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Dual functional bite
DUAL
FUNCTIONAL
BITE
A CASF, REPORT JULES B. SELDIN, D.D.S., NEW YORK, N. I’.
T
HE patient, a boy 14 years of age, was of normal stature but his appearance suggested an early arrestment (Figs. 1 and 2). This was due to a dull depressed look to be found in his face, occasioned by a marked underdevelopment of the maxilla and a constantly drooping lower jaw. Clinical examination showed that the patient could find no normal position of rest in articulation (Fig. 3). The mandible would swing from side to side until it found one of the two positions that would permit him to achieve mastication but not comfort. In either position there was occlusion on only one side; the mandibular teeth of the other side were entirely lingual in their relation to the nmxilla. The upper jaw was wider than normal in the molar and premolar region, whereas t,hr lower jaw in the same region was slightly collapsed: In occlusion the chin was deflected to one side or the other, dependent upon the choice of the patient to close to either side. Because of the type of the malocclusion there was a cross-bite, with the attendant constant trauma of the crossing anterior teeth. It was a mouth that was in urgent need of orthodontic interference for fumtional, as well as est’hetic, reasons. The patient came of a normal middle-class family whose history showed nothing to indicate that t,here might have been any hereditary or prenatal inThe child was delivered with instrufluence upon this case of malocclusion. ments but there was no indication of injury at birth or at any time thereafter. During his childhood he had suffered none of t,he familiar children diseases which occasionally interfere wit,21 normal development, and had been bothered only by allergies of rose fever and hay fever with a mild sinusitis. His tonsils and adenoids were removed at the age of 4 years. He remained a mouth breather, however, until the orthodontic treatment had been completed. Treatment was ,instituted in January, 1942, in the Orthodontic Clinic of the Hospital for Joint Diseases. Radiographs, photographs, and casts of both jaws were taken. A profile head radiograph was taken and this showed a well-formed skull and apparently normal jaw relationships when at rest (Fig. 4). Unfortunately a registration of the condylar positions were not recorded. The radiographic examination of the teeth showed them to be normal with a few well-constructed fillings. Since there were no temperomandibular pictures available, the case was approached from a purely clinical aspect. From the Presented
Orthodontic before the
Service, Hospital New York Society
for Joint Diseases, New York, N. Y. of Orthodontists. Nov. 14. 1944.
318
Fig.
1.
Fig.
2.
Fig.
3.
320
JULES
B.
SELDIN
It was necessary from the beginning to ascertain which of the two bites that the patient was able to assume was nearer to the normal clinically, so that it was efficient, comfortable, and in accordance with the facial harmony and cranial anatomy. We then had to determine if that bite could be utilized as a basis for the course of treatment we had contemplated. Careful examination of the patient during mastication and in both centric positions indicated that the position of the mandible when it was directed to the left appeared to be the most satisfactory and this recommended its choice. There was less chin deflection and a slightly better median line relationship.
Fig.
4.
Having accepted this as a basis for operation, an upper vulcanite bite plate was constructed (Fig. 5). It was built so as to disengage the anterior teeth and thus eliminate the trauma that resulted from the cross-bite. There were added to the anterior retaining wire two buccal arms about 2 cm. in length directed posteriorly, which were carried back behind the second molars and imbedded in the vulcanite. To the buccal arm on the right side there had been attached two T bars so that force could be applied to the premolars that would drive them
DUSI,
FUNCTIONAL
BITE
321
lingually unt,il they engaged t,he lower antagonizing teeth. As the maxillary premolars were moved lingually, t,he hitc plate was festooned on its lingual contacting perimeter to allow for further movement as the teeth engaged the outlines of the bite plate. The molars involved were assisted in realizing correct buccolingual relations by the application of cross elastics.
Fix.
5.
D. Fig.
6
In the mandible, lingual appliance was inserted at the same t.ime from the first molar on one side to the first molar on the other, and, by means of auxiliary springs of 0.020 gauge, pressure was applied to the teeth on the right side. These were moved buccally simultaneously to meet the uppers which were being moved lingually.
322
JULES
B.
SELDIN
Within a year and with a minimum of discomfort for the patient, the teeth had been brought to such a normal functional relation that there was occlusion on both sides. Having ascertained that the patient could tolerate the changes and that the shifting bite had been eliminated, the treatment was changed to the use of a modified edgewise appliance. All the t.eeth were measured and charted. From these measurements there was constructed a predetermined arch form. All the teeth were then banded with 0.003 by 0.125 inch bands to which had been soldered a modified edgewise bracket and staples for rotations, if necessary. The molars were banded with 0.006 by 0.180 inch band material and to
Big.
7.
Fig.
8.
these molar bands were attached buecal tubes t.o receive a 0.022 by 0.028 inch wire. Regulating arch wires formed from the predetermined arch form were ligated to the teeth. The case was started with a 0.014 inch stainless steel wire, and then as the case progressed, the succeeding 0.016 and 0.018 inch wires were used, until finally a 0.022 by 0.028 inch precious metal arch was used to finish the case. During this time the patient was seen every four weeks, when the old arches were removed and new arches employed.
Fig.
9.
Fig.
10.
324
JULES
B.
SELDIN
After t ion and the Patient perfectly comfortable and happy. 6 shows casts of the completed case. After removing the appliances, the teeth appeared so well interdigitated that it was decided to eliminate the use of retainers. Stability of the dentures bore out the confidence of this, for, aside from a slight settling, tile teeth have been self-retaining. Esthetically the result is pleasant, and although there is a slight deflection of the chin to the left side, it is not objectionable (Fig. 7). The profile shows a marked development of the maxilla and a better facial contour (Fig. 8). There is an added alertness in his appearance and a complete loss of t,he instability of of the mandible and the look that attends a patient suffering with enlarged adenoids. It is quite evident that it would have been almost impossible to in’troduce treatment in this case had we attempted to select an intermediate position of the mandible as the basis from which to start. It is also interesting to note that practically all the movements in this case were accomplished by the use of intramaxillary force. Posttreatment roentgenograms of the temperomandibular joints, as shown in Figs. 9 and 10,” revealed an interesting relation that was different in both joints. The left side exhibited a position mildly posterior and superior to the normal, while the right side showed an inferior ‘and backward relation. While the lack of earlier registrations affords no means of comparison, it is interesting to note the accommodation the condyles have taken in response to the drivSince the force exercised was essentially ing force of occlusal cusp guidance. one of intramaxillary origin, it is significant that similar changes occur in our daily treatments of even far greater:d&$e. than these registered, because of the employment of intermaxillary elasticsin’different typ’es ?f therapy. Just what will happen to these joints in the future will be an interesting feature to watch. Where the readjustment will take place, and lo whet extent, will be pertinent and important considerations in future treatments. S WEST 40~1% STREET
*The
mandibular
Hospital
joints.
is
indebtecl~mtd
Dr.
Sidney
Riemer
for
the radiographs
of- tllr: tkmporo-
FUNCTIONAL
BITE
A CASF, REPORT JULES B. SELDIN, D.D.S., NEW YORK, N. I’.
T
HE patient, a boy 14 years of age, was of normal stature but his appearance suggested an early arrestment (Figs. 1 and 2). This was due to a dull depressed look to be found in his face, occasioned by a marked underdevelopment of the maxilla and a constantly drooping lower jaw. Clinical examination showed that the patient could find no normal position of rest in articulation (Fig. 3). The mandible would swing from side to side until it found one of the two positions that would permit him to achieve mastication but not comfort. In either position there was occlusion on only one side; the mandibular teeth of the other side were entirely lingual in their relation to the nmxilla. The upper jaw was wider than normal in the molar and premolar region, whereas t,hr lower jaw in the same region was slightly collapsed: In occlusion the chin was deflected to one side or the other, dependent upon the choice of the patient to close to either side. Because of the type of the malocclusion there was a cross-bite, with the attendant constant trauma of the crossing anterior teeth. It was a mouth that was in urgent need of orthodontic interference for fumtional, as well as est’hetic, reasons. The patient came of a normal middle-class family whose history showed nothing to indicate that t,here might have been any hereditary or prenatal inThe child was delivered with instrufluence upon this case of malocclusion. ments but there was no indication of injury at birth or at any time thereafter. During his childhood he had suffered none of t,he familiar children diseases which occasionally interfere wit,21 normal development, and had been bothered only by allergies of rose fever and hay fever with a mild sinusitis. His tonsils and adenoids were removed at the age of 4 years. He remained a mouth breather, however, until the orthodontic treatment had been completed. Treatment was ,instituted in January, 1942, in the Orthodontic Clinic of the Hospital for Joint Diseases. Radiographs, photographs, and casts of both jaws were taken. A profile head radiograph was taken and this showed a well-formed skull and apparently normal jaw relationships when at rest (Fig. 4). Unfortunately a registration of the condylar positions were not recorded. The radiographic examination of the teeth showed them to be normal with a few well-constructed fillings. Since there were no temperomandibular pictures available, the case was approached from a purely clinical aspect. From the Presented
Orthodontic before the
Service, Hospital New York Society
for Joint Diseases, New York, N. Y. of Orthodontists. Nov. 14. 1944.
318
Fig.
1.
Fig.
2.
Fig.
3.
320
JULES
B.
SELDIN
It was necessary from the beginning to ascertain which of the two bites that the patient was able to assume was nearer to the normal clinically, so that it was efficient, comfortable, and in accordance with the facial harmony and cranial anatomy. We then had to determine if that bite could be utilized as a basis for the course of treatment we had contemplated. Careful examination of the patient during mastication and in both centric positions indicated that the position of the mandible when it was directed to the left appeared to be the most satisfactory and this recommended its choice. There was less chin deflection and a slightly better median line relationship.
Fig.
4.
Having accepted this as a basis for operation, an upper vulcanite bite plate was constructed (Fig. 5). It was built so as to disengage the anterior teeth and thus eliminate the trauma that resulted from the cross-bite. There were added to the anterior retaining wire two buccal arms about 2 cm. in length directed posteriorly, which were carried back behind the second molars and imbedded in the vulcanite. To the buccal arm on the right side there had been attached two T bars so that force could be applied to the premolars that would drive them
DUSI,
FUNCTIONAL
BITE
321
lingually unt,il they engaged t,he lower antagonizing teeth. As the maxillary premolars were moved lingually, t,he hitc plate was festooned on its lingual contacting perimeter to allow for further movement as the teeth engaged the outlines of the bite plate. The molars involved were assisted in realizing correct buccolingual relations by the application of cross elastics.
Fix.
5.
D. Fig.
6
In the mandible, lingual appliance was inserted at the same t.ime from the first molar on one side to the first molar on the other, and, by means of auxiliary springs of 0.020 gauge, pressure was applied to the teeth on the right side. These were moved buccally simultaneously to meet the uppers which were being moved lingually.
322
JULES
B.
SELDIN
Within a year and with a minimum of discomfort for the patient, the teeth had been brought to such a normal functional relation that there was occlusion on both sides. Having ascertained that the patient could tolerate the changes and that the shifting bite had been eliminated, the treatment was changed to the use of a modified edgewise appliance. All the t.eeth were measured and charted. From these measurements there was constructed a predetermined arch form. All the teeth were then banded with 0.003 by 0.125 inch bands to which had been soldered a modified edgewise bracket and staples for rotations, if necessary. The molars were banded with 0.006 by 0.180 inch band material and to
Big.
7.
Fig.
8.
these molar bands were attached buecal tubes t.o receive a 0.022 by 0.028 inch wire. Regulating arch wires formed from the predetermined arch form were ligated to the teeth. The case was started with a 0.014 inch stainless steel wire, and then as the case progressed, the succeeding 0.016 and 0.018 inch wires were used, until finally a 0.022 by 0.028 inch precious metal arch was used to finish the case. During this time the patient was seen every four weeks, when the old arches were removed and new arches employed.
Fig.
9.
Fig.
10.
324
JULES
B.
SELDIN
After t ion and the Patient perfectly comfortable and happy. 6 shows casts of the completed case. After removing the appliances, the teeth appeared so well interdigitated that it was decided to eliminate the use of retainers. Stability of the dentures bore out the confidence of this, for, aside from a slight settling, tile teeth have been self-retaining. Esthetically the result is pleasant, and although there is a slight deflection of the chin to the left side, it is not objectionable (Fig. 7). The profile shows a marked development of the maxilla and a better facial contour (Fig. 8). There is an added alertness in his appearance and a complete loss of t,he instability of of the mandible and the look that attends a patient suffering with enlarged adenoids. It is quite evident that it would have been almost impossible to in’troduce treatment in this case had we attempted to select an intermediate position of the mandible as the basis from which to start. It is also interesting to note that practically all the movements in this case were accomplished by the use of intramaxillary force. Posttreatment roentgenograms of the temperomandibular joints, as shown in Figs. 9 and 10,” revealed an interesting relation that was different in both joints. The left side exhibited a position mildly posterior and superior to the normal, while the right side showed an inferior ‘and backward relation. While the lack of earlier registrations affords no means of comparison, it is interesting to note the accommodation the condyles have taken in response to the drivSince the force exercised was essentially ing force of occlusal cusp guidance. one of intramaxillary origin, it is significant that similar changes occur in our daily treatments of even far greater:d&$e. than these registered, because of the employment of intermaxillary elasticsin’different typ’es ?f therapy. Just what will happen to these joints in the future will be an interesting feature to watch. Where the readjustment will take place, and lo whet extent, will be pertinent and important considerations in future treatments. S WEST 40~1% STREET
*The
mandibular
Hospital
joints.
is
indebtecl~mtd
Dr.
Sidney
Riemer
for
the radiographs
of- tllr: tkmporo-