OLGU RAPORU (Case Report)

Hacettepe Di Hekimlii Fakltesi Dergisi Cilt: 32, Say: 4, Sayfa: 65-73, 2008

Effects of Fixed Anterior Biteplane Treatment on Stomatognathic System of a Patient with Deepbite Sabit Anterior Biteplane Tedavisinin Derin rtl Kapanl Bir Hastann Stomatognatik Sistemine Etkileri
*Bengisu Akarsu DDS, PhD, *Semra Cer 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-

ZET
Derin rtl kapann optimal tedavisi; dikkatli tan, uygun tedavi plan ve etkili aparey dizaynn gerektirmektedir. Ar rtl kapan mandibulann ve mandibular dentoalveolar blgenin geliimini snrlayabilmektedir. Temporomandibular eklem rahatszlklarna ve artm ineme kas aktivitesine de yol aabilmektedir. Bu nedenle byyen hastalarda derin rtl kapann tedavisi nemlidir. Derin rtl kapan keserlerin intrzyonu, posterior dilerin ekstrzyonu, anterior dilerin labiyale hareketi ve/veya cerrahi ile tedavi edilmektedir. Ksa anterior yz ykseklii olan bireylerde posterior dilerin ekstrze edilmesi rtl kapann azaltlmas iin uygun tedavi seeneidir. Sabit anterior biteplane apareyi eitli almalarda derin rtl kapann tedavisinde kullanlmtr. Fakat bu aratrmalar sadece klinik ve sefalometrik deiiklikler zerine odaklanmtr. Bundan dolay, bu olgu raporunun amac sabit anterior biteplane tedavisinin derin rtl kapanl bir hastann stomatognatik sistemi zerine etkilerini sunmaktr. 9,7 yanda erkek hastada azalm alt yz ykseklii, diklemi st santral kesici diler ve artm rtl kapan mevcuttu. Bireyden sabit anterior biteplane tedavisi ncesi (T0) ve sonras (T1) lateral sefalometrik radyografi, elektrovibratografik, elektromiyografik ve elektrognatografik kaytlar alnd. 6 aylk tedaviden sonra rtl

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sed and the inclination of upper incisors was improved successfully. Fixed anterior biteplane appliance did not cause any temporomandibular disorders and had no detrimental effect on chewing and speech.

kapan azald, alt yz ykseklii artt ve st kesici di inklinasyonlar baaryla dzeltildi. Sabit anterior biteplane apareyi herhangi bir temporomandibular rahatszla neden olmad ve ineme ve konuma zerine zararl bir etki gstermedi.

KEYWORDS Biteplane, deepbite, electromyograhy, electrognatography, electrovibratography

ANAHTAR KELMELER Biteplane, derin rtl kapan, elektromiyografi, elektrognatografi, 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. The factors that contribute to deepbite may be classified as dental, skeletal and soft tissue. Over-eruption of the mandibular or maxillary incisors, retroclination of the incisor teeth, infra-occlusion of the mandibular or maxillary posterior teeth may classified as dental factors1,2. The skeletal factor, on the other hand, is described as the counter clockwise rotation of the mandible and it occurs due to increased posterior vertical growth compared to anterior vertical growth3. 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. An optimal treatment of deepbite requires a careful diagnosis, a proper treatment plan and efficient appliance design. Deepbite can be corrected with intrusion of incisors6-8, extrusion of posterior teeth9,10, flaring of anterior teeth10-11, and/or surgery12,13. In patients with short vertical facial dimension, extrusion of posterior teeth using anterior biteplane, functional appliances, cervical headgear may be the treatment choice to reduce over-

bite3. To eliminate the patient compliance, fixed anterior biteplane has been used in deepbite patients14-16. In these clinical and cephalometric investigations, fixed anterior biteplane therapy was found to be effective in reduction of deepbite14-16. Yet in literature, no study was found about the effects of fixed anterior biteplane on temporomandibular joint sounds, masticatory muscles and masticatory movements in patients with deepbite. Therefore, the aim of this case report is to present the effects of fixed anterior biteplane treatment on stomatognathic system of a patient with deepbite.

CASE REPORT
A 9.7-year-old male patient was referred to orthodontic treatment. He had labially inclined upper laterals and uprighted centrals, increased overbite, reduced lower anterior facial height, and mixed dentition (Figure 1-6). Cephalometric analysis of the patient showed brachyfacial growth pattern. Overbite was 6 mm and lower incisors to A-Pog plane was -3 mm. (Table I, Figure 7). Ethic committee report was taken from the Medical, Surgical and Medicine Research Ethic Committee of Hacettepe University in advance of the start of the research. The patient

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4 3

5
FIGURE 1-6

Pre-treatment extraoral and intraoral photograhs

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TABLE I Cephalometric measurements SNAo T0 T1 77.5 78 Lower facial heighto T0 T1 33.5 36.9 FMIAo T0 T1 73 65 SNBo 74 75.5 Na-Me mm 106.5 111.5 IMPAo 93 96 ANBo 3.5 2.5 ANS-Me mm 58 61.7 L1-MP mm 37 37 Facial deptho 81.5 83.5 Na-ANS mm 51 52 L6-MP mm 29 31.5 Maxillary heighto 53 53.5 FMAo 10 15 GoGnSNo 23 27 Lower lip to esthetic plane mm -5 -2.5

Overbite mm

U1-SNo

U1-FHo

Saddle o

6 2 L1 extrusion mm 5 3

93 99 U1-PP mm 26 25.5

106 112 U6-PP mm 17.5 17

126 124 L1-Apog mm -3 -1.5

FIGURE 7 Lateral cephalometric analysis (1:SNAo, 2:SNBo, 3:ANBo, 4: Facial deptho, 5: Maxillary heighto, 6: FMAo, 7: GoGnSNo, 8: Lower facial heighto, 9: Overbite mm, 10: U1-SNo, 11: U1-FHo, 12: FMIAo, 13: IMPAo, 14: L1-MP mm, 15: L6-MP mm, 16: L1 extrusion mm, 17: U1-PP mm, 18: U6-PP mm)

was informed about the treatment which would be carried out; and he was voluntary for the research. Treatment objectives were to reduce the overbite, increase the lower anterior facial height, correct the inclination of the upper incisors and improve mandibular position. A fixed anterior biteplane appliance was used to reduce the need for the patient s cooperation (Figure 8,9).

Fabrication of the fixed anterior biteplane appliance: In the patient, maxillary first molars were fitted with orthodontic bands and alginate impressions were than taken. On the maxillary dental cast, a lingual arch extended between the first maxillary molars was made and welded to the bands. The arch was also equipped with occlusal stops resting on the first premolars. Labiolingual springs were placed behind the upper central incisors. Bite registration was taken causing a separation of the upper and lower molars of approximately 4 mm. The dental models were transferred to the articulator, thereafter the fixed anterior biteplane was prepared and was placed to first molars (Figure 8,9). No other orthodontic appliances were used during the period of treatment. In addition to lateral cephalometric radiographs, electromyographic (EMG), electrognatographic (EGN) and electrovibratographic (EVG) records were taken by using a computer program (BioPAC Version 2,03 System,BioResearch INC.,Milwaukee, Wisconsin) at the beginning (T0) and at the end of the fixed anterior biteplane treatment (T1). After 6 months of treatment, fixed anterior biteplane appliance was removed (Figure 10-15).

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8
FIGURE 8-9

Fixed anterior biteplane cemented to the maxillary first molars

10

11

12

13

14
FIGURE 10-15

15

Post-treatment extraoral and intraoral photograhs

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FIGURE 16 Pre-treatment and post-treatment cephalometric superimpositions

Deepbite decreased, lower anterior facial height increased and inclination of upper incisors increased. An increase of 1.5o of SNB angle and an increase of 2o of facial depth angle was found at T1 (Table I). Labial inclination of the upper and lower incisors, extrusion of the mandibular first molar, anterior and inferior position of the mandible were found in local superimpositions. Upper and lower lips were positioned more anteriorly after the fixed anterior biteplane treatment (Figure 16). Electromyographic, electrognatographic and electrovibratographic measurements at T0 and T1 are presented in Table II-IV.

DISCUSSION
The measurements which are used to assess the facial growth pattern (FMA, GoGnSN, lower anterior facial height, Na-Me, ANS-Me) increased

at T1. These results are in conformity with the previous studies14,15. 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. Growth of mandible and the mandibular dentoalveolar region were restricted by excessive overbite in growing patients17,18. The increase of SNB angle and facial depth angle, the decrease of ANB angle at T1 could show anterior position of the mandible after reduction of the deepbite. With regard to dental findings, the height of lower incisors (L1-MP) did not change significantly with treatment. This is consistent with the previous studies14,15. On the other hand, the distance between the lower incisor and occlusal plane (lower incisor extrusion) decreased and the amount of eruption of the lower molars (L6-MP)

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TABLE II Electromyographic measurements at rest position EMG (V) T0 Rest position TA right 2.3 TA left 5.7 MM right 1 MM left 1.2 SCLM right 0.4 SCLM left 5.2 DA right DA right

5.3 2.9

1.3 1

T1

0.3

3.1

0.5

0.9

0.6

4.4

TABLE III Electrognatographic measurements at chewing and speech EGN Opening time ms T0 Chewing timing (right) Chewing timing (left) 330.4 T1 279.1 Closing time ms T0 281.9 T1 235.1 Occlusal timing ms T0 456.4 T1 339.4 Total timing ms T0 1068 T1 853.6

247.4

223.7

318.1

192.8

482.4

337.9

1048.0

754.50

Sagittal mm T0 Speech 8.0 T0 Freeway space 3.1 T1 8.8 T1 3.3 T0

Frontal mm T1 7.8

Horizontal right mm T0 0.8 T1 1.9

Horizontal left mm T0 2.2 T1 2.8

7.7

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 27.4 17.5 33.4 15.9 21.1 12.9 26.4 11.6 6.3 4.6 7 4.3 Mouth closing 34.2 14.4 18.3 14.8 26.4 10.9 13.7 11 7.8 3.5 4.6 3.8

Right Integral<300 Left

Right Integral>300 Left

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increased at T1. 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. With the placement of labiolingual spring in the biteplane, the palatally inclined upper incisors improved to ideal values. The proper inclination of the upper incisors was shown to facilitate the stability of the deepbite reduction19. Surface EMG is a commonly used diagnosing method in evaluation of facial muscle activities. In literature, EMG values in healthy patient were given between 0,5-1,4 V for masseter muscle (MM), and 1,0-1,9 V for anterior temporal muscle (TA) at rest position20. The appointed normal values for anterior digastricus (DA) and sternocleidomastoideus (SCLM) varried between 1,01,5 V20. In the present case, the EMG activities at rest position was found higher than normal. Recent studies showed that the patients with deepbite had greater masticatory muscle activities compared to normal subjects21,22. After reduction of deepbite, masticatory muscle activities at rest got closer to normal values (Table II). EGN is the process that records the speed, direction and displacement of the mandibular movements as 3D data by the means of a magnet placed on mandible and BioResearch JT-3 Tracker. Chewing timing was in normal range at T0 and T123. The findings about speech was found lower when compared with the findings of Nielsen et al24. The patient was told to count from 80 to 90 loudly during speech recordings. Nielsen et al.24 might have used different words during the speech recordings and this might be responsible for the difference. Posterior teeth extrusion obtained after fixed anterior biteplane treatment did not change freeway space (Table III). This was stated as a factor that increase the stability of deepbite treatment by Nanda25. Measurements were done separately for opening and closing mouth movements during the EVG recordings. High reliability and repeatability of the EVG method used in this case report to evaluate joint sounds were reported26.

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).

CONCLUSION
Fixed anterior biteplane appliance reduced the overbite, 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.

REFERENCES
1. Solberg WK, Bibb CA, Nordstrom BB, Hansson TL. Malocclusion associated with temporomandibular joint changes in young adults at autopsy. Am J Orthod. 1986;89(4):326-30. 2. Isaacson JR, Isaacson RJ, Speidel TM, Worms FW. Extreme variation in vertical facial growth and associated variation in skeletal and dental relations. Angle Orthod. 1971;41(3):21929. 3. Naini FB, Gill DS, Sharma A, Tredwin C. The aetiology , diagnosis and management of deep overbite. Dental Update 2006;July/August:326-36. 4. Ogata Y. Nonextraction Class II division 2 treatment. Am J Orthod. 1974; 65: 67-75. 5. Bjork A. Prediction of mandibular growth rotation. Am J Orthod. 1969;55(6):585-99. 6. Burstone CR. Deep overbite correction by intrusion. Am J Orthod. 1977;72:1-22. 7. Otto RL, Anholm JM, Engel GA. A comparative analysis of intrusion of incisor teeth achieved in adults and children according to facial type. Am J Orthod. 1980;77(4):437-46. 8. Woods MG. The mechanics of lower incisor intrusion: experiments in nongrowing baboons. Am J Orthod Dentofacial Orthop. 1988;93(3):186-95. 9. Schudy FF. The control of vertical overbite in clinical orthodontics. Angle Orthod. 1968;38:19-39. 10. Ball JV, Hunt NP. The effect of Andresen, Harvold, and Begg treatment on overbite and molar eruption. Eur J Orthod. 1991;13(1):53-8. 11. Nanda R. Correction of deepoverbite in adult. Dent Clin North Am. 1997;41(1):67-87. 12. McDowell EH, Baker IM. The skeletodental adaptations in deep bite correction. Am J Orthod Dentofacial Orthop.1991;100(4):370-5.

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13. Watted N, Bartsch A. Esthetic aspects of orthodontic-surgical treatment of sagittal-vertical anomalies: the example of the short face syndrome. J Orofac Orthop.2002;63(2):12942. 14. Forsberg CM, Hellsing E. The effect of a lingual arch appliance with anterior bite plane in deep overbite correction. Eur J Orthod. 1984;6(2):107-15. 15. Ballester A, Langlade M. Unlocking the malocclusion with a semifixed bite plate. J Clin Orthod. 2001;35(9):544-8. 16. Hellsing E, Hellsing G, Eliasson S. Effects of fixed anterior biteplane therapy--a radiographic study. Am J Orthod Dentofacial Orthop. 1996;110(1):61-8. 17. Nanda RS. The rates of growth of several facial components measured from serial. cephalometric roentgenograms. Am J Orthod. 1955;41:658-73. 18. Nanda RS, Ghosh J. Longitudinal growth changes in the sagittal relationship of maxilla and mandible. Am J Orthod Dentofacial Orthop. 1995;107(1):79-90. 19. Houston WJ. Incisor edge-centroid relationships and overbite depth. Eur J Orthod. 1989;11(2):139-43.

20. Harper RP, de Bruin H, Burcea I. Muscle activity during mandibular movements in normal and mandibular retrognathic subjects. J Oral Maxillofac Surg. 1997;55(3):225-33. 21. Algren J, Sonesson B. An electromyographic analysis of the temporalis function of normal occlusion . Am J Orthod. 1985;87:230-9. 22. Ueda HM. Relationship between masticatory muscle activity and vertical craniofacial morphology. Angle Orthod. 1998;68(3):233-8. 23. Users Guide: BioPAK Diagnostic System. BioResearch Associates INC., Milwakuee. 24. Nielsen IL, Marcel T, Chun D, Miller AJ. Patterns of mandibular movements in subjects with craniomandibular disorders. J Prosthet Dent. 1990;63: 202-217. 25. Nanda R. Correction of deepoverbite in adult. Dent Clin North Am. 1997;41(1):67-87. 26. Christensen LV, Orloff J. Reproducibility of temporomandibular joint vibrations (electrovibratography). J Oral Rehabil. 1992;19(3), 253-63.

Geli Tarihi : 09.07.2008 Kabul Tarihi : 17.11.2008

Received Date : 09 July 2008 Accepted Date : 17 November 2008

CORRESPONDING ADRESS
Hacettepe University Faculty of Dentistry Department of Orthodontics 06100 Shhiye-ANKARA Tel. (312) 311 64 61 Fax: (312) 309 11 38 E-posta: bengisuakarsu@yahoo.com

Bengisu AKARSU DDS, PhD