- Email: [email protected]
Correction of deep overbite
172
J. Cranio-Max.-Fac. Surg. 17 (1989)
J. Cranio-Max.-Fac. Surg. 17 (1989) 172-174 © Georg Thieme Verlag Stuttgart • New York
Correction of Deep Overbite A Modified Splint Permitting Rapid Extrusion of Posterior Teeth Dirk B. Tuinzing, Rokus Greebe, Johannes Dorenbos Dept. of Oral and Maxillofacial Surgery (Head: Prof. W.A.M. van der Kwast, D.D.S., PhD.), Free University Hospital, Amsterdam, The Netherlands
Submitted 3.3.88; accepted 16.8.88
Summary The use o f a modified splint in the surgical-orthodontic treatment of Class II deep overbite deformities is presented. The splint permits a reduction of the preoperative orthodontic treatment-time because hardly any (time consuming) levelling of the dental arch is indicated while the time of postoperative orthodontic treatment is shortened, because of the possibility of continuing orthodontic treatment during the intermaxillory fixation period. The clockwise rotational movement which occurs with this treatment modality has, additionally, a favourable effect on the anterior facial height and in many cases on the position of the chin. Finally the intake of food during the immobilization period is facilitated.
Introduction
Key words
Acrylic splints are used extensively in orthognathic surgery to obtain a stable occlusion during the intermaxillary fixation period or for orientation of a mobilized jaw during bimaxillary surgery. However, when a splint covering the whole occlusal surface of the dentition is used, during the intermaxillary fixation period the orthodontic part of the treatment comes to a standstill: "Setting" of the occlusion is impeded, the effect of orthodontic forces is blocked and moreover the intake of food might be difficult (Stoelinga and Leenen, 1981; Zetz et al., 1984). In the past it was felt that a good interdigitated occlusion postoperatively was important in achieving stable occlusal results (Balan, 1976; Bauman and Moser, I977) which in some instances made extensive surgery necessary (Fig. 1). Before forward movement of the whole mandible could take place, the deep overbite had to be corrected by orthodontic means, which is time-consuming and not easy to achieve, or by segmental osteotomies, a technique not very advantageous to the often already traumatized periodontium. Because of the direction of the forward movement of the mandible in some cases the position of a prominent chin became even more unfavourable, which made a reduction of the chin, with its unpredictable results, necessary. Having more knowledge concerning some trends in skeletal relapse after mandibular advancement procedures (Greebe and Tuinzing, 1984; Van Sickels et al., 1986; Greebe, 1987), the interdigitation appears not to be essential w h e n the mandible is surgically advanced in a clockwise rotational movement. This allows the use of a modified splint to facilitate the surgical orthodontic treatment to a considerable extent.
Surgical orthodontics - Technical note - Splint design
which not only appears to be favourable to the skeletal stability, as mentioned before; in many cases it also affects the position of the chin in a favourable way. The splint is placed and intermaxillary fixation with 0.5 mm ligatures and skeletal fixation through the nasal spine and mandibular symphysis are applied. The open bite in the bicuspid-molar region (up to 4-5 ram) is gradually closed by extrusion of the teeth. In most instances this occurs during the five weeks intermaxillary fixation period (Fig. 3). Relatively light wire in the orthodontic appliance of the dental arch which needs extrusion makes this closure possible. If at the time of removal of the intermaxillary fixation the closure is not complete, the remaining open bite is closed by light elastic bands. In this way, treatment of the occlusion as well as the profile are improved by a sagittal split osteotomy alone. The construction of the splint is rather simple. After placing the cast models in an articulator in the decided interocclusal relationship, 1.0 mm orthodontic wire is bent, running from the interdental space between the first and second upper molar just on the incisal cingulum; acrylic is placed in such a way that the incisal edges of the incisors just make an impression in the splint. In the same way, acrylic is placed on the second upper molars allowing the antagonist to leave a slight impression (Fig. 4).
Conclusions The Modified Splint Cases of class II deep overbite, the malocclusion may be treated in the following fashion utilizing the modified splint: The upper and lower dental arches are aligned orthodontically, while reduction of the deep overbite is ignored. Then, after a sagittal split osteotomy, the mandible is placed in a forward position. Because of the reduction of the deep overbite a clockwise rotational movement occurs,
In the literature, similar techniques of extrusion of posterior teeth in deep overbite cases are mentioned. When full splints are utilized, after the immobilization period extrusion takes place by selective grinding of the splint, and elastic bands. With the modified splint presented, not only is the postoperative orthodontic treatment period reduced, because extrusion of the posterior teeth takes place during the intermaxillary fixation period, but also the preoperative treat-
Correction of Deep Bite
J. Cranio-Max.-Fac. Surg. i7 (1989)
173
Fig. 1 a In the past it was felt that to obtain stable results after the surgical-orthodontic correction of Class II deep overbite deformities, a good interdigitated occlusion was important. Fig.1 b To achieve this good interdigitation, orthodontic or surgical intrusion of the lower incisors was required. The forward movement of the mandible after a sagittal split osteotomy resulted in some cases in such a prominent chin, that a chin reduction was indicated as well.
Fig.1 a
Fig.1 b
F i g . 2 a In a class II deep overbite case, the upper and lower dental arches are aligned orthodontically while hardly any levelling of the dental arches is aimed for.
I/
Fig. 2 a
-X ""-k .~ ~(~1~a_M /
Fig.2 b After a sagittal split osteotomy the modified splint is placed. A clockwise rotational movement has a favourable effect on the anterior facial height and in many cases on the position of the chin.
Fig. 2 b
Fig.2c The facial appearance is changed in a positive way in addition.
17 4
D.B. Tuinzing et al.: Correction of Deep Bite
J. Cranio-Max.-Fac. Surg. 17 (1989)
Fig.3 The modified splint in place, Extrusion of the posterior teeth during the five weeks intermaxillary fixation period is possible.
facial appearance and the facilitation of food-intake during the intermaxillary fixation period makes the use of this modified splint, in many deep overbite cases, advisable.
References
Fig.4 After placing the cast models in an articulator, orthodontic wire is bent to run from the upper molar area along the cingulum of the incisors. Acrylic is placed in such a way that impressions of the lower dentition in the acrylic occur,
ment-time is shortened, while hardly any (time consuming) reduction of the deep overbite is required. Thus, together with the limitation of the surgical procedure to a sagittal split only, the favourable effect on the
Balan E.H.: Erfahrungen mit der pr~operativen prothetischen Versorgung zur Rezidiwerhiitung bei Progenie-operierten. Fortschr. Kiefer-Gesichtschir. 21 (1976) 69 Bauman, T., F. Moser: Neue Wege in der Vor- und Nachbehandlung bei Horizontalverschiebung des Unterkiefers mit sagittaler Osteotomie. Dtsch. Z. Mund-Kiefer-Gesichtschir. 1 (1977) 93 Greebe, R.B., D.B. Tuinzing: Mandibular advancement procedures; predictable stability and relapse. Oral Surg. 57 (1984) 13 Greebe, R.B.: Stabiliteit en recidief na chirurgische verplaatsing van de onderkaak. Thesis, Vrije Universiteit, Amsterdam 1987 Van Sickels, J. E., A. Larsen, W. J. Thrash: Relapse after rigid fixation of mandibular advancement. J. Oral. Max. Fac. Surg. 44 (1986) 698 Stoelinga, P.J.W., R.J. Leenen: The surgical orthodontic approach to Angle ClassII div. 2 anomalies. J. Oral. Surg. 39 (1981) 855 Zetz, M.R., C.D. Dean, A.G. Burris, A.R. Griffi'th: Correction of Skeletal Class II malocclusions with deep bite by rapid extrusion of posterior teeth. Oral Surg. 57 (1984) 631
D. B. Tuinzing, D.M,D. Department of Oral and Maxillo-Facial Surgery Free University Hospital Amsterdam The Netherlands
J. Cranio-Max.-Fac. Surg. 17 (1989)
J. Cranio-Max.-Fac. Surg. 17 (1989) 172-174 © Georg Thieme Verlag Stuttgart • New York
Correction of Deep Overbite A Modified Splint Permitting Rapid Extrusion of Posterior Teeth Dirk B. Tuinzing, Rokus Greebe, Johannes Dorenbos Dept. of Oral and Maxillofacial Surgery (Head: Prof. W.A.M. van der Kwast, D.D.S., PhD.), Free University Hospital, Amsterdam, The Netherlands
Submitted 3.3.88; accepted 16.8.88
Summary The use o f a modified splint in the surgical-orthodontic treatment of Class II deep overbite deformities is presented. The splint permits a reduction of the preoperative orthodontic treatment-time because hardly any (time consuming) levelling of the dental arch is indicated while the time of postoperative orthodontic treatment is shortened, because of the possibility of continuing orthodontic treatment during the intermaxillory fixation period. The clockwise rotational movement which occurs with this treatment modality has, additionally, a favourable effect on the anterior facial height and in many cases on the position of the chin. Finally the intake of food during the immobilization period is facilitated.
Introduction
Key words
Acrylic splints are used extensively in orthognathic surgery to obtain a stable occlusion during the intermaxillary fixation period or for orientation of a mobilized jaw during bimaxillary surgery. However, when a splint covering the whole occlusal surface of the dentition is used, during the intermaxillary fixation period the orthodontic part of the treatment comes to a standstill: "Setting" of the occlusion is impeded, the effect of orthodontic forces is blocked and moreover the intake of food might be difficult (Stoelinga and Leenen, 1981; Zetz et al., 1984). In the past it was felt that a good interdigitated occlusion postoperatively was important in achieving stable occlusal results (Balan, 1976; Bauman and Moser, I977) which in some instances made extensive surgery necessary (Fig. 1). Before forward movement of the whole mandible could take place, the deep overbite had to be corrected by orthodontic means, which is time-consuming and not easy to achieve, or by segmental osteotomies, a technique not very advantageous to the often already traumatized periodontium. Because of the direction of the forward movement of the mandible in some cases the position of a prominent chin became even more unfavourable, which made a reduction of the chin, with its unpredictable results, necessary. Having more knowledge concerning some trends in skeletal relapse after mandibular advancement procedures (Greebe and Tuinzing, 1984; Van Sickels et al., 1986; Greebe, 1987), the interdigitation appears not to be essential w h e n the mandible is surgically advanced in a clockwise rotational movement. This allows the use of a modified splint to facilitate the surgical orthodontic treatment to a considerable extent.
Surgical orthodontics - Technical note - Splint design
which not only appears to be favourable to the skeletal stability, as mentioned before; in many cases it also affects the position of the chin in a favourable way. The splint is placed and intermaxillary fixation with 0.5 mm ligatures and skeletal fixation through the nasal spine and mandibular symphysis are applied. The open bite in the bicuspid-molar region (up to 4-5 ram) is gradually closed by extrusion of the teeth. In most instances this occurs during the five weeks intermaxillary fixation period (Fig. 3). Relatively light wire in the orthodontic appliance of the dental arch which needs extrusion makes this closure possible. If at the time of removal of the intermaxillary fixation the closure is not complete, the remaining open bite is closed by light elastic bands. In this way, treatment of the occlusion as well as the profile are improved by a sagittal split osteotomy alone. The construction of the splint is rather simple. After placing the cast models in an articulator in the decided interocclusal relationship, 1.0 mm orthodontic wire is bent, running from the interdental space between the first and second upper molar just on the incisal cingulum; acrylic is placed in such a way that the incisal edges of the incisors just make an impression in the splint. In the same way, acrylic is placed on the second upper molars allowing the antagonist to leave a slight impression (Fig. 4).
Conclusions The Modified Splint Cases of class II deep overbite, the malocclusion may be treated in the following fashion utilizing the modified splint: The upper and lower dental arches are aligned orthodontically, while reduction of the deep overbite is ignored. Then, after a sagittal split osteotomy, the mandible is placed in a forward position. Because of the reduction of the deep overbite a clockwise rotational movement occurs,
In the literature, similar techniques of extrusion of posterior teeth in deep overbite cases are mentioned. When full splints are utilized, after the immobilization period extrusion takes place by selective grinding of the splint, and elastic bands. With the modified splint presented, not only is the postoperative orthodontic treatment period reduced, because extrusion of the posterior teeth takes place during the intermaxillary fixation period, but also the preoperative treat-
Correction of Deep Bite
J. Cranio-Max.-Fac. Surg. i7 (1989)
173
Fig. 1 a In the past it was felt that to obtain stable results after the surgical-orthodontic correction of Class II deep overbite deformities, a good interdigitated occlusion was important. Fig.1 b To achieve this good interdigitation, orthodontic or surgical intrusion of the lower incisors was required. The forward movement of the mandible after a sagittal split osteotomy resulted in some cases in such a prominent chin, that a chin reduction was indicated as well.
Fig.1 a
Fig.1 b
F i g . 2 a In a class II deep overbite case, the upper and lower dental arches are aligned orthodontically while hardly any levelling of the dental arches is aimed for.
I/
Fig. 2 a
-X ""-k .~ ~(~1~a_M /
Fig.2 b After a sagittal split osteotomy the modified splint is placed. A clockwise rotational movement has a favourable effect on the anterior facial height and in many cases on the position of the chin.
Fig. 2 b
Fig.2c The facial appearance is changed in a positive way in addition.
17 4
D.B. Tuinzing et al.: Correction of Deep Bite
J. Cranio-Max.-Fac. Surg. 17 (1989)
Fig.3 The modified splint in place, Extrusion of the posterior teeth during the five weeks intermaxillary fixation period is possible.
facial appearance and the facilitation of food-intake during the intermaxillary fixation period makes the use of this modified splint, in many deep overbite cases, advisable.
References
Fig.4 After placing the cast models in an articulator, orthodontic wire is bent to run from the upper molar area along the cingulum of the incisors. Acrylic is placed in such a way that impressions of the lower dentition in the acrylic occur,
ment-time is shortened, while hardly any (time consuming) reduction of the deep overbite is required. Thus, together with the limitation of the surgical procedure to a sagittal split only, the favourable effect on the
Balan E.H.: Erfahrungen mit der pr~operativen prothetischen Versorgung zur Rezidiwerhiitung bei Progenie-operierten. Fortschr. Kiefer-Gesichtschir. 21 (1976) 69 Bauman, T., F. Moser: Neue Wege in der Vor- und Nachbehandlung bei Horizontalverschiebung des Unterkiefers mit sagittaler Osteotomie. Dtsch. Z. Mund-Kiefer-Gesichtschir. 1 (1977) 93 Greebe, R.B., D.B. Tuinzing: Mandibular advancement procedures; predictable stability and relapse. Oral Surg. 57 (1984) 13 Greebe, R.B.: Stabiliteit en recidief na chirurgische verplaatsing van de onderkaak. Thesis, Vrije Universiteit, Amsterdam 1987 Van Sickels, J. E., A. Larsen, W. J. Thrash: Relapse after rigid fixation of mandibular advancement. J. Oral. Max. Fac. Surg. 44 (1986) 698 Stoelinga, P.J.W., R.J. Leenen: The surgical orthodontic approach to Angle ClassII div. 2 anomalies. J. Oral. Surg. 39 (1981) 855 Zetz, M.R., C.D. Dean, A.G. Burris, A.R. Griffi'th: Correction of Skeletal Class II malocclusions with deep bite by rapid extrusion of posterior teeth. Oral Surg. 57 (1984) 631
D. B. Tuinzing, D.M,D. Department of Oral and Maxillo-Facial Surgery Free University Hospital Amsterdam The Netherlands