Professional Documents
Culture Documents
Intrusion de Molares en El Tratamiento de Maloclusiones de Mordida Abierta Anterior en Pctes en Crecimiento
Intrusion de Molares en El Tratamiento de Maloclusiones de Mordida Abierta Anterior en Pctes en Crecimiento
Abstract: The treatment of the hyperdivergent phenotype and/or anterior openbite is one of the common
problems facing orthodontists. The purpose of this study is to present a new appliance (Molar Intruder)
for molar intrusion and to determine its effects in the treatment of anterior openbite. The study group
comprised 14 patients (eight girls and six boys), with a mean age of 10 years and 7 months. All presented
anterior open bite malocclusions between the second premolars. The study was carried out on lateral head
films taken before (T1) and after (T2) molar intrusion. Periapical radiographs, study models, and standard
photographs of all the patients were also obtained before and after molar intrusion. The paired sample t-
test was used to determine the differences between the parameters. The average treatment time with the
Molar Intruder was five months. The mean intrusion of maxillary and mandibular molars was 1.86 mm
and 1.04 mm, respectively. Maxillary incisors extruded 0.54 mm with a labial tipping of 1.468 and overbite
increased by 4.00 mm. The mandibular plane angle was decreased by 1.578, and the anterior face height
was decreased by 1.86 mm on average. The mandible showed a counterclockwise rotation, the chin moved
forward, and the posterior facial height/anterior facial height ratio was increased. Anterior openbites of the
patients were significantly rehabilitated at the end of the intrusion period, simplifying further orthodontic
treatment. (Angle Orthod 2004;74:454–464.)
Key Words: Molar intrusion; Anterior openbite; Hyperdivergency
Appliance construction
Impressions for working models were obtained from the
patient. A construction bite exceeding the freeway space by
two mm was taken using softened wax rims, and the rim
was transferred to the working models. The working mod-
els were mounted on a fixator, and the bite was registered
(Figure 1A). Buccal undercuts where clasps were planned
were scraped (0.5 mm) with a spatula for extra retention.
Adams clasps were bent (0.7-mm stainless steel wire) for
the maxillary premolars (Figure 1B) or maxillary first mo-
lars if only the second molars were to be intruded (patient
1). Eyelet clasps (0.7 mm) were incorporated to reinforce
the retention of the appliance. Molar intrusion springs were
bent from 0.7-mm stainless steel wire. The design of the
springs was altered if the second molars were erupted (Fig-
ure 1B,C). Upper springs were coated with modeling wax
from the helixes to the occlusal rests and were fixed on the
working model, whereas the lower springs were fixed on
FIGURE 1. Bite registration and the intrusion springs of the MI ap-
the model only at the occlusal rests. The acrylic of the pliance.
appliance was formed filling the space between the teeth
and polymerized in a pressure pot, after which the appliance
was trimmed and polished (Figure 2). (Figure 2B). A 110-g force was applied on each first molar
when the second molars were absent; however, if the sec-
Clinical management ond molars were in occlusion, 180 g of force was exerted
to the molar teeth in every quadrant. The force was mea-
The MI was adjusted and controlled in the mouth in a sured by pulling back the springs to their original positions
passive state, and then the intrusion springs were activated using a gauge (Dentaurum 006-013-00). The upper springs
Statistical method
The statistical analyses were performed using the SPSS
10.0 (SPSS Inc., Chicago, Ill) statistical program. Using the
tests of normality we observed that the variables were dis-
tributed normally. Therefore, the ‘‘Paired Sample t-test’’
was used to determine the differences between the param-
eters. The Mann-Whitney U-test was used for the compar-
ison of intrusion movements of the single and two molars.
The descriptive statistics are shown as arithmetic means 6
standard deviation. P values less than or equal to .05 were
evaluated as being statistically significant.
RESULTS
The treatment changes of the group are shown in Table
1. The SNB angle was increased by 1.5718 (P 5 .001), and
FIGURE 2. Passive (A) and active (B) forms of the MI appliance.
the ANB angle was decreased by 1.298 (P 5 .01). The Y
axis was decreased by 1.368 (P , .001), the SN/MP angle
was decreased by 1.578 (P 5 .001), and the gonial angle
usually needed readjustment after activation. The ‘‘U’’ was decreased by 1.508 (P 5 .001). The NV-Pog distance
bends were narrowed, and the occlusal rests were readjust- was also decreased, by 1.214 mm.
ed with pliers. The MI was seated in place, and the patient The anterior face height was decreased by 1.86 mm, and
was told to close his/her mouth slowly. The lower springs the ramus length was increased by 0.46 mm. The posterior
were guided with forefingers during mouth closure and facial height/anterior facial height ratio showed an increase
seated in place. The patient was instructed how to guide of 2.25%. The U6-FH distance was decreased by 1.86 mm,
the lower springs and advised to wear the appliance all day and the L6-MP distance was decreased by a mean of 1.04
except during meals. mm. The U1-FH distance and the U1/SN angle were in-
The patients were seen at three-week intervals to adjust creased by 0.54 mm and 1.468, respectively. The occlusal
and reactivate the springs if necessary. The average treat- plane angle was decreased by 2.258 (P , .001), and the
ment time with the MI was five months. After the appliance overbite was increased by 4.00 mm (P , .001). Finally,
was removed, orthodontic treatments of the patients were the mandibular sulcus contour (MSC) was decreased by
carried out with edgewise mechanics and multiloop arch- 3.571 mm (P , .001).
wires.10,34,35 Extraoral and intraoral photographs of two pa- When the intrusion movements of the single and two
tients treated with the MI are presented in Figures 3–6. molars were compared, single molar intrusion was statisti-
cally significant both in the maxilla (P , .012) and man-
Cephalometric analysis dible (P , .029) (Table 2).
Lateral cephalograms were performed with the Frankfort
Horizontal plane parallel to the floor and the teeth in centric DISCUSSION
occlusion. The radiographs were taken using the same It is generally agreed that treatment of skeletal anterior
cephalostat with standardized settings and traced by one open bite malocclusion is difficult. An adult skeletal open-
FIGURE 4. Intraoral views of the MI appliance (A, B), the bite closure (C), and extraoral photographs of the patient after MI use (C–E).
bite case is ideally corrected with a combination of ortho- divergent cases with anterior openbites not only eliminates
dontics and orthognathic surgery43 because the relapse after the risks associated with orthognathic surgery but also im-
surgery is usually less than that seen with nonsurgical treat- proves a child’s self-esteem by improving the appearance.15
ment alone.44 On the other hand, early treatment of hyper- In this study, the mean age of the sample was 10 years
7 months. The first molars of eight patients, the second force of 20 g for incisors, the optimum magnitude of force
molars of one patient (64.3%), and both the first and second has not been established to intrude posterior teeth or large
molars of five patients (35.7%) were intruded by the MI segments of teeth. Kalra et al28 applied 90 g of intrusive
appliance. Although Burstone45 recommended an intrusive force per tooth with fixed magnetic appliances. Umemori
FIGURE 9. Periapical radiographs of patient 2 after MI use. Minimal root resorption was observed at the apex of the palatinal root of the
maxillary left first molar (B).
TABLE 2. Comparison of the Intrusion Movement of Single Molar ings of several studies in which vertical chincups,19 mag-
vs Two Molars netic bite-blocks,28,30 miniplate anchorage,36,37 and high-pull
Measure-
Single Molar T2-T1 Two Molars T2-T1
Signifi- headgear 1 bite-block41 were used. Mandibular incisors
ments Mean SD Mean SD cancea were stable after the MI was used, but the maxillary inci-
sors were extruded an average of 0.54 mm with a labial
U6-FH 22,222 0.618 21,200 0.570 *
L6-MP 21,278 0.441 20.600 0.418 * tipping of 1.468. This was attributed to the anterior force
vector of the lower springs, affecting the acrylic plate of
a
* P , .05; ** P , .01; *** P , .001.
the appliance. The occlusal plane angle was decreased by
2.258, and overbite was increased by 4.00 mm, matching
length with buccal undercuts. Patient compliance problems the findings of Sherwood et al36 and Umemori et al.37
due to dislodgement were not observed, but we did consid- Sankey et al42 treated 38 patients with vertical skeletal
er that MI may pose dislodgement problems in the patients dysplasia using a bonded palatal expander and a crozat/lip
with deficient crown length and buccal undercuts. bumper, intraorally. A high-pull chincup was added to the
Although counterclockwise rotation of the mandible by treatment regimen in 16 patients. They reported that the
intruding the molars is most favorable15 in the treatment of increase in SNB was insignificant, whereas the decrease in
open bite cases, it has been shown10,33–35 that anterior open- ANB was found to be statistically significant. We also
bites can also be treated successfully by correcting the cant found a 1.298 decrease in ANB, but contrary to the expe-
of occlusal planes and uprighting the posterior teeth rience of Sankey et al,42 SNB increased significantly by
(MEAW therapy). However, because this technique deals 1.578. This was related to absolute molar intrusion of the
with the dentoalveolar parameters of anterior openbite, MI and was supported by a decrease (1.21 mm) in the NV-
counterclockwise rotation of the mandible was not reported Pog distance.
and the findings of these studies were, in general, contrary Insoft et al24 and Umemori et al37 have also noted similar
to our findings. findings at SNB and ANB in their case reports. The Y axis
The results of this study showed that the mean maxillary (1.368), mandibular plane (1.578), and gonial (1.508) angles
and mandibular molar intrusion was 1.86 and 1.04 mm, were significantly decreased. Anterior face height was de-
respectively. However, when both the first and second mo- creased by 1.86 mm, whereas ramus length was increased
lars were intruded, the average molar intrusion was reduced by 0.46 mm. As a result, the posterior to anterior face
by nearly half. It was considered that 180 g of force might height ratio increased 2.25%. These findings indicated man-
be insufficient for simultaneous intrusion of two molars. dibular autorotation resulting in reduction of anterior face
The findings of molar intrusion were similar to the find- height. Controlling the vertical dimension requires much
effort, and it was suggested in a number of studies42,46–48 be kept in mind that MI use may be difficult in the
that it was hard to achieve this goal with high-pull headgear, patients presenting deficient crown length.
extraction therapy, or a combination of both because of 4. Overerupted maxillary molars can sometimes be in con-
compensatory eruption of posterior teeth. However, man- tact with the alveolar mucosa of the mandible, inhibiting
dibular autorotation was also reported in the studies carried the eruption of mandibular molars. In many of these
out with vertical-pull chincups,19 active bite-blocks,28,30 cases a posterior vertical dentoalveolar excess accom-
miniplate anchorage,36,37 and high-pull headgear 1 bite- panies the malocclusion. Our clinical practice with such
blocks.41 cases showed that the MI is also effective in selective
Sankey et al42 did not find a decrease in the anterior face molar intrusion in the treatment of these malocclusions.
height with their treatment regimen, but they mention that
molar eruption was controlled and mandibular autorotation REFERENCES
was achieved with a significant decrease in ramus length
1. Proffit WR. Contemp Orthod. St Louis, Mo: CV Mosby; 1986.
as in our study. In contrast, Baumrind et al49 reported that 2. Noar JH, Shell N, Hunt NP. The physical properties and behavior
the growth of ramus length was reduced with high-pull of magnets used in the treatment of anterior openbite. Am J Or-
headgear treatment. thod Dentofacial Orthop. 1996;109:437–444.
Although significant treatment results were observed 3. Cangialosi T. Skeletal morphologic features of anterior openbite.
with magnetic bite-blocks, it was reported that they might Am J Orthod. 1984;85:28–36.
4. Worms F, Meskin LH, Isaacson RJ. Open bite. Am J Orthod.
create asymmetric mandibular posture and subsequent uni- 1971;59:589–595.
lateral crossbites because of the shearing forces of the re- 5. Subtelny JD, Sakuda M. Open-bite: diagnosis and treatment. Am
pelling magnets.25,31 Such side effects were not observed in J Orthod. 1964;50:337–358.
the other effective treatment methods19,36,37,41 and in our 6. Nahoum HI, Horowitz SL, Benedicto EA. Varieties of anterior
study. However, when periapical radiographies were eval- openbite. Am J Orthod. 1972;61:486–492.
7. Fields HW, Proffit WR. Facial pattern differences in long faced
uated, minimal root resorption was observed in the maxil- children and adults. Am J Orthod Dentofacial Orthop. 1984;85:
lary first molars (Figure 9B) of three patients. Maxillary 217–223.
second molars were in occlusion in one of the patients and 8. Ellis E, McNamara JA. Components of adult Class III open-bite
not erupted in the remaining two. The resorption rate was malocclusion. Am J Orthod Dentofacial Orthop. 1984;86:277–
minimal, but this finding was more or less similar to the 290.
9. Ellis E, McNamara JA, Lawrence TM. Components of adult Class
findings of Melsen et al,25 who demonstrated increased root II open-bite malocclusion. J Oral Maxillofac Surg. 1985;43:92–
resorption with the use of magnetic bite-blocks caused by 105.
extended periods of intrusive forces. 10. Kim YH. Anterior openbite malocclusion: nature, diagnosis and
The long-term effects of the treatment have not been es- treatment by means of multiloop edgewise archwire technique.
tablished. However, it was mentioned in several stud- Angle Orthod. 1987;57:290–321.
11. Dung DJ, Smith RJ. Cephalometric and clinical diagnosis of
ies22,28,50 that relapses of varying degrees were found in the openbite tendency. Am J Orthod Dentofacial Orthop. 1988;94:
vertical position of the molars, in the overbite, the gonial 484–490.
angle, and the forward rotation of the mandible after open- 12. Nahoum HI. Anterior open-bite: a cephalometric analysis and
bite treatment. Further studies are needed to evaluate the suggested treatment procedures. Am J Orthod. 1975;67:513–521.
long-term stability of the treatment effects of the MI ap- 13. Lavergne J, Gasson N. A metal implant study of mandibular ro-
tation. Angle Orthod. 1976;46:144–150.
pliance. 14. Horn AJ. Facial height index. Am J Orthod Dentofacial Orthop.
1992;102:180–186.
CONCLUSIONS 15. English JD. Early treatment of skeletal openbite malocclusions.
Am J Orthod Dentofacial Orthop. 2001;121:563–565.
1. The intrusion springs of the MI were effective in in- 16. Meldrum RJ. Alterations in the upper facial growth of Macaca
mulatta resulting from high-pull headgear. Am J Orthod. 1975;
truding the molars and in reducing the anterior openbite. 67:393–411.
Overbite and occlusal plane angle were decreased and 17. Orton HS, Slattery GA, Orton S. The treatment of severe ‘‘gum-
maxillary incisors were extruded with a significant labial my’’ Class II Div 1 malocclusion using a maxillary intrusion
tipping after MI use. splint. Eur J Orthod. 1992;14:216–223.
2. Mandibular plane and gonial angles were decreased. An- 18. Smith SS, Alexander RG. Orthodontic correction of a Class II
division 1 subdivision right openbite malocclusion in an adoles-
terior face height was reduced, and anteroposterior chin cent patient with a cervical pull face-bow headgear. Am J Orthod
position was significantly improved with the forward ro- Dentofacial Orthop. 1999;116:60–65.
tation of the mandible. As a result, the SNB angle was 19. Pearson LE. Vertical control in treatment of patients having back-
increased, whereas the ANB angle was decreased. ward-rotational growth tendencies. Angle Orthod. 1978;48:132–
3. The intrusive effect of the MI springs almost doubled in 140.
20. Gehring D, Freeseman M, Frazier M, Southard K. Extraction
the absence of second molars, and this should be taken treatment of a Class II, Division 1 malocclusion with anterior
into consideration in the treatment planning of open bite openbite with headgear and vertical elastics. Am J Orthod Den-
cases when second molars are in occlusion. It must also tofacial Orthop. 1998;113:431–436.
21. Frankel R, Frankel C. A functional approach to treatment of skel- openbite treatment. Am J Orthod Dentofacial Orthop. 1999;115:
etal openbite. Am J Orthod. Dentofacial Orthop. 1983;84:54–68. 29–38.
22. Kuster R, Ingervall B. The effect of treatment of skeletal open 36. Sherwood KH, Burch JG, Thompson WJ. Closing anterior open-
bite with two types of bite-blocks. Eur J Orthod. 1992;14:489– bites by intruding molars with titanium miniplate anchorage. Am
499. J Orthod Dentofacial Orthop. 2002;122:593–600.
23. Iscan HN, Akkaya S. The effects of the spring-loaded posterior 37. Umemori M, Sugawara J, Mitani H, Nagasaka H, Kawamura H.
bite block on the maxillo-facial morphology. Eur J Orthod. 1992; Skeletal anchorage system for open-bite correction. Am J Orthod
14:54–60. Dentofacial Orthop. 1999;115:166–174.
24. Insoft MD, Hocevar RA, Gibbs CH. The nonsurgical treatment 38. Epker BN, Fish LC. Surgical-orthodontic correction of openbite
of a Class II openbite malocclusion. Am J Orthod Dentofacial deformity. Am J Orthod. 1977;71:278–299.
Orthop. 1996;110:598–605. 39. Conley RS, Legan HL. Correction of severe vertical maxillary
25. Melsen B, McNamara JA, Hoenie DC. The effect of bite-blocks excess with anterior open bite and transverse maxillary deficien-
with and without repelling magnets studied histomorphologically cy. Angle Orthod. 2002;72:265–274.
in the rhesus monkey (Macaca mulatta). Am J Orthod Dentofacial 40. Takeuchi M, Tanaka E, Nonoyama D, Aoyama J, Tanne K. An
Orthop. 1995;108:500–509. adult case of skeletal open bite with a severely narrowed maxil-
26. Huang GJ, Justus R, Kennedy DB, Kokich VG. Stability of an- lary dental arch. Angle Orthod. 2002;72:362–370.
terior openbite treated with crib therapy. Angle Orthod. 1990;60: 41. Galletto L, Urbaniak J, Subtelny DJ. Adult anterior openbite. Am
17–24. J Orthod Dentofacial Orthop. 1990;97:522–526.
27. Hering K, Ruf S, Pancherz H. Orthodontic treatment of openbite 42. Sankey WL, Buschang PH, English J, Owen AH. Early treatment
and deepbite high-angle malocclusions. Angle Orthod. 1999;69: of vertical skeletal dysplasia: the hyperdivergent phenotype. Am
470–477. J Orthod Dentofacial Orthop. 2000;118:317–327.
28. Kalra V, Burstone CJ, Nanda R. Effects of a fixed magnetic ap- 43. Bell WH. LeFort I osteotomy for the correction of maxillary de-
pliance on the dentofacial complex. Am J Orthod Dentofacial formities. J Oral Surg. 1975;33:412–426.
Orthop. 1989;95:467–478. 44. Denison TF, Kokich VG, Shapiro PA. Stability of maxillary sur-
29. Woods MG, Nanda RS. Intrusion of posterior teeth with magnets: gery in open bite versus nonopen bite malocclusions. Angle Or-
an experiment in growing baboons. Angle Orthod. 1988;58:136– thod. 1989;59:5–10.
150. 45. Burstone CI. Deep overbite correction by intrusion. Am J Orthod.
30. Dellinger EL. A clinical assessment of the active vertical correc- 1977;72:1–22.
tor: a nonsurgical alternative for skeletal open-bite. Am J Orthod 46. Creekmore TD. Inhibition or stimulation of the vertical growth
Dentofacial Orthop. 1986;89:428–436. of the facial complex, its significance to treatment. Angle Orthod.
31. Kiliardis S, Egermark I, Thilander B. Anterior open bite treatment 1967;37:285–297.
with magnets. Eur J Orthod. 1990;13:447–457. 47. Pearson LE. Vertical control through use of mandibular posterior
32. Barbre RE, Sinclair PM. A cephalometric evaluation of anterior intrusive forces. Angle Orthod. 1973;43:194–200.
openbite correction with the magnetic active vertical corrector. 48. Dougherty HL. The effect of mechanical forces upon the man-
Angle Orthod. 1991;61:93–102. dibular buccal segment during orthodontic treatment. Am J Or-
33. Kim YH. Treatment of severe openbite malocclusion without sur- thod. 1968;54:29–49.
gical intervention. In: McNamara JA, ed. Monograph No. 35, 49. Baumrind S, Korn EL, Molthen BS, West EE. Changes in the
Craniofacial Growth Series. Ann Arbor, Mich: Center for Human facial dimensions associated with the use of forces to retract the
Growth and Development; 1999:193–212. maxilla. Am J Orthod. 1981;80:17–30.
34. Miyajima K, Iizuka T. Treatment mechanics in Class III open bite 50. Rowe TK, Carlson DS. The effect of bite-opening appliances on
malocclusion with Tip Edge technique. Am J Orthod Dentofacial the mandibular rotational growth and remodeling in the rhesus
Orhop. 1996;110:1–7. monkey (Macaca mulatta). Am J Orthod Dentofacial Orthop.
35. Chang YI, Moon SC. Cephalometric evaluation of the anterior 1990;98:544–549.