Treatment of vertical direction anomalies
Introduction :
Vertical anomalies are rarely found in isolation.
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.
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.
- Treatment of vertical alveolar anomalies:
- anterior infra alveolus (anterior open bite):
It is necessary to differentiate isolated anterior gapes of functional origin from anterior gapes which constitute the accompanying sign of a severe basal anomaly of the vertical direction which we call skeletal gapes.
Functional treatment:
- improvement of parafunctions and elimination of deforming habits, in mixed dentition;
- swallowing rehabilitation, labial myotherapy;
- nasal ventilation rehabilitation;
- Gentle anti-thumb sucking psychotherapy
Mechanical treatment:
Complete multi-attachment device and anterior vertical intermaxillary traction
- anterior supra alveolus:
Management of early incisor overbite is necessary to remove the growth barrier it represents and reduce the joint and periodontal risks it generates.
Almost systematic in mandibular hypodivergences, it can also be encountered without associated vertical skeletal anomaly and even in the case of hyperdivergence.
incisor intrusion:
The incisive ingression is the most difficult movement to obtain since it
stresses the teeth and periodontium in the direction in which they are best organized to resist. The forces applied must be of low intensity.
- Segmented arches,
- Continuous arc with Curve of Spee.
- Minivis.
- Posterior supraalveolus:
Rare anomaly.
More common in the maxilla than in the mandible.
Often associated with posterior rotation of the mandible.
The treatment consists of molar intrusion, a movement that is difficult to obtain:
- The miniscrews
- Continuous arc with reversed spee curve.
- Extra oral forces…
- Posterior infra-alveolus:
Also called Infra-alveolar molars.
Characterized by insufficient vertical development of the premolar-molar alveolar region, most often bilateral.
Characterized by incisal contact and absence of premolar and molar contact.
Functional treatment preventing tongue interposition.
Molar egression can be achieved by :
- activators (class II cases with overbite);
- Planas’ crew
- retro-incisal stops
- intermaxillary tractions
- extraoral cervical traction forces
- Sved’s plaque.
- Treatment of vertical skeletal anomalies:
- Vertical excesses (hyperdivergence, Openbite):
Except for the vertical chin sling, there is no orthopedic device that can treat mandibular hyperdivergence.
Faced with this dysmorphosis, therapeutic action is therefore based on:
Preventive action which aims to:
– remove all functional factors promoting mandibular posterotation during growth;
– avoid or control the parasitic vertical effects of sagittal and transverse orthopedic and orthodontic therapies.
- eliminate non-nutritive sucking habits
- Nasal ventilation should be restored as soon as possible
- the muscle activity of the elevators must be reinforced by chewing hard foods;
- the interposition of the tongue in the gap must be eliminated, most often by a device such as a lingual screen or anti-tongue grid
Posterior vertical control:
Control of maxillary posterior alveolar growth and maxillary molar egressions can be achieved by:
- a palatal bar;
- OEMs on 16 and 26 high-traction;
- mini anchor screws.
Extractions:
Extraction of molars to close the vertical dimension, reduce hyperdivergence and attempt to modify the direction of growth.
- In all cases, a multi-ring or multi-attachment technique is essential.
Surgical-orthodontic treatment:
In severe cases, the aesthetic and functional damage (lip inocclusion) requires a surgical-orthodontic solution.
The most frequent surgical protocol seeks closure of the vertical direction by mandibular anterotation after posterior impaction of the maxilla.
- LEFORT Low Osteotomy 1
- Segmental posterior maxillary elevation osteotomy
- Sagittal osteotomy of the two horizontal branches
- Soft tissue procedures:
- Removal of adenoids
- Tonsillectomies
- Glossotomy
- Treatment of vertical development insufficiency (hypodivergence, Deepbite)
Except in extreme cases and in class III, mandibular hypodivergence and anterior rotations of the mandible are rather considered as favorable elements, especially in class II where they facilitate correction.
It is the incisor overbite that most often accompanies it that constitutes the major problem, creating a real blockage of the mandible and its growth, justifying its early management.
- Elimination of associated functional disorders:
Lateral lingual interposition between the arches must be corrected.
In some cases, myotherapy may be considered to relax the often hypertonic labiomental musculature.
- Correction of incisor overbite:
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.
- Orthopedic treatment:
- Class I : Equiplan
- Class II : Cervical traction activators and FEBs
- Class III : The occipito-mental sling.
- Orthodontic treatment:
- Multi-attachment fixed treatment: correction can be done:
- Either using continuous arches : (Edgwise) tip-back: ingression of the incisors and egression of the molars) after anchorage preparation,
- Either using segmented arcs (Ricketts) which seems the most effective:
- Kurz lingual brackets:
- The brackets are glued to the palatal surfaces of the upper teeth, which for the anterior teeth have a small flat surface called the “bite plane”, intended to receive the occlusal shock of the opposing teeth.
- The retro incisive stop:
- Inspired by the previous technique, the stops are made of a mass of composite glued to the palatal faces of the incisors and sometimes the maxillary canines, their occlusal face is flat and receives the occlusal contact of the mandibular incisors.
- Intermaxillary elastics:
- In class II: from the upper canine to the 1st lower molar (in the absence of a gummy smile).
- Class III: from the lower canine to the upper molar
- Use of mini-screws as anchors to ingress the incisors
- Extractions in hypodivergents:
The main aesthetic risk of this vertical typology and its evolution during growth is the establishment of a concave subnasal profile.
- Extractions are generally contraindicated in hypodivergent patients.
- Surgical treatment
- Total maxillary surgery type LEFORT I with egression of the entire arch or combined, where the anterior segment will sometimes have to be ingressed if there is a significant gummy smile (severe class II / 2).
- At the mandibular level, mandibular derotation surgery will restore the mandible vertically and sagittally while maintaining posterior alignment.
- Surgery is performed as a last resort, in severe cases that do not respond to previous treatments.
- Basilar horizontal osteotomy
- Double alveolar osteotomy .
Treatment of vertical direction anomalies
Conclusion
- In orthodontics, vertical anomalies often accompany those of the sagittal and transverse direction, increasing the aesthetic damage and complicating their treatments.
- Therefore, it is very important to know perfectly their signs, whether clinical or radiological, their etiologies and the consequences of the disturbed functions on the orofacial sphere,
Treatment of vertical direction anomalies
Untreated cavities can damage the pulp.
Orthodontics aligns teeth and jaws.
Implants replace missing teeth permanently.
Dental floss removes debris between teeth.
A visit to the dentist every 6 months is recommended.
Fixed bridges replace one or more missing teeth.