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OLGU RAPORU (Case Report

)
Hacettepe Diş Hekimliği Fakültesi Dergisi Cilt: 32, Sayı: 4, Sayfa: 65-73, 2008

Effects of Fixed Anterior Biteplane Treatment on Stomatognathic System of a Patient with Deepbite Sabit Anterior Biteplane Tedavisinin Derin Örtülü Kapanışlı Bir Hastanın Stomatognatik Sistemine Etkileri
*Bengisu Akarsu DDS, PhD, *Semra Cİğer DDS, PhD
*Hacettepe University Faculty of Dentistry Department of Orthodontics

ABSTRACT
An optimal treatment of deepbite requires a careful diagnosis, a proper treatment plan and efficient appliance design. Excessive overbite may restrict growth of the mandible and mandibular dentoalveolar region. It may cause temporomandibular joint disorders and increased masticatory muscle activities. Hence, treatment of deepbite in growing patients is critical. Deepbite can be corrected with intrusion of incisors , extrusion of posterior teeth, flaring of anterior teeth, and/or surgery. In patients with short anterior facial height, extrusion of posterior teeth may be the proper treatment choice to reduce overbite. Fixed anterior biteplane appliance has been used in correction of deepbite in several studies. But these investigations only focused on clinical and cephalometric changes. Therefore, the aim of this case report is to present effects of fixed anterior biteplane appliance on stomatognathic system of a patient with deepbite. A 9.7 year old male patient had decreased lower facial height, uprighted maxillary central incisors and increased overbite. Lateral cephalometric radiographs, electrovibratographic, electromyographic and electrognatographic recordings were obtained from the subject before (T0) and after fixed anterior biteplane treatment (T1). After 6 months of treatment, overbite was reduced, lower anterior facial height was increa-

ÖZET
Derin örtülü kapanışın optimal tedavisi; dikkatli tanı, uygun tedavi planı ve etkili aparey dizaynını gerektirmektedir. Aşırı örtülü kapanış mandibulanın ve mandibular dentoalveolar bölgenin gelişimini sınırlayabilmektedir. Temporomandibular eklem rahatsızlıklarına ve artmış çiğneme kası aktivitesine de yol açabilmektedir. Bu nedenle büyüyen hastalarda derin örtülü kapanışın tedavisi önemlidir. Derin örtülü kapanış keserlerin intrüzyonu, posterior dişlerin ekstrüzyonu, anterior dişlerin labiyale hareketi ve/veya cerrahi ile tedavi edilmektedir. Kısa anterior yüz yüksekliği olan bireylerde posterior dişlerin ekstrüze edilmesi örtülü kapanışın azaltılması için uygun tedavi seçeneğidir. Sabit anterior biteplane apareyi çeşitli çalışmalarda derin örtülü kapanışın tedavisinde kullanılmıştır. Fakat bu araştırmalar sadece klinik ve sefalometrik değişiklikler üzerine odaklanmıştır. Bundan dolayı, bu olgu raporunun amacı sabit anterior biteplane tedavisinin derin örtülü kapanışlı bir hastanın stomatognatik sistemi üzerine etkilerini sunmaktır. 9,7 yaşında erkek hastada azalmış alt yüz yüksekliği, dikleşmiş üst santral kesici dişler ve artmış örtülü kapanış mevcuttu. Bireyden sabit anterior biteplane tedavisi öncesi (T0) ve sonrası (T1) lateral sefalometrik radyografi, elektrovibratografik, elektromiyografik ve elektrognatografik kayıtlar alındı. 6 aylık tedaviden sonra örtülü

masticatory muscles and masticatory movements in patients with deepbite. kapanış azaldı. infra-occlusion of the mandibular or maxillary posterior teeth may classified as dental factors1. CASE REPORT A 9. The patient . flaring of anterior teeth10-11. the aim of this case report is to present the effects of fixed anterior biteplane treatment on stomatognathic system of a patient with deepbite. and/or surgery12. a proper treatment plan and efficient appliance design.13. The skeletal factor. electromyograhy. Figure 7). cervical headgear may be the treatment choice to reduce over- bite3.7-year-old male patient was referred to orthodontic treatment. Deepbite can be corrected with intrusion of incisors6-8. no study was found about the effects of fixed anterior biteplane on temporomandibular joint sounds. Soft tissue factors are high lower lip line that guide the maxillary and mandibular incisors to erupt in a more retroclined position4 and lateral tongue thrust5. elektromiyografi. Overbite was 6 mm and lower incisors to A-Pog plane was -3 mm. derin örtülü kapanış. electrognatography. skeletal and soft tissue. (Table I. An optimal treatment of deepbite requires a careful diagnosis. Surgical and Medicine Research Ethic Committee of “ Hacettepe University” in advance of the start of the research. on the other hand. and mixed dentition (Figure 1-6). Cephalometric analysis of the patient showed brachyfacial growth pattern. increased overbite. To eliminate the patient compliance. reduced lower anterior facial height. is described as the counter clockwise rotation of the mandible and it occurs due to increased posterior vertical growth compared to anterior vertical growth3. In patients with short vertical facial dimension. In these clinical and cephalometric investigations. elektrovibratografi INTRODUCTION Deepbite is defined as the vertical overlap of the mandibular incisors by the maxillary incisors more than 3mm when the posterior teeth are in occlusion1. Therefore. extrusion of posterior teeth9. elektrognatografi. Fixed anterior biteplane appliance did not cause any temporomandibular disorders and had no detrimental effect on chewing and speech. extrusion of posterior teeth using anterior biteplane. KEYWORDS Biteplane. alt yüz yüksekliği arttı ve üst kesici diş inklinasyonları başarıyla düzeltildi. Ethic committee report was taken from the Medical. retroclination of the incisor teeth. Over-eruption of the mandibular or maxillary incisors.2. fixed anterior biteplane has been used in deepbite patients14-16. He had labially inclined upper laterals and uprighted centrals. fixed anterior biteplane therapy was found to be effective in reduction of deepbite14-16. The factors that contribute to deepbite may be classified as dental. deepbite. Sabit anterior biteplane apareyi herhangi bir temporomandibular rahatsızlığa neden olmadı ve çiğneme ve konuşma üzerine zararlı bir etki göstermedi. Yet in literature.66 sed and the inclination of upper incisors was improved successfully.10. electrovibratography ANAHTAR KELİMELER Biteplane. functional appliances.

67 1 2 4 3 5 FIGURE 1-6 6 Pre-treatment extraoral and intraoral photograhs .

5 Na-Me mm 106. 2:SNBo.5 ANS-Me mm 58 61. thereafter the fixed anterior biteplane was prepared and was placed to first molars (Figure 8. The arch was also equipped with occlusal stops resting on the first premolars.5 78 Lower facial heighto T0 T1 33. 16: L1 extrusion mm. .5 111.9).5 106 112 U6-PP mm 17.5 FMAo 10 15 GoGnSNo 23 27 Lower lip to esthetic plane mm -5 -2. 6: FMAo. 18: U6-PP mm) was informed about the treatment which would be carried out.9 FMIAo T0 T1 73 65 SNBo 74 75. On the maxillary dental cast. fixed anterior biteplane appliance was removed (Figure 10-15). 14: L1-MP mm..5 36. 12: FMIAo. 4: Facial deptho. 5: Maxillary heighto.5 83. 9: Overbite mm. In addition to lateral cephalometric radiographs. No other orthodontic appliances were used during the period of treatment. a lingual arch extended between the first maxillary molars was made and welded to the bands. Fabrication of the fixed anterior biteplane appliance: In the patient. 8: Lower facial heighto.5 Maxillary heighto 53 53. The dental models were transferred to the articulator. electromyographic (EMG). 3:ANBo.9). A fixed anterior biteplane appliance was used to reduce the need for the patient’ s cooperation (Figure 8.5 17 126 124 L1-Apog mm -3 -1. maxillary first molars were fitted with orthodontic bands and alginate impressions were than taken.7 L1-MP mm 37 37 Facial deptho 81. electrognatographic (EGN) and electrovibratographic (EVG) records were taken by using a computer program (BioPAC Version 2. Wisconsin) at the beginning (T0) and at the end of the fixed anterior biteplane treatment (T1). Treatment objectives were to reduce the overbite.68 TABLE I Cephalometric measurements SNAo T0 T1 77. 15: L6-MP mm. After 6 months of treatment.5 Na-ANS mm 51 52 L6-MP mm 29 31.5 IMPAo 93 96 ANBo 3. correct the inclination of the upper incisors and improve mandibular position. Labiolingual springs were placed behind the upper central incisors.BioResearch INC.Milwaukee. 7: GoGnSNo.5 2. 11: U1-FHo.5 Overbite mm U1-SNo U1-FHo Saddle o 6 2 L1 extrusion mm 5 3 93 99 U1-PP mm 26 25. 10: U1-SNo. increase the lower anterior facial height. 17: U1-PP mm. 13: IMPAo. and he was voluntary for the research. Bite registration was taken causing a separation of the upper and lower molars of approximately 4 mm.5 FIGURE 7 Lateral cephalometric analysis (1:SNAo.03 System.

69 8 FIGURE 8-9 9 Fixed anterior biteplane cemented to the maxillary first molars 10 11 12 13 14 FIGURE 10-15 15 Post-treatment extraoral and intraoral photograhs .

With regard to dental findings.70 FIGURE 16 Pre-treatment and post-treatment cephalometric superimpositions Deepbite decreased. This is consistent with the previous studies14. extrusion of the mandibular first molar.18. DISCUSSION The measurements which are used to assess the facial growth pattern (FMA. electrognatographic and electrovibratographic measurements at T0 and T1 are presented in Table II-IV. ANS-Me) increased at T1. lower anterior facial height. Upper and lower lips were positioned more anteriorly after the fixed anterior biteplane treatment (Figure 16).15.5o of SNB angle and an increase of 2o of facial depth angle was found at T1 (Table I). the height of lower incisors (L1-MP) did not change significantly with treatment. GoGnSN.15. The increase of SNB angle and facial depth angle. Labial inclination of the upper and lower incisors. Electromyographic. On the other hand. The upper face height (NANS) and maxillary height angle did not show any significant change. Fixed anterior biteplane had an inhibiting effect on the vertical development of the maxilla14. An increase of 1. the distance between the lower incisor and occlusal plane (lower incisor extrusion) decreased and the amount of eruption of the lower molars (L6-MP) . These results are in conformity with the previous studies14. Na-Me. lower anterior facial height increased and inclination of upper incisors increased. anterior and inferior position of the mandible were found in local superimpositions. Growth of mandible and the mandibular dentoalveolar region were restricted by excessive overbite in growing patients17. the decrease of ANB angle at T1 could show anterior position of the mandible after reduction of the deepbite.

8 3.4 Total timing ms T0 1068 T1 853.4 SCLM left 5.8 T1 1.4 10.6 4.0 754.0 T0 Freeway space 3.3 TA left 5.4 15.4 223.3 T0 Frontal mm T1 7.4 TABLE III Electrognatographic measurements at chewing and speech EGN Opening time ms T0 Chewing timing (right) Chewing timing (left) 330.9 Horizontal left mm T0 2.50 Sagittal mm T0 Speech 8.2 14.2 DA right DA right 5.5 0.8 T1 3.4 337.7 318.3 4.7 MM right 1 MM left 1.1 192.9 26.4 T1 339.9 13.6 3.1 Occlusal timing ms T0 456.9 1048.3 2.1 T1 8.8 482.8 7.6 7 4.4 11.6 247.8 Right Integral<300 Left Right Integral>300 Left .1 0.2 T1 2.9 0.7 11 7.4 18.71 TABLE II Electromyographic measurements at rest position EMG (µV) T0 Rest position TA right 2.3 14.4 17.4 T1 279.3 1 T1 0.3 3.1 Closing time ms T0 281.6 6.3 Mouth closing 34.5 4.9 1.7 TABLE IV Electrovibratographic measurements during mouth opening and closing EVG (Hz) Right Total integral Left T0 T1 T0 T1 T0 T1 T0 T1 T0 T1 T0 T1 Mouth opening 27.2 SCLM right 0.8 26.1 12.8 Horizontal right mm T0 0.9 21.9 T1 235.5 33.

CONCLUSION Fixed anterior biteplane appliance reduced the overbite.13(1):53-8.77(4):437-46. 11.41(1):67-87. After reduction of deepbite. Ogata Y. The findings about speech was found lower when compared with the findings of Nielsen et al24. Schudy FF. Recent studies showed that the patients with deepbite had greater masticatory muscle activities compared to normal subjects21. The proper inclination of the upper incisors was shown to facilitate the stability of the deepbite reduction19. Am J Orthod. The patient was told to count from 80 to 90 loudly during speech recordings.01. 1969. Ball JV. A comparative analysis of intrusion of incisor teeth achieved in adults and children according to facial type. McDowell EH. Correction of deepoverbite in adult.5-1. Extreme variation in vertical facial growth and associated variation in skeletal and dental relations. Measurements were done separately for opening and closing mouth movements during the EVG recordings. 1968. Chewing timing was in normal range at T0 and T123. 1980. Sharma A.93(3):186-95. The skeletodental adaptations in deep bite correction.72 increased at T1. The electrovibrotographic values were in normal range at the beginning of the treatment and did not change after the treatment in the present case (Table IV).22. The mechanics of lower incisor intrusion: experiments in nongrowing baboons. 5. Isaacson RJ. direction and displacement of the mandibular movements as 3D data by the means of a magnet placed on mandible and BioResearch JT-3 Tracker. With the placement of labiolingual spring in the biteplane. 12. The control of vertical overbite in clinical orthodontics. Posterior teeth extrusion obtained after fixed anterior biteplane treatment did not change freeway space (Table III). Am J Orthod Dentofacial Orthop. Harvold. Am J Orthod. Tredwin C. Hansson TL. Am J Orthod. 1986. Burstone CR. Am J Orthod. 9. Anholm JM. and 1. Deep overbite correction by intrusion. The appointed normal values for anterior digastricus (DA) and sternocleidomastoideus (SCLM) varried between 1.72:1-22. Bjork A. Nordstrom BB. High reliability and repeatability of the EVG method used in this case report to evaluate joint sounds were reported26.41(3):21929. the EMG activities at rest position was found higher than normal.4 µV for masseter muscle (MM). diagnosis and management of deep overbite. Dental Update 2006. the palatally inclined upper incisors improved to ideal values. Am J Orthod Dentofacial Orthop. Engel GA.24 might have used different words during the speech recordings and this might be responsible for the difference. 3. Am J Orthod.0-1. masticatory muscle activities at rest got closer to normal values (Table II). Malocclusion associated with temporomandibular joint changes in young adults at autopsy.100(4):370-5. Nonextraction Class II division 2 treatment.89(4):326-30.55(6):585-99. Dent Clin North Am. 6. Isaacson JR. Surface EMG is a commonly used diagnosing method in evaluation of facial muscle activities. 8. Angle Orthod. 1988. 65: 67-75. This was stated as a factor that increase the stability of deepbite treatment by Nanda25. and Begg treatment on overbite and molar eruption. 1971. Speidel TM. Nanda R. EGN is the process that records the speed.38:19-39. It can be said that relative intrusion of the lower incisors was obtained due to the mandibular posterior teeth extrusion that changed the occlusal plane. 1977. Prediction of mandibular growth rotation. 10.9 µV for anterior temporal muscle (TA) at rest position20. In literature. Angle Orthod. Eur J Orthod.5 µV20. Otto RL. EMG values in healthy patient were given between 0. Worms FW. Nielsen et al. Gill DS. increased the lower anterior facial height and improved the inclination of the upper incisors successfully. It did not cause any temporomandibular disorders and had no detrimental effect on chewing and speech in the present case. 7. 1974. REFERENCES 1. 1997. In the present case. 4.1991.July/August:326-36. Bibb CA. The aetiology . The effect of Andresen. Baker IM. Hunt NP. . Woods MG. Solberg WK. Naini FB. 2. 1991.

35(9):544-8. Correction of deepoverbite in adult.2008 Received Date : 09 July 2008 Accepted Date : 17 November 2008 CORRESPONDING ADRESS Hacettepe University Faculty of Dentistry Department of Orthodontics 06100 Sıhhiye-ANKARA Tel. Hellsing G.2008 Kabul Tarihi : 17. 1992.55(3):225-33. 1997.87:230-9. J Orofac Orthop. 16. Dent Clin North Am. Nielsen IL. The rates of growth of several facial components measured from serial. cephalometric roentgenograms.68(3):233-8. Effects of fixed anterior biteplane therapy--a radiographic study. 1990. 1996.11(2):139-43.07. Am J Orthod Dentofacial Orthop. Esthetic aspects of orthodontic-surgical treatment of sagittal-vertical anomalies: the example of the short face syndrome. Langlade M. Relationship between masticatory muscle activity and vertical craniofacial morphology. Ballester A. Angle Orthod.2002. 18. Marcel T. 22. Milwakuee.63(2):12942. Miller AJ. Chun D. Hellsing E. Unlocking the malocclusion with a semifixed bite plate. J Oral Rehabil. de Bruin H. Harper RP. Eur J Orthod. 1989. (312) 311 64 61 Fax: (312) 309 11 38 E-posta: bengisuakarsu@yahoo. Muscle activity during mandibular movements in normal and mandibular retrognathic subjects. Am J Orthod.6(2):107-15.com Bengisu AKARSU DDS. Am J Orthod.63: 202-217. Patterns of mandibular movements in subjects with craniomandibular disorders. Eliasson S. 253-63. Forsberg CM. Reproducibility of temporomandibular joint vibrations (electrovibratography). Nanda R. 21. 1984. 26. Am J Orthod Dentofacial Orthop. Nanda RS. 19. Sonesson B. J Prosthet Dent. 1985. Algren J. Burcea I. 1995.110(1):61-8.107(1):79-90. 2001. Incisor edge-centroid relationships and overbite depth. Nanda RS.73 13. 17. 23. The effect of a lingual arch appliance with anterior bite plane in deep overbite correction. Geliş Tarihi : 09. Ueda HM.. Hellsing E. 1955. 1997. 14. Bartsch A. Houston WJ. J Clin Orthod. Eur J Orthod. An electromyographic analysis of the temporalis function of normal occlusion . PhD . User’s Guide: BioPAK Diagnostic System. Ghosh J.19(3). 15. Christensen LV.11.41(1):67-87.41:658-73. BioResearch Associates INC. 24. Watted N. Orloff J. Longitudinal growth changes in the sagittal relationship of maxilla and mandible. 25. 20. 1998. J Oral Maxillofac Surg.

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