THE PHILIPPINE JOURNAL OF ORTHODONTICS

PBO Phase IV Case Report

Treatment of Malocclusion: Class 1 Open Bite

Roberto B. Tan, DMD, DPBO
Dr. Roberto B. Tan graduated from the Centro Escolar University in 1985 and underwent the orthodontic preceptorship under the late Dr. Luz C. Macapanpan and the MEAW Course given by the MEAW Study Club of the Philippines. He remains to date only the second APO member to have completed the Philippine Board of Orthodontic Phases I to IV Examinations for which he was conferred Diplomate status by the Philippine Board of Orthodontics.

A case report is presented of an Angle Class I Open Bite case that was treated nonextraction.

Figure 1. Pre-Treatment Photographs

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Diagnosis: The patient is of Filipino-Chinese heritage presented with a Class 1 Open Bite malocclusion. He has a straight profile with slight contraction of the mentalis muscle when he closed his lips. His facial type is dolichocephalic and there is a significant steep vertical pattern. Because of his age & maturity, additional skeletal growth was expected. The molar relationship is in Class 1 relationship. There is negative overbite and only the 1st and 2nd molars on both right & left side are in occlusion. There are rotations on tooth # 25, 34 & 44. Minimal amount of attached gingival on the labial surface of the lower anterior were noted. (Figure 1) Panoramic radiograph reveals the presence of all the teeth except for tooth # 18 & 28.(Figure 2) Cephalometric analysis reveals a high angle case as presented by high measurement of SMP angle of 38.5 degrees and FMA of 32 degrees. The maxillary & mandibular denture base is within normal limits in relation to the cranial base as presented by SNA (79.5) and SNB (77). The interrelationship of the maxillary & mandibular denture base is within normal limit as presented by the ANB of 2.5 degree. A skeletal Class 3 tendency as revealed by the AO-BO (Wits Analysis) reading of 0. Upper incisors are proclined labially as revealed by U1 to NA < (35.5 degrees) and the relationship of Upper & lower incisors are too proclined labially as revealed by interincisal angle of 109.(Figure 3) History and Etiology: Medical : Good overall health. Medical history reveals no significant findings. Dental : Overall dental health is good. Restorative fillings on Tooth # 16, 26, 36, 36 & 46. Etiology : Early loss of Upper & Lower deciduous anterior teeth resulting to tongue thrusting
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& abnormal swallowing pattern that provide seal on anterior space. Posterior discrepancy on the lower resulting to squeezing effect and supra-eruption of the posterior teeth. Chief Complaint: Upper & lower teeth are not in contact. Treatment Plan: Prior to initiating the treatment, the patient & his mother were informed of 2 important things in the treatment process; a.) The need for patients cooperation in wearing the rubber elastics b.) The possibility of gum recession on the lower cuspid area and the need for gingival grafting due to the thin zone of attached gingival. 1. Surgical removal of Tooth # 38 & 48 for the following reasons; a.) To remove Posterior Discrepancy on the lower. b.) There is no opposing upper tooth #18 & 28. 2. Full Upper & lower Straight Wire Appliance .018 Slot, Roth Prescription 3. Debonding & Retention Specific Objectives of Treatment (A-P, Transverse, Vertical) Maxilla: - Maintain AP length of the maxilla. - Achieve a more downward & forward change in the anterior - Maintain transverse width of the maxilla. - Prevent downward vertical change in the posterior Mandible: - Maintain transverse width of the mandible. - Avoid clockwise rotation of the mandible. Maxillary Dentition: - Level & align - Maintain molar anchorage - Avoid eruption the molars

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Achieve good cusp-fossa relationship with the lower dentition. Mandibular Dentition: - Level & align avoiding protraction of the anteriors - Intrude & upright posterior teeth - Contain the lower anteriors with proper overjet & overbite. Occlusion: - Obtain self-maintaining overjet & overbite. - Achieve Class I canine relationships - Achieve incisal and canine guidance - Achieve a functional occlusion that preserves the integrity of the Stomatognathic system. Facial Esthetics: - To improve patients profile and achieve a more pleasing smile. Treatment Progress/Mechanotherapy: 1. Extraction of Tooth # 38 & 48 2. Full Upper & Lower Straight Wire Appliance .018 Slot Roth Prescription 3. Leveling & Alignment of teeth. Upper .014 to .016 Stainless Steel Wire Lower .014 to .016 Stainless Steel Wire 4. Sequential increased archwires to .017 x .025 stainless steel 5. Anterior Vertical Elastics (Upper 3 & 2 hooks Lower 3 hooks) 6. Detailed Occlusion with archwire bends & elastics 7. Debonding & Retention Results Achieved (A-P, Transverse, Vertical) Maxilla: - AP length of the maxilla was well controlled. - Achieved a more downward & forward change in the anterior area of the Maxilla

- Maintained transverse width of the maxilla. - Slight downward vertical changed in the posterior Mandible: - Maintained transverse width of the mandible. - Slight clockwise rotation of the mandible. - Maintained mandibular position Maxillary Dentition: - Leveled & aligned - Supraversion & lingual crown tipping of the anteriors - Slight eruption of the molars - Achieved good cusp-fossa relationship with the lower dentition. Mandibular Dentition: - Leveled & aligned - Supraversion & lingual crown tipping of the anteriors - Uprighting of posterior teeth - Contained the lower anteriors within proper overjet & overbite. Occlusion: - Obtained good overjet & overbite. - Achieved Class I canine relationships - Achieved incisal and canine guidance - Achieved a final occlusion that preserves the integrity of the Stomatognathic system. Facial Esthetics: - Existing Facial profile & type remained essentially the same. - Improved smile esthetics. Retention: Upper wrap around and lower Hawley retainers were installed after the debonding. The patient was instructed to wear his retainers full time for 1 year. 1 year Post retention records were taken.(Figures 7 & 9) After this, a 6 months
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night time wear was prescribed. Another 6 months of every other night time wear again was prescribed. Retainers were discontinued after 2 years of retention. Patient was recalled every 6 months for check up & evaluation. 2 years post retention records was taken. (Fig. 10, 11, 12) Final Evaluation of Treatment: Patients cooperation is the key to correct the open bite. We were able to establish a good overbite and overjet that appears to be stable 3 years after debonding. The persistent used of vertical elastic causes the open bite to close & achieved a normal overbite. The canine and molars are in Class 1 relationship and all posterior teeth are in good cusp to fossa relationship. (Figure 4) There was a slight increase in the vertical dimension of the face as represented by the increase in SN-MP angle & the FMA angle of 3 degrees which I wanted to avoid during my treatment plan. The lower border of the mandible has been repositioned downward which makes the
Figure 2. Pre-Treatment Panoramic Radiograph

mandibular plane steeper. The probable reasons for the increase in the vertical height are the ff: 1.) Lack of control in the treatment mechanics 2.) Growth factors since patient have a significant growth potential. (Figure 6) Superimposition of the Cephalometric x-rays at ages 13:7, 15:1, 16:1& 18:1 shows the following: (Figure 13) 1. Maxillo-mandibular relationship shows downward positioning of the maxilla and the mandible. There was no forward movement of the maxilla while mandible shows little as seen with the repositioning of the symphysis. 2. Inclination of the upper incisor has changed assuming a more vertical position. While lower incisors moved lingually by controlled tipping movement. Upper molars erupted a little while lower molar were uprighted & were supraverted. 3. Vertical relationship has increased. There is lengthening of the ramus of the mandible resulting from condylar growth.(Table 1)

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Figure 3. Pre-Treatment Cephalometric Radiograph & Tracing

Figure 4. Post-Treatment Photographs

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Figure 5. Post-Treatment Panoramic Radiograph

Figure 6. Post-Treatment Cephalometric Radiograph & Tracing

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Figure 7. 1-Year Retention Photograph

Figure 8. 1-Year Retention Panoramic Radiograph

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Figure 9. 1-Year Retention Cephalometric Radiograph & Tracing

Figure 10. 2-Years Retention Photograph

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Figure 11. 2-Years Retention Panoramic Radiograph

Figure 13. Composite Tracings

Figure 12. 2-Years Retention Cephalometric Radiograph & Tracing

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In spite of having the AP length of the maxilla and the mandible as well as the dentition is contained, there is still recession on the gingival area particularly on the lower canine area as anticipated prior to the initiation of treatment because of the thin attached gingival on the area. The patient & the mother are not bothered at all by this periodontal condition and patient doesnt like to undergo gingival grafting. The major achievement we have accomplished in this treatment is that that we were able to achieve a functional occlusion that preserves the integrity of the Stomatognathic system. Also the smile esthetics of the patient has markedly improved. (Figure 1,10)
Table 1. Cephalometric Summary

References:
1. Graber TM; Vanarsdall RL, Jr: Diagnosis and Treatment Planning in Orthodontics, Orthodontics - Current Principles and Techniques, 1994. Moby-Year Book, Inc. 2. Alexander RG: The Use of Elastics and Other Extra-Oral Appliances in the Vari-Simplex Discipline, The Alexander Discipline, 7: 149-165, 1986. 3. Alexander RG. The Vari-Simplex Discipline - Part 3 Extraction Treatment, J Clin Ortho pp. 537-547, August 1983. 4. Subtleny JD, Saluda M. Openbite Diagnosis and Treatment. Am J Ortho 1964, 50:337-358.

Cephalometric Summary
Area of Study Cranial Base Maxilla to Cranial Base Mandible to Cranial Base Maxillo-mandibular Relationship Vertical Height Maxillary & Mandibular Incisor Position Measurement BA-S-N SNAN-A-FH SNBNPog-FH ANBA-NPog mm Wits SN-MPFMA U1-Namm U1-NA Degr 1MPA L1-NBmm L1-NB deg U1-Apog mm U1-L1 degree E-Line-L-Lip Line Standard 130 84.5 82.8 2.54.7-1 to 2 31.3 6.4 24.7 96 7.5 29.8 8.6 122.8 -2 Pre-Tx 122 79.5 77.8 2.5 37.5 6 35.5 98.5 7.5 33 7 108 0 Post Tx 122 79.8 76.5 3.5 40.5 5 24 90 7.5 24.5 6.5 126.5 1.5 1 Yr. Retention 122 79.8 76.8 3.0 39.3 7 27 91.5 7.5 26 7 124.5 .5 2 Yr. Retention 122 78.8 76.5 2.5 39.3 6.5 29 91.5 7.5 26.5 6.5 123 0

Soft Tissue

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