TREATMENT OF BASAL ANOMALIES OF THE VERTICAL SENSE

TREATMENT OF BASAL ANOMALIES OF THE VERTICAL SENSE

Plan

1. Introduction
2. Etiology
3. Diagnosis
4. Factors influencing therapeutic choice

5. Treatment of basal anomalies of the vertical sense

5.1 Treatment of maxillary vertical excess 

2. Treatment of maxillary vertical insufficiency 

6. Contention

7. Prognosis

8. Conclusion 

bibliography 

1. INTRODUCTION :

• The vertical dimension is an essential component of dysmorphoses, closely linked to growth phenomena and the muscular context of the subject. When it is disturbed, it aggravates the aesthetic damage of the dysmorphosis and complicates its treatment. 

• Basal anomalies of the vertical direction are characterized by excess or insufficiency of the lower level of the face, they can be isolated and appear in skeletal class I or associated with other dysmorphoses of the sagittal or transverse direction, aggravating the anomaly 
• These vertical skeletal anomalies have few specific orthopedic therapies. Therapeutic action is limited and is based on the prevention of factors that may aggravate an unfavorable type of growth and the control of vertical dental movements. In extreme cases, the aesthetic and functional damage may require surgical correction.

2. ETIOLOGIES: 

The etiopathogenic mechanisms of vertical anomalies show that their main causes are; 

• Primary; hereditary and congenital 
• Functional; dysfunctions, parafunctions and posture disorders 
• Iatrogenic; dental egression by most orthodontic devices with increase in vertical dimension DV 

3. DIAGNOSIS;

• vertical excesses of the maxilla (EVM): VERTICAL EXCESS OF THE MAXILLA (EVM): These anomalies correspond to a vertical development of the maxilla, with a very significant aesthetic impact, they are characterized by:  

•  An exaggeratedly long and narrow face.
•  an excessively lower floor increases.
• Lip inocclusion in usual posture.
• A profile is convex with a concealed chin.
• Posterior rotation of the mandible with an open goniac angle.
• Very often associated with a skeletal gap (molar to molar infraclusion) 
• All functions are disrupted.

Open bite with a skeletal gape

• vertical maxillary insufficiencies (VMI)

These anomalies correspond to an insufficiency of vertical development of the jaws, they are characterized by: 

•  A short and wide face.
•  a lower floor decreases.
• The lip occlusion in habitual and constant posture.
• A profile is concave with a prominent chin.
• Anterior rotation of the mandible with a firm goniac angle.
• An incisor overbite sets in 
• Imploring muscle tone without disruption of various functions.

TREATMENT OF BASAL ANOMALIES OF THE VERTICAL SENSE

Deep bite with real overbite

4. FACTORS INFLUENCING THERAPEUTIC CHOICE :

4.1. growth

• Growth direction

 Each type leads to the choice of certain devices that are contraindicated for the other.   

• Growth stage

• During the infantile period, the restoration of the muscular environment is sought.
• Beyond this stage, the treatment will be orthodontic by alveolar compensation; 
• If the discrepancy exceeds orthodontic possibilities, surgical treatment is necessary.

4.2. the teething stage

• Type of treatment: either interceptive or corrective

interception of anomalies, for maxillary vertical insufficiency whose major manifestation is overbite, the child must be seen after the fall of the temporary teeth therefore before the formation of the mixed dentition to allow the eruption of the Incisors to be blocked

4.3. functional factors:  

• To prepare the favorable neuromuscular environment through the rehabilitation of functions.
• Deleting para functions

4.4. age: 

• Early treatment

       – avoid extractions

       – recovery of normal function is possible 

4.5. the severity of anomalies 

Allowing a significant anomaly in mixed dentition to develop in permanent dentition runs the risk of lesions or more complex problems appearing. 

• Moderate degree  : orthodontic treatment
• Severe anomalies  : surgical treatment

4.6. motivation 

Is a key element for the success of each therapy, mainly certain devices, which involve total cooperation on the part of the patient, 

5. TREATMENT OF BASAL ANOMALIES OF THE VERTICAL SENSE

 5.1. Treatment of anterior vertical excess:

• Processing purposes:
• Aesthetic : 

• Improve the harmony of the face and profile floors
• Achieving good lip coaptation 
• Improve the impression of a concealed chin.
• Skeletal: 

• Decrease the vertical dimension.
• Limit skeletal divergence.
• Correcting skeletal gaping
• Occlusal: 
• harmonize occlusal relationships. 
• Functional :
• Restoration of functions.
• Treatment in temporary dentition

Consultation with an ENT specialist may be recommended around the age of 5-6 years. This will involve carrying out a respiratory assessment and possibly intervening to free the congested upper respiratory tract. In the same vein, lingual dysfunction can be taken into consideration by an assessment and orthodontic treatment.

• Treatment in mixed dentition
• Functional therapy
• non-mechanical functional therapy   
• Rehabilitation of tongue dysfunction: The lips and tongue are

 key players in the creation and maintenance of gaps.

• Myotherapy: labial myotherapy, masticotherapy 
• Correction of dysfunctions: Reeducation of swallowing and nasal ventilation 
• Elimination of distorting habits: EX : Gentle anti-thumb sucking psychotherapy
• . Mechanical functional therapy  : 

TREATMENT OF BASAL ANOMALIES OF THE VERTICAL SENSE

• Nocturnal lingual envelope (NLE) 
• Bonnet  proposes a device called an envelope

 lingual night (ELN); to educate the tongue

 towards secondary motor skills; in order to achieve 

a pre-correction of the operating space 

lingual. 

• Anti-tongue grid  
• Pearl of Tucat

These types of devices directly combat the effect of dysfunction (prevent the tongue from getting between the teeth or having an action on them) or parafunction (thumb), and allow reflexes to be modified and rehabilitation to be facilitated after improvement of the dental environment.

• Mechanical treatment :
•  High-traction chin strap and occlusal elevation plate : 

Some authors used this device (during the growth period) in order to cause an anterior rotation of the mandible and therefore a reduction in the DV, the chin moves forward and up, the facial angle increases. 

Currently many authors have doubts about the effectiveness of this process and reject it.

High-traction chin strap and occlusal elevation plate

• FEB high traction with transpalatal arch :

It is a removable mechanical device that allows to exert an intermittent force in a vertical direction on the upper first molars without taking support on the anterior teeth, taking their support outside the oral cavity, the transpalatal arch allows to counteract the vestibulo-version of the upper molars; bite planes can be added to optimize the intrusion of the posterior teeth.

High traction FEB (with transpalatal arch) causes maxillary postero-rotation with anterior mandibular rotation and closure of the mandibular compass .

TREATMENT OF BASAL ANOMALIES OF THE VERTICAL SENSE

FEB high traction with transpalatal arch

These FEBs must be placed at the time of growth to benefit from its maximum potential. They can be used alone or in association with a multi-attachment fixed device. They are indicated in cases of increased DV with or without incisor gap.

• Use of intermaxillary elastics (TIM):

Integrated into the framework of fixed therapy, intermaxillary elastics applied laterally can close the skeletal gap and thus reestablish the incisal guide.

TREATMENT OF BASAL ANOMALIES OF THE VERTICAL SENSE

Vertical elastics

• Mini screws and mini anchor plates
• These temporary skeletal anchoring devices allow: 

•  block maxillary posterior alveolar growth, 
• or even the intrusion of the maxillary molar. 

(can be used vestibularly and/or lingually).

Mini screw in vestibular

• Orthodontic therapy with extraction  ; 
• Extraction of permanent teeth reduces DV
• The choice of teeth to be extracted is made according to the associated anomaly:

•  The greater the proalveoli, the more anterior the extraction.
• The more extensive the gap, the more posterior the extractions are:
• According to Bassigny:
•  In case of gaping: extraction of molars: 16/26 and 37/47.
• In case of proalveolus: extraction of the four 1st PM 
• According to Bou Serhal:
• Extraction of the four first premolars + chin sling 

 (450g pd 12h/day).

TREATMENT OF BASAL ANOMALIES OF THE VERTICAL SENSE

        In all cases, a multi-band or multi-bracket technique is essential (to mesialize the posterior teeth and close the extraction spaces).

       Loss of anchorage during extraction treatments is easy in hyperdivergent patients due to low occlusal forces and the mesial orientation of the teeth in the lateral sectors. This loss of anchorage must therefore be carefully controlled.

       When closing the extraction spaces, it is necessary to avoid versions of adjacent teeth which cause their extrusion.

• . Surgical therapy  
• In the maxilla; 

Segmental osteotomy of the maxilla with posterior impaction and anterior tilt 

The amplitude of this impaction is dictated by the aesthetic objective presented: the exposure at rest of 2 to 3 mm of the maxillary incisors

 a “harmonious” smile, that is to say revealing 1 to 2 mm of gum when fully smiling

• posterior impaction (SCHUCHART)  ; involves the molar-premolar region, with extraction of wisdom teeth

Its aim is to modify the position of the dento-skeletal portion of the mandible to normalize dental occlusion.

• OBWEGESER DALPONT osteotomy  ; Elevation of the horizontal branch segment 

TREATMENT OF BASAL ANOMALIES OF THE VERTICAL SENSE

OBWEGESER DALPONT osteotomy

• Symphyseal genioplasty  :

• Glossotomy : in the case of a large tongue with interposition 

5.2. Treatment of anterior vertical insufficiency  

• Processing purposes:
• Aesthetics:  
• Improve the appearance of the “toothless smile”.
• Skeletal: 

• Unlocking growth. 
• Improve the vertical dimension.
• Alleviate anterior rotation
• Occlusal: 

• Correct the overbite.
• Achieve mandibular function in propulsion.
• Periodontal  : 
• Elimination of mechanical aggression.

• Treatment of overbite 
• According to Parker in 1995 “correction of overbite is one of the primary goals of orthodontic treatment, it is considered one of the most common anomalies and the most difficult to treat successfully”
• Among the different methods of correcting incisor overbite, those which induce extrusion of the lateral sectors are preferred in hypodivergent children to open the vertical dimension and reduce the tendency towards anterior rotation.
• Preventive treatment

Orthostatic feeding Rehabilitation of selective grinding incision

    the muscular activity of the elevators must be reinforced by chewing hard foods. The almost exclusive consumption of chopped or mixed foods should be avoided,

• Interceptive treatment 
• prevent the development of an overbite. 

            These signs include:

• A significant reduction in the lower level of the face  
• The presence of an overbite in temporary teeth.

• The incisal coverage is normally very weak in the temporary dentition. An overbite at this stage leads to a strong overbite in the permanent dentition.
• Jullien Philippe’s inter-incisive plate : Just after the baby teeth fall out, when there is already an overbite in the temporary dentition, it prevents the tooth from coming out and it is the gum that rises.
• Activators and gutters covering the incisor eruption area: 

It is easy on a classic activator (ANDRESEN type) to add an extension covering the eruption zone of the incisors which will play the same role as the “inter-incisor plate”

• Corrective treatment
• Promote spontaneous egression

   This method is frequently used in mixed dentition during the evolution of the lateral sectors.

   It consists of causing a disocclusion at the level of the lateral sectors and allowing the teeth to spontaneously erupt to close this gap.

    Many devices allow this action:

• Retro-incisive planes on the palatal plate (occlusal elevation plate, Korn plate) or on the palatal arch contribute to the intrusion of the mandibular incisors when lifting the overbite.
• Unilateral gutters allow successive egression on both sides: egression on the side opposite the gutter initially, then after removal of the device, egression on the side of the gutter.
• Planas’ equiplan: steel blade interposed between the incisors on a device that promotes mandibular propulsion and consequently the incisal end-to-end position. It releases the growth of the mandibular alveolar processes contributing to the leveling of the curve of Spee by egression while having an ingressive action on the incisors. 

• Philippe’s retro-incisive stops: composite resin wedges glued to the palatal surface of the maxillary incisors and sometimes the canines to be intruded, have a flat occlusal surface on which the mandibular incisors rest during closure. This contact induces ingressive forces on the incisors and creates a disocclusion of the lateral sectors which can freely egress.

• activators for sagittal orthopedics: grinding of their inter-occlusal surfaces can promote controlled egression of the lateral sectors

TREATMENT OF BASAL ANOMALIES OF THE VERTICAL SENSE

• Exert egressive forces on the lateral sectors  ;

These forces can be exerted by:

• extraoral cervical traction forces that egress the maxillary molars;

• intermaxillary tractions which all have an egression component on their anchor teeth
• molar anchored incisor intrusion arches or sectionals which exert an egression action on these teeth
• Extractions are generally contraindicated in hypodivergent patients in order to avoid:

• Close the vertical dimension because they potentiate the subject’s growth direction and thus increase the incisor overbite;
• Excessively retracting the incisors in the presence of a flat profile
• Surgical treatment:

• In adults, when vertical insufficiency causes excessive aesthetic and functional damage or when the associated dysmorphosis requires it, surgical-orthodontic correction can be implemented.
• It can also be due to:

• the impossibility of correcting the incisor overbite orthodontically
• to aesthetic damage linked to vertical insufficiency and crushing of soft tissues. 
• Depending on the case, the increase in the vertical dimension can be obtained by:

•  lowering of the maxilla after Lefort I surgery and placement of bone grafts,
•  posterior rotation of the occlusal plane after maxillary posterior impaction and mandibular advancement.
•  genioplasty.
•  mandibular advancement. 

TREATMENT OF BASAL ANOMALIES OF THE VERTICAL SENSE

                                               Sagittal osteotomy of the ascending branches 

in propulsion and clockwise rotation of the mandible

Lefort osteotomy 1

5. CONTENTION 

• Infra-alveoli: with the help of rehabilitation, insisting 

on swallowing “tight arches”

• Supra-Alveoli: 

         Sved toothpositioner plate Cingulate plasty

• Basal abnormalities

• Contention by hypercorrection associated with a tooth-positioner.
• In cases treated by surgery, care is taken to maintain a good transverse relationship of the maxilla over the long term.
• The palatal plate must be worn at all times.

6 – PROGNOSIS :

• Infra-clusion: 

• Prognosis Good in the short and medium term if the lingual interposition is removed.
• Very rapid recurrence: Untreated macroglossia. 
• Long term stability: questionable.

• Supra-clusion:
• Favorable short-term prognosis.
• Long-term forecast reserved.

• Anterior vertical excess (AVO):
• Anterior vertical insufficiency (AVI):

– According to TWEED  : skeletal modifications are difficult to obtain and very recurrent

– According to RICKETTS  : More stable surgical treatment.

• The greater the opening of the FMA angle or the facial axis, the more difficult it will be for the muscles to adapt to this new bone position; the more powerful the musculature, the less easy the adaptation will be and the worse the long-term prognosis.

8. CONCLUSION

• Vertical dysmorphias represent the most difficult and most recurrent anomalies to treat. Rarely isolated, they condition and complicate the treatment of other anomalies.
• Early diagnosis and interoceptive therapy remain the best assets for good care of our patients and improving the prognosis of this type of pathology.
• The stability of the results depends largely on the quality of the occlusion obtained and especially on the normalization of functions and if possible of muscular activity.

  Wisdom teeth can be painful if they are misplaced.
Composite fillings are aesthetic and durable.
Bleeding gums can be a sign of gingivitis.
Orthodontic treatments correct misaligned teeth.
Dental implants provide a permanent solution for missing teeth.
Scaling removes tartar and prevents gum disease.
Good dental hygiene starts with brushing twice a day.
 

TREATMENT OF BASAL ANOMALIES OF THE VERTICAL SENSE