- Email: [email protected]
A new type of modified Essix Retainer for anterior open bite retention
progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/pio
Clinical contribution
A new type of modified Essix Retainer for anterior open bite retention Fakir Uzdil a , Mustafa Kayalioglu b,∗ , Egemen Kendi c , M. Serdar Toroglu d a
DDS, Research Assistant, Department of Orthodontics, Faculty of Dentistry, University of Cukurova, Adana, Turkey DDS, PhD, Lecturer and Clinical Instructor, Department of Orthodontics, Faculty of Dentistry, University of Cukurova, Adana, Turkey c DDS, PhD, Private Practice, Department of Orthodontics, Faculty of Dentistry, University of Cukurova, Adana, Turkey d DDS, PhD, Associate Professor, Department of Orthodontics, Faculty of Dentistry, University of Cukurova, Adana, Turkey b
a r t i c l e
i n f o
a b s t r a c t
Article history:
The most problematic malocclusion type to retain is anterior open bite although many clas-
Received 20 December 2007
sical retention appliances are known. The difficulty of maintaining the occlusion arises from
Accepted 20 November 2009
the lack of control over the tongue behavior and posture in open bite cases. In the current article, a 2 year follow-up of 2 open-bite patients who were retained with a new type of
Keywords: Open bite
retention appliance, successfully, were presented. © 2010 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.
Retention Essix
1.
Introduction
The anterior open bite malocclusion is considered one of the most challenging problems in orthodontics to treat and maintain successfully. Although a geat deal of attention has been devoted over the years to the correct diagnosis, successful treatment and long term retention of open bites, there is still controversy for the etiology, lack of agreement over the treatment protocols, and a high percentage of relapse. Many treatment modalities have been proposed for the treatment of anterior open bite malocclusions1 : high pull headgears for inhibiting maxillary growth, chin cups for limiting and redirecting mandibular growth, vertical elastics for extruding anterior segments, functional appliances, bite
∗
blocks, elastic modules, magnets, reverse curve arch wires or multi loop arch wires with vertical elastics, temporary anchorage devices for intruding posterior teeth,2 orthognathic surgery and finally cribs and spurs for moderating tongue behavior.3 Efficiency of open bite treatment through changing the rest posture of tongue, whether with a crib or a spur, is still a controversy. While Subtelny and Sakuda4 found no closure of open bite in eight patients treated for six months with crib therapy, Epker and Fish5 stated that the crib therapy is only effective in class I growing patients with good facial balance. Justus6 reported effective closure of the bite with crib therapy when worn for one year. Huang et al.7 also reported encouraging results and high percentage of stability with an average of 5 years post-treatment, even in non growing patients.
Corresponding author. Department of Orthodontics, Faculty of Dentistry, Cukurova University, Adana, 01330, Turkey. E-mail address: [email protected] (M. Kayalioglu). 1723-7785/$ – see front matter © 2010 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved. doi:10.1016/j.pio.2010.04.009
46
progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
Although not as widely used as tongue cribs, sharp spurs have been described in the orthodontic literature since 1927. First to mention spurs for open bite management through modifying tongue rest posture is Rogers8 in 1927. Parker9 demonstrated dramatic open bite closure using sharp spurs soldered to the central incisor bands. Justus3 presented successfully treated cases and good long term stability with sharp spurs. Justus3,6 argues that the neurophysiologic basis of the spur therapy, unlike the cribs that passively keeps the tongue in a certain position, is quite different, and is based on conditioned reflexes. The movement and the rest position of the tongue that has been elicited repetitively by successive stimuli of sharp spurs, may, after a period of time, be evoked without the need of conditioning stimuli to the tongue. Thus the tongue “learns” to stay in its place rather than being confined in it as is the case with a crib. Justus3 also believes that the pressure applied to the crib by the tongue, unlike the spurs, might cause molars to move forward and cause or increase a class II situation. The real success of any treatment is measured with long term stability. Lopez and Gavito10 reported that more than one
third of the patients treated with conventionally orthodontic appliances relapsed more than three millimeters. The studies of Dension et al.,11 Haymond et al.,12 and Hoppenreijis et al.13 unfortunately dismisses the belief that the surgical correction is the ultimate solution for open bites. Data from the study of Denison et al.11 suggested that the relapse caused mainly by dentoalveolar changes, not skeletal changes. That alone indicates the importance of maintaining dental correction with retention. Denison et al.11 also suggests that the differences in treatment response might be contributed to the musculature. The authors proposed that the tongue posture may have been the etiology of the open bite and that it might have been the reason why these patients had their open bites to relapse.11 Anyhow, open bite cases are still considered the most problematic to retain, and uncertainty of the bite to stay stable is still one of the chief problems clinicians face when finishing such case. In this article, we are presenting 2 year follow-up of 2 openbite patients who were retained successfully, with a modified, spur-implanted Essix retainer (Raintree Essix, Inc., 1071 S. Jeff Davis Parkway, New Orleans, LA 70125) after the conventional and non-surgical orthodontic treatment.
Fig. 1 – Intraoral and extraoral photographs of ‘Patient I’ before treatment. a) Right. b) Left. c) Facial photograph with smiling.
progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
Fig. 2 – Intraoral and extraoral photographs of ‘Patient I’ at the end of the treatment. a) Frontal. b) Right. c) Left. d) Frontal with spurs. e) Facial photograph with smiling.
Fig. 3 – Intraoral and extraoral photographs of ‘Patient I’ two years post-treatment. a) Frontal. b) Right. c) Left. d) Facial photograph with smiling.
47
48
progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
2.
Case history
2.1.
Patient I
P.B. was referred to our clinic due to inadequate incisor display while smiling and an anterior open bite malocclusion when she was 16 years old. Clinical and radiographic examination revealed that the patient had a dental and skeletal class I relationship, a moderately increased lower face height, normal upper and lower incisor inclinations, and an abnormal tongue posture (Fig. 1). The treatment plan was non-extraction, extrusion of anterior segments with straight wires on a 0.018 Roth bracket system and anterior box elastic wear. After establishing a class I molar and canine relationship with adequate bite and incisor display while smiling, anterior box elastic use ceased, but the bite re-opened after a month. The anterior box elastics were re-applied for another 2 months. When the correct dental and aesthetic relation established again, the patient asked for the treatment to be stopped despite the warnings about the stability of the treatment. The total treatment time was 18 months and for the retention, modified Essix retainers with spurs were fabricated and applied (Fig. 2). The patient was instructed to wear the retainer full-time for the first year except for eating and drinking and only at nights (sleeping hours) for the following 12 months. She was moving to another city and could not to travel for the routine reviews. When the patient was able to come for her recall appointment after 2 years post-treatment, lateral cephalometrics had been
Fig. 4 – Superimposition of the post-treatment (regular line) and the 2 years post-retention (dashed line) cephalometrics.
Fig. 5 – Intraoral and extraoral photographs of ‘Patient II’ before treatment. a) Frontal. b) Right. c) Left. d) Facial photograph with smiling.
progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
49
Fig. 6 – Intraoral and extraoral photographs of ‘Patient II’ at the end of the treatment. a) Frontal. b) Right. c) Left. d) Frontal with spurs. e) Facial photograph with smiling.
Fig. 7 – Intraoral and extraoral photographs of ‘Patient II’ two years post-treatment. a) Frontal. b) Right. c) Left. d) Facial photograph with smiling.
50
progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
obtained. Post treatment and two years follow up superimposition revealed no significant change in the dentoalveolar structures (Figg. 3 and 4).
2.2.
The author(s) declare that the work has been realized in agreement with the Helsinki Declaration principles and that the Informed Consent has been achieved from all the participants involved in the study.
Patient II
E.S. was referred to our clinic with the chief complaint of mild anterior crowding of the lower and upper arches. In the clinical and radiological examination of the 21-years old girl, dental and skeletal class I relationship, moderately increased lower face height, normally inclined upper and lower incisors with an open bite malocclusion, inadequate incisor display while smiling was observed (Fig. 5). Non-extraction with an 0.018 Alpern bracket system and anterior box elastics to close the bite was the treatment plan. After the leveling and aligning phase of treatment, anterior box elastics were used for 3 months and the correct incisal overlap established. The same problem as the previous patient occurred when the use of box elastics ceased; the bite reopened. Box elastics were re-applied and when the overbite was reestablished the patient asked for her treatment to be finished. Since she was marrying, she didn’t want braces after her wedding. Again the patient was warned about the risk of relapse, and a modified Essix retainer with spurs was fabricated (Fig. 6). The total treatment time was 16 months. The patient was instructed to wear the retainer as mentioned in the first case. When the patient was reevaluated 2 years after treatment, cephalometric superimposition revealed that the occlusion was stable (Figg. 7 and 8).
Fig. 8 – Superimposition of the post-treatment (regular line) and the 2 years post-retention (dashed line) cephalometrics.
3. Fabrication of the spur-implanted Essix Retainers Following debonding and polishing procedures, upper and lower impressions were taken. Before the fabrication of Essix plate on the upper cast, a small amount of dental stone was added near the incisive papilla region in order to create space for insertion and securing of the wire. C type Essix plates (0.40 ) were fabricated over the casts and trimmed. A 0.9 mm stainless steel laboratory wire is bent in “U” shape with a small helix at the base for retention. The wire is heated and inserted to the space created on the lingual side of incisors. The hot wire easily punctures, and when cooled, sticks to the Essix plate. A small amount of self-curing acrylic is applied to fill the rest of the space in order to keep the wire firmly in place. The spurs are sharpened and polished accordingly after the curing of the acrylic (Fig. 9).
4.
Discussion
Whatever the treatment modality is, stability and retention are the main concern for any open bite patients. The studies of Justus3 and Huang et al.7 suggest that when the function or the posture of the tongue is addressed with the help of intraoral spurs and cribs, improved long-term stability can be achieved in both growing and non-growing patients. Open bite retention, especially in patients with higher relapse tendency, can be carried out by active retention, which includes use of high pull headgear to upper molars during retention, an appliance with bite blocks between posterior teeth (an open bite activator or bionator), a tooth positioner,14 or a crib integrated Hawley.15 Bonded retainers extended through posterior teeth, can also be used. A headgear during retention might be difficult for the patient to tolerate, longer bonded retainers are both hard to place and maintain and unfortunately not so much effective for controlling vertical relapse. A positioner can maintain the overbite even improve it through mild force applied to the posterior segments. But positioners require considerable amount of laboratory fabrication time, and therefore very expensive.14 Moreover, because of their bulk, patients often have difficulty wearing a positioner and also, positioners do not retain incisor irregularities and rotations as well as standard retainers.14 Essix retention appliances are widely used since their introduction in 1993.16 The researches suggest that the Essix appliances are as effective retention appliances as Hawleys and bonded retainers.15,17 Over the time Essix appliances not only used as retainers but also reported to be useful for many other applications.15 The new modified appliance has primarily two feature targeted especially for maintaining the over bite: (1) the slight thickness of the appliance over the posterior teeth creates a bite block effect and (2) the implanted spurs act as a tongue posture moderator. Justus3 stated that if the patient did not
progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
51
Fig. 9 – Fabrication of spur-implanted Essix retainer. a) Upper cast. b) Bump on the lingual side of incisors. c) U shaped wire. d) Essix plate for the upper cast. e) Insertion of the wire. f) Addition of self-curing acrylic. g) Retainer after polishing.
have spurs during treatment, a spur incorporated retention appliance might not be successful because he argues that the spurs works only if they are worn full time and its not likely for a removable retainer to be worn full time. With a well informed patient about the risks of relapse, the higher esthetic acceptability and comfort of an Essix appliance might be the answer for those concerns about cooperation. The duration of the spur treatment is another concern. Haryet et al.,18 in a 3 years follow up study about thumb sucking, found 91% success rate when cemented spurs used for 10 months compared to 64% when the appliance used for only 3 months. Justus3 suggests the spurs to remain at least 6 months after a proper over bite relation is achieved. Both patients presented in our report instructed to wear their modified retainers full time for 12 months and only at nights for the following 12 months, which according to Justus more than enough. Ceasing the open bite mechanic during the end of treatment while the patient still have brackets is always a sensible approach to have an insight about the relapse tendency. Patients presented in the report had their open bites relapsed
when they cease using anterior box elastics. Both patients in the current report wanted to remove their appliances, due to personal reasons, before any overcorrection or any other means to keep bite stable is made, when they believe they have acceptable over bite, despite having history of considerable relapse and despite being strongly advised to continue treatment, and warned about the risks of relapse. A positioner for night time together with bonded lingual retainers was the first retention modality offered to the patients. Because they both refused to use the positioners for their bulk, new appliance was designed. The modified Essix retainer is very easy to fabricate and aesthetically very pleasant and acceptable for the patient. Although the appliance seems very uncomfortable, even torturous in the first instance, the patients were unlikely to report any complaints after the first few days. Almost certainly, after some point, the patient subconsciously places the tongue away from the sharp edges and does hardly feel any discomfort. It was well known that the classical retention appliances, methods and limitations were in keeping with the stable
52
progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
occlusion in open bite patients. As is the case with all case reports, two patients are by no means sufficient to confirm a sound scientific basis. But, especially the stability attained in these two patients who both had a high relapse tendency, at least gives us some insights about the possibilities with the new type of Essix retention appliance.
5.
Conclusions
The present findings provide evidence that modified Essix retainers with spurs are effective in maintaining the overbite after the openbite closure.
Conflict of interest The authors have reported no conflicts of interest.
Riassunto La malocclusione nella quale è più difficile operare una contenzione efficace è il morso aperto anteriore, nonostante siano disponibili numerosi apparecchi di ritenzione. La difficoltà di stabilizzare l’occlusione deriva dalla mancanza di controllo sul comportamento e sulla postura della lingua nei casi con morso aperto. Nel presente studio viene presentato un follow-up di 2 anni su due pazienti con morso aperto nei quali è stata fatta contenzione con un nuovo dispositivo di ritenzione.
Résumé Le type de malocclusion le plus difficile à avoir stable pendant la contention est l’openbite antérieure bien que beaucoup d’appareils classiques de contention soient connus. La difficulté de maintenir l’occlusion résulte de l’absence de contrôle du comportement et de la posture de la langue. Dans l’article courant, on present des controls à 2 ans de patients avec une retention nouvelle après traitement d’openbite.
Resumen El tipo de maloclusión más complicado de mantener, es la mordida abierta anterior aunque si se conocen muchos aparatos de retención clásica. La dificultad de mantener la oclusión es causada la falta de control sobre el comportamiento de la lengua y la postura en los casos de mordida abierta. En este articulo se presenta un nuevo retenedor, con buenos resultados.
references
1. Beane Jr RA. Nonsurgical management of the anterior open bite: A review of the options. Semin Orthod 1999;5:275–83. 2. Erverdi N, Keles A, Nanda R. The use of skeletal anchorage in open bite treatment: A cephalometric evaluation. Angle Orthod 2004;74:381–90. 3. Justus R. Correction of anterior openbite with spurs: Long term stability. World J Orthod 2001;2:219–31. 4. Subtelny JD, Sakura M. Open bite: Diagnosis and treatment. Am J Orthod 1964;50:37–58. 5. Epker BN, Fish LC. Surgical orthodontic correction of open bite deformity. Am J Orthod 1977;71:278–99. 6. Justus R. Treatment of anterior open bite: A cephalometric and clinical study. ADM 1976;33:17–40. 7. Huang G, Justus R, Kennedy DB, Kokich VG. Stability of anterior open bite treated with crib therapy. Angle Orthod 1990;60:17–24. 8. Rogers AP. Open bite cases involving tongue habits. Int J Orthod 1927;13:837. 9. Parker J. Interception of open bite in early growth period. Angle Orthod 1971;41:22–44. 10. Lopez-Gavito G, Wallen TR, Little RM, Joondeph DR. Anterior open-bite malocclusion: A longitudinal 10-year postretention evaluation of orthodontically treated patients. Am J Orthod 1985;871:175–86. 11. Denison TF, Kokich VG, Shapiro PA. Stability of maxillary surgery in openbite versus nonopenbite malocclusions. Angle Orthod 1989;591:5–10. 12. Haymond CS, Stoelinga PJ, Blijdorp PA. Surgical orthodontic treatment of anterior skeletal open bite using small plate internal fixation: One to five year follow-up. IntJ Oral Maxillofac Surg 1991;201:223–7. 13. Hoppenreijs TJ, Freihofer HP, Stoelinga PJ. Skeletal and dento-alveolar stability of Le Fort I intrusion osteotomies and bimaxillar osteotomies in anterior open bite deformities. A retrospective three-centre study. lnt J Oral Maxillofac Surg 1997;261:161–75. 14. Proffit WR, Fields WH. Contemporary orthodontics. 2nd ed Mosby Year Book; 1993. p. 530–43. 15. Graber TM, Vanarsdall RL, Vig KWL. Orthodontics: Current Principles and Techniques. 4th ed Elsevier inc; 2005. p. 980 and 1153-76. 16. Sheridan JJ, LeDeux W, McMinn R. Essix retainers: Fabrication and supervision for permanent retention. J Clin Orthod 1993;27:37–45. 17. Lindauer SJ, Schoff RC. Comparision of essix and hawley retainers. J Clin Orthod 1998;32:95–7. 18. Haryett RD, Hansen FC, Davidson PO. Chronic thumb-sucking. A second report on treatment and psychologic effects. Am J Orthod 1970;57:164–78.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/pio
Clinical contribution
A new type of modified Essix Retainer for anterior open bite retention Fakir Uzdil a , Mustafa Kayalioglu b,∗ , Egemen Kendi c , M. Serdar Toroglu d a
DDS, Research Assistant, Department of Orthodontics, Faculty of Dentistry, University of Cukurova, Adana, Turkey DDS, PhD, Lecturer and Clinical Instructor, Department of Orthodontics, Faculty of Dentistry, University of Cukurova, Adana, Turkey c DDS, PhD, Private Practice, Department of Orthodontics, Faculty of Dentistry, University of Cukurova, Adana, Turkey d DDS, PhD, Associate Professor, Department of Orthodontics, Faculty of Dentistry, University of Cukurova, Adana, Turkey b
a r t i c l e
i n f o
a b s t r a c t
Article history:
The most problematic malocclusion type to retain is anterior open bite although many clas-
Received 20 December 2007
sical retention appliances are known. The difficulty of maintaining the occlusion arises from
Accepted 20 November 2009
the lack of control over the tongue behavior and posture in open bite cases. In the current article, a 2 year follow-up of 2 open-bite patients who were retained with a new type of
Keywords: Open bite
retention appliance, successfully, were presented. © 2010 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.
Retention Essix
1.
Introduction
The anterior open bite malocclusion is considered one of the most challenging problems in orthodontics to treat and maintain successfully. Although a geat deal of attention has been devoted over the years to the correct diagnosis, successful treatment and long term retention of open bites, there is still controversy for the etiology, lack of agreement over the treatment protocols, and a high percentage of relapse. Many treatment modalities have been proposed for the treatment of anterior open bite malocclusions1 : high pull headgears for inhibiting maxillary growth, chin cups for limiting and redirecting mandibular growth, vertical elastics for extruding anterior segments, functional appliances, bite
∗
blocks, elastic modules, magnets, reverse curve arch wires or multi loop arch wires with vertical elastics, temporary anchorage devices for intruding posterior teeth,2 orthognathic surgery and finally cribs and spurs for moderating tongue behavior.3 Efficiency of open bite treatment through changing the rest posture of tongue, whether with a crib or a spur, is still a controversy. While Subtelny and Sakuda4 found no closure of open bite in eight patients treated for six months with crib therapy, Epker and Fish5 stated that the crib therapy is only effective in class I growing patients with good facial balance. Justus6 reported effective closure of the bite with crib therapy when worn for one year. Huang et al.7 also reported encouraging results and high percentage of stability with an average of 5 years post-treatment, even in non growing patients.
Corresponding author. Department of Orthodontics, Faculty of Dentistry, Cukurova University, Adana, 01330, Turkey. E-mail address: [email protected] (M. Kayalioglu). 1723-7785/$ – see front matter © 2010 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved. doi:10.1016/j.pio.2010.04.009
46
progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
Although not as widely used as tongue cribs, sharp spurs have been described in the orthodontic literature since 1927. First to mention spurs for open bite management through modifying tongue rest posture is Rogers8 in 1927. Parker9 demonstrated dramatic open bite closure using sharp spurs soldered to the central incisor bands. Justus3 presented successfully treated cases and good long term stability with sharp spurs. Justus3,6 argues that the neurophysiologic basis of the spur therapy, unlike the cribs that passively keeps the tongue in a certain position, is quite different, and is based on conditioned reflexes. The movement and the rest position of the tongue that has been elicited repetitively by successive stimuli of sharp spurs, may, after a period of time, be evoked without the need of conditioning stimuli to the tongue. Thus the tongue “learns” to stay in its place rather than being confined in it as is the case with a crib. Justus3 also believes that the pressure applied to the crib by the tongue, unlike the spurs, might cause molars to move forward and cause or increase a class II situation. The real success of any treatment is measured with long term stability. Lopez and Gavito10 reported that more than one
third of the patients treated with conventionally orthodontic appliances relapsed more than three millimeters. The studies of Dension et al.,11 Haymond et al.,12 and Hoppenreijis et al.13 unfortunately dismisses the belief that the surgical correction is the ultimate solution for open bites. Data from the study of Denison et al.11 suggested that the relapse caused mainly by dentoalveolar changes, not skeletal changes. That alone indicates the importance of maintaining dental correction with retention. Denison et al.11 also suggests that the differences in treatment response might be contributed to the musculature. The authors proposed that the tongue posture may have been the etiology of the open bite and that it might have been the reason why these patients had their open bites to relapse.11 Anyhow, open bite cases are still considered the most problematic to retain, and uncertainty of the bite to stay stable is still one of the chief problems clinicians face when finishing such case. In this article, we are presenting 2 year follow-up of 2 openbite patients who were retained successfully, with a modified, spur-implanted Essix retainer (Raintree Essix, Inc., 1071 S. Jeff Davis Parkway, New Orleans, LA 70125) after the conventional and non-surgical orthodontic treatment.
Fig. 1 – Intraoral and extraoral photographs of ‘Patient I’ before treatment. a) Right. b) Left. c) Facial photograph with smiling.
progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
Fig. 2 – Intraoral and extraoral photographs of ‘Patient I’ at the end of the treatment. a) Frontal. b) Right. c) Left. d) Frontal with spurs. e) Facial photograph with smiling.
Fig. 3 – Intraoral and extraoral photographs of ‘Patient I’ two years post-treatment. a) Frontal. b) Right. c) Left. d) Facial photograph with smiling.
47
48
progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
2.
Case history
2.1.
Patient I
P.B. was referred to our clinic due to inadequate incisor display while smiling and an anterior open bite malocclusion when she was 16 years old. Clinical and radiographic examination revealed that the patient had a dental and skeletal class I relationship, a moderately increased lower face height, normal upper and lower incisor inclinations, and an abnormal tongue posture (Fig. 1). The treatment plan was non-extraction, extrusion of anterior segments with straight wires on a 0.018 Roth bracket system and anterior box elastic wear. After establishing a class I molar and canine relationship with adequate bite and incisor display while smiling, anterior box elastic use ceased, but the bite re-opened after a month. The anterior box elastics were re-applied for another 2 months. When the correct dental and aesthetic relation established again, the patient asked for the treatment to be stopped despite the warnings about the stability of the treatment. The total treatment time was 18 months and for the retention, modified Essix retainers with spurs were fabricated and applied (Fig. 2). The patient was instructed to wear the retainer full-time for the first year except for eating and drinking and only at nights (sleeping hours) for the following 12 months. She was moving to another city and could not to travel for the routine reviews. When the patient was able to come for her recall appointment after 2 years post-treatment, lateral cephalometrics had been
Fig. 4 – Superimposition of the post-treatment (regular line) and the 2 years post-retention (dashed line) cephalometrics.
Fig. 5 – Intraoral and extraoral photographs of ‘Patient II’ before treatment. a) Frontal. b) Right. c) Left. d) Facial photograph with smiling.
progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
49
Fig. 6 – Intraoral and extraoral photographs of ‘Patient II’ at the end of the treatment. a) Frontal. b) Right. c) Left. d) Frontal with spurs. e) Facial photograph with smiling.
Fig. 7 – Intraoral and extraoral photographs of ‘Patient II’ two years post-treatment. a) Frontal. b) Right. c) Left. d) Facial photograph with smiling.
50
progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
obtained. Post treatment and two years follow up superimposition revealed no significant change in the dentoalveolar structures (Figg. 3 and 4).
2.2.
The author(s) declare that the work has been realized in agreement with the Helsinki Declaration principles and that the Informed Consent has been achieved from all the participants involved in the study.
Patient II
E.S. was referred to our clinic with the chief complaint of mild anterior crowding of the lower and upper arches. In the clinical and radiological examination of the 21-years old girl, dental and skeletal class I relationship, moderately increased lower face height, normally inclined upper and lower incisors with an open bite malocclusion, inadequate incisor display while smiling was observed (Fig. 5). Non-extraction with an 0.018 Alpern bracket system and anterior box elastics to close the bite was the treatment plan. After the leveling and aligning phase of treatment, anterior box elastics were used for 3 months and the correct incisal overlap established. The same problem as the previous patient occurred when the use of box elastics ceased; the bite reopened. Box elastics were re-applied and when the overbite was reestablished the patient asked for her treatment to be finished. Since she was marrying, she didn’t want braces after her wedding. Again the patient was warned about the risk of relapse, and a modified Essix retainer with spurs was fabricated (Fig. 6). The total treatment time was 16 months. The patient was instructed to wear the retainer as mentioned in the first case. When the patient was reevaluated 2 years after treatment, cephalometric superimposition revealed that the occlusion was stable (Figg. 7 and 8).
Fig. 8 – Superimposition of the post-treatment (regular line) and the 2 years post-retention (dashed line) cephalometrics.
3. Fabrication of the spur-implanted Essix Retainers Following debonding and polishing procedures, upper and lower impressions were taken. Before the fabrication of Essix plate on the upper cast, a small amount of dental stone was added near the incisive papilla region in order to create space for insertion and securing of the wire. C type Essix plates (0.40 ) were fabricated over the casts and trimmed. A 0.9 mm stainless steel laboratory wire is bent in “U” shape with a small helix at the base for retention. The wire is heated and inserted to the space created on the lingual side of incisors. The hot wire easily punctures, and when cooled, sticks to the Essix plate. A small amount of self-curing acrylic is applied to fill the rest of the space in order to keep the wire firmly in place. The spurs are sharpened and polished accordingly after the curing of the acrylic (Fig. 9).
4.
Discussion
Whatever the treatment modality is, stability and retention are the main concern for any open bite patients. The studies of Justus3 and Huang et al.7 suggest that when the function or the posture of the tongue is addressed with the help of intraoral spurs and cribs, improved long-term stability can be achieved in both growing and non-growing patients. Open bite retention, especially in patients with higher relapse tendency, can be carried out by active retention, which includes use of high pull headgear to upper molars during retention, an appliance with bite blocks between posterior teeth (an open bite activator or bionator), a tooth positioner,14 or a crib integrated Hawley.15 Bonded retainers extended through posterior teeth, can also be used. A headgear during retention might be difficult for the patient to tolerate, longer bonded retainers are both hard to place and maintain and unfortunately not so much effective for controlling vertical relapse. A positioner can maintain the overbite even improve it through mild force applied to the posterior segments. But positioners require considerable amount of laboratory fabrication time, and therefore very expensive.14 Moreover, because of their bulk, patients often have difficulty wearing a positioner and also, positioners do not retain incisor irregularities and rotations as well as standard retainers.14 Essix retention appliances are widely used since their introduction in 1993.16 The researches suggest that the Essix appliances are as effective retention appliances as Hawleys and bonded retainers.15,17 Over the time Essix appliances not only used as retainers but also reported to be useful for many other applications.15 The new modified appliance has primarily two feature targeted especially for maintaining the over bite: (1) the slight thickness of the appliance over the posterior teeth creates a bite block effect and (2) the implanted spurs act as a tongue posture moderator. Justus3 stated that if the patient did not
progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
51
Fig. 9 – Fabrication of spur-implanted Essix retainer. a) Upper cast. b) Bump on the lingual side of incisors. c) U shaped wire. d) Essix plate for the upper cast. e) Insertion of the wire. f) Addition of self-curing acrylic. g) Retainer after polishing.
have spurs during treatment, a spur incorporated retention appliance might not be successful because he argues that the spurs works only if they are worn full time and its not likely for a removable retainer to be worn full time. With a well informed patient about the risks of relapse, the higher esthetic acceptability and comfort of an Essix appliance might be the answer for those concerns about cooperation. The duration of the spur treatment is another concern. Haryet et al.,18 in a 3 years follow up study about thumb sucking, found 91% success rate when cemented spurs used for 10 months compared to 64% when the appliance used for only 3 months. Justus3 suggests the spurs to remain at least 6 months after a proper over bite relation is achieved. Both patients presented in our report instructed to wear their modified retainers full time for 12 months and only at nights for the following 12 months, which according to Justus more than enough. Ceasing the open bite mechanic during the end of treatment while the patient still have brackets is always a sensible approach to have an insight about the relapse tendency. Patients presented in the report had their open bites relapsed
when they cease using anterior box elastics. Both patients in the current report wanted to remove their appliances, due to personal reasons, before any overcorrection or any other means to keep bite stable is made, when they believe they have acceptable over bite, despite having history of considerable relapse and despite being strongly advised to continue treatment, and warned about the risks of relapse. A positioner for night time together with bonded lingual retainers was the first retention modality offered to the patients. Because they both refused to use the positioners for their bulk, new appliance was designed. The modified Essix retainer is very easy to fabricate and aesthetically very pleasant and acceptable for the patient. Although the appliance seems very uncomfortable, even torturous in the first instance, the patients were unlikely to report any complaints after the first few days. Almost certainly, after some point, the patient subconsciously places the tongue away from the sharp edges and does hardly feel any discomfort. It was well known that the classical retention appliances, methods and limitations were in keeping with the stable
52
progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
occlusion in open bite patients. As is the case with all case reports, two patients are by no means sufficient to confirm a sound scientific basis. But, especially the stability attained in these two patients who both had a high relapse tendency, at least gives us some insights about the possibilities with the new type of Essix retention appliance.
5.
Conclusions
The present findings provide evidence that modified Essix retainers with spurs are effective in maintaining the overbite after the openbite closure.
Conflict of interest The authors have reported no conflicts of interest.
Riassunto La malocclusione nella quale è più difficile operare una contenzione efficace è il morso aperto anteriore, nonostante siano disponibili numerosi apparecchi di ritenzione. La difficoltà di stabilizzare l’occlusione deriva dalla mancanza di controllo sul comportamento e sulla postura della lingua nei casi con morso aperto. Nel presente studio viene presentato un follow-up di 2 anni su due pazienti con morso aperto nei quali è stata fatta contenzione con un nuovo dispositivo di ritenzione.
Résumé Le type de malocclusion le plus difficile à avoir stable pendant la contention est l’openbite antérieure bien que beaucoup d’appareils classiques de contention soient connus. La difficulté de maintenir l’occlusion résulte de l’absence de contrôle du comportement et de la posture de la langue. Dans l’article courant, on present des controls à 2 ans de patients avec une retention nouvelle après traitement d’openbite.
Resumen El tipo de maloclusión más complicado de mantener, es la mordida abierta anterior aunque si se conocen muchos aparatos de retención clásica. La dificultad de mantener la oclusión es causada la falta de control sobre el comportamiento de la lengua y la postura en los casos de mordida abierta. En este articulo se presenta un nuevo retenedor, con buenos resultados.
references
1. Beane Jr RA. Nonsurgical management of the anterior open bite: A review of the options. Semin Orthod 1999;5:275–83. 2. Erverdi N, Keles A, Nanda R. The use of skeletal anchorage in open bite treatment: A cephalometric evaluation. Angle Orthod 2004;74:381–90. 3. Justus R. Correction of anterior openbite with spurs: Long term stability. World J Orthod 2001;2:219–31. 4. Subtelny JD, Sakura M. Open bite: Diagnosis and treatment. Am J Orthod 1964;50:37–58. 5. Epker BN, Fish LC. Surgical orthodontic correction of open bite deformity. Am J Orthod 1977;71:278–99. 6. Justus R. Treatment of anterior open bite: A cephalometric and clinical study. ADM 1976;33:17–40. 7. Huang G, Justus R, Kennedy DB, Kokich VG. Stability of anterior open bite treated with crib therapy. Angle Orthod 1990;60:17–24. 8. Rogers AP. Open bite cases involving tongue habits. Int J Orthod 1927;13:837. 9. Parker J. Interception of open bite in early growth period. Angle Orthod 1971;41:22–44. 10. Lopez-Gavito G, Wallen TR, Little RM, Joondeph DR. Anterior open-bite malocclusion: A longitudinal 10-year postretention evaluation of orthodontically treated patients. Am J Orthod 1985;871:175–86. 11. Denison TF, Kokich VG, Shapiro PA. Stability of maxillary surgery in openbite versus nonopenbite malocclusions. Angle Orthod 1989;591:5–10. 12. Haymond CS, Stoelinga PJ, Blijdorp PA. Surgical orthodontic treatment of anterior skeletal open bite using small plate internal fixation: One to five year follow-up. IntJ Oral Maxillofac Surg 1991;201:223–7. 13. Hoppenreijs TJ, Freihofer HP, Stoelinga PJ. Skeletal and dento-alveolar stability of Le Fort I intrusion osteotomies and bimaxillar osteotomies in anterior open bite deformities. A retrospective three-centre study. lnt J Oral Maxillofac Surg 1997;261:161–75. 14. Proffit WR, Fields WH. Contemporary orthodontics. 2nd ed Mosby Year Book; 1993. p. 530–43. 15. Graber TM, Vanarsdall RL, Vig KWL. Orthodontics: Current Principles and Techniques. 4th ed Elsevier inc; 2005. p. 980 and 1153-76. 16. Sheridan JJ, LeDeux W, McMinn R. Essix retainers: Fabrication and supervision for permanent retention. J Clin Orthod 1993;27:37–45. 17. Lindauer SJ, Schoff RC. Comparision of essix and hawley retainers. J Clin Orthod 1998;32:95–7. 18. Haryett RD, Hansen FC, Davidson PO. Chronic thumb-sucking. A second report on treatment and psychologic effects. Am J Orthod 1970;57:164–78.