1. MANAGEMENT OF VERTICAL MAXILLARY EXCESS www.indiandentalacademy.

com
2. 2. CONTENTS Mixed dentition treatment approach 1. Habit breaking appliance 2.

Myotherapy A. Appliance B. Exercise 3. Functional appliances 4. Orthodontic

appliance a. High pull HG b. Vertical chin cup c. Bite block d. Bonded RPE and vertical
chin cup e. Magnetic activator device IV f.. AVC Permanent dentition treatment
approach Dental open bite – Draw bridge effect (extraction of 1st bicuspid and
retraction of anterior ) Skeletal open bite – A. Questionable growth— MEAW, Bite
block, Skeletal anchorage, Bite block, repelling magnet, spring loaded). B. Surgical
www.indiandentalacademy.com
3. 3. • Introduction: Vertical malocclusion results from interplay of many etiological

factors during growth period. These growth factors include growth of maxilla and
mandible, variations in rate of growth in both the maxillary suture and mandibular
condyles and dentoalveolar development with the eruption of the teeth. The
potential etiological factors other than unfavorable growth patterns are, digit
sucking habits, lymphatic tissue, tongue and orofacial muscle activity, heredity,
orofacial functional matrices, jaw posture, head position. • The correction of vertical
dysplasia are more difficult and more challenging than the correction of anterior-
posterior, transverse malocclusions, hence the need for proper diagnosis and
treatment plan www.indiandentalacademy.com
4. 4. • Depending on the growth status of an individual treatment mechanics to be
considered. • Deciduous dentition • Mixed dentition—Orthopedic • Orthodontic
approach • Myotherapy • Habit breaking appliance • Permanent dentition : • Dental
open bite • Skeletal open bite • A. Questionable growth • B. Surgical
www.indiandentalacademy.com
5. 5. • Issacson (1971) and Worms et al believed that spontaneous correction occurs in
upto 80% of mixed dentition open bite cases and suggested that interceptive
treatment is of little or no value. Reasoned that Tongue thrust is the main mode of
swallowing upto age of 10 yrs. After that age, marked decrease in this form of
swallowing account for spontaneous correction. • Parker &Johnson (1993) believed
that interceptive treatment should be carried out for the cases that do not self
correct. • INTERCEPTIVE TREATMENT • 1) Altering mode of breathing. • 2)

1
 Myotherapy. • 3) Habit breaking appliance • 4) Functional orthopedic appliance • 5)
Orthodontic appliance. www.indiandentalacademy.com
6. 6. • ALTERING MODE OF BREATHING • Altering the mouth open breathing to mouth
closed breathing respond to reduction in lower face height at an early age. •
According to Linder - Aronson, Adenoidectomy must be performed at an early age •
(6-8 yrs) to provide a post surgical growth. • Study by Linder-Aronson and Behltet on
post- adenoidectomy and post tonsillectomy for 5 yrs observation period,
established hypothesis that change in mouth open breathing to mouth closed
breathing reverses the symptoms. www.indiandentalacademy.com
7. 7. • Adenoidectomy Reduced size of adenoids Increased nasal flow Change to nose

breathing Tongue position and mandibular position raised Lips closed breathing •
Increase width of maxillary arch • Increase inclination of maxillary and mandibular
incisors. • Increase in depth of bony nasopharynx • Decrease lower anterior facial
height. www.indiandentalacademy.com
8. 8. • Contra Indication of Adenoidectomy • On clinical examination, if palate is
observed to have a bifid uvula/ deep oropharynx which indicates palatopharyngeal
insufficiency. Adenoidectomy is contraindicated in such cases because of the
potential for creating hyper nasality/cleft palate speech.
www.indiandentalacademy.com
9. 9. • Study by WOODSIDE & HENRIKSON LATER, Confirms this hypothesis and
reasoned that Change in incisor inclination due to • (a) Change in tongue and
orbicularis oris pressure. • (b) According to Lowe et al. correlated between
genioglossus muscle and overbite. They suggested that change in tongue postural
activity exerts definite pressure on incisor tooth. • Decreased LAFH, due to
autorotation and horizontal mandibular growth. www.indiandentalacademy.com
10. 10. • MYOTHERAPY • According to Profitt myofunctional therapy is defined as any

therapeutic approach that involves muscle exercises with appliance or not. He

consider myofunctional therapy as an adjunct to orthodontic appliance therapy in
patient's age 10 or older i.e. late mixed dentition or early permanent dentition with a
treatment objective to alter resting tongue and lip posture. This approach takes
advantage of function to adapt to form. Myofunctional therapy is not preventive
measure. • Also A.P.Roger in 1906 suggested that muscle exercise be used as an

2
 adjunct tomechanical correction of malocclusion. • The principal purpose of
myotherapy is creation of normal orofacial muscular function to aid growth and
development of normal occlusion. www.indiandentalacademy.com
11. 11. • Exercises • 1) Ask the patient to hold a piece of paper between the lips. • 2)

Ask the patient to sip water and hold on tongue with the tip pressed hard against the
spot, the patient swallows with biting teeth firmly together. • 3) The patient is
instructed to practice correct swallowing pattern by placing the tip of tongue on the
palate, close teeth, close lips and swallow with tongue in that position. After the new
swallowing pattern learned on the conscious level, it is necessary to reinforce in
subconsciously. Flat, sugarless fruit drops are used to reinforce subconsciously by
asking the patient to hold fruit drops against the palate. • 4) Place the elastics in tip
and dorsum of the tongue and ask the child to swallow. Child tends to hold the
elastics by placing against palate in proper position. • 5) Thompson--- Ask the patient
to squeeze teeth together as hard as possible for 15 secs, relax and repeat three
times for total of one minute. This exercise should be done five times a day
(Clenching exercises).www.indiandentalacademy.com
12. 12. • Myoappliance: • 1. Lingual pearl • 2. Scorpion appliance • 3. Blue grass
appliance • MYO APLIANCE • 1. Lingual Pearl (Jco -98,may) used when tongue is the
only etiology factor responsible for malocclusion. Pearl, elevates the tongue against
the palate. In most cases, the tongue will adapt to the new position of the dentition.
However, to control the muscular forces of the tongue during space closing or bite
opening, the Lingual Pearl can be attached to a transpalatal bar or a quad-helix • A
Lingual Pearl can be used in the final phase of treatment of an open-bite case where
vertical elastics were used to close the bite. Lingual retraining will help prevent
reopening of spaces and subsequent relapse. www.indiandentalacademy.com
13. 13. • When used during finishing, the pearl can be bonded to the palatal sides of the

premolars and remain there until tongue movement has been normalized. • A
surgical patient is also a good candidate for the pearl, given the abrupt change in the
amount of space available for the tongue --especially in an open-bite case.
www.indiandentalacademy.com
14. 14. Scorpion appliance 2. Scorpion appliance Tongue crib prohibits protrusive tongue
activity during swallowing. However, the tongue may reach under the appliance and

3
 over the lower incisors to protrude anteriorly. The Scorpion is designed to provide a
prohibitive response to low anterior tongue posturing during swallowing.Tongue
movement is controlled in the vertical plane and is not limited anteroposteriorly.
www.indiandentalacademy.com
15. 15. • If the tongue ventures between the appliance and the lower incisors, the
tongue is met by the spur. The next venture will then be above the spur and through
the anterior "ring" of the appliance. The ring directs the tongue to the normal
dentoalveolar contact. • This design can also be used on Hawley retainers during
interceptive or retention therapy. www.indiandentalacademy.com
16. 16. • HABIT BREAKING APPLIANCE • Tongue crib appliance • Vestibular screen with

breathing holes. • Bluegrass appliance. • Pearl appliance

www.indiandentalacademy.com
17. 17. • 1. Tongue crib appliance • Act as inhibitory appliance, inhibits the thumb
sucking habit and tongue thrusting habit. The appliance for the anterior open bite
patients consists of a palatal acrylic plate with horse shoe-shaped wire crib and labial
bow. The length of the crib is usually 6-12 mm and placed 3 to 4mm lingual to the
upper incisors. If the crib is placed at the gingival third, a proper adjustment can
stimulate the eruption of the anterior teeth, thereby useful in the correction of the
open bite. The acrylic can also be interposed between the teeth, covering the
occlusal surfaces of the upper molars, in order to prevent the eruption of the
posterior teeth. www.indiandentalacademy.com
18. 18. • Posterior tongue crib appliances are used to correct the unilateral (or) bilateral

open bite, by preventing the lateral thrust of the tongue. • Fixed tongue crib is also
used for the correction of open bite by banding to the abutment teeth [molars]. •
Haryett reported that cribs were very effective in stopping the habit when they were
worn for 10 months. • Cooper & Skewida reported that tongue crib appliance alone
is not effective in closure of open bite. www.indiandentalacademy.com
19. 19. • Vestibular screening appliance • This appliance extends into the vestibular sulci

and eliminates pressure without creating tension in periosteum, to enhance bone in

periosteum. This shield interrupts the contact between tip of tongue and lower lip,
which leads to maturational deglutitionand indirectly influence tongue position.

4
 These appliances removes abnormal sucking habits, lipdysfunction and establishes
proper oral seal. www.indiandentalacademy.com
20. 20. • It is a screening appliance used to correct the mouth breathing habit.
Construction: edge-to- edge bite is taken without the consideration of the facial
pattern. This bite does not predetermine a precise mandibular forward posturing but
requires only that the mandible be moved forward to edge to edge relationship.
www.indiandentalacademy.com
21. 21. • The acrylic shield should extend vertically from the upper labial fold to the

lower labial fold and extends to the distal margin of the last erupted molar. It should
be in contact only with the upper and lower labial fold during the anterior
positioning of the mandible. • If the crib is placed at the gingival third, a proper
adjustment can stimulate the eruption of the anterior teeth, thereby useful in the
correction of the open bite. The acrylic can also be interposed between the teeth,
covering the occlusal surfaces of the upper molars, in order to prevent the eruption
of the posterior teeth. Lip exercises should be advocated along with it. Lip exercises
such as holding a piece of paper between the lips while wearing the vestibular shield
is advocatedwww.indiandentalacademy.com
22. 22. • It is effective in eliminating the mouth breathing habit, abnormal sucking habits

and lip dysfunction in order, to achieve a proper lip seal, which is of prime
importance. This lip seal will indirectly influences the posture of the tongue, and
thereby leading to maturation of the deglutition cycle and creates a somatic
swallowing pattern. • The appliance is usually worn at night and 2 to 3 hours per day
when the child is not in school. • This appliance only eliminates the pressure. It
cannot create a tension effect on the vestibular periosteum to enhance the bone
formation in this region. The most important factor in treatment is to have a soft
tissue seal of the screen with no strain in the peripheral portions.
www.indiandentalacademy.com
23. 23. • Modification of the vestibular screen are, vestibular screen with holes at the

inter-incisor area for certain patients, who find difficult in the breathing, vestibular
screen with the tongue crib, and vestibular screen with the acrylic tongue crib.
www.indiandentalacademy.com

5
24. 24. • Haskell & Mink (in 1991) introduced easy to wear appliance called Bluegrass
appliance. He used a hexagonal Teflon roller on a cross palatal wire. He claimed that
appliance almost always ends a sucking habit within several days, if not immediately
and begins training the tongue towards a normal posture. Normalizing facial growth
and allowing proper speech. They did not recommend this appliance for pre-school
age children. •BLUE GRASS APPLIANCE (Habit breaking and Tongue Retainer)
www.indiandentalacademy.com
25. 25. • Chris baker (2000) modifiedthe Bluegrass appliance design to utilize4mm

acrylic beads on the cross palatalwire. Advantage of modification • It encourages the

maximum neuromuscular stimulation by using two or more beads • It reduced
bulkiness of appliance, which results in less obstruction and more stimulation of
tongue function. • Wire and beads cemented to second a deciduous molar that is
not seen from outside mouth. A child quickly becomes comfortable with the
Bluegrass and enjoys the sensation of the tongue playing with the beads.
www.indiandentalacademy.com
26. 26. • Chris baker claimed that there is a direct relationship between the age of child

at the time of appliance placement and speed of correction. • Younger children show
cessation of habit in first few days and quickly and completely tongue position
becomes normalized. • Older children --- take few weeks. • Retention : • Appliance
left in the mouth for six months after the habits has stopped. If the low tongue
position persists after six months, leave the appliance in place to continue retraining.
www.indiandentalacademy.com
27. 27. Nanda found that the vertical pattern of development was established before the
eruption of the permanent first molar and long before the adolescent growth spurt.
Anterior vertical dimension is a key feature that is related to existing vertical growth
patterns. VHA, is essentially a transpalatal arch with an acrylic pad. The VHA uses
tongue pressure to reduce the vertical dentoalveolar development of maxillary
permanent first molars Vertical holding appliance www.indiandentalacademy.com
28. 28. ORTHOPEDIC APPROACH Functional appliance in growing patient Activator
Principle Woodside viscoelastic properties of muscle contraction induces skeletal
adaptation. Activator can be used for vertical malocclusion especially in open bite
cases to eliminate tongue thrusting, finger sucking and facilitates eruption of

6
 anterior teeth, prevents eruption of posterior teeth and facilitates mandibular
growth. www.indiandentalacademy.com
29. 29. • Eschler (1952) says that if the bite opening with activator increases 4 mm
beyond postural position, it will act as a muscle stretching method, works
alternatively with isotonic and isometric muscle contractions. He describes the cycle
as at the insertion of the appliance the mandible is elevated by isotonic muscle
contractions and when the mandible assumes a static position with the appliance,
isometric contract arise. Because the mandible cannot reach the postural rest
position, the elevators remain stretched. When the fatigue occurs, the contracting
muscle relaxes and the mandible drops. As soon as the muscle has recovered, the
cycle begins again www.indiandentalacademy.com
30. 30. • Bite registration : • The forward positioning of the mandible is not necessary,

when this appliance is primarily used for the vertical problems. • Hence, the bite is
opened 4 to 5 mm beyond postural rest position to develop sufficient elastic
depressing force and load the molars that are in premature contacts. This appliance
is used to achieve retroclination of the maxillary base with the restriction of the
patient's vertical growth pattern. This will "close the V" between the upper and
lower maxillary bases, depressing the posterior maxillary segment. If the divergent
rotations of the jaw bases are present, the correction of open bite with activator is
not possible. www.indiandentalacademy.com
31. 31. • Weinback & Smith (AJO - 1992) evaluated the effectiveness of appliance; found
that there is decrease of 1.3mm in open bite and has less effect on lower molars . •
Limitation- When divergent rotation of base is apparent, activator is not the choice
of treatment. www.indiandentalacademy.com
32. 32. • Intrusion of molars is performed by loading only the cusps of these teeth. The
acrylic detail is ground away from the fossae and the fissures to eliminate any
possible inclined plane stimulus to molar movement to achieve vertical depressing
action. This will allow the activator to deliver greater amount of force. • Extrusion of
the incisors requires loading their lingual surfaces above the area of greatest
concavity in maxilla and below this area in the mandible. And the extrusion can be
enhanced by placing the active labial bow above the area of greatest convexity
(gingival third).www.indiandentalacademy.com

7
33. 33. Vertical Control with a Headgear-Activator Combination • The rigid acrylic
activator consists of two parts: an upper “ horseshoe” splint covering all the teeth up
to the gingiva, and a lower portion adapted lingually to the mandibular arch and
alveolar process, with lower wings as long as possible. Labial coverage of the incisal
edges can be added to prevent proclination of the incisors.
www.indiandentalacademy.com
34. 34. High angle cases are particular domain of this combination since, unlike the use
of activator only treatment, vertical control is optimal. • In vertically critical cases the
force vector of the headgear is adjusted so that even pressure is distributed between
the incisal and molar regions, i.e. through the centre of resistance of upper dentition.
No acrylic is removed in the lower molar region. The amount of force should not be
less than 400 gm. • By changing the direction of the outer facebow, it is possible to
achieve different biomechanical effects on both the alveolar and skeletal units.
Moments can be positive, negative, or nonexistent, resulting in clockwise rotation,
counterclockwise rotation, or pure translation, according to treatment objectives.
www.indiandentalacademy.com
35. 35. • Lowering the outer facebow enhances the tipping effect of the activator, thus
increasing anterior overbite and reducing posterior facial height. This effect should
be avoided in brachyfacial cases, but can be used to advantage in mesofacial or
dolichofacial types with tendencies to anterior open bite .
www.indiandentalacademy.com
36. 36. Since the outer facebow was bent downward so the direction of force passed

behind both the alveolar and skeletal centers of resistance. Thus, positive moments
and clockwise rotation were generated • Clockwise rotation of the palatal plane, •
Downward tipping of the occlusal plane without eruption of the upper molars. •
Eruption and retroclination of the upper incisors, resulting in correction of the
overjet and anterior open bite. • Closing of the facial axis and anterior mandibular
rotation, with forward displacement of pogonion. • Inhibition of forward maxillary
growth, combined with forward mandibular growth, resulting in correction of the
Class II skeletal relationship.(disadvantage in class 3 cases ) • Backward displacement
of the upper dentition and forward displacement of the lower, without tilting of the

8
 incisors, resulting in correction of the Class II
malocclusion.www.indiandentalacademy.com
37. 37. • Bionator • Bionator mainly used to correct abnormal posture and function of
tongue. • Principle • 1) According to Balter, equilibrium between tongue and
circumoral muscles is responsible for shape of dental arches and intercuspation. The
functional space or the tongue is essential to the normal development of the
orofacial system. • 2)Not to activate muscles but to modulate muscle activity,
thereby enhancing normal development of inherent growth pattern and elimination
abnormal and potentially deforming environmental factor. • 3) Construction bite is
as low as possible with slight opening for posterior bite block to prevent extrusion of
posterior teeth. • 4. To inhibit tongue movement, the acrylic portion of lower lingual
part extends into upper incisor region as a lingual shield closing the anterior space
without touching upper teeth. www.indiandentalacademy.com
38. 38. • The palatal bar is used to position the tongue more posterior (or) into caudal

position. • The labial bow should run between the incisal edges of the upper and
lower incisors. The labial part of the labial bow is placed at the height of the correct
'lip closure, thereby stimulating the lip to achieve a competent lip seal and
relationship. The vertical strain on the lip tends to encourage the extrusive
movement of the incisors, after eliminating the adverse tongue pressures
www.indiandentalacademy.com
39. 39. Weinback et al (AJO-92) concluded that openbite bionator is not useful in severe
open bite cases and useful in mild case were posterior eruption would be
undesirable due todivergent skeletal pattern. www.indiandentalacademy.com
40. 40. Frankel FR- IV • Out-to be matrix'-Allows muscle to exercise to adapt. The

working principle of R, establishes the mandible forward rotation with posterior

edges of buccal shields as rotational centers. Anteriorly the force of anterior vertical
muscle chain being strengthened by lip seal exercise raises the mandible. •
Appliance effectively changes dentoalveolar structures without producing skeletal
changes. www.indiandentalacademy.com
41. 41. OWEN s modification of a function regulator differs from other Frankel

appliances in the addition of posterior acrylic bite blocks to arrest molar eruption
through the function of the elevator muscles. The vertical dimension or anterior

9
 facial height (ANS-Me) decreased through the holding or intrusion of the upper
molars. www.indiandentalacademy.com
42. 42. It also has headgear tubes that accept a facebow for an occipital pull headgear,
which provides the appliance with positive control of the posterior maxilla The
construction bite was taken 3-4mm protrusive, with 3-4mm posterior (molar)
clearance to allow for the bite blocks and headgear tubes
www.indiandentalacademy.com
43. 43. www.indiandentalacademy.com

44. 44. • Study by Erbay et al (AJO-95) showed that this appliance produce favorable
mandible rotation with extrusion of upper and lower incisors thereby correcting
malocclusion. As a result of treatment with the FR-4 appliance and lip seal training,
the growth and development pattern of the mandible was altered. The spontaneous
downward and backward growth direction of the mandible which was observed in
the control group was changed to an upward and forward direction by FR-4 therapy,
allowing the skeletal anterior open bite to be successfully corrected through upward
and forward mandibular rotation. www.indiandentalacademy.com
45. 45. • Reduction in total anterior facial height growth was due to successful inhibition
of lower anterior facial growth by the FR-4 appliance. It appears most likely that this
reduction in mandibular plane angles was the result of differential increase between
total posterior and anterior facial height (4.5 and 3.9 mm, respectively). Greater
posterior vertical growth would result in a lowering of the gonial region and
subsequent upward and forward mandibular rotation. Theoretically, Fränkel and
Fränkel explained this rotation mechanism with the possible effect of the function
regulator's buccal shields and lip seal exercises. They hypothesized that the posterior
edges of the buccal shields are deeply positioned in the vestibular sulcus and
provoke pressure sensation in this area. This could cause the inferior translation of
the posterior part of the mandible with a compensatory translative growth at the
condyles, leading to an increase in ramus length. They suggested that, concomitant
with the lowering of the posterior part of the mandible, its anterior part could be
raised with the posterior edges of the FR as a rotational
center.www.indiandentalacademy.com

10
46. 46. • They concluded that such a forward rotation of the mandible was brought
about by the force of the vertical muscle chain being strengthened by lip seal
exercises. This hypothesis is supported by the findings of Ingervall . They found
considerable anterior mandibular rotation in children with long- face structure
during muscle training with chewing gum. However, Ingervall suggested the anterior
mandibular rotation could be explained by reduced midfacial vertical growth due to
increased masticatory muscle strength, instead of increased mandibular condylar
growth. • The occlusal rests of the FR-4 appliance on the upper first molars appear
to restrict the rate of growth in upper posterior dentoalveolar structures.
www.indiandentalacademy.com
47. 47. • Twin blocks • Twin blocks with modification can be used to achieve vertical
control and includes posterior & also erupts anterior, which aid in correction of
excess vertical height malocclusion especially in mixed dentition. The principle of this
appliance is to correct the malocclusion by correcting the unfavorable cuspal
contacts and maximize the growth potential of the jaws. Rapid correction of the
malocclusion is achieved by transmitting favorable occlusal forces to the occlusal
inclined planes covering the posterior teeth. In treating the patients with vertical
growth pattern associated with increased lower facial height, the contact between
the occlusal bite blocks and the posterior teeth should be maintained to prevent the
eruption of the posterior teeth. www.indiandentalacademy.com
48. 48. • Modifications : • 1.A palatal spinner comprising of a bead which rotates on a
transpalatal wire ositioned in the palate which encourages the tongue to curl
upward and backward instead of thrusting between teeth. • 2. Twin block with
headgear to upper 1st molar • (Intrude and corrects VME) • Headgear tubes can be
attached to the upper molar and high pull extra-oral traction can be applied to a
modified face bow worn at night to intrude the upper molars. • 3. Concord face bow
is a unique way to deliver an intrusive force to upper molar and protrusive force to
the lower molar. • In the Concorde face bow, the outer bow should be slightly above
than the inner bow, producing an upper component of force, to stabilize the upper
appliance. This upward force is balanced by the horizontal elastic attached to the
recurved labial hook and the vertical component of orthopedic force is applied to the
upper molars by cervical headcap (or) headgear. www.indiandentalacademy.com

11
49. 49. Concord face bow twin block www.indiandentalacademy.com
50. 50. • 4. Vertical elastics used to twin blocks to upper and lower posterior premolar

regions which helps in intruding posterior teeth thereby altering vertical dimension.
They intrude the posterior teeth especiaIIy the upper molars, by encouraging the
patient to bite into the appliance consistently and producing more amounts of
intrusive forces on the opposing molars. This effect is useful to the patients with
vertical growth pattern and weak musculature and so they do not close consistently
on the appliance. • 5. Use of repelling rare earth magnets in the occlusal bite blocks
to reduce the vertical dimension. www.indiandentalacademy.com
51. 51. • JASPER JUMPER • This appliance produces both sagittal and intrusive forces like

Herbst bite jumping mechanism, but affords the patients much more freedom of
mandibular movement. • The Jasper Jumper is relatively new auxiliary capable of
producing rapid change in occlusal relationships. It is flexible fixed appliance that
delivers light continuous force. It can be used to move single teeth, most of teeth or
an entire arch. It can deliver functional bite jumping forces, or a combination of
these. • Its modular system can be attached to most commonly use fixed appliances.
• This system is composed of two parts, the force module and the anchor units. •
ROBERT G.CASH57, 1991 had described the non-extraction treatment for on adult
patient with a bilateral Class II malocclusion and an open bite, using a Jasper Jumper
appliance to distalize and to intrude the maxillary molars.
www.indiandentalacademy.com
52. 52. • ORTHODONTIC APPROACH to limit vertical dimension, in growing patient are: •

High pull headgear with/without splint • Extraction therapy • Bite blocks

(passive/active) • Vertical pun chin cup • Combination of these.
www.indiandentalacademy.com
53. 53. • High pull headgear • Used to treat hyperdivergent open bite, by effectively

holding maxillary sutural rowth and vertical dentoalveolar development (Armstrong,

Woodside and Baumrind). • Study by Creekmore and Pearson, showed that high pull
headgear alone modifies maxillary growth but compensatory eruption of mandibular
molars prevents autorotation of mandible and control of anterior facial height. •
Study by Melsen and Caldwell, showed that high pull headgear attached to a splint
more effectively modifies maxillary growth to a more posterosuperior direction and

12
 this is an effective approach for vertical maxillary excess
www.indiandentalacademy.com
54. 54. Maxillary traction splint: • Caldwell (AJO-84) used acrylic splint With headgear
(high pull) showed that, this approach produce a superior and distal displacement of
maxilla, reduction in SNA angle, clockwise rotation of palatal plane and relative
intrusion of upper molar with increased lower molar eruption, decreased mandibular
growth and increased SNB angle. www.indiandentalacademy.com
55. 55. 1. High pull HG short and high outer bow: Line of HG force is mesial to Centre of

resistance. • Moment tends to flatten the OP. • Distal and intrusive force
component. 2. HG force passing through center of resistance. Intrusive and distal
component of force. No moment. 3.High pull with long outer bow: • Moment at
center of resistance tends the steepen the OP. • Force with distal and intrusive
component. • Indication : Class II open bite patients.
www.indiandentalacademy.com
56. 56. Vertical chin cup • Pearson used vertical chin up in mixed and permanent
dentition to reduce the Mpa and limit in increase in anterior facial height. • Haas
used vertical chin cup with Kloehn cervical headgear, and showed that appliance
inhibit upper molar eruption and descent of maxilla, while mandibular growth was
redirected toward a more horizontal direction. • Cups have ben used during active
RPE therapy to minimize the vertical displacement of the maxilla and control the
opening of MPA. • Eren studied the effect of vertical chin cup alone and found a
decrease in Mpa, posterior rotation of maxilla, increase in upper facial height, a
decrease in total anterior and lower anterior facial height, an increase in lower post
dentoalveolar height and an increase in overbite.www.indiandentalacademy.com
57. 57. • Study by Iscan (AJO-2002) effect of vertical chin cup on mandibular morphology
in treating Skeletal open bite. Concluded that Mpa decreased significantly. Gonial
angle closed, ramal inclination angle decreased, corpus inclination increased all
indicating anterior rotation of mandible. Anterior rotation of mandible occurred as a
result of inhibiting vertical growth in mandibular post dentoalveolar region. Eruption
of mandibular incisors played an important role in correcting open bites in vertical
chin cap therapy. • Study by Pearson, showed that mandibular plane angle
decreased to 3.9°, with all 4 extractions and a vertical pull chin cup for 9 months of

13
 treatment. • Study by Nanda, showed that high pull chin cup prevents increase in
anterior facial height and mandibular plane angle in hyperdivergent individual during
maxillary expansion. www.indiandentalacademy.com
58. 58. Passive posterior bite block Do not contain any active elements like

springs/magnet. According to Kuster et al bite blocks are like functional appliances,

with interocciusal space of 3-4 m beyond rest position, which inhibit extrusion of
buccal segments effectively. This is most effective prior to growth completion of
jaws. Modification of bite blocks 1.Removable spring loaded - Kuster & IngeNal (AJO-
90) It shows greater reduction in ANB angle and molar intrusion than passive bite
block. 2. Repelling magnet - Iscan et al (AJO-97) 3. Active vertical corrector (AVC) -
Dellinger(AJO-86) -Tooth borne appliance -Fixed/ Removable type Advantage Rate of
tooth movement is greater than conventional appliance such as high pull headgear,
bionator, activator (or) conventional bite block therapy. Correction of LAFH range
from 0.9 - 2.4 mm www.indiandentalacademy.com
59. 59. • BITE BLOCK • DELLINGER (1986) proposed the use of occlusal bite blocks
containing repelling magnets, the effect of the force of the magnets was reported to
cause intrusion of the posterior teeth, allowing the mandible to rotate upward and
forward. • Michael G. Woods and Ram S. Nanda (1988) in their experiment in
growing baboons found magnetic bite blocks are effective in intrusion of posterior
teeth. There was significant eruption of anterior teeth. This dentoalveolar
compensation was greater in animals wearing magnetic appliances than bite blocks
without magnets. Bone remodeling changes at the gonial angle wear also marked
with magnetic appliances. www.indiandentalacademy.com
60. 60. • Study by Thilander & Dellinger, showed that a bite block is effective in

controlling anterior facial height. • Study by McNamara and Dellinger, showed that
magnetic bite blocks produce significant treatment effect with the disadvantage • a)
Creating asymmetric mandibular posture and subsequent unilateral cross bites due
to shearing forces created by repelling magnets. • b) Increased root resorption due
to excessive intrusive force for extended periods. www.indiandentalacademy.com
61. 61. • Kalra and Nanda (AJO 1989 ) • A fixed magnetic appliance was designed that

hinged the mandible open and exerted an intrusive force on the teeth. Treatment
with this appliance resulted in: • An increase in length of the mandible ( age group 8

14
 – 10 yrs ) • Intrusion of teeth • Upward and forward autorotation of the mandible •
Reduction of A-B to occlusal plane • Improvement in the angle of facial convexity •
Creation of temporary buccal crossbite caused by the shearing force of repelling
magnetswww.indiandentalacademy.com
62. 62. • The MAD IV Appliance • M. ALI DARENDELILER (JCO) • The Magnetic Activator
Device IV (MAD IV) uses anterior attracting magnets as well as posterior repelling
magnets. The anterior magnets guide the mandible into a centered-midline position,
add an anterior closing effect, and enhance the anterior rotation of the mandible. •
The MAD IV consists of removable upper and lower plates, each of which contains
three cylindrical neodymium (Nd2Fe17B) magnets coated with stainless steel. The
four posterior magnets, embedded in a repelling configuration, generate an intrusive
force of 300g each, with a bite opening of 5.5-6mm at the first molars. The two
midline magnets apply an attracting force of 300g.www.indiandentalacademy.com
63. 63. • 1. The MAD IV-a is used in cases where the anterior segment of the maxilla is

vertically correct or overdeveloped (gummy smile). Because posterior intrusion and

mandibular autorotation are needed, the posterior and anterior magnets are placed
in full contact www.indiandentalacademy.com
64. 64. • 2. MAD IV-b is used when an additional extrusive effect is needed in the

maxillary anterior region. The anterior magnets are positioned with a vertical
opening of 2-3mm, while the posterior magnets are placed in full contact. These
selective anterior and posterior effects can be accentuated by dividing the upper
plate in two and joining the two sections with a hinge.
www.indiandentalacademy.com
65. 65. • . The MAD IV-c is used when only anterior extrusion is needed. The posterior

magnets are omitted, and the anterior magnets are placed with an opening of 1-
2mm, depending on the severity of the anterior open bite.
www.indiandentalacademy.com
66. 66. • THE ACTIVE VERTICAL CORRECTOR (AVC ) • Active Vertical Corrector (AVC) is a

simple removable or fixed orthodontic appliance that intrudes the posterior teeth in
both the maxilla and mandible by reciprocal forces. AVC is a tooth borne appliance. •
By the use of effective posterior intrusion of teeth, the mandible is allowed to rotate
in upward and forward directions. The uniqueness of this appliance is that it allows

15
 the clinician to correct anterior open bite problems by actually reducing anterior
facial height. • It is an adaptation of present-day bite block therapy .
www.indiandentalacademy.com
67. 67. • The AVC works as an energized bite block. The energy system is obtained by

the repelling force of samarium cobalt magnets. Because samarium cobalt is a highly
reactive, rare earth material and therefore best kept isolated from the oral
environment, these magnets are hermetically sealed in a stainless steel capsule.
Stainless steel was selected over epoxy as the material for encasing the magnets
because epoxy tends to crack and abrade from occlusal contact.
www.indiandentalacademy.com
68. 68. • The method of action is reciprocal intrusion of the maxillary and mandibular
teeth This movement results in autorotation of the mandible and open bite
correction. The force system presently used in this appliance generates 700 g of
force per magnetic unit. The magnets are placed immediately over the teeth to be
intruded. The placement is viewed as a pure vector problem and varies from case to
case. One or two magnets per distal quadrant are used, depending on the force
required. www.indiandentalacademy.com
69. 69. • Method of action • The AVC force system generated by repelling magnets is

considered superior to a static bite block appliance energized only by the

intermittent force from the muscles of mastication. The constant force system of the
AVC results in greater rapidity of tooth movement. It has been shown that increased
cellular activity occurs when tissues are subjected to an intermittent electromagnetic
field. Saliva is an electrolyte and the magnets are at times in motion. The possibility
of microcurrent flow in the periodontium should be considered a positive tissue
stimulator. www.indiandentalacademy.com
70. 70. • The rate of tooth movement is considerably greater than conventional

approaches such as high-pull headgear, Bionators, activators, or conventional bite

block therapy. • The impressions for constructing the dental casts are critical
because the taking of the working bite demands a precise clinical technique and is an
absolutely essential element in the correct functioning of the AVC. Another
extremely important factor is the placement of the magnets because the appliance is
a direct reciprocal vector appliance between the maxilla and mandible. A specially

16
 designed headcap and chin strap is worn during sleep and at all other times deemed
socially fitting by the patient. • The appliance has been successfully used in both
adults and children, growing children experience more rapid correction than the
skeletally mature adult. • Study by Ingervall showed that AVC produce quicker
response in dental and skeletal vertical relationship in growing individuals. i.e. an
average of 3mm of anterior open bite closure over a 8 months treatment period.
www.indiandentalacademy.com
71. 71. OPEN BITE CORRECTION IN INDIVIDUALS WITH NO POETENTIAL FOR GROWTH

MODIFICATION • Dental open bite • Wiseman (AJO-95), provides a guideline to treat

dental open bite. • 1) Prociined maxillary/mandibular incisors, • 2) Normal
craniofacial pattern • 3) Little/no gingival smile • 4) 2-3 mm of incisor exposure at
rest. • His approach is extraction and retraction of incisor, commonly involved teeth
for extraction is 1st premolar . Mechanics of treatment aimed at changing
angulations and extrusion of anterior teeth (Draw bridge effect). The limiting factor
in this type of treatment is relationship of upper incisor to upper lip.
www.indiandentalacademy.com
72. 72. • YOUNG H.KIM 1987 has described the multi loop edgewise Archwire • (MEAW)
technique in the treatment of the Anterior open- bite. The MEAW technique • 16x22
SS archwire + heavy anterior elastics - to achieve molar intrusion and simultaneous
incisor extrusion. • 1. ELIMINATE all rotations, spaces and crowding before
treatment. • 2. Double edgewise brackets with .018 slots, preferably auxilIary
vertical slot are used. • 3. Two types of loop components, vertical and horizontal.
Vertical loop provides’ horizontal control and horizontal loop provides vertical
control. • 4. Individual loops are in the form L shape.'- • 5. Using 2 1/2 times (30 cm)
more than the normal span of wire, it provides ten-fold reduction in the
load/deflection rate over a typical ideal archwire. www.indiandentalacademy.com
73. 73. • 6. Requires 5 loops on each side. • 7 Vertical loops centered at the
interproximal areas horizontal loops should be directed mesially. • 8. Typical tip back
bends 3° to 5° should be incorporated. • 9. Upper MEA W has deep curve of spee
and lower reverse curve; this will apply intrusive forces on incisors further worsening
the open-bite. So this force is counteracted by anterior vertical elastic force. The
elastics must be in a place for full-time. • He concluded that the MEAW technique is

17
 very effective in the treatment of the open-bite. In addition he says that the
extraction 2nd or 3 rd molar in open-bite cases offers feasible diagnostic and
therapeutic situation and while treating the open bite, individual occlusal plane
should be corrected, teeth must be uprighted to occlusal plane for stability and
function. www.indiandentalacademy.com
74. 74. Effect • Increase upper anterior alveolar height • No effect on upper posterior

alveolar height. • Reduction in lower posterior dentoalveolar height • Distal

movement of entire dentition. • Increase in inter incisal angle. • Alters the occlusal
plane by preventing upper molar extrusion and intrudes lower molar. • MEAW
influence dentoalveolar changes with minimal effect on skeletal pattern. • Limitation
- Patients with gingival show. www.indiandentalacademy.com
75. 75. Implants • As Stationary Anchorage • Prosterman et al (AJO-95) used Osseo

integrated implants to intrude/at least prevent extrusion of posterior segment in

correction of vertical facial height and anterior open bite. • Umemori at al (AJO-98)
used titanium miniplates in buccal cortical bone in apical region of 1st & 2ndmolars
and produce 3-5 mm of intrusion and counter clockwise rotation of occlusal plane
without unfavorable side effect. www.indiandentalacademy.com
76. 76. Leibinger miniplates, screws, and screwdriver. The plate should be positioned so

that only the last loop on the vertical (most occlusal) leg of the plate projects
through the mucosal incision into the oral cavity. This loop should be several
millimeters apical to the brackets on the molars and adjacent to the teeth requiring
the greatest amount of intrusion. Two self-tapping screws are placed to secure the
plate to the bone. www.indiandentalacademy.com
77. 77. • Since the intrusive force is buccal to centre of resistance , molar buccal flaring

can occur. Lingual crown torque was applied to the lower molars with Burstone’s
precision lingual arch to avoid buccal flaring during intrusion . In the upper arch TPA
can be used. www.indiandentalacademy.com
78. 78. SURGICAL TREATMENT When the severity of vertical deformity is so great that

reasonable correction cannot be obtained by growth modification/camouflage, a

combination of orthodontics and orthognathic surgery is the viable treatment
option. Ways to counteract this malocclusion: 1) Superior repositioning of the
maxilla (or) at least posterior part of the maxilla by total/segmental maxiiiary

18
 osteotomy. This indirectly repositions the mandibie in an upward and forward
direction. Care taken not to elevate anterior maxilla and may be indicated to rotate
downward so that an esthetic smile arc is maintained. 2). Mandibuiar surgery to
bring lower jaw forward and upward, in a open bite cases, by fitting he body of
mandibie up after a ramus osteotomy (this approach indicated when problem is
largely in mandible and no alteration in maxilla is required). 3).Superior repositioning
of chin by mandibular lower-border osteotomy. This procedure is useful adjunct to
above approaches, but it is not adequate to solve severe discrepancy.
www.indiandentalacademy.com
79. 79. 4).Double jaw procedure - Maxillary surgery is the primary procedure. After

maxilla repositioned vertically, mandibular ramus osteotomy is recommended only

as a secondary procedure. 5) Glossectomy In cases where abnormal large tongue is
the causative factor in excess vertical facial height, partial glossectomy procedure is
recommended. And also where tongue is large to small mandible, either functional
orthopedic appliance/jaw advancement surgery is indicated (Bite jumping). Primary
focuses on maxilla, for two reasons • Usually the maxilla has excessive vertical
development with influence on mandible rotation down and backward. • Stability -
moving maxilla up produces stable surgical correction, whereas mandibular ramus
osteotomy in a counter clockwise rotation stretches soft tissue posteriorly resulting
unstable. www.indiandentalacademy.com
80. 80. • INDICATIONS • 1. Cases where normal mandibular length, rotated to Class II
pattern, superior repositioning of maxilla alone will bring mandible to Class I. • 2.
Cases where small mandible and rotated backward, superior repositioning of maxilla
and mandibular ramus osteotomy indicated(For advancement of mandible). • 3.
Cases where large mandible and rotated backward, i.e. (ClassIII to Class I), superior
repositioning of maxilla and mandibular ramus osteotomy indicated (to shorten
mandible www.indiandentalacademy.com
81. 81. • Presurgical Consideration • 1) Lefort-1 osteotomy has tendency of gingival

stripping during healing process, scar contractions pulls gingival attachment

gingivally. When gingival attachment is questionable. gingival attachment should be
augmented by placing gingival grafts in doubtful areas atleast 2-3 months before
surgery (esthetic problem). • 2) In anterior open bite planned for segmental

19
 maxillary osteotomy with anterior and posterior dentoalveolar segments, it is
important not to level upper arch during presurgical orthodontics.If upper arch is
leveled presurgicalty,in severe open bite cases. produce a relapse tendency, i.e.
primarily leveling occurs by elongating upper incisor. When appliance removed post
surgically the incisors tend to relapse apically to some extent and would lead to
opening of bite anteriorty. www.indiandentalacademy.com
82. 82. • 3) Transverse, If arch requires expansion orthodontically, do at the very
beginning of presurgical orthodontic procedure and maintain as long as possible
before the expansion appliance is removed. If arch expansion planned at surgery,
orthodontic expansion should not be carried out in presurgical procedure.
www.indiandentalacademy.com
83. 83. • ANTERIOR MAXll,LARY AND MANDIBUULAR SUB APICAL OSTEOTOMY • This

surgery is mainly executed for the extrusion of the anterior segment of maxilla (or)
mandible (or) both to close the anterior open bite. • Indication for anterior maxillary
sub-apical osteotomy: • 1..A small open bite associated with the minimal tooth
exposure (or) none,lip competence, a good naso labial angle, and adequate lower
anterior facial height • 2.The relationship between the upper lip and concealed
maxillary incisors of rest,speech and smiling produces an unaesthetic edentulous
appearance. • Indication for anterior mandibular sub-apical osteotomy: If the open
bitemanifests in the anterior portion of the mandible as a reverse curve in the
mandibular archwith transverse maxillo- mandibular harmony and good esthetic
balance between upperlip and maxillary anterior teeth. Relapse potential is very
minimal.www.indiandentalacademy.com
84. 84. KOLE MODIFICATION OF MADIBULAR SUB-APICAL OSTEOTOMY Indications :

Mandibular prognathism associated with anterior open bite, severe reverse curve,
and excessive chin height along with the patient should have a functional posterior
occlusion, no transverse deficiency problem in maxilla and a satisfactory lip to tooth
relationship in maxilla. . The main objective of this surgery is the close the open-bite
by elevating the lower anterior segment and reducing the chin height it includes
horizontal sub-apical bone incision and vertical ostectomies in the premolar (or)
molar extraction sites. The choice of extraction site depends on the magnitude of the
anterior open bite and location of the reverse curve in the mandibular occlusal

20
 plane. .The principle disadvantage of the surgery relates to unpredictable soft tissue
profile and chin height changes. So that a well placed pressure dressing for 7 days
minimizes the soft tissue changes. www.indiandentalacademy.com
85. 85. • LEFORT I MAXILLARY OSTEOTOMY FOR THE CORRECTION OF THE VME • This

surgical procedure is indicated in cases with high and constricted palatal vault,
excessive curvature of the maxillary occlusal plane, lip incompetence high
mandibular plane angle and a long distance between the palatal roof apices and the
nasal floor. • This down fracture Le fort I osteotomy is more useful when interdental
osteotomies are indicated to level the maxillary occlusal plane, widening the
maxillary arch, less problematic, more versatile and easier to execute than anterior
(or) posterior maxillary osteotomies. www.indiandentalacademy.com
86. 86. • Post-surgical orthodontics • The most difficult part in post-surgical orthodontic

in long face is maintaining transverse maxillary expansion, particularly surgical

expansion. To stabilize transverse expansion, Heavy labial auxiliary wire in headgear
tube along with light working archwire. • Transpalatal lingual arch.
www.indiandentalacademy.com
87. 87. • Surgical management of the growing patient remains controversial. Growing
patients can present to the clinician with maxillary dentofacial deformities that
require combined surgical and orthodontic correction. • Around 12 years of age,
most transverse maxillary growth is complete.Anteroposterior (AP) growth of the
maxilla is basically complete by about the age of 14 years. Normal vertical maxillary
growth, however, continues into adulthood. • Early surgical correction may be
beneficial in some patients for functional, esthetic, and psychosocial reasons.If
surgery is performed during growth, the patient and parents must be informed that
future surgery will probably be necessary. Surgery is often undertaken with the
expectation that additional treatment, including more surgery, may be required after
the completion of growth. Surgical management of the growing patient
www.indiandentalacademy.com
88. 88. • Le Fort I maxillary osteotomy. The Le Fort I osteotomy , when performed during
growth, effectively inhibits further anterior growth of the maxilla. Vertical maxillary
growth, however, can be expected to continue postoperatively at the same rate as

21
 before surgery. • In patients with normal mandibular growth, the occlusion should
remain stable. www.indiandentalacademy.com
89. 89. • Horseshoe maxillary osteotomy (dentoalveolar osteotomy). • With the
horseshoe maxillary osteotomy procedure the nasal septum remains attached to the
stable palate, and only the dentoalveolar structures are mobilized. Thus, some AP
maxillary growth may be expected to occur postoperatively. The overall growth rate,
however, will remain deficient. • Vertical maxillary growth remains unaffected and
continues at the same rate as before surgery • Tunnel procedure -- risky • Flap--
Raised labialy and buccalywww.indiandentalacademy.com
90. 90. • The most predictable results will be obtained if surgery is performed after age

14 in girls and age 16 in boys. If done at an earlier age (12 years in girls and 14 years
in boys), there is a possibility of the excessive vertical maxillary growth rate
recreating a vertical maxillary excess after surgery, although to a lesser extent than
would occur if surgery was not performed. The occlusion will usually remain stable •
Either procedure can be performed before the patient reaches age 10, provided
sufficient space exists above the apices of the developing permanent teeth to place
the osteotomies and apply fixation. Damage to developing tooth roots may result in
dento-osseous ankylosis, and localized dentoalveolar growth impairment.
www.indiandentalacademy.com
91. 91. • Orthognathic surgery for the correction of vertical maxillary hyperplasia can be
performed with corrective mandibular surgery for retrognathia or prognathism, if
the preoperative rate of mandibular growth is normal, and the TMJs are healthy. The
Le Fort I osteotomy will inhibit further AP maxillary growth while allowing vertical
maxillary growth to continue. www.indiandentalacademy.com
92. 92. • Sagittal split ramus osteotomy. • The sagittal split ramus Osteotomy is more
difficult to perform on younger patients because of greater bony elasticity, the
thinness of the cortical bone, the presence of unerupted molar teeth, and the
relatively shorter posterior vertical mandibular body height, as compared with
adults. It does have the advantages of easy application of rigid fixation as well as
better positional control of the proximal segment. SSRO is best reserved for patients
over the age of 12 years—that is, after the eruption of the permanent second

22
 molars, so that damage to these teeth during surgery can be
avoided.www.indiandentalacademy.com
93. 93. • Vertical ramus osteotomy. • The vertical ramus osteotomy (VRO) can be used
to advance the mandible and vertically lengthen the ramus with appropriate bone or
synthetic bone grafting as indicated to control the positional orientation of the
proximal segment and fill bony voids. • The amount of mandibular advancement and
vertical lengthening possible with this technique is limited by the temporalis muscle
attachment and interference of the coronoid processes on the zygomatic arch.
www.indiandentalacademy.com
94. 94. • Inverted “L” osteotomy. ( Subsigmoid osteotomy ) • Alternate to BSSO • 5 mm

advancement or retraction can be done--Limitation The inverted “L” osteotomy (ILO)

can be used to advance the mandible and vertically lengthen the ramus, but it may
require bone or synthetic bone grafting to control the positional orientation of the
proximal segment and to fill the bony voids between segments. The use of rigid
fixation is recommended. www.indiandentalacademy.com
95. 95. With any of the above mandibular ramus procedures, the preoperative rate of

growth can be expected to be maintained after surgery. Mandibular growth should

not be affected by any of these techniques, provided that the condylar head is not
damaged during surgery. The vector of facial growth, however, may be altered by a
change in the orientation of the proximal segment and thus the condyle, similar to
moulding of regenerate in D.Og. The use of rigid fixation will improve long-term
stability www.indiandentalacademy.com
96. 96. • TMJ & VME • The TMJs are the foundation for orthognathic surgery. If the TMJs
are not stable and healthy, orthognathic surgical results may be unstable, with
increased TMJ dysfunction and pain as a result. The TMJs must be appropriately
evaluated before surgery. The most common TMJ disorder seen in orthognathic
surgery patients is the displaced articular disk. Significant problems can occur when
orthognathic surgery is performed in the presence of untreated disk displacement. •
Pullinger et al demonstrated a higher prevalence of open bite in DD with reduction
and DDN . Out of 614 patients with TMJ disorders 32 had anterior open bite and 27 /
32 had disk displacement. • Riolo et al ( AJO 1987 ) suggested that open bite was

23
 positively associated with TMD and muscle tenderness.
www.indiandentalacademy.com
97. 97. • Kerstens et al ( J cranio Max S ) studied 480 OS patients both pre and post
operatively and found that retrognathic patients with low and normal angle MPA
were more likely to have preoperative TMJ signs and showed improvement of signs
and symptoms postoperatively.High angle patients with mandibular retrognathism
had highest post surgical incidence of TMJ signs and symptoms. ( Surgery done BSSO
and LF –I). • Stringert and Worms ( AJO 1986 )compared cephalometric data from a
group of 62 subjects with documented internal derangements with a sample of 102
subjects from normative sample. Results indicated an increased proportion of
subjects with "high plane" characteristics and a decreased proportion of subjects
with "low plane" characteristics in the experimental sample.
www.indiandentalacademy.com
98. 98. Relapse Tongue will adapt to new environment to both orthodontic treatment

Copey (AJO-85) and surgical treatment Denison (AngIe-89). Tongue habit should be
corrected by Myotherapy. Fixed retainer Use tongue crib during treatment-to alter
tongue posture and after treatment. Placing retainer that cover occlusal surface.
www.indiandentalacademy.com

24