Treatment of Vertical Sense Anomalies
1. Introduction
Vertical dysmorphoses are the result of the interference of multiple factors
etiological during growth period
These dysmorphias are not completely isolated, but generally combined.
to others that affect the sagittal and/or transverse dimensions.
Hence the complexity of our intervention which must be three-dimensional.
We will discuss the different therapeutic alternatives available to us in order to achieve optimal occlusal, aesthetic and skeletal relationships; all in an adapted musculo-functional environment.
2. Diagnostic reminder
- Alveolar anomalies in the vertical direction:
Anterior infra-alveoli: Anomaly of the vertical direction, located in the anterior alveolodental sector.
Lateral infra-alveolia: Characterized by the absence of dental contact in ICM at the level of the cuspid teeth; can reach the 2nd molar .
Supra-alveolia Vertical alveolodental anomaly located in the ant sector, characterized by excessive incisal overlap affecting the 04 incisors or even the incisor-canine block.
Treatment of Vertical Sense Anomalies
2.2 Basal anomalies of the vertical sense:
Anterior vertical insufficiency: Skeletal deepbite, short face, hypodivergent face, all these definitions have in common a vertical height of the anterior face too low due to an insufficiency of vertical development. The overbite is constant with a weak overjet and an exaggerated curve of speech in the lower arch
Anterior vertical excess: Long face syndrome, hyperdivergent face, skeletal gap, excess development of the bony bases in the vertical direction.
3. Factors influencing the therapeutic choice
3.1 Growth:
It is indeed necessary for the establishment of a treatment plan, in orthodontics, to specify the stage of maturation of the subject.
Growth direction:
A treatment that acts in the direction of growth will be more effective; if growth is unfavorable, the treatment will be relatively powerless against the effects of this type of growth, so it will be better to start treatment after the maximum growth has passed.
Two different types of growth: EVA (post growth direction), IVA (anterior growth direction), each type directs towards the choice of certain devices which are contraindicated for the other.
Growth stage:
According to the Bjork curve, during the infantile period, the treatment is functional and mainly etiological which consists in restoring the adequate muscular environment, so the treatment must be established before the cerebral engrammation, beyond this stage, the treatment will then be orthodontic by alveolar compensation, in the adult period. And if the discrepancy exceeds the orthodontic possibilities, surgical treatment is necessary.
3.2 The teething stage:
At each period of morphogenesis of the arches, a stage of orthodontic treatment can be located,
It plays a key role in intercepting anomalies, for IVA 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 Inc. to be blocked or rather guide their eruption while establishing a correct angle of attack.
3.3 Functional factors:
It is necessary to prepare the favorable neuromuscular environment by reeducating functions, suppressing parafunctions. This preparation requires an etiological treatment step.
3.4 The severity of the 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
3.6 Motivation:
Is a key element for the success of each therapy, mainly certain devices, which involve total cooperation on the part of the patient, as well as at the end of treatment by fairly long periods of contention.
4. The different therapeutic alternatives:
Aims to better identify the choice and channel our intervention, it helps us to discern:
Treatment with tooth extractions, treatments without extraction depending on the philosophy of each practitioner and therapeutic limitations.
The orthodontic and orthopedic approach according to age, cooperation and assessment of aesthetics and facial typology.
Orthodontic intervention alone or combined with surgery depending on the list of problems mentioned and the orthodontic possibilities of achieving the aesthetic, dental, and
5. treatment of vertical direction anomalies:
5.1 Treatment of vertical alveolar anomalies:
5.1.1 Supra-alveoli:
- Processing purposes:
They are mainly occlusal, it is necessary to re-establish a correct incisal coverage.
According to Parker in 1995 “correcting 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”
- treatment principles:
Molar egression.
Vestibulo-version of the incisors.
Incisor intrusion
- Preventive treatments:
– Their aim is to eliminate in infants or very young children the conditions which promote the appearance of an overbite.
-. If heredity makes one fear the appearance of an overbite, one can only be in favor of the use of a pacifier or a soother. One will especially seek to develop the mandibular functions.
– To promote this functional dynamism, 3 processes are at our disposal:
- Orthostatic feeding: P. ROBIN advised to place the thorax of the child who suckles the breast or bottle vertically. He is thus obliged to propel the mandible to suckle, as most mammals do.
- Selective grinding: P. PLANAS recommends intervention from the age of 3 or 4 years in children who can neither chew laterally nor perform propulsion movements. PLANAS practices selective grinding to allow and balance lateral movements as well as occlusion in propulsion.
- Incision rehabilitation: We must advise our patients to eat anything that promotes propulsion, incision, and mandibular excursion movements (apples, radishes, etc.). We must also recommend hard foods: “eating soft foods” can only lead to weakening and reduction of oral functions.
- Interceptive treatments:
-They aim to prevent the development of an overbite diagnosed as soon as the first signs appear
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.
- The inter-incisal plate:
-The indication is given in temporary dentition. After the observation of an overbite, the plate must be placed immediately after the fall of the first, or the first two maxillary temporary incisors.
-it is a palatal plate with a resin extension on the area disinhabited by the loss of the central and temporary lateral incisors, the vestibular extension is thick enough for the mandibular incisors to come into contact with its lower face.
Effects:
-The anterior part of the plate covering the eruption site opposes the egression of the maxillary incisors. This abuts on the internal, upper face of the plate.
- Activators and gutters covering the incisor eruption area:
-In cases that simultaneously present signs announcing an overbite and a Class II arch relationship, both anomalies must be treated simultaneously. Several procedures can be considered:
-It is easy on a classic activator (Balters bionators) to add an extension covering the eruption zone of the incisors which will play the same role as the “interincisive plate”.
It should be noted that an activator which repositions the occlusion by the resin placed between the molars can be installed later than the plate, that is to say after a partial evolution (3 or 4 mm) of the permanent incisors.
-How can we use a 4P Castle?
- Corrective treatment
The therapeutic approach requires the determination at the beginning of treatment of the incisor intrusion and molar egression movements necessary for vertical correction.
- Maxillary incisor intrusion devices using cranial support: These are the only devices that can be guaranteed to cause intrusion of the maxillary incisors without risking extrusion of the molars.
– main indications:
- OpenBite with weak musculature and posterior rotation.
- Severe “gummy smile” cases
High extraoral forces:
- This device consists of a high-placed cranial support, long J-shaped hooks, the WITTMANN bars, the anterior part of which is attached to the Edgewise arch which passes between the brackets and the posterior part of which is pulled by elastics anchored on the cranial support.
- The elastic traction transmitted by the bar is powerful. The force applied to the incisor bracket is directed upwards and backwards which tends to tilt the incisors lingually.
B. Incisor intrusion devices by molar support:
The basic RICKETTS arc of ingression:
Placed in the mouth, the anterior part must be above the necks, and it is forced into the brackets trying to find its initial configuration,
it intrudes the incisors. The intrusion of the incisors which rests on the molars, generates a reaction force which tends to egress the molars.
C. Devices that egress molars:
-Treating a slightly severe overbite by simply egressing the molars presents two risks:
- a posterior rotation which would increase the offset of the bases and the retraction of the chin.
- recurrence, especially if the egression exceeds the “free space” between the arches.
- The support must be well adapted and continued for many years.
Raising gutter:
Experience shows that a tooth without an antagonist erodes, especially if a raised surface (resin or metal)
When occlusal contact is obtained on teeth that were free and have egressed, the elevation surface can be reduced or eliminated. Such an elevation surface can take the form of a unilateral elevation splint taking up only a few teeth.
D. Devices that intrude the incisors and egress the molars:
Treatment of Vertical Sense Anomalies
The PLANAS crew:
-It is a “steel blade” that fits freely between the upper and lower incisors, raising the occlusion and maintaining an incisal overlap of 1mm.
The equiplan is held on the lower incisors by a device which, by resting on a removable maxillary plate, pushes the mandible almost end to end,
It is designed to allow incisor intrusion and molar egression.
Activators with equiplan:
Activators can be extensively modified to be better suited to correcting the overbite.
We then deliver a 4-piece castle:
- Top plate with jack
- Bottom plate
- W propeller
- And the Planas crew
- Surgical treatment:
- At the level of the maxilla:
- WASSUMND osteotomy : limited to the anterior alveolar sector, it allows posterior tilting and elevation of the resected block.
- KOELE intrusion osteotomy: Allows the mobilization of the mandibular incisor-canine group, used mainly to ingress these teeth
5.1.2 Treatment of anterior infraalveolar:
5.1.2.1 Processing purposes:
Aesthetic goals
– Harmonious lip relations.
– Closing of the lips at rest.
Occlusal objectives
– Restore correct over bite.
Treatment of Vertical Sense Anomalies
Functional objectives
– Rehabilitation of atypical swallowing with anterior lingual interposition
– Elimination of distorting habits
5.1.2.2 Principle: – the search for the etiology is essential in establishing the treatment plan for an anterior open bite. It is necessary to differentiate between isolated anterior open bites, of functional origin, and anterior open bites which constitute the accompanying sign of a severe basal anomaly of the vertical direction which we call skeletal open bites.
Functional treatment
- Non-mechanical
-Rehabilitation of nasal ventilation
-Lingual posture rehabilitation
-Swallowing rehabilitation
-Lip and tongue myotherapy
-Removal of parafunctions and distorting habits
- Mechanical treatment:
The nocturnal lingual envelope:
- The implementation of the ELN performs a pre-correction of the lingual functioning space, acting directly on the functions: the tongue modifies its motor skills, the morphogenetic normalization of the structures occurs secondarily and spontaneously.
- Mode of action: Lingual dysfunctions, both in posture and function, aggravate or establish a large number of dysmorphoses. The ELN, due to its bulwark function, makes it possible to stop the deforming forces
Palatine plate with Tucat pearl:
Invites the tip of the tongue to play with it and prevents it from getting between the teeth.
HINZ oral screen:
-The simple screen is interposed between the lips and the teeth and is used to help the child stop sucking his thumb, the lower lip, using his pacifier, and to re-educate his nasal breathing. The one with grid is indicated for anterior open bites due to lingual interposition.
Treatment of Vertical Sense Anomalies
Balters Bionator gapes:
-The anterior part is covered by resin to prevent the interposition of the tongue between the incisors.
- Orthopedic treatment: Vertical FEB on splint: used in stable mixed dentition, sometimes in stable adolescent dentition. FEB on splint with low external branches allows the Hourly tilt of the occlusal and palatal plane The vertical chin sling : It is indicated in all cases of class I or Class II with anterior open bite
– Anterior rotation of the mandible, the chin moves forward and up.
– reduction in the height of the lower floor of the face.
-Increased incisal coverage
- Orthodontic treatment:
Multi-attachment fixed therapy
- a basic Ricketts egression arc which has the effect of:
-on the Incisors a vertical component of egression which tends to increase the incisal coverage and a component of coronal lingoversion which accompanies the egression movement
-on the molars a coronal mesioversion component
- anterior vertical intermaxillary tractions: elastics stretched from the upper arch to the lower arch to allow the gap to close.
- Surgical treatment:
When alveolar abnormalities could not be corrected during growth by orthodontic treatment or when this no longer seems indicated in adulthood, they can be reduced by alveolar (segmental) osteotomies.
Depending on the origin of the infraclusion, we distinguish:
SCHUCHARDT osteotomy:
-It is a bilateral osteotomy involving the molar-premolar region, with extraction of the wisdom teeth, which allows impacting the most posterior teeth of the arch.
DAUTREY osteotomy:
-Extraction of the first premolar and segmental osteotomy, which allows the advancement and elevation of the fragment.
KOELE osteotomy.
This is an alveolar elevation osteotomy that will restore the anterior dental occlusion.
On soft tissues:
Glossotomy:
-Consists of reducing lingual volume
-Intervention technique: this involves a median diamond resection or at the tip.
5.1.3 Treatment of lateral gaping:
- Functional therapy: Rehabilitation of lingual posture using mechanical (ELN, lateral wings, lateral screens) and non-mechanical functional devices.
- Orthopedic therapy: Using low-traction FEBs for molar intrusion.
- Orthodontic therapy: Using posterior vertical elastics.
- Surgical therapy: Glossotomy with central drawing.
Treatment of Vertical Sense Anomalies
5.2 Treatment of basal vertical anomalies:
5.2.1 Treatment of anterior vertical excess: EVA
Processing purposes:
Decrease the vertical dimension.
Limit skeletal divergence.
Correct dental gapping and labial inocclusion.
Improve the impression of a concealed chin.
Treatment principles:
– intrusion or blockage of the eruption of maxillary and mandibular molars,
– extraction of teeth as far back as possible if extractions are indicated
-Pearson considers that in the treatment of hyperdivergent patients, the role of the orthodontist is the control of environmental factors, such as mouth breathing, lingual habits and the reorientation of growth in a more horizontal direction.
- Various procedures have proven their clinical effectiveness:
- In temporary dentition:
Treatment of these pathologies can be considered at a relatively young age, as soon as signs of dysfunction appear, consultation with an ENT specialist can be recommended around 5-6 years old. This will involve carrying out a respiratory assessment and possibly intervening to free the congested upper airways, lingual dysfunction can be taken into consideration by an assessment and orthodontic treatment. (lingual myotherapy, ELN, Hinz pacifier, etc.)
- In mixed dentition:
- The vertical chin sling: Molar intrusion
Mandibular compass closure
Reorientation of growth
- FEB with low external branches on gutter with high traction:
Maxillary molar intrusion
Clockwise shift of the palatal and occlusal planes
- In adult teeth:
The choice of teeth to be extracted is made according to the associated anomaly: the more significant the proalveolus, the more anterior the extraction and the more extensive the gap, the more posterior the extractions:
According to Bou Serhal:
Exercise of the four 1st PM + a chin sling (450 g. Pd 12h/day)
According to Bassigny:
In case of gaping: exo of molars: 16-26 and 37-47
In case of proalveolus: exo of the first four PM
For a significant reduction in DV: multiple exo
In the mandible it is preferable to extract the 2nd molar.
- Surgical therapy:
– SCHUCHARDT osteotomy.
-DAUTREY osteotomy
-LEFORT I impaction
-Osteotomy of the ascending branch of OBEWEGESER-DALPONT:
-The transramal osteotomy cleaves the ascending ramus of the mandible in its thickness. This mobilization allows the horizontal ramus segment to be elevated.
-Its aim is to modify the position of the dento-skeletal portion of the mandible to normalize dental occlusion.
Muscle disinsertions
This is an essential part of the surgery, at the end of which the mandibular body must be truly “floating”.
Muscles and ligaments that oppose the movement of the mandible and are subject to detachment: pterygo-masseter strap, sphenomandibular ligament, suprahyoid muscles.
5.2.2 Treatment of anterior vertical insufficiency: IVA:
Processing purposes:
- Skeletal
- Improve bone ratios
- Increase DV
- Aesthetics
- Improve your smile
- Erase the labiomental groove
- Occlusal
- Correct the overbite.
- Treatment of Vertical Sense Anomalies
-The therapeutic choice will depend on the inclination of the occlusal plane, the relationship of the incisors with the upper lip and the importance of the attached gingiva presented in relation to the lower incisors.
-For LANGLADE:
- Orthodontics: it requires:
- Ingression of the upper incisors.
- Ingression of the lower incisors.
- Vestibuloversion of the incisors .
- Avoid mandibular extractions.
But it is unstable and very relapsing.
- Surgical:
Surgical techniques that allow the correction of anterior vertical insufficiency include:
- LEFORT type I osteotomy for spreading or lowering
- LEFORT type I osteotomy with mandibular lowering genioplasty.
6. contention:
- Overbite:
- Contention by cingulate plasty
- Sved plate
- Overcorrection
- Anterior infra-alveoli:
This will be done with the help of rehabilitation, with emphasis on swallowing with “tight jaws”
Overcorrection
ELN
- EVA and IVA: Care is taken to maintain the transverse relationship of the maxilla over the long term. The palatal plate must be worn permanently.
7. Prognosis:
- overbite
Favorable short-term prognosis “intrusion of upper and lower inc.”
Unfavorable long-term prognosis.
The type of mandibular rotation plays an important role, the overbite will recur more easily in a type of anterior mandibular rotation, a lot of attention must be given to the repositioning of the Incisors in these cases.
- Infra-alveolar
Treatment of infra-alveolitis of functional origin most often has a good prognosis.
Most often, the anterior gap closes if the lingual protrusion is removed. The prognosis is not the same in cases of Macroglossia where recurrence will occur very quickly.
- EVA: They represent the most difficult and most recurrent anomalies to treat; if orthopedic treatment can have an effect on the alveolar processes, even during the growth period, vertical skeletal modifications are very difficult to obtain and very recurrent.
For TWEED: Skeletal modifications difficult to obtain and very recurrent
For RICKETTS: surgical treatment more stable.
- Anterior vertical insufficiency (AVI)
The stability is very remarkable, except for the accompanying overbite.
8. Conclusion:
Vertical dysmorphias represent the most difficult and recurrent anomalies to treat. Rarely isolated, they condition and complicate the treatment of other anomalies. Nowadays, with the orthodontic orientation towards aesthetics and the smile, it becomes essential to apply individualized orthodontic therapy that will take into consideration, not only the vertical positioning of the teeth in relation to the facial skeleton, but especially
their position relative to the skin tissues of the face.
Good oral hygiene is essential to prevent cavities and gum disease.
Regular scaling at the dentist helps remove plaque and maintain a healthy mouth.
Dental implant placement is a long-term solution to replace a missing tooth.
Dental X-rays help diagnose problems that are invisible to the naked eye, such as tooth decay.
The dentist uses local anesthesia to minimize pain during dental treatment.