable results by a combination of a removable functional appliance and high-pull headgear, (Quintessence Int 1992,-23:323-333.) Introduction A dental open bite is one that is limited to the an- terior region in an individual with good facial propor- Anterior open bite is defined as the absence of con- tions," Current orthodontic treatment often consists of tact between the maxillary and mandibular incisors at fabrication of a habit appliance such as a tongue re- centric relation,' In youuger children, il can be caused strainer, evaluation for airway insufficieucy, and place- by one factor or a combination of factors, including ment of fixed orthodontic appliances if needed. How- finger- and lip-sucking habits: enlarged tonsils or ever, it is rare that a patient who requests orthodontic adenoids that interfere with proper tongue position, care has an anterior open bite that is solely the result creating mouth breathing, a constricted maxilla, and a of a habit. Dental changes are frequently complicated skeletal open bite growth pattern; mouth breathing as- by a Class II skeletal growth pattern with vertical and/ sociated with allergies and inadequate nasal breathmg; or transverse complications. abnormal tongue habits with tongue thrust and cheek The hallmarks of skeletal anterior open bite are in- biting: macrogiossia: or abnormal tongue position. creased anterior facial height, a steep mandibular plane, and excessive eruption of posterior teeth. Be- cause the mandible is rotated downward and hackward in this circumstance, the patient is likely to have a Class II jaw relationship in addition to the vertical Associate Professor, Department of Orthodontics, Ohio StateUniversity, College of Dentistry, 305 West I2tli Avenue, problem. Columbus, Ohio432tÜ, One approach to the treatment of skeletal open bite Assistant Professor. Department "i Pediatric Dentistry, Ohio State University, is to control all subsequent growth so that the mandible Dental Student, Ohio State University. will rotate in a counterelockwise direction, upward Professor and Head, Department of Children's Dentistry and and forward. Successful early treatment of these prob- Orthodontics. University of Hong Kong, Prince Philip Dental Hospital, 34 Hospital Road. Hong Kong, lems in the mixed dentition ean prevent the worsening Quintessence International Volume 23, Number 5/1992 323 Orthodontics of the facial profile. The elimination of anterior open producing a backward and upward displacement at the bite can also improve tongue function and lip seal. maxillary sutures." The orthopedic concept of using a Recent research has shown that tongue thrust swallow combination of activator and headgear appliances was is more often ati adaptation to the open bite than a introduced hy Hasund.'- Pfeiffer and Grobety''' re- cause of it.^ Myofunctional therapy for tongue thrust- fined the combined orthopedic concept further to better ing in skeletal Class II open bite patients is. for that cope with the demands of differential diagnosis. They reason, ineffectual and not recommended. chose the use of a eervicai headgear to extrude maxil- This paper discusses the use of high-pull headgear lary molars and to apply orthopedic traction to the and functional appliances to maintain the vertical maxilla and an activator to induce orthopedic man- position of the maxilla and inhibit eruption of the dibular changes, restrain maxillary growth, and cause maxillary posterior teeth during the mixed dentition selective eruption of teeth. Levin'** reported the period. Cephalometric analysis was used to evaluate skeletal changes in 30 patients treated with activator the skeletal and dental adaptations to this treatment and cervical headgear. Patienis treated with this eom- modality. Because the general dentist is often the first bination of appliances were found to have their Class lo diagnose anterior open bite in the child piitient, the II molar occlusion corrected to Class I and a simuhane- clinician's awareness of the differences between dental ous reduction of overbite and overjet. Teuscher'^'"' and skeletal open bite and the proper timing for inter- was the first to attach the facebow directly to the ac- cepting these malocclusions will facihtate subsequent tivator and, with applied occipital traction, achieved orthodontic treatment. better vertical and rotational control during orthopedic Class II treatment. The simultaneous use of both activator and high-pull Rationale for appliance selection headgear appliances may result in a number of desirable treatment effects greater than those induced by each Effect of functional appliances appliance separately. The effeetive changes are believed Functional appliances, such as activators, have been to be restraint of downward and forward maxillary used to treat Class II, division 1, patients who present growth, selective guidance of maxillary and mandibular with a retrognathic mandible. Functional appliances denloalveolar development, and some influence on reportedly alter a Class II relationship through trans- mandibular growth and/or position. mission of muscular force to the dentition and alveolus, The purpose of this study was to demonstrate the thereby positioning the mandible anterior to its maloc- elinical and cephalometric findings of a sample of clnded position. Additionally, they are often designed eight patients with Class II skeletal open bite who were to alter the amount and direction of tooth eruption, in- treated with a high-pull activator (HPA) appliance. fluencing the horizontal and vertical positions of the teeth. The use of simulated functional appliance therapy in animal models has been found to induce increased Method and materials cellular activity in the mandibular eondyle.''"' presum- ably leading to altered mandibular form and length. Treated sample Harvold* and Harvold and Vargervick,' however, The sample eonsisted of eight patients, two boys and . found no evidence of increased mandibular growth in six girls, with Class II skeletal open bite malocclusion patients treated with activator therapy, but rather who were treated with HPAs during the mixed dentition reported, as a primary effect, a selective influence on period. All subjects were treated by one of the authors the occlusal development of the dentition. In another at the Ohio State University, College of Dentistry. study, it was reported that vertical maxillary growth Before treatment, each patient had (1) a Class II, divi- was restrained during activator therapy by the hindered sion 1, malocclusion with bilateral Class II molar re- eruption of the maxillary posterior teeth.'" lationship and excess overjet; (2) an anterior open bile, as measured by the overlapping of the maxillary Effect offiinctional appliances in combination with high- to mandibular incisai edges; and (3) a skeletal open pull headgear bite pattern, measured cephalometrically and consi- High-pull headgear has heen used with the aim of dered to be a ratio of posterior facial height (sella- produeing intrusion and posterior displacement of gonion) to anterior facial height (nasion-menton) of maxillary molars with backward maxillary rotation. less than 62%. The mean age of the subjects was 10 324 Quintessence internalional Volume 23, Number Orthodontics Fig 1 Activator prior to placement. Note the lingual exten- sions and the acrylio resin ledge covering the occtusal surfaces of the molars and premolars. The Frankel iip shield has been incorporated in the appliance tor this particular patient, who has mentalis hyperactivity. Fig 2 (right) Activator together with the high-pull headgear. Note the position of the torquing springs, which are adjusted to touch the crowns ol the incisors as cioseiy as possible to the gingival margin on the maxillary incisors. yeaTS 3 months before treatment. The average treatment diameter) was used, and the palate was kept free to time was 1 year 2 months. provide as much room as possible for the tongue. To link the activator to the inner arch of the facebow, a Control sample 0.045-inch headgear tube was fastened in the acryhc A control sample, consisting of eight untreated Class n resin between the maxiiiary and mandibular arches. children with a skeletal open bite pattern as described The tube was placed sagittally between the primary in the treated sample, were obtained from the Ohio first and second molars or premolars. The magnitnde State University Growth Study
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