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Molar intrusion with mini-implant to correct anterior skeletal open bite…
Al-Labani MA et al
Journal of International Oral Health 2016; 8(12):1132-1135
Received: 21st July 2016 Accepted: 01st October 2016 Conflicts of Interest: None
Source of Support: Nil
Case Report
Doi: 10.2047/jioh-08-12-17
Upper Molar Intrusion with Mini-implants to Correct Anterior Skeletal Open Bite: A Case
Report
Mohammed A Al-Labani1, Sakhr A Murshid2, Fuad Lutf Almotareb1, Mohammed M Al-Moaleem3
Contributors:
1
Assistant Professor, Department of Orthodontics, Faculty of
Dentistry, Sana’a University, Sana’a City, Yemen; 2Assistant
Professor, Department of Pedodontics, Orthodontics and Preventive
Dentistry, Faculty of Dentistry, Thamar University, Thamar City,
Yemen; 3Assistant Professor, Department of Prosthetics Dental
Science College of Dentistry, Jazan University, Jazan, KSA.
Correspondence:
Dr. Al-Moaleem MM. Department of Prosthetics Dental Science,
College of Dentistry, Jazan University, P.O. Box 114, Jazan
45142, Kingdom of Saudi Arabia. Phone: 00966-550599553.
Email: [email protected]
How to cite the article:
Al-Labani MM, Murshid SA, Almotareb FL, Al-Moaleem MM.
Upper molar intrusion with mini-implants to correct anterior
skeletalopenbite:A casereport.J IntOralHealth2016;8(12):1132-1135.
Abstract:
This article reported a treatment of an adult male patient, his age
was 17 years 3 months, his chief complaint was difficulty in chewing,
pronunciation, and esthetics. He was diagnosed of having 6 mm
of anterior skeletal open bite on skeletal Class II, overjet 5 mm,
negative overbite – 4 mm, and tongue trust habit. The patient was
successfully treated using mini-implants anchorage, 022 MBT
appliance, and muscles exercises. Our results suggested that using
mini-implant anchorage, muscles exercises, and repositioning the
brackets as needed delivered good final results in skeletal anterior
open bite cases.
The proper treatment approach would be orthognathic surgery
during which maxillary anterior teeth are proclined forward to
obtain some overjet and move the mandible forward. This type
of treatment is suitable to the age of our case, but the financial
condition is notable for the fees of surgery.12
Recently, mini-implant is used as skeletal anchorage device for
treatment of anterior open bite and with the use of this system,
intrusion of upper posterior molars without unfavorable side
effects became possible.13 In this article, we will present an adult
case of skeletal anterior open bite and its management using
mini-implants and muscle exercises.
Case Report
A 17-year-old male, the patient attended to the clinic. The
patient complains were a presented vertical facial pattern with
Class II molar relationship, an anterior open bite of 6 mm
supported by an improper tongue posture, increased overjet,
altered occlusal plane, and high mandibular plane angle.
The patient’s chief complaint was the poor esthetics and the
difficulty in pronunciation and chewing because of his anterior
open bite. The medical and oral history were within normal
and he had good oral health. The extraoral view showed lip
incompetents and improper face proportions (Figure 1a). The
intraoral examination showed, open bite, Class II angle molar
relationship with group function occlusion (Figure 1b), free
caries mouth, and good oral hygiene (Figure 1c and d). While
the cephalometric and panoramic pre-operative radiographs
X-rays showed clear skeletal abnormality (Figure 2a and b).
A maxillary and mandibular arches impressions were done
using dust free alginate. Then pouring of the diagnostic cast,
interpretation of the diagnostic data was done, in addition to
that cephalometric analysis was performed properly.
Key Words: Anterior open bite, Class II, mini-implant, orthodontic
treatment
Introduction
Open bite is generally classified in two categories skeletal and
dental. The causes are multifactorial which can be developed from
genetic and (or environmental factors). It’s considered one of the
most difficult problems to treat.1,2 The diagnosis is important due
to the different treatment modalities; a dental open bite can be
treated with orthodontic alone, while skeletal open bite requires
a combination of orthodontic and surgical approaches.3
The treatment objectives, in this case, were an elimination of
the tongue trust habit, correction of molar Class II molar and
canine relationship, correction of both the overjet and the
overbite. In addition to that creating a space to correct the
crowding in the anterior region of maxillary teeth. Also decrease
the lower facial heights, elimination of functional and speech
problems, and finally to stabilize all results together.
Many therapeutic options have been proposed for the
treatment and retention of anterior open bite malocclusion.
Conventional orthodontic treatment has been directed at
inhibiting the vertical maxillary growth with headgear, chin
cups for retarding the mandibular growth, or vertical elastics
for extruding anterior teeth,4-6 tongue crib therapy,7 posterior
bite blocks,8 posterior magnets,9 vertical corrector activated by
magnets,10 and functional appliances.11
The first choice of treatment was discussed with the patient.
Which includes the extraction of two first maxillary bicuspid
to correct the anterior open bite and the increased overjet.
Considerations over the unpredictable effect in the facial profile
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Molar intrusion with mini-implant to correct anterior skeletal open bite…
Al-Labani MA et al
were made, including the necessity of orthognathic surgery
after the space closure and facial reevaluation. The patient
and his parents did agree with this sequence of treatments,
the second option was presented to them, and it was related
to the use of mini-implant to provide skeletal anchorage and
intrude the upper molars.
Journal of International Oral Health 2016; 8(12):1132-1135
After scaling and polishing of teeth, trans-palatal arch was
delivered 2 mm off the palate to intrude the buccal and palatal
cusps of maxillary six molars. 022 slot MBT brackets system
was used, the archwire sequence progressed to 0.19 × 0.25 S.S
to stabilize the arch. 3 months into treatment box elastics were
used, then after 6 months into treatment triangular elastics
were used as needed to help in closing anterior open bite
(Figure 3a and b). Regarding muscles exercises, the patient
asked to clench isometrically for five seconds and rest for five
seconds for one minute five to six times a day.
At 11 months from the beginning of the treatment, two
mini-implant (Jeil Medical Corp, Seoul, Korea), with 8 mm
in length, and 1.4 mm in diameters were inserted between
upper first molars and second premolars as inferiorly as
possible. 2 weeks later mini-implant on the right side
was removed due to loosening and changes the position.
Repositioning the brackets of upper incisors and detailing
was complete, so all fixed appliance and mini-implants were
removed (Figure 3c).
a
b
The results of the treatment were obvious and clear as shown
in the post-operative views (extraoral and intraoral views),
the anterior open bite no longer exists and it is possible to
note the improvement in the occlusal plane position and in
the tongue posture. Furthermore, it is possible to notice the
profile improvement and the smile arc in harmony with the
length of the lower face (Figure 4a-d). The speech, function,
and esthetic had improved significantly. Furthermore, it is clear
in the post-operative radiographs (Figure 5a and b).
d
c
Figure 1: (a-d) Extraoral and intraoral pre-operative view.
a
The patient was recalled for 6 months (once per month) to
evaluate the stability of the case. A maxillary and mandibular
fixed maintainers were used for retention. The patient was
instructed to continue the muscle exercises, proper oral hygiene
with different cleaning aids.
b
Figure 2: (a and b) Cephalometric and panoramic preoperative view.
a
b
c
Figure 3: (a-c) During treatment progress with mini-implants and regular band.
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Molar intrusion with mini-implant to correct anterior skeletal open bite…
Al-Labani MA et al
by a gummy smile. But by the using of a micro-implant, we can
intrude posterior teeth, allowing the mandible to auto-rotate
counterclockwise direction, thus closing the open bite without
jaberdising the esthetic of the patient. The second decreased
the treatment time, as well as the cost of the treatment since
we did not go for orthognathic surgery. In addition to that,
we preserved the aesthetic of the patient since the incisor had
shown acceptable alignments at the beginning of the treatment.
a
b
Conclusion
The skeletal anterior open bite, in this case, was treated
successfully as documented by photos and cephalometric
X-rays. Mini-implant with good orthodontic biomechanics
was effective tolls to treat this skeletal anterior open bite cases
conservatively although we may achieve the same result with
orthognathic or extraction of teeth.
d
c
Figure 4: (a-d) Extraoral and intraoral post-operative views.
a
Journal of International Oral Health 2016; 8(12):1132-1135
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b
Figure 5: (a and b) Cephalometric and panoramic postoperative view.
Discussion
A skeletal open bite is considered to be one of the most
complicated malocclusion and its treatment depends on the
severity of the skeletal discrepancies. Orthognathic surgery
is usually the preferred treatment option for a severe skeletal
anterior bite with deficient chin.13-15 Camouflage treatment with
premolar extraction is a common alternative option, but in our
case, it was refused by the patient. The patient was opposed
to surgery of any teeth; therefore, he accepted the treatment
with mini-implants.
The use of mini-implant as a temporary anchorage for skeletal
anchorage is clearly not a replacement for other proven
anchorage systems. Skeletal anchorage should serve merely
to expand the orthodontic services we can offer our patients.16
Multi-loop edgewise archwire is effective for correcting the
case17 but it was not selected because it is not capable of
decreasing the lower facial high wire bending time. The most
significant problem encountered where the failure of initial
mini-implant on the right side and continued breakage of
brackets of lower seconds premolars due to biting exercises,
but this has been corrected after 4 time of breakage.17
The clinical significant of treating this case first, from the
orthodontic biomechanics point of view if we used conventional
methods, by extruding of the interior teeth this may lead to
compromising the smile line by extrusion of incisors ending
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Molar intrusion with mini-implant to correct anterior skeletal open bite…
Al-Labani MA et al
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Orthodontics - Basic Aspects and Clinical Considerations,
Ch. 9. Rijeka, Croatia: InTech, 2012. p. 195-218.
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Kawamura H. Skeletal anchorage system for openbite correction. Am J Orthod Dentofacial Orthop
1999;115(2):166-74.
14. Epker BN, Fish L. Surgical-orthodontic correction of openbite deformity. Am J Orthod 1977;71(3):278-99.
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15. Proffit WR, Bailey LJ, Phillips C, Turvey TA. Long-term
stability of surgical open-bite correction by Le Fort I
osteotomy. Angle Orthod 2000;70(2):112-7.
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anchorage devices - Mini-implants. Natl J Maxillofac Surg
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van’t Hof MA, van der Linden FP, et al. Skeletal and dentoalveolar stability of Le Fort I intrusion osteotomies and
bimaxillary osteotomies in anterior open bite deformities.
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