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OPEN-BITE TREATMENT UTILIZING
CLEAR REMOVABLE APPLIANCES
WITH INTERMAXILLARY AND
INTRAMAXILLARY ELASTICS
Jae Hyun Park, DMD, MSD,
MS, PhD1
Tae Weon Kim, DDS, MSD,
PhD2
Clear removable appliances with elastics can be effective and efficient in extruding maxillary teeth during aligner treatment or following a relapse of an open bite. Some patients with open bites refuse to
wear conventional fixed appliances. In these individuals, clear aligners with elastics could be a valuable alternative. World J Orthod
2009;10:130–134.
pen bites are dif ficult to treat
because they result from the interaction of multiple etiological factors. 1–3
Many patient reports describe the orthodontic treatment of anterior open bites
with various techniques. One option is to
apply intrusive forces to posterior
teeth.4,5 Another possibility, if not contraindicated, would be the extrusion of
maxillary anterior teeth. Reitan6 reported
that extruded teeth have a greater tendency to relapse than intruded ones.
Clear aligners with elastics represent
an unproblematic way to treat open-bite
patients when minor extrusions (less than
2 to 3 mm) are indicated.
USA). 7–9 The teeth to be extruded are
supplied with buttons and connected to
the opposite arch with elastics where
buttons were attached to the aligner
(Fig 1). When the expected extrusion is
achieved, the respective teeth will contact the inner surface of the aligner so
that no additional extrusion occurs.
Thus, it is a fail-safe appliance. More
examples of Cow-Catch aligners are
given in Figs 2 to 4.
CLEAR ALIGNERS WITH
INTERMAXILLARY ELASTICS
(COW-CATCH ALIGNERS)
If a patient cannot tolerate the limited
opening while wearing Cow-Catch aligners with intermaxillary elastics or needs
to verbally communicate a lot, it is recommended to use an appliance modification characterized by buttons on the
lingual side of the aligner (Figs 5 and 6).
The application of this modified CowCatch aligner is the same as that of the
regular one. This type of aligner is more
convenient and comfor table for all
patients because it allows a more normal
function (Figs 7 and 8).
O
To fabricate a clear aligner for correcting
an open bite, an impression is taken and
a working cast produced. The teeth on
this cast are ideally set-up (extruded)
before a 1-mm plastic sheet (Duran,
Scheu-Dental, Iserlohn, Germany) is
formed with either a pressure-molding
machine (Biostar, Scheu-Dental, Iserlohn, Germany) or a vacuum machine
(Raintree Essix, Sarasota, Florida,
CLEAR ALIGNERS WITH
INTRAMAXILLARY ELASTICS
(MODIFIED COW-CATCH
ALIGNERS)
130
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1Assistant
Professor and Director,
Postgraduate Orthodontic Program,
Arizona School of Dentistry & Oral
Health, Mesa, Arizona, USA.
2President, Korean Society of Lingual
Orthodontics, Seoul, South Korea.
CORRESPONDENCE
Dr Jae Hyun Park
Postgraduate Orthodontic Program
Arizona School of Dentistry & Oral Health
5855 East Still Circle
Mesa, AZ 85206
Email: [email protected]
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Park/Kim
a
b
c
Fig 1 Frontal (a) and lateral (b) view of clear aligners with intermaxillary elastics. To allow for this arrangement, the cervical
portion of the maxillary aligner is removed. To prevent dislodging of the mandibular aligner, undercuts are created in the posterior interproximal spaces with a Clear Aligner Plier (IV-Tech, Seoul, South Korea) or Undercut Enhancing Hilliard Thermoplier
(Raintree Essix, Sarasota, Florida, USA). (c) Situation after the expected extrusion is achieved.
Fig 2 Patient 1. (a) Pretreatment situation. (b) Set-up casts for Cow-Catch
aligners. To simultaneously correct the
minor crowding in the mandibular arch,
the set-up included all anterior teeth. (c)
Extrusive force exerted by Cow-Catch
with triangular elastics, 3/16-in medium
(4 oz) (arrow shows the extrusive force
applied to the maxillary right lateral
incisor). (d) Situation after 6 weeks of
treatment.
Fig 3 Patient 2. (a) Clear buttons are
attached to the target teeth. (b) Application of Cow-Catch aligners with vertical elastics, 3/16-in medium (4 oz). (c)
After 4 weeks, transparency of the
appliance increased which indicates
that extrusion has occurred due to good
patient cooperation. (d) After 6 weeks
of treatment, a sound anterior overbite
has been established.
a
b
c
d
a
b
c
d
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Fig 4 Patient 3. (a) Relapse 2 years
after orthodontic treatment. (b) Overbite has been increased by Cow-Catch
aligners after 8 weeks of treatment.
a
b
Fig 5 Sagittal (a) and occlusal (b) view
of how the extrusive force (arrow) is
produced by the intramaxillary elastics.
a
b
Fig 6 Frontal (a) and sagittal (b) view
of how the extrusive force is produced
by intramaxillary elastics (arrows) . (c
and d) Situation after extrusion has
occurred. Note that the plastic is cut off
buccodistogingivally of the terminal
molar to facilitate appliance removal.
a
b
c
d
DISCUSSION
Anterior open bite is considered to be
most difficult to treat. Proper diagnosis,
treatment planning, successful treatment,
and retention all contribute to the longterm stability of any open bite therapy.
Some of the numerous factors responsible for the development of an open bite
comprise an unfavorable (hereditary)
mandibular growth pattern, digit-sucking
habits, nasopharyngeal airway obstructions, and incorrect tongue and head
posturing.3
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Fig 7 Pretreatment frontal view (a)
with inserted aligner (b) and occlusal
view (c) of clear aligner with intramaxillary elastics, 3/16-in medium (4 oz). (d)
Situation after 4 weeks of treatment.
a
b
d
c
Fig 8 Schematic view of the difference between Cow-Catch aligner with
intermaxillary (a) and intramaxillary (b)
elastics (arrows indicate extrusive force
applied to the target teeth).
a
Various treatment modalities have been
proposed for the correction of anterior
open bites. Nonsurgical therapies include
multiloop edgewise archwires,10 tongue
cribs,11 posterior bite blocks with12 and
without magnets,13 and functional appliances.14 Previous studies15,16 have indicated that one common reason for relapse
is a persisting anterior tongue posture.
After extrusion, it is recommended to
bond a lingual 0.0175-in Twistflex wire in
the maxilla and mandible from canine to
b
canine. In addition, patients should be
taught to swallow correctly. To prevent a
reintrusion of the extruded teeth, small
projections can be added into the interpromixal areas of the target teeth with
Clear Aligner Pliers (IV-Tech, Seoul, South
Korea). However, a removable appliance
with a tongue crib is recommended if the
tongue-thrust habit persists after treatment.
A potential disadvantage of this type of
appliance is that it is highly dependent on
patient compliance.17 These aligners and
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the respective elastics should be worn at
least 17 hours a day.7–9 Yet, current data
suggest that this rarely occurs.17,18 The
great advantage of this approach is that
more detailing can take place simultaneously. With good cooperation, the
intended treatment is achieved within 6
to 8 weeks. If any patient is concerned
about mouth opening or speaking while
wearing a Cow-Catch aligner, a modified
Cow-Catch aligner with intramaxillary
elastics could be used.
CONCLUSION
If a patient wears a clear removable
appliance with intra-/intermaxillary elastics, teeth can be extruded. Esthetics is
excellent because the aligner is hardly
visible. This can be a definite psychological advantage in teenagers and adults
alike. These kinds of clear aligners with
elastics can be an effective alternative in
patients with open bite who refuse to
wear conventional fixed appliances.
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