Julia Harfin

Somchai Satravaha
Bernd G. Lapatki
Editors

Clinical Cases in
Early Orthodontic
Treatment
An Atlas of When, How and Why to Treat
Second Edition

123
Clinical Cases in Early Orthodontic Treatment
Julia Harfin • Somchai Satravaha
Bernd G. Lapatki
Editors

Clinical Cases in Early

Orthodontic Treatment
An Atlas of When, How and Why to Treat

Second Edition
Editors
Julia Harfin Somchai Satravaha
Department of Orthodontics Department of Orthodontics, Faculty of Dentistry
Maimonides University Mahidol University
Buenos Aires, Argentina Bangkok, Thailand
Health Sciences Maimonides University
Buenos Aires, Argentina

Bernd G. Lapatki
Department of Orthodontics and Dentofacial
Orthopedics
Ulm University Medical Center
Ulm, Germany

ISBN 978-3-030-95013-2    ISBN 978-3-030-95014-9 (eBook)

https://doi.org/10.1007/978-3-030-95014-9

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and
retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter
developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Contents

1 Introduction�����������������������������������������������������������������������������������������������������������������   1
Julia Harfin
2 
Digital Technology as an Aid to Early Orthodontic Treatment ����������������������������� 19
Bryce Lee
3 
The Treatment of Class II Division 1 Malocclusion in Stages��������������������������������� 33
Kurt Faltin Jr
4  Early Class II Treatment Worth the Effort? ������������������������������������������������������� 73
Is
Amit Bhardwaj
5 
Early Treatment of Cover-Bite and Class II Division 2 Malocclusion������������������� 115
Bernd G. Lapatki
6 
Early Treatment of Class III Malocclusions������������������������������������������������������������� 203
Somchai Satravaha
7 
Early Treatment of Open Bite Problems������������������������������������������������������������������� 265
Julia Harfin
8 
Correction of the Transverse Problems ������������������������������������������������������������������� 295
Julia Harfin
9 Management of Dental Asymmetries ����������������������������������������������������������������������� 311
Julia Harfin
10 Mandibular Incisor Agenesis������������������������������������������������������������������������������������� 339
Julia Harfin
11 
Impacted Central Incisors: Different Options for Treatment��������������������������������� 357
Julia Harfin
12 
How Orthodontic Movement Can Avoid Future Periodontal
Problems in Children������������������������������������������������������������������������������������������������� 369
Julia Harfin
13 
Early Orthodontic Treatment in Cleft Lip / Palate Patients����������������������������������� 381
Somchai Satravaha
14 
Diabetes in Childhood and Adolescents ������������������������������������������������������������������� 435
Olga Ramos
15 
Orthodontics in Hemophilia Patients����������������������������������������������������������������������� 443
Eduardo Rey
16 
How to Avoid Long Term Relapse in Early Orthodontic Treatment��������������������� 451
Julia Harfin

v
vi Contents

17 Controversies
 in Cleft Lip / Palate Patients������������������������������������������������������������� 469
Julia Harfin
18 Controversies Concerning Early Treatment������������������������������������������������������������� 475
Julia Harfin and Kurt Faltin Jr
About the Editors

Julia Harfin is Professor and Chair of the Orthodontic Department at the School of Dentistry,
Maimónides University, Buenos Aires, Argentina. Dr. Harfin has served as the president of
various organizations: the Argentine Society of Orthodontics (1990–1996), ALADO (1999–
2008), the Argentine Chapter of the International College of Dentists (1997–2001), the
Argentine Chapter of the Pierre Fauchard Academy (1992–1993), and the International College
of Dentists Section IV (2010–2012). Currently, she is the Vice President of the National
Academy of Dentists. She was a member of the Executive Committee of the World Federation
of Orthodontists from 2000 to 2010. She is an honorary member of the Argentine, Chilean, and
Polish Orthodontic Societies and in 2010 she became a member of the National Academy of
Dentistry. Also in 2010, she was named Woman of the Year in Medicine and Healthcare. Dr.
Harfin is the author or editor of several previous books, including Achieving Clinical Success
in Lingual Orthodontics (Springer, 2014). Dr. Harfin received the 2018 Regional Award of
Merit from the World Federation of Orthodontists in recognition of significant contributions to
the art and science of orthodontics.

Somchai Satravaha is a Clinical Associate Professor at Mahidol University, Bangkok,

Thailand and a Diplomate of the Thai Board of Orthodontics. She received her DDS (Hons)
from Chulalongkorn University, Bangkok and later earned the qualification of Zahnärztin für
Kieferorthopädie (Orthodontist) from Baden-Württemberg, Germany and the Dr. med. dent.
degree (magna cum laude) from Munich, Germany. Dr. Satravaha served as an executive com-
mittee member of the World Federation of Orthodontists (WFO) from 2005 to 2015 and is a
past president of both the Thai Association of Orthodontists and the Asian Pacific Orthodontic
Society. She received a Lifetime Achievement Award from the Thai Association of Orthodontists
in 2013 and was a recipient of an Outstanding Alumni Award from Chulalongkorn University
Dental Alumni Association in 2014. She obtained later the WFO Regional Award of Merit in
2018 and was recognized an Outstanding Expert in Orthodontics by the Royal College of
Dental Surgeons of Thailand in 2019. She is an honorary member of the Association of
Philippine Orthodontists, the Indian Orthodontic Society, Ho Chi Minh Association of
Orthodontists, the Bangladesh Orthodontic Society, the Orthodontic and Dentofacial
Orthopedic Association of Nepal (ODOAN), and honorary fellow of the Asian Pacific
Orthodontic Society. She is currently president of the Advisory Board of the Thai Association
of Orthodontists.

Bernd G. Lapatki received the degree in dentistry from the University of Freiburg, Germany,
in 1994. He defended his thesis leading to the Dr. med. dent. degree in 1998, and his Habilitation
Thesis on the pathogenesis and treatment stability of cover-bite and Class II Division 2 maloc-
clusion in 2007. He also received a Ph.D. degree in neurophysiology from Radboud University
Nijmegen (NL) in 2010 for the electrophysiological characterization of the facial motor sys-
tem at a motor unit level. He started his clinical career in 1995 practicing as a general dentist
for 2 years before he began his postgraduate study at the Department of Orthodontics, Freiburg
University Medical Center. During his clinical work at this department as Specialist in
Orthodontics from 2000 to 2009, he was also a Research Fellow at the Department of Clinical

vii
viii About the Editors

Neurophysiology, Radboud University Nijmegen Medical Center, The Netherlands. Since

2009, he is a Full Professor and Head of the Department of Orthodontics at the University of
Ulm. From 2013 to 2019 he was the Director of the Centre of Dentistry, and since 2019 he is
the Dean of Studies in Dentistry at this University. Bernd G. Lapatki was awarded in 1999 by
the Faculties of Medicine and Applied Sciences of the University of Freiburg the best disserta-
tion in the field of medicine/medicine technique. In 2004, he received the Alex Motsch Award
by the German Society of Dentistry and Oral Medicine, and the Arnold Biber Award (the high-
est scientific award of Orthodontics in Germany) by the German Orthodontic Society in 2007.
The research of this group focuses on the development of methods for clinical force-moment
monitoring in orthodontics, numerical simulation, and experimental mechanical evaluation of
orthodontic treatment approaches including multi-bracket appliances and aligners, and the
(patho-) physiology of the facial and masticatory motor systems.
 Introduction
1
Julia Harfin

This atlas was written taking into consideration the most (Behrents 2006). At this time, growth modification will be
common problems that are frequently encountered in young limited.
children. Specific indications for early treatment include Class II or
Interceptive treatment is intervening in the developing Class III malocclusion, with maxillary midface deficiency
dentition to allow it to achieve the best occlusion possible, or anterior and posterior crossbite (unilateral and bilateral),
to make subsequent treatment as simple and short as possible midline discrepancies due to early loss of deciduous teeth
(DiBiase 2002). with a midline shift, severe anterior open-bite, severe deep-
There is no doubt that early treatment can be justified if it bite with palatal impingement, finger-sucking habits, crowd-
provides additional benefits to the patient. ing resulting in ectopic positioning of permanent teeth, etc.
The question of when, how, and why is answered in depth (Dugoni 1998; Dugoni et al. 2006).
in all the clinical cases contained in this atlas. The goal is to But not all the circumstances are black or white, each
focus on functional and skeletal rather than dental patient is unique. For example, the most appropriate timing
correction. for the treatment of Class II malocclusion is controversial
Knowing the diagnosis criteria and which type of cases (Cozzani et al. 2013). Some clinicians advocate starting the
should be treated early will permit the clinician to offer the first phase in mixed or temporary dentition, but others prefer
most efficient solution for each individual patient. In general, to wait until the second molars have erupted.
the first phase of treatment in the early mixed dentition has to Also, the timing of treatment interventions can be influ-
be followed by the second phase in the permanent dentition. enced by the severity of the malocclusion, the age, and matu-
When and how much growth will occur is unpredictable rity of the patient at the time the treatment begins.
in some patients, but the direction of growth can be managed It is important to emphasize that different types of brack-
(Suresh et al. 2015). However, it is important for the clinician ets and wires were used by the authors to treat the patients
to be able to diagnose and intercept certain developing prob- since there isn’t a single type of bracket or wire that performs
lems through early treatment. a correct diagnosis in each clinical case, until now.
Many other cases should be supervised, but not treated The role of the orthodontist is to manage the problem in
until the permanent teeth are in place. We must base our the most efficient way for a better diagnosis. It is fully recog-
decision on a correct diagnosis taking into account that the nized that some malocclusions are best treated early for bio-
correction of functional and skeletal imbalances are funda- logical, functional, and social reasons.
mental before the eruption of all the permanent teeth. Different alternatives for each malocclusion will be
One of the most important advantages to begin the treat- described step by step in each chapter.
ment early is to take advantage that in early mixed dentition, It is evident that to design an efficient treatment plan, the
the skeletal growth pattern can be modified to a certain point. clinician must understand the growth and development pro-
Other doctors with different protocols suggest that the treat- cess very clearly.
ment has to begin after the eruption of the second molars It is well-known that the difference in the response of
patients with the same orthodontic treatment is the result of
J. Harfin (*) variability in the direction and rate of craniofacial growth.
Department of Orthodontics, Maimonides University, It is impossible to decide the best time to begin the treat-
Buenos Aires, Argentina
ment based solely on the chronological age since the major-
Health Sciences Maimonides University, ity of the malocclusions that have to be treated during mixed
Buenos Aires, Argentina
dentition are the result of multiple factors.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 1

J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_1
2 J. Harfin

In general, mixed dentition is the best time to start treat- it advisable to begin now or to wait until 11–12 or 18 years
ment when the correction of habits with or without anterior of age?
or lateral transverse crossbite are indicated. There is no doubt that the normalization of the anterior
A panoramic radiograph is mandatory at age 8–10 years negative crossbite should take place as early as possible
to confirm the presence or absence of agenesis, supernumer- since it will help achieve a normal development of the max-
ary teeth, cysts, mesiodens, etc. illa and to improve the soft tissue profile.
The last chapter (Chap. 18) analyzes the most main con- These were the results after 26 months with a functional
troversies regarding early treatment in depth. appliance (Fig. 1.3a, b). Overjet and overbite were improved
The following examples show the importance of the tim- and midlines were almost normal. The objectives of Phase I
ing of treatment according to the initial pathology, direction of treatment were accomplished. It was important to improve
of growth, and the normalization of the functional problems the anterior position of the tongue.
such as nasal breathing and tongue posture at rest or during However, the most important question is if the treatment
swallowing. Although they were skeletal and dental Class III results will remain stable over the long term.
at the beginning of the treatment with a similar biotype, the These were the photos 9 years after treatment. The results
results that were achieved in the long term were completely were maintained or even improved even though some gingi-
different. val retractions were seen in the upper canine area (Fig. 1.4a,
The parents of this 6-year-old patient asked for a sec- b). Fortunately, in this particular clinical case the second
ond opinion about the best time to begin his treatment. phase of treatment was not necessary.
They were very interested in having him treated very early The comparison between the smile photos at the begin-
and avoid the orthognathic procedure that was suggested. ning and 9 years after treatment was the best proof that the
The front photographs confirmed a significant negative results were maintained throughout his whole childhood and
overjet and overbite that was present in the anterior region adolescence (Fig. 1.5a, b).
(Fig. 1.1a, b). As a conclusion, it is possible to affirm that the treatment
From the etiological point of view it is important to con- of very young Class III patients with a significant anterior
sider that his two older sisters had Class I molar and canine deep-overbite is more reliable than when the Class III is in
but two of his seven cousins were Class III and were treated combination with a significant open-bite, as it is observed in
with orthognathic surgery. the second patient.
The dental front and lateral photographs showed that the The next case is very different from the first. It was very
lower incisors were in contact with the upper labial gingival clear that early treatment would be beneficial for him,
tissues and until then and for unknown reasons, he only ate although the success was questionable due to the unfavorable
soft meals. type and direction of growth. She was only 4 years, 9 months
The lateral radiograph confirmed the negative anterior of age. Her dental history showed that her parents were skel-
position of the front teeth. Ricketts analysis demonstrated etal Class III but not her young sister.
normal convexity with a retruded upper lip and everted lower The front photographs showed an important dentoalveo-
lip. An increased facial axis was present (95°), along with a lar Class III with a significant open bite in the anterior region
short lower anterior height (41°) (Fig. 1.2a, b). and crossbite in the lateral areas.
The real question is when would be the best treatment As a consequence of the lower and anterior position of the
time to begin the correction of this Class III malocclusion? Is tongue, significant diastemas were present in the lower arch

a b

Fig. 1.1 (a, b) Frontal and lateral pre-treatment photographs. A significant negative overbite was present
1 Introduction 3

a b

Fig. 1.2 (a, b) Pre-treatment lateral radiograph and Ricketts analysis

a b

Fig. 1.3 (a, b) Frontal and lateral post-treatment photographs at the end of Phase I of treatment

(Fig. 1.6a, b). The normalization of the position of the tongue Class III and deepbite. The normalization of the tongue pos-
is one of the most difficult issues and requires a lot of time ture at rest and in function is mandatory to avoid relapse
and effort for the patients and their parents. (Fig. 1.7a, b).
Although Ricketts analysis was developed for 9-year-old The real question is until when it is possible to redirect
patients, the lateral radiograph confirmed that the patient had a growth in these Class III patients and how to know, at an
dental and skeletal open-bite—Class III with braquifacial bio- early age, how the mandible will develop.
type. This combination has the poorest long-term prognosis. Evaluation of the overall treatment and post-treatment
It is very important to take into account that patients with changes confirm that overcorrection in this first phase of
Class III and open-bite are harder to treat than those with treatment is recommendable (Baccetti and Franchi 2006).
4 J. Harfin

a b

Fig. 1.4 (a, b) Control 9 years after treatment. The results were maintained. Overjet, overbite, and midlines were improved

a b

Fig. 1.5 (a, b) Comparison of the smile photographs pre- and 9 years after treatment
1 Introduction 5

a b

Fig. 1.6 (a, b) Frontal and lateral pre-treatment photographs. A significant skeletal and dental Class III with a considerable open-bite was present
in this 4-year, 9-month girl

a b

Fig. 1.7 (a, b) Lateral radiograph and Ricketts analysis at the beginning of the treatment Class III with a significant open-bite was confirmed

The Figs. 1.8 and 1.9 show the results after 3 years of The lateral radiograph at the end of the first phase of treat-
treatment with a rapid maxillary expander in conjunction ment confirmed the clinical results (Fig. 1.9a, b).
with a face mask. Although most of the treatment objectives The patient returned after 5 years without any previous
were achieved, it would have been better to finish this first follow-up. The parents admitted that due to some personal
phase of treatment with more overjet and overbite, but the problems they neglected her treatment. She also discontin-
patient and her parents decided to conclude this phase for ued the treatment with the speech therapist and never used
personal reasons. No speech therapy treatment was recorded. the retainers. The results were totally unexpected.
At the end of this first phase, the posterior crossbite was The clinical photos clearly showed that the open-bite in
not totally corrected and midlines were not coincident. conjunction with Class III molar and canine worsened more
The change of color of the right upper central incisor was than expected (Fig. 1.10a, b).
the result of trauma produced while riding her bicycle The cephalometric radiograph and Ricketts analysis con-
(Fig. 1.8a, b). firmed the skeletal open-bite—Class III. The treatment plan
6 J. Harfin

a b

Fig. 1.8 (a, b) Frontal and lateral photos at the end of this phase of treatment. Not all the objectives for Phase 1 were completed

a b

Fig. 1.9 (a, b) Lateral radiographs and Ricketts cephalogram at the end of the Phase I of treatment. Most of the objectives were fulfilled

at that time had to include an orthognathic surgical ­procedure It is important to take into consideration that maintaining
when the patient was almost 20 years old (Fig. 1.11a, b). the results for a long term depends on a number of factors:
These two clinical cases clearly demonstrated the impor- facial biotype, direction of growth, heredity, control of hab-
tance of the normalization of the function and that the pos- its, etc.
sibility to redirect growth is one of the major goals in this The early treatment of the following patient was mandatory
phase of treatment. not only because of his profile but also due to the position and
The difference in the response of patients with a similar protrusion of the upper incisors (Figs. 1.12, 1.13 and 1.14).
orthodontic treatment protocol is the result of variability in The objectives of the first phase of treatment included the
the direction and rate of craniofacial growth as it was demon- normalization of the position and inclination of the upper
strated with these two young Class III patients. incisors to prevent any type of dental or dentoalveolar frac-
Integrated diagnosis is the basis that will allow us to ture as a consequence of an accident at home or at school. At
determine the best treatment plan while considering the the same time, the improvement of the position of the lower
direction and quantity of growth. lip was necessary (Franchi et al. 2011).
1 Introduction 7

a b

Fig. 1.10 (a, b) Frontal and lateral photographs 5 years without follow-up. The results were worse than expected

a b

Fig. 1.11 (a, b) Lateral radiographs and Ricketts analysis 5 years later. The results clearly showed the adverse direction of growth

The consultation with the otorhinolaryngologist was also A consultation with the otorhinolaryngologist was funda-
mandatory because it was necessary for the patient to be able mental since the patient had to learn how to start breathing
to breathe without any problems in order to re-educate the through his nose.
position of the lips and the tongue. Before selecting the best treatment plan for this patient, it
The real question is what the best orthodontic treatment was necessary to determine which type of Class II he had.
approach for this specific patient with prominent upper front Without knowing the etiology, it is very difficult to deter-
teeth is. The answer can vary from beginning at that time or mine the correct, individualized treatment plan.
waiting until all the permanent teeth erupt. It is well-known that functional matrix facilitates the
Since one of the treatment objectives was to avoid the lower third development in the three directions thus in early
fracture of the anterior upper incisors, there is no doubt that mixed dentition the normalization of habits is fundamental to
the treatment had to begin at that moment. facilitate tooth eruption in normal position.
8 J. Harfin

a b

Fig. 1.12 (a, b) Frontal and lateral facial pre-treatment photographs. Difficulties in closing his mouth were clearly visible

a b

Fig. 1.13 (a, b) Pre-treatment right and left sides. Total lack of space for the left lower canine was confirmed along with the retroinclination of
the lower incisors

To complete the diagnosis protocol, the patient was sent tion with difficulties to close his mouth. Also, he had some
to his pediatrician because he snored loudly at night. He had respiratory problems along with thumb sucking and lower lip
a convex profile with a closed naso-labial angle in conjunc- interposition (Fig. 1.12a, b).
1 Introduction 9

a b

Fig. 1.14 (a, b) Pre-treatment panoramic and lateral radiograph. The anterior position of the upper incisors was confirmed

In order to determine the best and most efficient treatment The mother and the patient were very enthusiastic about
protocol, it is necessary to consider if it is only an antero-­ the treatment since another colleague suggested to wait until
posterior problem or if it is combined with a transversal one. 18 years of age and then correct the malocclusion with the
In this situation, it is highly recommended to treat the trans- help of an orthognathic procedure.
versal discrepancy first (Subtelny 2000). Also, it is advisable The patient was controlled by the orthodontist every
to restrain the forward displacement of the maxillary denti- 2 months, but he went to the speech therapist twice a week
tion and its alveolar process and at the same time allow the during the first year and then only once a week.
normal development of the mandible. It is advisable that the patient uses the appliance 2 h dur-
As a consequence of all the functional problems, the man- ing the day and all night.
dibular dentition was retro-positioned with retroinclined These are the results after 3 years of treatment with a
mandibular incisors and total lack of space for the lower left functional appliance that helped to normalized function and
canine (Fig. 1.13a, b). as a consequence redirected the position of the erupting teeth
The panoramic radiograph confirmed the normal path of (Fig. 1.15a, b).
eruption of the other permanent teeth. The lateral radiograph The patient continued using the appliance every night
showed the important frontal displacement of the upper inci- with a 3 months control. No brackets were bonded until that
sors. He had a meso-facial biotype with a convexity of 9 mm. moment of the treatment, and the mother confirmed that the
The interincisal angle was 135° and his facial axis 85° snoring disappeared.
(Fig. 1.14a, b). His profile improved more than expected. No brackets
The evidence suggests that providing early orthodontic were used during the entire second phase of treatment.
treatment for children with prominent upper front teeth is Since he was able to breathe normally, his behavior
more effective in reducing the incidence of incisal trauma improved not only at school but also at home with his broth-
than providing one course of orthodontic treatment when ers too (Fig. 1.16a, b). There was an important improvement
the child is in his adolescence (Thiruvenkatachari et al. in his profile and in his dental anterior position.
2014). A control 6 months later confirmed that the results were
A myo-functional appliance (Trainer) was suggested in maintained. The incisors are normally positioned with good
order to normalize nasal breathing and the position of the overjet and overbite. The gingival line and the occlusal plane
oral muscles. were parallel (Fig. 1.17a, b).
10 J. Harfin

a b

Fig. 1.15 (a, b) Frontal view with and without the appliance in place after 3 years of treatment

a b

Fig. 1.16 (a, b) Frontal and profile photograph at this moment of the treatment. The normalization of the anterior occlusion and the position of
the lips was remarkable

a b

Fig. 1.17 (a, b) Control 6 months after treatment. Midlines, overjet and overbite were pretty normal
1 Introduction 11

The lateral views confirmed that the lower canines erupted Front and occlusal photographs 1 year after treatment. All
normally although they didn’t have sufficient space at the the teeth erupted in normal position. Class I canine and molar
beginning of the treatment (Fig. 1.18a, b). were achieved and maintained with perfect alignment. The
The normalization of the upper and lower arch was the patient had good oral hygiene during the whole treatment
result of the new function of the oral muscles. Now they (Fig. 1.22a, b).
were rounded with space for all the permanent teeth The comparison between the two profile photographs is
(Fig. 1.19a, b). the best demonstration of the results that were achieved
In order to maintain the results and to control the position when the function is recovered. No extractions were per-
of the tongue and the width of the upper and lower arches, a formed in the upper arch (Fig. 1.23a, b). The change in the
new, more rigid (Phase II) Trainer was recommended ­naso-­labial angle was better than expected as a consequence
(Fig. 1.20a, b). of the normalization of the stomatognathic system.
After analyzing this type of patient, the conclusions This clinical case strongly supports the benefits of the
would be that the early transitional dentition period seems to protocol that include second or third phase treatment. An
be the best time to correct these functional alterations in a early and accurate diagnosis is the most important issue, no
very controlled and efficient manner. matter the number of phases that the patient requires to
The final photographs clearly demonstrated the normal- achieve the best result in a more conservative manner with
ization not only of the frontal teeth but also of the soft tis- fewer orthognathic procedures.
sues. At that point, he could close his mouth without any Another malocclusion that has to be treated very early is
muscle tension and the naso-labial angle was within normal the anterior deepbite since the musculature plays an impor-
ranges (Fig. 1.21a, b). tant role before, during, and after treatment during the long

a b

Fig. 1.18 (a, b) Right and left lateral views. Class I molar was maintained and at this moment the right and left canine had enough space to erupt

a b

Fig. 1.19 (a, b) Upper and lower arch at this moment of the treatment. They had normal transverse and antero-posterior dimension
12 J. Harfin

a b

Fig. 1.20 (a, b) Phase II. Trainer was recommended in order to maintain the excellent results that were achieved

a b

Fig. 1.21 (a, b) Post-treatment front and profile photographs. The lips closed without any muscular tension and the naso-labial angle was totally
normal

retention period. The early treatment protocol to correct the To design the best treatment plan, a careful analysis of the
anterior deepbite can be divided into three big groups: intru- smile at rest and during function is fundamental. The posi-
sion of the anterior teeth, extrusion of the posterior ones, or tion of the upper incisors during the smile determines if the
a combination of both. upper incisors have to be intruded or not.
1 Introduction 13

a b

Fig. 1.22 (a, b) Frontal and occlusal view 1 year after treatment. The results improved with good oral hygiene. Midlines, overjet, and overbite
were maintained

a b

Fig. 1.23 (a, b) Comparison of pre- and post-treatment profiles. A significant improvement in the soft tissues was achieved and maintained
14 J. Harfin

The next patient is a clear example. She was 9 years, Taking into consideration that in this specific patient the
6 months of age. Her mother, a well-known odontopediatric, first priority was the normalization of the anterior vertical
was very disappointed since her daughter never used any dimension four lingual brackets were bonded on the palatal
removable functional appliances in order to correct the con- surface of the central and lateral incisors along with a coaxial
siderable anterior deepbite. arch. An indirect method with an individualized setup was
The front photograph confirmed an overbite of 100% in fully recommended to bond the brackets correctly. No bands
the central incisor region that was confirmed in the lateral or tubes were placed on the molars to allow their physiologi-
radiograph. Dental midlines were coincident and the upper cal eruption and achieve a normal overbite (Fig. 1.26a, b).
lateral left incisor was more extruded than the right one. The As a consequence, an expected lateral open-bite was pres-
lower anterior height was clearly diminished (41°) ent in the posterior region (Fig. 1.27a, b). Bearing in mind
(Fig. 1.24a, b). that when the molars erupt slowly they erupt with bone, no
The lateral views confirmed the significant overbite and other appliance was used in this phase.
the retroclination of the upper incisors. The first upper and A follow-up 4 months later showed a significant improve-
lower molars were not fully erupted (Fig. 1.25a, b). The ment of the anterior overbite only with this fixed appliance.
occlusal plane wasn’t parallel to the gingival line. The lower incisors were clearly visible (Fig. 1.28a, b).

a b

Fig. 1.24 (a, b) Frontal view and lateral radiograph showing the significant deep frontal overbite

a b

Fig. 1.25 (a, b) Class I right and left molar and canine was observed. The anterior overbite was almost 100% and the retroinclination of the upper
incisors was confirmed
1 Introduction 15

a b

Fig. 1.26 (a, b) Lingual brackets were bonded on the palatal surface of the upper incisors with a partial coaxial arch

a b

Fig. 1.27 (a, b) Lateral views after the indirect placement of the lingual brackets with an expected transitional lateral open-bite

a b

Fig. 1.28 (a, b) Frontal and occlusal photos after 4 months of treatment
16 J. Harfin

a b

Fig. 1.29 (a, b) The extrusion in the temporary and first permanent molar region can be recognized

a b

Fig. 1.30 (a, b) Comparison of pre- and after 6 months of treatment with a partial fixed lingual appliance acting as anterior bite planes

The extrusion on the right and left region was remarkable. There is no doubt regarding all the benefits of the early
Since this extrusion was performed very slowly, the jaw clos- orthodontic treatment, no matter if more than one phase of
ing muscles could adapt and consequently relapse would be treatment (Bowman 1998) is necessary.
not expected (Fig. 1.29a, b). The focus has to be placed on the treatment response
The comparison pre- and post-treatment (6 months) con- since each patient is unique.
firmed that the treatment plan that was suggested was effi-
cient. Phase I was very important since the adaptation of the
musculature system is very predictable. It is possible that the 1.1 Conclusions
second phase of treatment would be necessary when all the
permanent teeth erupted. Although a significant posterior One of the benefits of the early orthodontic treatment is the
extrusion was performed, the midlines were stable improvement of the self-esteem of the patients since per-
(Fig. 1.30a, b). sonal interactions at school are very significant at this age. It
The key was that the patient use this fixed anterior bite is important to emphasize that different types of brackets and
planes 24 h a day, and in this way the whole stomatologic wires were used since there is no intelligent bracket that per-
system would adapt to the new vertical dimension and a forms a correct diagnosis in each patient.
normal functional occlusion would be achieved. The reten- The early normalization of the neuro-muscular behavior
tion plan has to include a functional appliance until all the is more important than simply the position of some teeth and
permanent teeth were erupted to maintain the achieved as a result early treatment has a real advantage to avoid
results. adverse effects.
1 Introduction 17

The role of the orthodontist is to manage in the most effi- Behrents R. The decisión of when to intervene: the nature of the ques-
tion in terms of faith, passion and evidence. In Early orthodontic
cient way for a better diagnosis, prognosis, treatment, and
treatment: is the benefit worth the burden. Thirty-third Annual
retention plan. Moyers Symposium, Ann Harbor, Michigan; 2006.
It was totally demonstrated that there is no appliance that Bowman SS. One stage vs two stages treatment: are two really neces-
fits all the patients even with a similar age and malocclusion. sary? Am J Orthod Dentofacial Orthop. 1998;113:111–6.
Cozzani M, Mazzota L, Cozzani P. Early interceptive treatment in the
In general, the treatment plan was divided into one, two, or
primary dentition. A case report. J Orthod. 2013;40:345–51.
more phases: the first phase has to be undertaken only on the DiBiase A. The timing of orthodontic treatment. Dent Update.
primary teeth or early mixed dentition to correct habits and 2002;29:434–41.
alleviate functional problems before the second or third phase Dugoni S. Comprehensive mixed dentition treatment. Am J Orthod
Dentofacial Orthop. 1998;113:75–84.
of treatment with fixed appliances in the permanent dentition.
Dugoni S, Aubert M, Baumrind S. Differential diagnosis and treatment
The key question is: diagnosis, timing, and efficacy of planning for early mixed dentition malocclusions. Am J Orthod
treatment. Dentofacial Orthop. 2006;129(4 Suppl 1):S80–1.
The selection of the best therapy has to be based on avail- Franchi L, Baccetti T, Giuntini V, Masuccu C, Vangelistia C, DeFraia
E. Outcomes of two-phase orthodontic treatment of deepbite maloc-
able evidence.
clusions. Angle Orthod. 2011;81(6):945–52.
It is important to remember that an early treatment phase Subtelny JD. Early orthodontic treatment. Carol Stream, IL:
cannot avoid the second phase of treatment but does reduce Quintessence Publishing Co; 2000.
its length and complications. Suresh M, Ratnaditya A, Kattimanis VS, Karpe S. One phase versus
two phase treatment in mixed dentition: a critical review. J Int Oral
Health. 2015;7:144–7.
Thiruvenkatachari B, Harrison JE, Worthington HV, O’Brien KD. Early
References orthodontic treatment reduced incisal trauma in children with class
II malocclusions. Evid Based Dent. 2014;15:18–20.
Baccetti T, Franchi L. The long term perspective on orthopedic treat-
ment of Class III malocclusion. In Early orthodontic treatment: is the
benefit worth the burden. Thirty-third Annual Moyers Symposium,
Ann Harbor, Michigan; 2006.
 Digital Technology as an Aid to Early
Orthodontic Treatment 2
Bryce Lee

2.1 Introduction

The use of digital technology has had great impact on our

lives. Its influence in the management of an orthodontic
patient is no different.
The chapter has been divided into three sections:

1. The digital workflow in an orthodontic office.

2. Clinical indications and applications for early orthodon-
tic treatment aided with digital technology.
3. Concluding remarks including a discussion on the pitfalls
and an overreliance of digital technology.
Fig. 2.1 The computer’s ability to use the numerical binary format
The following are certain definitions of terms to be used (circuits being turned on/off) enables the assimilation of information by
machines
in this chapter which may be helpful:

• Digital technology – this is an all-encompassing term

used nowadays. But its roots lie in the fact that such tech- 2.2 The Digital Workflow
nology is able to convert information into numbers (a in an Orthodontic Clinic
binary format of zero and one) for machines to assimilate
and use this information (Fig. 2.1). Emerging technology has improved the digital workflow,
• Artificial Intelligence (AI) – this uses algorithms and resulting in increased patient engagement, time efficiency,
digitized patterns to mimic the cognitive function of the and better data acquisition, within the orthodontic office
human mind to “learn” and “solve problems” (Fig. 2.2). (Christensen 2017) (Fig. 2.4).
• CAD-CAM (computer-aided design-computer-aided Logs of staff, patients, and visitors are kept in a central
manufacturing) – introduced to dentistry in the 1970s, the computer (Fig. 2.5) to monitor attendance and body temper-
use of CAD-CAM in orthodontics has exponentially ature (a new requirement at our office, ever since the
increased in the last 20 years with changes in treatment COVID-­19 pandemic).
philosophies and modalities. For example, the use of Digital records and attendance keep a log of patient’s infor-
appliances from 3-D printed models. Figure 2.3 illustrates mation and treatment progress. Patients’ attendance (includ-
such an example. ing time in and out) is an important tool nowadays as well.

B. Lee (*)
Atria-City Dental Group, National University of Singapore,
Singapore

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 19

J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_2
20 B. Lee

Fig. 2.2 Artificial

Intelligence uses this
information in an attempt to
replicate the cognitive
functions of the human mind

Fig. 2.3 A simple orthodontic example of CAD-CAM is the simulated movement of teeth, the subsequent manufacturing of appliances, and the
resultant movement of the teeth

Having the ability to view patient records remotely gives and transmitting information. Cloud-based information can
flexibility (Fig. 2.6). be accessed easily and saves on physical storage space
Digital data acquisition has enabled efficient means of (Fig. 2.8).
accessing information. Radiographs and CBCTs can be Digital scans and subsequent simulations, when properly
remotely accessed (Fig. 2.7). executed, can be used to engage patients, manage expecta-
Digital scanners, both intraorally and extraorally, are con- tions, and aid in treatment planning. An example of such a
venient and a clinically acceptable way for record-keeping simulation is shown in Fig. 2.9.
2 Digital Technology as an Aid to Early Orthodontic Treatment 21

Clinic Workflow

Staff, Patients, Visitors

Facial scan and temperature for attendance

Registration, log in / out of treatment room with

accompanying digital notes

Facial scan, Intra-oral scan, radiographs

Treatment plan and presentation,

discussion with patient and consent

Initiation of treatment, fabrication of appliances

and progress monitoring

Retention and follow-up

Fig. 2.4 An illustration of the digital workflow in an orthodontic office

Fig. 2.5 A facial recognition scanner with clinic’s Quick Reader (QR)
code (for contact tracing by patients) along with an infrared tempera-
ture scanner

Fig. 2.6 Notes and patient’s payment log can be stored digitally
22 B. Lee

Fig. 2.7 Digital radiographs (of varying types) have enabled easy processing of films and access and transfer of data

Fig. 2.8 Digital extraoral scan. Good for integration with CBCTs when planning dentofacial corrections. Picture courtesy of Professor Dhirawat
Jotikasthira

Radiograph algorithms can be used to predict certain con- Monitoring the progress of cases will increase in demand.
ditions (Hunter 1966). An example of this is the study of The use of phone apps along with highly innovative phone
determining the growth and development of an individual cameras enable orthodontists to monitor their patients
using the stages of the cervical vertebra (Bacetti et al. 2002) remotely (Fig. 2.12). In view of the COVID-19 pandemic,
(Fig. 2.10). the demand for tele-dentistry and distance diagnosis has
The integration of scans can be used to give a more pre- become a need more than a luxury (Barenghi et al. 2020).
dictive treatment outcome. Surgical cases especially benefit Apps can be used to m ­ onitor patient compliance, progress,
from such outcomes. An example of this is shown in and oral conditions and hygiene.
Fig. 2.11.
2 Digital Technology as an Aid to Early Orthodontic Treatment 23

Fig. 2.9 An example of dental simulation (TRIOS treatment simulator) using 3-Shape TRIOS scanning software with actual before and after
scans of same patient. Note the scissor bite correction on the patient’s right and the mandibular displacement

Fig. 2.10 Cervical vertebra stage determination in order to predict growth. For instance, in these two cases of skeletal class III patients both aged 12
but with very different skeletal maturity. Researchers are looking at algorithms (Kok et al. 2019), with the aid of landmarks, to help determine this

Transfer portals and storage of data are important in hygienic as well. These scans can also be transferred via
today’s digital setting. Cloud-based portals enable safer stor- such portals to laboratories and coworkers reducing physical
age and management of data as well as good accessibility of material handling and improving infection control (Figs. 2.13
such data. Storage and transfer of such data is far more and 2.14).
24 B. Lee

Fig. 2.11 CBCT/dental scan integration for a more predictive outcome. It also aids in the fabrication of both the intermediate and final surgical
splints. Images courtesy of Dr. Andrew Ow

Fig. 2.12 Monitoring the progress of patients has become more urgent (Hansa et al. 2020). Actual pictures taken during the COVID-19 pandemic
enquiring about dental infection and orthodontic progress
2 Digital Technology as an Aid to Early Orthodontic Treatment 25

Fig. 2.13 Transfer of scans

between software for
management of cases are
made convenient by secure
cloud-based portals. An
example using the 3-shape
communicate platform

2.3 Clinical Indications and Application Customized appliance fabrication can result in personal-
for Early Orthodontic Treatment-­ ized tailor-fitted appliances. Force delivery and application
Aided Digital Technology can be more precise (Fig. 2.18).
Functional appliances—the augmentation of clear align-
Intraoral scanning has made many processes much easier and ers to include mandibular advancement components
safer (Chalmers et al. 2016) than impression materials includ- (Giancotti et al. 2020) is a very interesting avenue to be
ing applications beyond the original scope of the device use explored (Fig. 2.19).
such as scanning infants and young patients (Fig. 2.15). Clear aligners have been one of the two technologies (the
Removable appliances—design and production have ben- other being temporary anchorage devices) in orthodontics
efited greatly from digital technology (Fig. 2.16). Dedicated that have revolutionized the way we approach the manage-
laboratory software has enabled in-house and lab-based ment of our patients (Fig. 2.20).
manufacture of simple to custom-made appliances with a Retainers have been another avenue where digital tech-
faster turnaround time. nology can improve. More accurate retainers and shorter
Fixed appliances—prescription brackets and wires along manufacturing time would greatly improve retention proto-
with jig placement could change the way we manage our cols (Fig. 2.21 and 2.22).
fixed appliance cases (Fig. 2.17).
26 B. Lee

Fig. 2.14 Easy access (e.g.,

via mobile apps) to cases for
review and discussion is also
a huge advantage (phone
screen shots taken from the
3-shape communicate mobile
app)
2 Digital Technology as an Aid to Early Orthodontic Treatment 27

Fig. 2.15 Easily acceptable scans rid the patient of the discomfort of mixed dentition with highly mobile first and second primary molars that
impression materials (Chaudhari & Kharbanda 2017) and overcome the were removed and a digital study model taken immediately. An alginate
problems of mobile teeth. (a) Cleft case, picture courtesy of Professor impression for both cases would have been very uncomfortable and dif-
Dhirawat Jotikasthira. (b) The second example shows a patient in the ficult to undertake
28 B. Lee

Fig. 2.16 From the intraoral scan, sketch for laboratory technician to follow design, to 3-D printing for fit into the patient’s mouth

Fig. 2.17 CAD-CAM technology can provide us with customized prescriptions and customized arch wires. Pictures show treatment planning
with the Insignia system
2 Digital Technology as an Aid to Early Orthodontic Treatment 29

Fig. 2.18 Customized appliance for expansion. Made with the aid of
digital technology (Graf 2017). Picture courtesy of Dr. Nikhilesh Vaid

a b

Fig. 2.19 Functional appliance: the present or could the future be more efficient? (a) Present-day twin block appliance with lab-based support.
(b) Mandibular advancement along with dental alignment with clear aligners (Courtesy of Invisalign)
30 B. Lee

Fig. 2.20 The integration from records to treatment execution has improved by leaps and bounds with regard to the application in clear aligners (Keim
2018). Algorithms have also been refined and data bases increased to present a more predictable treatment option. An example below using Invisalign

Fig. 2.21 Removable retainers using digital technology. Cloud-based transfer to laboratory for 3-D print. Customized fabrication and delivery to
patient

Fig. 2.22 Fixed retainers using digital technology. Memotain by Ormco is a CAD-CAM retainer made by precision cuts of nickel-titanium alloy
(Kravitz et al. 2017) to fit exactly into the anatomy of the teeth
2 Digital Technology as an Aid to Early Orthodontic Treatment 31

2.4 Pitfalls and Overreliance of Digital References

Technology
Baccetti T, Franchi L, McNamara JA. An improved version of the cervi-
cal vertebral maturation (CVM) method for the assessment of man-
I carefully worded the title of this chapter as an aid to orth- dibular growth. Angle Orthod. 2002;72(4):316–23.
odontic management. Such technology, though extremely Barenghi L, Barenghi A, Cadeo C, Di Blasio A. Innovation by
helpful, cannot replace the clinician (see Fig. 2.23). computer-­aided design/computer-aided manufacturing technology:
When dealing with patients, health-care workers have a look at infection prevention in dental settings. Biomed Res Int.
2020;2019:6092018.
long since recognized that human communication and com- Chalmers EV, McIntyre GT, Wang W, Gillgrass T, Martin CB, Mossey
passion play a key role in the management of the disease. PA. Intraoral 3D scanning or dental impressions for the assessment
The dead pan responses of technology cannot replicate this of dental arch relationships in cleft care. Which is superior? Cleft
(Dunbar et al. 2014). Palate Craniofac J. 2016;53(5):568–77.
Chaudhari PK, Kharbanda OP. Intraoral 3D scanning in cleft care. Cleft
Detection and the implication of systemic and oral dis- Palate Craniofac J. 2017;54(5):618.
eases also require a dental surgeon’s input. Christensen LR. Digital workflows in contemporary orthodontics.
AI, although extremely good at helping to determine APOS Trends Orthod. 2017;7:12–8.
an ideal method in obtaining tooth movement, is unable, Dunbar AC, Bearn D, McIntyer G. The influence of using digital diag-
nostic information on orthodontic treatment planning—a pilot
as yet, to integrate facial forms and bony anatomy com- study. J Healthc Eng. 2014;5(4):411–27.
pletely. Patients also exhibit differing permutations of Faber J, Faber C, Faber P. Artificial intelligence in orthodontics. APOS
malocclusion and respond differently to similar treat- Trends Orthod. 2019;9(4):201–5.
ment modalities. Fine tuning and tailor-made plans are Giancotti A, Cozza P, Mampieri G. Aligners and mandibular advance-
ment: a comprehensive option for phase I treatment of class II, divi-
inevitable. Patients’ needs and mental makeup also sion 1 cases. J Clin Orthod. 2020;54(9):513–24.
determine an appropriate treatment plan and goal (Faber Graf S. Direct printed metal devices—the next level of computer-aided
et al 2019). Algorithms, as yet, cannot accomplish these design and computer-aided manufacturing applications in the orth-
requirements. odontic care. APOS Trends Orthod. 2017;7:253–9.
Hansa I, Semaan SJ, Vaid NR. Clinical outcomes and patient perspec-
Finally, one must always be aware that the medicolegal tives of dental monitoring GoLive with Invisalign—a retrospective
implications of using such technology do not absolve the cohort study. Prog Orthod. 2020;21:16.
user from responsibilities. Hunter CJ. The correlation of facial growth with body height and skel-
etal maturation at adolescence. Angle Orthod. 1966;36(1):44–54.
Keim RG. New possibilities for aligners. J Clin Orthod.
2018;52(4):195–6.
Human Touch - Multi-Tasking -detection
Communication and Compassion of systemic and oral disease Kok H, Acilar AM, Izgi MS. Usage and comparison of artificial intel-
ligence algorithms for determination of growth and development by
cervical vertebrae stages in orthodontics. Prog Orthod. 2019;20:41.
Differing responses for Individual variance of problem Kravitz ND, Grauer D, Schumacher P, Jo Y. Memotain: a CAD/CAM
similar trearment (no “one size fits all”) nickel-titanium lingual retainer. AJODO. 2017;151:812–5.

Patients’s Preference and

Medico-legal implications
Psycological make-up

Fig. 2.23 Shortfalls and inability for digital technology to accomplish

 The Treatment of Class II Division 1
Malocclusion in Stages 3
Kurt Faltin Jr

The treatment of Class II Division I malocclusion is a multi- During follow-up, after finishing treatment, the patient
factorial event whose factories should be analyzed and treated. used the last Bionator 6 full days during 6 months and night-
It has high clinical prevalence, about 40%. This anomaly is time for another 6 months. The results can be observed in
considered acquired during the growth and development Fig. 3.3a–e.
stages by general dysfunction of the neuromuscular epigenetic It is to be convinced that the functional orthopedic inter-
factors (Enlow 1968; Moyers 1988; Korkhaus 1940). vention normalizing development factors and correcting
The orthopedic diagnosis shows the prevalent of 80% of neurophysiologic impute, through the central neuron system,
mandible retrognathism and 20% of maxillary prognathism. promote a very balance and stable development and excel-
The treatment protocol for both categories must be totally lent result (Petrovic and Stutzmann 1977) (Figs. 3.4, 3.5, 3.6,
different. 3.7, 3.8, 3.9 and 3.10).
First of all, we must have very clear priorities of the We must consider that only a few patients can be treated
neuro-functional, orthopedic, and orthodontic aspects which exclusively with Balters’ Bionator, Frankel’s functional reg-
are individually determined by accurate diagnosis protocols ulator, or other functional therapies. Both therapies are simi-
(Björk 1955). lar and considered the only totally functional jaw orthopedic
The most important priority, as the first stage to be con- devices (Bishara and Ziara 1989).
sidered, is the maxillary transverse deficiency. It is abso- The great majority of Class II Division I is patients with
lutely necessary that the maxilla and upper dental arch be retrognathic mandible, transverse discrepancy of the max-
prepared to receive mandible in facial harmony, providing a illa, upper incisor protrusion, lower dental crowding, total
normal Class I occlusion (Faltin Jr. et al. 2003). Class II distal occlusion, and general dysfunctions. They
The Bionator was develop by Prof. W. Balters in Germany need to be prepared before being submitted to a functional
in the 1960s, which is still being used today. orthopedic treatment like the Bionator therapy.
RME is the first recommended intervention. The Schwarz
plate or Ricketts lower utility arch may be indicated.
3.1 The Mandibular Retrognathism The next step of treatment will be the functional orthope-
Treatment dic stage with Balters’ Bionator, respecting all aspects from
the construction bite to the adjustment in the patient’s mouth
The first example represents a case with a pronounced man- and instruction and during treatment control.
dible retrognathic posture without dental arch discrepancies. Unfortunately, a small percentage of cases can be treated
The treatment protocol was Balters’ Bionator to normalize only using Bionators.
facial harmony in anterior and vertical directions (Balters Patient 3: J.D.S., 9 years 3 months. at the beginning of
1964) (Figs. 3.1 and 3.2). treatment (Fig. 3.11).

K. Faltin Jr (*)
Face Orthopedics – Orthodontics, Rua Frei Caneca,
São Paulo, SP, Brazil
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 33

J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_3
34 K. Faltin Jr

a b

c d

Fig. 3.1 (a–e) Patient 1: M.S., 9 yeas 3 months. at the beginning of treatment
3 The Treatment of Class II Division 1 Malocclusion in Stages 35

a b

Fig. 3.2 (a–c) During 3 years 2 months, the patient used three Balters’ Bionators
36 K. Faltin Jr

a b

c d

Fig. 3.3 (a–e) With no use of any other fixed appliance. He got a normal occlusion, an excellent facial harmony (divine proportion), and balanced
neuromuscular functions
3 The Treatment of Class II Division 1 Malocclusion in Stages 37

a b

Fig. 3.4 (a, b) Illustrate a lateral cephalometric study before and after the treatment

After a total analysis of the various complementary exam- The retention was upper plate and lower lingual fixed
inations and appropriate analysis, the diagnosis will demon- (Fig. 3.13 shows the final case and Fig. 3.14 lateral cephalo-
strate upper transverse discrepancy in comparison with the metric image). There has been an absolutely excellent facial
lower one, a deep bite, or an open bite, dental crowding, and result. Facial dimensions are according to Fibonacci’s divine
respiratory dysfunction (van der Linden 1986) (Fig. 3.12). proportion.
The patient must be prepared before being submitted to In cases like this, orthopedic and orthodontic treatment
functional therapy like Balters’ Bionator (Fig. 3.11). must be started very soon in order to be able to correct facial
Sequence of the first stage: rapid maxillary expansion and harmony, normal occlusion, and neuromuscular behavior.
simultaneously lower utility arch were indicated to correct G. Sander (2001) developed a new appliance—the SII. It
the lower incisors’ implantation. This phase took 8 months. consists of two plates with expansion screws and the upper
The second stage started immediately and was related one with a metallic guide that contacts the lower plate in the
with the facial harmony. She must be treated with an anterior region.
­appropriated protocol in vertical, latero-lateral, and antero- SII appliance is a mandible protractor with transverse
posterior directions. In this stage, the patient used a modified expansion of the maxilla and up righting of molar posterior
Balters’ Bionator. teeth. The advantage of SII treatment is the possibility to
Balters’ Bionator was installed without removing the lower widen the maxilla, correct deep bite, and open space for den-
utility arch in place. The use of Balters’ Bionator took 1 year. tal orthodontic treatment and mandible advance at the same
The purpose of the third stage is to correct teeth alignment time. In these cases, it is recommended to use Sander’s plate
and implantation and finally achieve functional normal (SII).
occlusion.
38 K. Faltin Jr

a b

c d

Fig. 3.5 (a–e) The long-term evaluation after 7 years was performed and demonstrates the stability and even a better situation after orthopedic
mandible Class II treatment
3 The Treatment of Class II Division 1 Malocclusion in Stages 39

a b

Fig. 3.6 (a–c) Frankel’s functional regulator (FR2) is another orthopedic appliance that can be used in the treatment of Class II Division I maloc-
clusion with mandible retrognathism, in growing prepubertal period (Fränkel 1989)
40 K. Faltin Jr

a b

c d

Fig. 3.7 (a–e) The next clinical case: Patient 2: P.H.L., 8y at the beginning of treatment is similar to the first patient, but this case has some
orthodontic problems such as crowding, upper arch protruded teeth, narrow maxilla arch, deep vertical bite, and dysfunctions
3 The Treatment of Class II Division 1 Malocclusion in Stages 41

a b

c d

Fig. 3.8 (a–e) The patient used three FR2 over 5 years of treatment, progress situation at 12 years 7 months
42 K. Faltin Jr

a b

c d

Fig. 3.9 (a–e) The stability posttreatment over 2 years with no retention
3 The Treatment of Class II Division 1 Malocclusion in Stages 43

a b

Fig. 3.10 (a, b) Illustrate a lateral cephalometric study before and after the treatment and the excellent quality of mandibular development

Fig. 3.11 Initial records

44 K. Faltin Jr

Fig. 3.12 The sequence before Balters’ Bionator use

Fig. 3.13 Shows the final case

3 The Treatment of Class II Division 1 Malocclusion in Stages 45

Fig. 3.14 Lateral cephalometric study before and 5 years after

Sander’s SII and Clark’s Twin Block have a similar action cular function. That is the real stimulation for normal
(Fig. 3.15). functional adaptation including form, size, and shape of the
The first stage of treatment which lasted 1 year and masticator system.
6 months shows the evolution and complete treatment with The advanced of SII treatment is the possibility to wide
SII. The next stage was with fix appliance and included a maxilla, correct deep bite, open space for dental orthodontic
retention of 15 months (Sander 2001) (Fig. 3.16). treatment and advanced mandible.
Figs. 3.17 (a–e) present the end of treatment. Patient 5: L.M., 4 years 6 months. at the beginning of
Cases of patients with pronounced Class II Division I with treatment. The treatment will take a long time using the
severe retrognathic mandible, upper protrusion, deep bite, and Balters’ Bionator during the first stage and Sander’s double
dysfunctions but without lower crowding must be treated imme- plates (SII) during the second stage (Figs. 3.20, 3.21, 3.22
diately, even in the deciduous dentition (Figs. 3.18 and 3.19). and 3.23).
The biological reason is that the development of the den- The observed result is very important taking in mind that
tal facial complex under such reverse epigenetic factors will he has a long development future. (Fig. 3.22)
get worse with time. These excellent results could only be obtained when the
All priorities could be normalized and have facial ortho- treatment starts at a very young age (Figs. 3.24, 3.25, 3.26,
pedic harmony, balanced occlusion, and balanced neuromus- 3.27 and 3.28).
46 K. Faltin Jr

a b

c d

Fig. 3.15 (a–e) Patient 4: R.L.B.H., 12y at the beginning of treatment

3 The Treatment of Class II Division 1 Malocclusion in Stages 47

Fig. 3.15 (continued)

a b

Fig. 3.16 The next stage with fixed appliance including retention took 15 months in retenetion with stable results
48 K. Faltin Jr

a b

c d

Fig. 3.17 (a–e) Represent the result of patient who finished treatment with an excellent result
3 The Treatment of Class II Division 1 Malocclusion in Stages 49

a b

c d

Fig. 3.18 (a–e) The long-term evaluation confirms a very stable result
50 K. Faltin Jr

Fig. 3.19 Lateral cephalometric: before, immediate after, and a long-term treatment

Fig. 3.20 Pre treatment photographs

3 The Treatment of Class II Division 1 Malocclusion in Stages 51

Fig. 3.21 The patient used upper expansion removable plate with superelastic screws, SII, and Bionator from November 2001 to March 2005
52 K. Faltin Jr

Fig. 3.22 From June 2010 to June 2013, the second stage, the patient was treated with fixed appliance and retention

Fig. 3.23 After long-term treatment

3 The Treatment of Class II Division 1 Malocclusion in Stages 53

Fig. 3.24 Patient 6: K.B., 10y at the beginning of treatment

Fig. 3.25 Balters’ Bionator result

54 K. Faltin Jr

Fig. 3.26 Then fixed appliance, and quadri-helix

Fig. 3.27 The end of treatment

The patient was treated in a unique stage. The priority was Balters’ Bionator philosophy and then fix appliance accord-
to achieve first the facial harmony because of the poor verti- ing to Ricketts’ philosophy.
cal dimensions. In sequence she was treated with Patient 7: F.A., 10 years 2 months. at the beginning of
biomechanics-­fixed therapy. treatment. Another typical case of mandible retrognathism
The treatment sequence: (Figs. 3.29a–c and 3.30a–c), again priority number 1 facial
In this case because of the advanced stage of develop- harmony (Figs. 3.31, 3.32, 3.33 and 3.34).
ment, we decided to treat first the facial harmony with
3 The Treatment of Class II Division 1 Malocclusion in Stages 55

Fig. 3.28 Lateral cephalometric study: before and immediate after and a long term

a b c

Fig. 3.29 Pre treatment photographs

56 K. Faltin Jr

a b

Fig. 3.30 Frontal and lateral photographs at the beginning of the treatment

Figures 3.35 (a, b) are images from helicoidal tomogra- After the orthopedic correction, the treatment is finalized
phy, before and after the treatment, demonstrating the func- with biomechanics-fixed appliances and finale retention.
tional adaptation on TMJs, relocating the condyles in glenoid Patient 8: S.C.W., 11y at the beginning of treatment
cavities. (Figs. 3.37a, b and 3.38a–c).
The first stage of treatment was maxillary expansion with
upper removable expansion plate, and the treatment time was
3.2 The Maxillary Prognathism Treatment 8 months (Fig. 3.39).
The second stage of treatment was extraoral traction for
When Class II division I is characterized as maxillary protru- 12 months, fixed orthodontic, and retention. The treatment
sion, the treatment protocol must be realized and indicated time was a total of 2 years and 11 months (Fig. 3.39).
extraoral traction, developed by G. Sander (Fig. 3.36). This The long treatment evaluation is shown in Fig. 3.40.
special extraoral traction appliance has constant cervical Lateral cephalometric evaluation (Fig. 3.41) before, dur-
force of 4–5 Newtons. The appliance should be used for ing, and long-term control shows a total stable situation.
18 h/day. Patient 9: C.P., 9y 10 m. at the beginning of treatment
The traction is always cervical. If the patient has a hori- (Fig. 3.42). This case illustrates a combined treatment of
zontal growth tendency, it is necessary to associate with an extraoral appliance and Balters’ Bionator.
upper anterior bite plate. If the patient has a vertical growth
tendency, it is indicated a lower posterior bite plate.
3 The Treatment of Class II Division 1 Malocclusion in Stages 57

Fig. 3.31 The occlusion with and without the Balters’ Bionator when the class I was achieved. The patient used five Balters’ Bionator during
2 years and 3 months and completed the treatment using fixed appliance

The sequence was as follows: 3. Extraoral appliance (1 year) and total fixed appliance
(Fig. 3.44), shows the case at the end of the treatment.
1. Maxilla transverse correction. 4. Long-term control (Fig. 3.45).
2. Balters’ Bionator therapy during 2y and 10 m. (Fig. 3.43). 5. Lateral cephalometric images before and after the treat-
ment (Fig. 3.46).
58 K. Faltin Jr

Fig. 3.32 Present end of the treatment time was 4 years 3 months
3 The Treatment of Class II Division 1 Malocclusion in Stages 59

Fig. 3.33 The stability of the treatment in long-term observation 6 years after retention
60 K. Faltin Jr

Fig. 3.34 The lateral Rx where it is possible to observe very clear the development of the face and recognize the mandible growth
3 The Treatment of Class II Division 1 Malocclusion in Stages 61

a Before After

b Before After

Fig. 3.35 (a) Right condyle. (b) Left condyle

62 K. Faltin Jr

Fig. 3.36 Cervical extraotral appliance in place

a b

Fig. 3.37 Photographs at the beginning of the treatment

3 The Treatment of Class II Division 1 Malocclusion in Stages 63

a b

Fig. 3.38 Frontal and lateral pre treatment photographs

64 K. Faltin Jr

Fig. 3.39 Second stage of treatment

3 The Treatment of Class II Division 1 Malocclusion in Stages 65

Fig. 3.40 Final photographs

66 K. Faltin Jr

Fig. 3.41 Comparison pre and post lateral radiographs

3 The Treatment of Class II Division 1 Malocclusion in Stages 67

Fig. 3.42 Initial photographs

68 K. Faltin Jr

Fig. 3.43 A bionator was indicated An important improvement was observed

3 The Treatment of Class II Division 1 Malocclusion in Stages 69

Fig. 3.44 Final photos

70 K. Faltin Jr

Fig. 3.45 Control 5 years later

Fig. 3.46 Comparison Pre and post treatment cephalograms

3 The Treatment of Class II Division 1 Malocclusion in Stages 71

3.3 Conclusion Bishara SE, Ziara RR. Functional appliances: a review. Am J Orthod
Dentofac Orthop. 1989;95:250–8.
Björk A. Cranial base development: a follow-up x-ray study of the indi-
According to the knowledge of the biological process vidual variation in growth occurring between the ages of 12 and
involved in the dental masticatory system, such as the use of 20 years and its relation to brain case and face development. Am J
methods to individualize diagnosis and to create and corre- Orthod Oral Surg. 1955;41:106–24.
Enlow DH. The human face. New-York: Hoeber Med Div, Harper and
spond treatment planning, using the most efficient and Row; 1968.
appropriate therapeutic appliances, we certainly achieved Faltin K Jr, Faltin RM, Baccetti T, Franchi L, Ghiozzi B, Mc Namara
facial harmony, normal occlusion, and neurophysiological JA Jr. Long-term effectiveness and treatment timing for bionator
corrections which provided a homodynamic activity. therapy. Angle Orthod. 2003;73:221–30.
Fränkel R. Orofacial orthopedics with function regulator. Berlim:
The future tendency of science philosophy of our profes- Karger Gmbh; 1989.
sional activity encourages us to recognize that facial ortho- Korkhaus G La Escuela Odontológica Alemana. Editorial Labor.
pedics is the first priority before orthodontics every time. Génesis de las anomalías de la oclusión y de las deformaciones de
The neuromuscular balance gives the long-term stability and los maxilares, 1940.
Moyers RE. Handbook of orthodontics. Chicago: Year Book Medical
the maintenance of the normal occlusion. Publishers; 1988.
The orthodontists must be prepared to understand the per- Petrovic A, Stutzmann J. Further investigations of the functioning of the
manent evolution of our specialty respecting the basic “comparator” of the servosystem (respective positions of the upper
principles. and lower dental arches) in the control of the condylar cartilage growth
rate and of the lengthening of the mandible. The Biology of Occlusal
Development, Ann Arbor, Monograph No. 7; 1977. p. 255–291.
Sander FG. Functional processes when wearing the SII appliance dur-
References ing the day. J Orofac Orthop. 2001;62(4):264–74.
van der Linden FPGM. Facial growth and facial orthopedics. Chicago:
Balters W. Die Technik und Übung der allgemeinen und speziellen Quintessence, Inc.; 1986.
Bionator- Therapie. Quintessenz, Heft, 5.77 IV, 1964.
 Is Early Class II Treatment Worth
the Effort? 4
Amit Bhardwaj

Class II malocclusions are of interest to orthodontists since Simple orthodontic appliances can be used to correct
they constitute a significant 45% of the cases they treat axial inclination(s) of the upper and/or lower anterior teeth.
(Bishara and Saunders 2001). In individuals with Class II
malocclusions, etiology can be dental, skeletal, or a combi-
nation of both. Most children with Class II malocclusions 4.2 Functional Class II Malocclusion
have skeletal problems. (Figs. 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 4.10,
Early treatment mainly aims to modify growth of the jaws 4.11, 4.12, 4.13, 4.14, and 4.15)
and reduce skeletal discrepancy and muscular imbalance
(Moyers 1988). Objectives are to achieve good function, 4.2.1 Case # 1 (Figs. 4.5, 4.6, 4.7, 4.8, 4.9, 4.10,
good esthetics, and good stability. 4.11, 4.12, 4.13, and 4.14)
Before starting the treatment, we must begin with end
results in mind, which means we must go through compre- This functional Cass II case fits into Reichenbach and Taatz’s
hensive examination, diagnosis, and treatment planning. explanation of foot and shoe phenomenon (McNamara and
We do case analysis to recognize the problems, make a Brudon 1993, 2001).
list of the problems, carry out necessary examination(s), and
interpret examination results to diagnose.
According to Thomas Rakosi, cephalometric classification 4.3 Skeletal Class II with Fault
of Class II malocclusions is as follows (Graber et al. 1997): in the Maxilla (Fig. 4.16)

1. Dentoalveolar Class II malocclusion. Many authors suggested the use of extraoral appliances to
2. Functional Class II malocclusion. inhibit growth of the maxilla such as headgears, e.g., cervi-
3. Skeletal Class II with fault in the maxilla. cal pull headgear for horizontal growth pattern (Fig. 4.17a)
4. Skeletal Class II with fault in the mandible. and high-pull headgear for vertical growth pattern
5. Combination of 3 and 4. (Fig. 4.17b, c) (Firouz et al. 1992; Southard et al. 2013).

One must bear in mind that we must treat at the right

place at the right time with proper appliances. 4.4 Skeletal Class II with Fault
in the Mandible (Fig. 4.18)

4.1 Dentoalveolar Class II Malocclusion 4.4.1 Case # 2 (Figs. 4.19, 4.20, 4.21, 4.22, 4.23,
(Figs. 4.1, 4.2, and 4.3) 4.24, 4.25, 4.26, 4.27, and 4.28)

Abnormal oral habits, such as lip biting (Fig. 4.2) and thumb Functional appliances, both removable and fixed, are used
sucking (Fig. 4.3) (Fleming 2017), play important roles in to forward the mandible into a new position with the objec-
causing this type of Class II malocclusion. tive to minimize skeletal discrepancy. There is no consen-
sus about the best functional appliance to be used for this

A. Bhardwaj (*)
Department of Orthodontics, Modern Dental College & Research
Centre, Indore, MP, India

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 73

J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_4
74 A. Bhardwaj

Maxilla

Mandible

Fig. 4.3 Thumb sucking

SNB SNA

Fig. 4.1 Dentoalveolar Class II malocclusion, fault at axial

inclination(s) of upper and/or lower anterior teeth

Maxilla

Mandible

SNB SNA

Fig. 4.4 Functional Class II relationship with a distally forced bite.

From an anterior rest position, the mandible glides into a posterior
habitual occlusion, under the influence of tooth guidance

Fig. 4.2 Lip biting, lower lip trapped between upper and lower anterior
teeth
4 Is Early Class II Treatment Worth the Effort? 75

Fig. 4.5 An extraoral picture of a 12-year-old boy at rest showed pro-

clined maxillary incisors, his lower lip was trapped between the upper
and lower anterior teeth

a b

Fig. 4.6 (a, b) His intraoral pictures showed stage of mixed dentition; he had large overjet and poor oral hygiene
76 A. Bhardwaj

a b

Fig. 4.7 (a, b) Intraoral pictures showed V-shaped maxillary arch U-shaped (b); therefore, he could only occlude his teeth when he bit
form, two supernumerary teeth located posterior to the upper central behind the supernumerary teeth
incisors at the level of teeth # 12 and # 22. The lower arch form was

Fig. 4.8 His lateral cephalogram showed severe skeletal discrepancy

between the maxilla and the mandible, as he could only occlude his
teeth when he bit behind the supernumerary teeth
4 Is Early Class II Treatment Worth the Effort? 77

a b

Fig. 4.9 (a, b) After the supernumerary teeth were extracted, the V-shaped upper arch gradually transformed into U-shaped

a b

Fig. 4.10 (a, b) The lower arch transformed gradually as well to fit the transformed upper arch

a b

Fig. 4.11 (a, b) Intraoral pictures showed obvious changes occurred after extraction of the supernumerary teeth
78 A. Bhardwaj

a b

Fig. 4.12 (a, b) Improvement of both overjet and overbite

a b

Fig. 4.13 (a, b) Comparison of extraoral pictures pre- (a) and postextraction of the supernumerary teeth (b); facial appearance and smile were
improved
4 Is Early Class II Treatment Worth the Effort? 79

a b

Fig. 4.14 (a, b) Comparison of his lateral cephalograms pre- and postextraction of the supernumerary teeth showed reduction of overjet as he
could bite in a more forward position

Upper arch

Lower arch

Fig. 4.15 The foot in figure represents U-shaped lower arch, could not
slide forward to fit the narrow head shoe which represents the V-shaped
upper arch
80 A. Bhardwaj

a b

Maxilla
Maxilla

Mandible
Mandible

SNB SNA
SNB SNA

Fig. 4.16 (a) Skeletal Class II relationship with fault in the maxilla; maxilla is prognathic, mandible is orthognathic. (b) Skeletal Class II relation-
ship with prognathism and ante-inclination of the maxilla (anterior end tipped up)

a b c

Fig. 4.17 (a) Cervical pull headgear. (b): High-pull headgear. (c) Splint with headgear tubes
4 Is Early Class II Treatment Worth the Effort? 81

purpose. There are many roads to Rome; we should use the

appliances which work best in our hands (Wishney et al.
2019).
Twin block, introduced by William J. Clark in 1977, is to
be used in growing patient with retrognathic mandible and
narrow maxillary arch (Clark and Clark 2014).

Maxilla
4.4.2 Case # 3 (Figs. 4.29, 4.30, 4.31, 4.32, 4.33,
4.34, 4.35, 4.36, and 4.37)

4.4.3 Case # 4 (Figs. 4.38, 4.39, 4.40, 4.41, 4.42,

4.43, 4.44, 4.45, 4.46, 4.47, 4.48, 4.49, 4.50,
and 4.51)
Mandible
After going through case # 2 to # 4, it can be concluded that
different treatment approaches were used in each case, as all
cases are unique. Therefore, we still have to emphasize on
SNB SNA
“treat at the right place, at the right time with proper
appliances.”
Fig. 4.18 Skeletal Class II relationship with fault in the mandible;
maxilla is orthognathic and mandible is retrognathic

a b c

Fig. 4.19 (a–c) Extraoral pictures of a 12-year-old boy; he had convex facial profile and incompetent lips
82 A. Bhardwaj

a b c

Fig. 4.20 (a–c) When smiling, his lower lip was trapped between the upper and lower anterior teeth, which could cause the upper anterior teeth
to be more proclined and lower anterior teeth more retroclined

Fig. 4.21 (a, b) Visual

treatment objective (VTO) a b
program was used to predict
the treatment outcomes
4 Is Early Class II Treatment Worth the Effort? 83

b c

d e

Fig. 4.22 (a–e) His intraoral pictures showed stage of late mixed den- had transposition of tooth # 13 (a, b, d), retention of tooth # 53, pro-
tition; he had V-shaped upper arch and U-shaped lower arch, Class II clined upper anterior teeth, large overjet, and mild spacing in the upper
molar relationships and Class II canine relationship on the left side, arch
while on the right side canine relationship could not be identified. He
84 A. Bhardwaj

b c

d e

Fig. 4.23 (a–e) Twin block with expansion screw in the upper plate in situ (Maspero et al. 2015)
4 Is Early Class II Treatment Worth the Effort? 85

a b c

Fig. 4.24 (a–c) Extraoral pictures of post twin block treatment; he had more pleasing profile and pleasing smile due to forward movement of the
mandible

b c

Fig. 4.25 (a–e) Post-twin block intraoral pictures showed the mandi- bite could be seen here. Upper arch was expanded transversally (d) and
ble moved anteriorly. Class I molar relationships and Class I canine fit well with the lower arch (e)
relationship on the left side and decreased overjet and decreased over-
86 A. Bhardwaj

d e

Fig. 4.25 (Continued)

Fig. 4.26 (a, b) Comparison

a b
of lateral cephalograms
pre- and post-­twin block
showed the mandible in a
more anterior position with
reduction of overjet and
overbite (Mills and
McCulloch 1998)

a b

Fig. 4.27 (a, b) Orthopantomogram (OPG) pre- and post-twin block showed transposition of tooth # 13 and retention of # 53
4 Is Early Class II Treatment Worth the Effort? 87

b c

d e

Fig. 4.28 (a–e) Second phase treatment with fixed appliance to align tooth # 13 was one of the main objectives. Two alternatives were considered,
either place it in between teeth # 14 and # 15 or move it forward to replace tooth # 53
88 A. Bhardwaj

a b c

Fig. 4.29 (a–c) Extraoral pictures of a 12-year-old boy showed convex facial profile; he had competent lips and strong mentalis muscle

a b c

Fig. 4.30 (a–c) When smiling, typical pattern of Class II div.2 incisor pattern could be obviously seen here
4 Is Early Class II Treatment Worth the Effort? 89

b c

d e

Fig. 4.31 (a–e) Pretreatment intraoral pictures showed stage of mixed dentition. His dentition showed typical Class II Div.2 features; Class II
molar relationships, retroclined upper central incisors, proclined upper lateral incisors, 80–90% deep bite, and reduced overjet
90 A. Bhardwaj

a b

c d

Fig. 4.32 (a–d) Intraoral pictures; modified protraction utility arch was used to alter axial inclination angle of upper central incisors

a b c

Fig. 4.33 (a–c) Intraoral pictures after correction of axial inclination angle of upper central incisors; the mandible could then be brought in a more
anterior position by using twin block
4 Is Early Class II Treatment Worth the Effort? 91

Fig. 4.34 (a–d) Twin block

with expansion screw in the a b
upper plate in situ

c d

a b c

Fig. 4.35 (a–c) Extraoral pictures of post-twin block; he had competent lips, nice smile, and more pleasing profile due to forward movement of
the mandible
92 A. Bhardwaj

b c

d e

Fig. 4.36 (a–e) Intraoral pictures of post-twin block showed stage of mixed dentition still; Class I molar relationships with acceptable overjet and
over bite, tooth # 23 was erupting into oral cavity
4 Is Early Class II Treatment Worth the Effort? 93

Fig. 4.37 (a–c) second phase a

treatment with fixed
appliances to optimize
treatment results

b c

a b c

Fig. 4.38 (a–c) Extraoral pictures of a 10-year-old girl showed gummy smile and typical Class II div.2 incisors pattern
94 A. Bhardwaj

Fig. 4.39 (a–e) Intraoral a

pictures showed stage of
mixed dentition; Class II
molar relationships and Class
II canine relationships with
square-­shaped upper arch,
complete cover bite, typical
Class II div.2 incisors pattern,
retroclination of teeth # 13
and #23, scissor bite at teeth #
24 and # 34, and severe
crowding of teeth in the lower
arch b c

d e

Fig. 4.40 (a–c) Intraoral

pictures showed the upper
a
teeth from teeth # 16 to # 26
were bonded with exception
of teeth # 55 and # 65; NiTi
wire was engaged to all
bonded teeth except # 14 and
# 24, in order to procline all
teeth from the upper right
canine to the upper left canine
b c
4 Is Early Class II Treatment Worth the Effort? 95

Fig. 4.41 (a, b) Extraoral

pictures during the treatment a b
showed a beautiful smile with
good smile line, smile arc,
and good buccal corridors.
Change in axial inclination of
the upper teeth could be seen
in Fig. b

Fig. 4.42 (a–e) Intraoral

pictures during the treatment
a
showed some of the lower
teeth were bonded, raised
bites on teeth # 14, # 16, # 24,
and #26 to align the lower
teeth and to unlock the
mandible. Tooth # 45 was
erupting and teeth # 55, # 65,
and # 75 were still present b c

d e
96 A. Bhardwaj

Fig. 4.43 (a, b) Comparison

of extraoral pictures at rest, a b
pre-, and during treatment
showed improvement of
frontal facial profile

Fig. 4.44 (a, b) Comparison

of extraoral pictures when a b
smiling; pre- and during
treatment showed no more
gummy but beautiful smile
4 Is Early Class II Treatment Worth the Effort? 97

Fig. 4.45 (a, b) Comparison

of lateral facial profile; pre-
a b
and during treatment showed
satisfactory improvement

a b

Fig. 4.46 (a, b) Comparison of intraoral pictures from frontal view; pre- and during treatment showed improvement of upper and lower arch
forms; upper and lower anterior teeth became less crowded, improvement of the overjet and overbite

a b

Fig. 4.47 (a, b) Comparison of intraoral pictures from the right side; pre- and during treatment; Class I molar relationship was achieved, improve-
ment of axial inclination of upper and lower anterior teeth as well as overjet and overbite
98 A. Bhardwaj

a b

Fig. 4.48 (a, b) Comparison of intraoral pictures from the left side; pre- and during treatment; Class I molar relationship was achieved, improve-
ment of axial inclination of upper and lower anterior teeth as well as overjet and overbite

a b

Fig. 4.49 (a, b) Comparison of intraoral pictures of the upper arch; pre- and during treatment, the upper teeth aligned nicely in a new well-formed
upper arch

a b

Fig. 4.50 (a, b) Comparison of intraoral pictures of the lower arch; pre- and during treatment, the lower teeth aligned nicely in a new well-formed
lower arch
4 Is Early Class II Treatment Worth the Effort? 99

a b

Fig. 4.51 (a, b) Lateral cephalograms pre- and during treatment showed improvement of lateral skeletal profile as well as the overjet and
overbite

4.5 Skeletal Class II with Fault in both 4.5.2 Case # 6 (Figs. 4.61, 4.62, 4.63, 4.64, 4.65,
the Maxilla and the Mandible 4.66, 4.67, 4.68, and 4.69)

Activator introduced by Viggo Andresen in 1908 was one of In this case, we used Activator to advance the mandible and
the first functional appliances used to correct jaw discrep- headgear to control maxillary growth (Bhardwaj et al.
ancy in growing patients. Applications for the use of the 2020).
Activator included Class II div.1, Class II div.2, Class III, and As mentioned previously, case analysis is very important.
anterior open-bite cases (Luder 1982). After comparing chronologic age, dental age, and skeletal
For skeletal Class II malocclusion with fault in both the age in this case, the patient was still in a stage of active
maxilla and the mandible; Luder recommended Activator growth. To use functional appliance with orthopedic extra-
with thin construction bite, which would lead to improve- oral appliance would have a great chance to success in solv-
ment in mandibular retrognathism and reduction in maxil- ing malocclusion.
lary prognathism (Luder 1982). So, Activator with high-pull headgear were used in
this case to advance the mandible and to inhibit growth of
the maxilla along with correction of maxillary
4.5.1 Case # 5 (Figs. 4.52, 4.53, 4.54, 4.55, 4.56, ante-inclination.
4.57, 4.58, 4.59, and 4.60)
100 A. Bhardwaj

a b c

Fig. 4.52 (a–c) Extraoral pictures of a 12-year-old girl showed convex facial profile; protruding upper anterior teeth and lower lip trapped
between upper and lower anterior teeth

a b c

Fig. 4.53 (a–c) When smiling she showed gummy smile, prognathic maxilla, and protruding upper anterior teeth
4 Is Early Class II Treatment Worth the Effort? 101

b c

d e

Fig. 4.54 (a–e) Intraoral pictures showed stage of mixed dentition, Class II molar relationships with large overjet and deep overbite. Tooth # 33
was erupting lingual to tooth # 73
102 A. Bhardwaj

Fig. 4.55 Lateral cephalogram showed skeletal Class II

malocclusion with large overjet, lower lip trapped between upper
and lower anterior teeth

b c

Fig. 4.56 (a–c) Activator with acrylic capped on incisal edges of lower anterior teeth was used in this case to prevent them from further
proclination
4 Is Early Class II Treatment Worth the Effort? 103

a b c

Fig. 4.57 (a–c) Extraoral pictures after Activator treatment showed more harmony of facial profile. She had everted upper lip resulting in incom-
petent lips; lower lip was not trapped

b c

Fig. 4.58 (a–e) Intraoral pictures after Activator treatment showed Class I molar relationships, end on canine relationships; well aligned upper
teeth and mild crowding in lower arch, upper and lower dental midlines were not coincided, acceptable overjet and overbite
104 A. Bhardwaj

d e

Fig. 4.58 (Continued)

a b

Fig. 4.59 (a, b) Comparison of lateral cephalograms pre- and post-Activator showed improvement of skeletal relationships between the maxilla
and the mandible due to anterior positioning of the mandible and reduction of overjet and overbite
4 Is Early Class II Treatment Worth the Effort? 105

b c

d e

Fig. 4.60 (a–e) Second phase treatment with fixed appliances to optimize treatment results
106 A. Bhardwaj

a b c

Fig. 4.61 (a–c) Extraoral pictures of a 12-year-old boy showed convex facial profile, lower lip trapped between upper and lower anterior teeth

a b c

Fig. 4.62 (a–c) When smiling he showed prognathic maxilla with gummy smile, protruding upper anterior teeth, and lower lip trapped
4 Is Early Class II Treatment Worth the Effort? 107

b c

d e

Fig. 4.63 (a–e) Intraoral pictures showed stage of transition from mixed dentition to permanent dentition; he had Class II molar and Class II
canine relationships, spacing in both arches, large overjet and deep overbite
108 A. Bhardwaj

Fig. 4.64 (a, b) Lateral

cephalogram showed skeletal a b
Class II malocclusion;
prognathic maxilla with
ante-inclination, retrognathic
mandible with large
mandibular symphysis as
illustrated in Fig. b, and lower
lip trapped. The patient was in
CS2–CS3 according to
cervical vertebral maturation
index, indicated active growth
potential (Baccetti et al. 2002)

Fig. 4.65 (a, b) The patient

with high-pull headgear a b
(extraoral orthopedic device)

a b c

Fig. 4.66 (a–c) Intraoral pictures showed Activator with headgear tubes in situ
4 Is Early Class II Treatment Worth the Effort? 109

a b

c d

Fig. 4.67 (a–f) Change of smiles after Activator and headgear treatment; before the treatment (a, c, e) and after the treatment (b, d, f). Improvement
in esthetic of the smiles is obvious
110 A. Bhardwaj

e f

Fig. 4.67 (continued)

b c

Fig. 4.68 (a–e) Intraoral pictures after Activator and headgear treatment showed Class I molar and Class I canine relationships; spacing in the
upper arch, reduction in overjet and overbite
4 Is Early Class II Treatment Worth the Effort? 111

d e

Fig. 4.68 (Continued)

a b c

Fig. 4.69 (a–c) second phase orthodontic treatment with fixed appliances to optimize treatment results

4.6 Stability

4.6.1 Case # 7 (Figs. 4.70, 4.71, 4.72, 4.73, 4.74,

4.75, and 4.76)
112 A. Bhardwaj

Fig. 4.70 (a, b) Extraoral

pictures of a 9-year-old girl a b
showed convex facial profile,
lower lip trapped between
upper and lower anterior teeth

a b c

Fig. 4.71 (a–c) Intraoral pictures showed stage of early mixed dentition; she had Class II molar relationships, large overjet, and deep overbite;
upper and lower dental midlines were not coincided

Fig. 4.72 (a, b) Extraoral

pictures at the end of the a b
treatment showed
improvement of her facial
profile. She had pleasing
smile with good combination
of smile line, smile arch, and
buccal corridors
4 Is Early Class II Treatment Worth the Effort? 113

a b c

Fig. 4.73 (a–c) Intraoral pictures at the end of the treatment showed Class I molar relationships; upper and lower dental midlines were coincided,
acceptable overjet and overbite

a b

Fig. 4.74 (a, b) Extraoral pictures 3 years and 5 months posttreatment showed stability of the treatment outcomes

a b c

Fig. 4.75 (a–c) Intraoral pictures 3 years and 5 months posttreatment showed as well stability of the treatment outcomes

a b c d

Fig. 4.76 (a–d) Comparison of lateral cephalograms before the treatment (a), 1 year later at the end of Class II Activator treatment (b), at the end
of the orthodontic treatment (c), and 1 year posttreatment (d)
114 A. Bhardwaj

4.7 Conclusion Baccetti T, Franchi L, McNamara JA Jr. An improved version of the

cervical vertebral maturation (CVM) method for the assessment of
mandibular growth. Angle Orthod. 2002;72(4):316–23. https://doi.
To answer the question whether it is worth the effort to treat org/10.1043/0003-­3219(2002)072<0316:AIVOTC>2.0.CO;2.
Class II malocclusions early, we must contemplate treatment Bishara SE, Saunders WB. Textbook of orthodontics. Saunders Book
results. Treatment results should meet the treatment objec- Company; 2001.
Clark W, Clark WJ. Twin block functional therapy. JP Medical Ltd;
tives, which are good function, good esthetics, and good 2014.
stability. Firouz M, Zernik J, Nanda R. Dental and orthopedic effects of high-­
To treat early, we can correct malocclusions and prevent pull headgear in treatment of class II, division 1 malocclusion. Am
them from becoming more severe in later stage. By using J Orthod Dentofac Orthop. 1992;102(3):197–205.
Fleming PS. Timing orthodontic treatment: early or late? Aust Dent J.
advantage of existing growth, orthodontists can harmonize 2017;62:11–9.
skeletal discrepancy to improve function and esthetics. If not Graber TM, Rakosi T, Petrovic AG. Dentofacial orthopedics with func-
treated early, in many cases, the malocclusions could cause tional appliances. 2nd ed. St. Louis: Mosby; 1997.
problem(s) in function and negative psychological impact on Luder HU. Skeletal profile changes related to two patterns of activator
effects. Am J Orthod. 1982;81(5):390–6.
the patients. Maspero C, Galbiati G, Giannini L, Farronato G. Sagittal and vertical
According to the author’s own experience, the author is effects of transverse sagittal maxillary expander (TSME) in three
convinced that early treatment gives positive results. The different malocclusion groups. Prog Orthod. 2015;16(1):6.
author feels that besides achieving improvement of function, McNamara JA, Brudon WL. Treatment of tooth-size/arch-size discrep-
ancy problems. In: Orthodontic and orthopaedic treatment in the
the patients gained more self-esteem. mixed dentition. Ann Arbor, MI: Needham Press; 1993.
Stability is a real concern to orthodontists as relapse could McNamara JA, Brudon WL, Kokich VG. Orthodontics and dentofacial
occur at any time after the treatment, no matter how early or orthopedics. Ann Arbor, Mich: Needham Press; 2001.
late. If stability could be added up to treatment results, the Mills CM, McCulloch KJ. Treatment effects of the twin block appli-
ance: a cephalometric study. Am J Orthod Dentofac Orthop.
answer is “it is worth it to treat class II malocclusions early!” 1998;114(1):15–24.
Moyers RE. Handbook of orthodontics. Chicago: Year Book Medical
Publishers; 1988.
References Southard TE, Marshall SD, Allareddy V, Uribe LM, Holton NE. An
evidence-based comparison of headgear and functional appliance
therapy for the correction of class II malocclusions. In Seminars in
Bhardwaj A, Mishra K, Singh P. “Functional orthopaedics” used orthodontics 2013 (19, 3, 174-195). WB Saunders.
in young growing individuals for correction of skeletal class II Wishney M, Darendeliler MA, Dalci O. Myofunctional therapy and
malocclusion: - most reliable method. Unique J Med Dent Sci. prefabricated functional appliances: an overview of the history and
2020;08:02. evidence. Aust Dent J. 2019;64(2):135–44.
 Early Treatment of Cover-Bite and
Class II Division 2 Malocclusion 5
Bernd G. Lapatki

5.1 Introduction patients. With regard to Angle’s class II div. 2 malocclusion,

however, it may be argued that the class II molar relationship
Retroclination of upper central incisors is characteristic for is not manifested in approx. 20–40% of patients with retro-
two common designations of malocclusion: cover-bite and clined maxillary central incisors (Schulze 1993). This means
Angle’s class II division 2 (div. 2). that a significant proportion of patients forming this clinical
In its original meaning, the term cover-bite refers to an entity is not considered in Angle’s classification scheme
extremely deep frontal overbite leading to the coverage of which may be considered as a limitation (Pancherz and
the lower incisors by the upper incisors (Mayrhofer 1912; Zieber 1998; Peck et al. 1998).
Herbst 1922). The fact that such vertical deviation is typi- Obviously, this controversy and also historical aspects are
cally combined with other characteristic symptoms, espe- the reason why cover-bite is still used in parallel to class II
cially with retroclination of the maxillary central incisors, div. 2 as designation for patients with upper incisor retrocli-
explains why “cover-bite” has been established as an inde- nation—despite the fact that the characteristic and faculta-
pendent designation with these two features as leading tive symptoms largely overlap (Fig. 5.1). It has to be
symptoms (Fränkel and Falck 1967; Pancherz and Zieber mentioned in this context that the term cover-bite is primar-
1998; Peck et al. 1998). The independent malocclusion cat- ily used in the German-speaking area and less frequently in
egory cover-bite seems also justified from a pathogenetic
perspective (see corresponding section below). There is a
controversy in the literature with respect to the question to
which extent these leading symptoms have to be manifested Retroclined maxillary
so that the malocclusion may actually considered as a cover- central incisors
bite. In this context, some authors designate patients with
more mild expression of deep frontal overbite and upper
incisor retroclination as “cover-­bite-­like” or an “anomaly Cover-bite Class II div. 2
with cover-bite character” (Hotz 1974; Schulze 1993).
The malocclusion classification scheme introduced by
Edward H. Angle at the end of the nineteenth century (Angle Specific pattern of
1899) distinguishes tooth and jaw malpositions primarily on anterior crowding
the basis of the sagittal relationships between maxillary and
mandibular first molars. The universal and sustainable appli- Deep frontal
cation of this scheme may be explained by the fact that cor- overbite
rection of the relationship between the upper and lower
arches plays a key role in the treatment concept for most
Distocclusion

Fig. 5.1 Leading symptoms (red and blue arrows) and frequent facul-
B. G. Lapatki (*) tative symptoms (gray arrows) of cover-bite and class II div. 2 maloc-
Department of Orthodontics and Dentofacial Orthopedics, clusion, respectively. Although the characteristic and facultative
Ulm University Medical Center, Ulm, Germany symptoms of these malocclusions overlap to a large extent, both desig-
e-mail: [email protected] nations are commonly used in orthodontic literature

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 115
J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_5
116 B. G. Lapatki

the English literature which reflects the global predominance encing factors such as a reduced mesiodistal width of the
of Angle’s classification scheme. Nevertheless, in many upper incisors (Kaiser 2002; Peck et al. 1998).
respects—e.g., in the description of the clinical picture, Several morphological studies (Isik et al. 2006; Uysal
pathogenesis, and possible treatment strategies—an overall et al. 2005; Lux et al. 2003; Walkow and Peck 2002) indi-
assessment including both cover-bite and class II div. 2 mal- cated that the increased sagittal dimension of the maxillary
occlusion seems reasonable. Accordingly, also in this chap- jaw base seems to be primarily related to an anterior position
ter, both anomalies are considered as one entity. of the incisors’ roots and not to a general overdevelopment of
Regarding the designation of an individual malocclusion the maxillary dentoalveolar complex as hypothesized in
with upper incisor retroclination, the following use of the most orthodontic textbooks.
terms cover-bite and class II div. 2 is suggested: malocclu- Particularly in cover-bite cases with an extremely deep
sions without a class II component are designated as “cover-­ overbite, gingival recessions may occur either at the palatal
bite” (if the lower central incisors are completely covered by gingival margins of upper incisors or at the labial gingival
the upper centrals) or “cover-bite-like” (if lower centrals are margins of the lower incisors. These recessions are in causal
only partially covered). The term “class II div. 2” is used relationship with traumatic contacts of the lower or upper
(according to Angle’s original definition) for patients with central incisors, respectively (Fig. 5.2c).
retroclined maxillary central incisors combined with a class Extraoral features often reported as characteristic for
II relationship of the buccal segments. If these patients addi- cover-bite and class II div. 2 are a pronounced chin and a rela-
tionally show a complete cover-bite, the malocclusion may tively large nose leading to a concave lower facial profile
be designated as “class II div. 2 with cover-bite.” (Jonas 2000; Schulze 1993; van der Linden 1988; Hotz 1974),
a pronounced supramental fold (Jonas 2000; Schulze 1993;
Fletcher 1975; Hotz 1974; Burstone 1967; Korkhaus 1953),
5.2 Cover-Bite and Class II Div. 2 and a reduced upper lip height (van der Linden 1988). The
Malocclusion patient shown in Figs. 5.3 and 5.4 demonstrates such extra-
oral features. Corresponding morphological studies, however,
5.2.1 Prevalence revealed that a specific facial morphology seems not to be
regularly present in patients with retroclined maxillary inci-
Reported percentages for the prevalence of cover-bite vary sors, which means that it cannot be considered as characteris-
between 4% and 14% (average 6.8%) (Christiansen-Koch tic (Themann 1974). A number of studies, however, revealed
1981), and those for class II div. 2 between 2% and 5% that individuals with a cover-bite or class II div. 2 show a
(Ingervall et al. 1972; Myllärniemi 1970; Ast et al. 1965). significantly higher lip line level when compared to controls
Obviously, this difference is related to the fact that investi- or other malocclusion groups (Devreese et al. 2006; Karlsen
gated class II div. 2 samples excluded patients without 1994; Luffingham 1982; Fletcher 1975; Mills 1973).
distocclusion. Also cephalometric studies revealed that many dentofa-
cial characteristics often associated with a cover-bite or class
II div. 2 are actually inconsistent (Lux et al. 2004; Pancherz
5.2.2 Characteristic Intraoral, Extraoral, and Zieber 1998; Fischer-Brandies et al. 1985; Droschl
and Skeletal Features 1974; Godiawala and Joshi 1974). More specifically, mor-
phological differences between such individuals and controls
Patients with cover-bite or class II div. 2 often show a specific were found to be limited to variables describing vertical
pattern of anterior crowding in the upper frontal segment deviations such as a reduced lower facial height and reduced
(Jonas 2000; Schulze 1993; van der Linden 1988; Hotz 1974) mandibular plane and gonion angles (Barbosa et al. 2017;
in which retroclined upper central incisors are combined with Lux et al. 2004; Brezniak 2002; Pancherz and Zieber 1998;
proclined, distorted, and infrapositioned upper lateral incisors Karlsen 1994; Maj and Lucchese 1982; Droschl 1974; Mills
(Fig. 5.2a). This pattern, which may occur only on one side 1973). With respect to the anteroposterior jaw base relation-
(Fig. 5.2b), differs significantly from the hereditary crowding ship, most cephalometric studies reported an orthognathic
pattern characterized by palatally displaced upper laterals position of the maxilla but found a retrognathic mandible
reflecting the persistence of their germ position. The pro- (Lux et al. 2004; Brezniak et al. 2002; Pancherz et al. 1997;
clined upper lateral incisors in cover-bite patients are usually Karlsen 1994; Fischer-Brandies et al. 1985; Hitchcock 1976;
less elongated when compared to the upper centrals. The fact Mills 1973). Some studies found a neutral sagittal jaw base
that also a pattern with inversion of all four maxillary incisors relationship (Barbosa et al. 2017; Peck et al. 1998) or even a
combined with labially displaced or aligned canines may skeletal class III (Brezniak et al. 2002; Demisch et al. 1992).
occur (Fig. 5.2c) indicates the importance of collateral influ- Such broad range of sagittal jaw base relationships found in
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 117

b1 b2

Fig. 5.2 (a–c) Variants of incisor malpositions in patients with a cover-­ lateral incisors. (b) Patient with retroinclination of only three of the four
bite and class II div. 2, respectively. (a) Retroclined maxillary central maxillary incisors; the right upper lateral is proclined and clearly less
incisors combined with the characteristic anterior crowding pattern in elongated than the other incisors. (c) Retroclination of all four upper
the upper anterior segment, i.e., proclination and distorotation of the incisors without anterior crowding

these studies may be related to different selection criteria sion (Pancherz and Zieber 1998). The great majority of ceph-
applied. Moreover, it indicates that a class II div. 2 is not alometric studies identified the high lip line as one of the
necessarily a skeletal class II but has more the character of a most prevailing morphological features of cover-bite and
dentoalveolar malocclusion (Barbosa et al. 2017). class II div. 2 malocclusion (Devreese et al. 2006; Karlsen
Regarding dentoalveolar morphology, cephalometric 1994; Luffingham 1982; Fletcher 1975; Mills 1973).
studies revealed that the retroclination frequently not only The fact that cephalometric studies could not identify any
concerns the upper incisors but also the lower incisors consistent dentofacial morphological feature beyond the
(Pancherz et al. 1997; Hitchcock 1976; Mills 1973), though increased overlap of the maxillary incisors by the lower lip
this trend is usually very mild or even statistically not signifi- has been confirmed by an own cephalometric study of the
cant (Brezniak et al. 2002; Peck et al. 1998; Godiawala and skeletal, dentoalveolar, and soft tissue morphology (Lapatki
Joshi 1974). A comparative study has shown that lower inci- et al. 2007). This study included a relatively large patient
sor retroclination appears to be more pronounced in cases sample covering the whole spectrum from very mild to
with neutral buccal occlusion than in cases with distocclu- severe retroclination of upper central incisors (U1-SN
118 B. G. Lapatki

a b

7.2 mm

c d

e f

Fig. 5.3 Initial records of a patient with a class II div. 2 with an incisors with a deviation from reference of −12° and the high lip line
almost complete cover-bite. (a) The facial morphology of this patient level of 7.2 mm. The patient has a horizontal growth pattern and a
is characterized by a concave lower facial profile, a deep supramental neutral sagittal relationship of maxillary and mandibular jaw bases
fold, and a pronounced chin. Although, these features are often with a deviation of the ANB-angle from the individualized reference
reported as typical for cover-bite and class II div. 2 malocclusion, of 0.6°. (c–f) Intraoral situation showing the traumatic contact of the
morphometric studies revealed that they are inconsistent. (b) upper central incisors with the labial gingiva in the lower jaw leading
Cephalogram showing the severe retroclination of the upper central to gingival recessions
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 119

a b

3.8 mm

c d

e f

Fig. 5.4 Situation in the patient depicted in Fig. 5.3, 5 years after ANB-angle from individualized reference: −2.5°). The high lip line
finalizing the active-mechanical therapy. (a) Facial profile. (b) was reduced from 7.2 to 3.8 mm. (c–f) Intraoral situation demonstrat-
Compared to the pretreatment cephalogram, upper central incisors ing the high stability of the correction of the frontal overbite and the
have been proclined by 17.4°. The sagittal jaw base relationship shows neutral buccal occlusion. The congenitally missing tooth 45 is replaced
a skeletal class III pattern (Wits appraisal: −2.5 mm, deviation of by an implant crown
120 B. G. Lapatki

between 104° and 64°). Results revealed that that the lip line increased collum angle of the upper centrals may rather
level alone accounted for 47% of inclinational variability of facilitate or contribute to upper incisor retroclination
the maxillary central incisors indicating the extraordinarily (Schulze 1993) than trigger or initiate its manifestation.
close correlation between these two variables. Multiple From all the morphogenetic factors considered, only the
regression analysis revealed that the proportion of explained characteristic lip-to-incisor relationship in cover-bite and
variability of upper central incisor inclination increased to a class II div. 2 patients expressed by a high lip line may be
value of 81% by additional inclusion of the sagittal jaw base regarded as a potential causative key factor. Indeed, this
relationship and the inclination of the mandibular central seems to be confirmed by experimental studies on the patho-
incisors. These results demonstrate the predominance of the genesis of the malocclusion.
specific vertical incisor-lip relationship as the characteristic
morphological feature for upper incisor retroclination. It
may be hypothesized that the other two statistically signifi- 5.2.4 Pathogenesis
cant model parameters, i.e., the skeletal class II pattern and
retroclination of the mandibular incisors, either provide Longitudinal studies suggest that the manifestation of a
favorable conditions for upper incisor retroclination due to cover-bite or class II div. 2 malocclusion is most likely not
the increased interincisal sagittal distance or are secondary related to any preliminary stage but is developing only dur-
symptoms. ing the eruption of the deciduous or even the permanent
upper incisors (Fletcher 1975; Fränkel and Falck 1967). It is
assumed that the inversion of the upper centrals itself plays
5.2.3 Etiology also an essential pathogenetic role, because it prevents the
mutual support of the upper and lower incisors (which physi-
The viewpoint that genetic factors play a major role in the ologically would inhibit the further eruption) and enhances
etiology of cover-bite and class II div. 2 is mainly based on the development of a deep frontal overbite (Kim and Little
studies of twins (Christiansen-Koch 1981; Nakasima et al. 1999; Karlsen 1994; Björk and Skieller 1972). Moreover, it
1982), families (Trauner et al. 1961; Kloeppel 1953; Corsten is hypothesized that the retroposition of the incisal edges of
1953), and probabilities of the anomaly’s manifestation the upper incisors may contribute or even cause retroinclina-
(Schulze 1993). Regarding the inheritance mechanism, a tion of the lower incisors and inhibit mandibular growth in
polygenic pattern is assumed (Christiansen-Koch 1981). The the sagittal direction (Schulze 1993). Based on the mutual
fact that environmental factors may significantly modify the reinforcement of the key morphological features of class II
phenotype or even may be crucial for the manifestation of div. 2 and cover-bite malocclusion during the eruption of the
upper incisor retroclination is impressively documented in upper incisors and in the subsequent period of dentoalveolar
the literature by two case reports describing the parallel man- growth, it may be hypothesized that an early therapeutic
ifestation of a class II div. 1 and a class II div. 2 in two dis- intervention may be highly beneficial for the prevention of
cordant monozygote twins (Ruf and Pancherz 1999; Leech an exacerbation of the malocclusion.
1955). It is assumed that this environmental influence is par- With respect to the initiation of the inversion process, sev-
ticularly effective during eruption of the permanent upper eral causative factors are discussed in the literature. The
central incisors (van der Linden 1983). “functional theory” refers to the “equilibrium of tooth posi-
Possible inherited morphological characteristics of indi- tion” (Proffit 1978; Weinstein et al. 1963), i.e., the mechani-
viduals with upper incisors retroclination mentioned in the cal balance of forces on the teeth from oral and vestibular
literature are an inverted inclination of the upper central inci- directions. It is supposed that the resting pressures exerted
sors’ germs (Fränkel and Falck 1967), specific morphologi- from the lips and cheeks are of particular importance due to
cal dental characteristics such as mesiodistally reduced tooth their more static character when compared to tongue pres-
widths (Peck et al. 1998) or an increased collum angle of the sures (Thuer et al. 1999a; Proffit et al. 1975; Lear et al.
upper centrals (Bryant et al. 1984; Delivanis and Kuftinec 1974). This means that, for the development of upper incisor
1980), a characteristic perioral soft tissue morphology (van retroclination, increased resting lip pressure may be the
der Linden 1988; Fletcher 1975; Fränkel and Falck 1967), or potential factor disturbing the equilibrium (Jonas 2000;
an unphysiological motor function of the perioral muscula- Schulze 1993; van der Linden 1983).
ture (Fischer-Brandies et al. 1985). After several experimental studies failed to demonstrate
It has to be noted that only a few of these factors are evi- an interrelation between pressure magnitude and upper cen-
dence based. Moreover, it is scarcely conceivable that all tral incisor inclination (Thuer and Ingervall 1986; Luffingham
these features are causative key factors. Instead, significant 1969; Gould and Picton 1968), an own study including 21
morphological characteristics of class II div. 2 samples such individuals with retroclined upper central incisors and 21
as decreased mesiodistal width of incisors or the slightly controls with physiological incisor inclination and neutral
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 121

occlusion could actually prove that the resting lip pressure already occurs prior to the eruption of the laterals, together
on the upper central incisors is significantly different in these with the specific eruption path of the laterals, provides a
groups (Lapatki et al. 2002). This difference was found to be plausible explanation for their position labial to the frontal
related to both the total resting pressure magnitude and its dental arch. The persistence of this position seems to be
distribution on the crown surface. More specifically, in the related, on the one hand, to the palatal displacement of the
controls, pressure data registered with two capacitive minia- upper central crowns leading to reduced mesiodistal space
ture pressure sensors on each of the two central incisors for the laterals between the central incisor and the deciduous
(Fig. 5.5a, b) revealed significantly higher resting pressures canine; this barrier makes lingual movement of the upper lat-
in the cervical region (+1.34 cN/cm2) when compared to the eral incisors impossible (van der Linden 1983; Fletcher
incisal region (−1.25 cN/cm2). In contrast, subjects with ret- 1975). On the other hand, due to their proclined eruption
roclined upper centrals showed the reverse pattern, i.e., sig- path, contacting of the upper laterals with the lower lip
nificantly higher resting pressure in the incisal region occurs in the cranial lower lip region (and not behind the
(+3.05 cN/cm2) compared to the cervical region (−1.24 cN/ lower lip). These aspects explain why in many individuals
cm2) (Fig. 5.5c). From correlation analyses, it could be con- with cover-bite or class II div. 2 malocclusion the upper lat-
cluded that actually the high lip line level accounts for this eral incisors remain in a more cranial position than the cen-
difference. trals. The fact that proclined upper laterals are more
From these data, the following three principles could be infrapositioned is demonstrated even more clearly in patients
derived: showing one retroclined and one proclined upper lateral inci-
sor (Fig. 5.2c).
1. In the region close to the lip line level, negligible pressure
is applied to the teeth; the experimentally determined
negative pressure values in this region might reflect the
negative intraoral pressure; this observation agrees with 5.3 Pros and Cons of Early Treatment
other studies (Shellhart et al. 1996; Thuer et al. 1999b). in the Mixed Dentition
2. Resting pressure exerted by the lower lip is approx. 2.5
times higher than those exerted by the upper lip. Basically, early orthodontic treatment may be performed as a
3. Total lip pressure magnitude exerted on the upper cen- sole intervention in the mixed dentition. It is much more
tral’s labial crown surfaces significantly depends from the common, however, that the intervention in the mixed denti-
level of the lip line which determines the amount of over- tion is the first component of an early two-phase treatment
lap between the upper centrals and the upper and lower approach which comprises fixed appliance therapy in the
lip, respectively. permanent dentition. The latter may be related to the fact that
the majority of patients require the correction of remaining
Consequently, in case of a physiological lip line level, minor single tooth malpositions and a refinement of the
which means that the contact between the upper and lower lip occlusion after removable appliance treatment, together with
occurs in the incisal third of the labial crown surface (Fig. 5.5d), the trend that patients become more and more demanding on
upper central incisors are predominantly exposed to the rela- the quality of the esthetical outcome.
tively low upper lip resting pressure. Conversely, a high lip Obviously, such two- or multiphase approach prolongs
line level leads to the application of relatively high resting total treatment time. Since decades, it is discussed in the
pressure magnitudes exerted by the lower lip (Fig. 5.5e). orthodontic literature whether the higher costs, longer
Based on perioral surface EMG measurements, this treatment duration, and demands on the patient’s compli-
experimental study has also proven that increased resting lip ance are actually in balance with the benefits (Ren 2004).
pressure in cover-bite and class II div. 2 is not related to Specifically in view of an early treatment of class II div. 2
increased perioral resting muscle activity. Hence, the specific and cover-bite malocclusion, the following issues may be
vertical lip-to-incisor relationship may be regarded as the relevant in this discussion: the effect of an early intercep-
primary determinant of these malocclusions. tion on the subsequent development of the malocclusion,
The frequent finding of proclined upper lateral incisors in the question whether the early intervention may signifi-
individuals with a cover-bite or class II div. 2 does not con- cantly reduce the extent of tooth movement and dentoalve-
tradict the causal interrelationship between incisor inclina- olar compensation required in the fixed appliance phase,
tion and soft tissue resting pressure. The maxillary lateral the question whether the risk for therapeutic side effects
incisors erupt approx. 1 year after the central incisors, and can be reduced, the aspect of treatment efficiency and
their eruption occurs from a position palatal to the central implications on post-orthodontic stability.
incisors in a labio-caudal direction (Schulze 1993; Baume The main justification for an early orthodontic interven-
1955). The fact that the retroclination of the central incisors tion is based on the interception of the pathogenesis before
122 B. G. Lapatki

a b

c 15
Physiologic overbite Class II div. 2
(Class I control group) (study group)

10
Lip pressure [cN / cm2]

-5
incisal cervical total incisal cervical total
Resting lip pressure Resting lip pressure

d e

LipL

LipL

Fig. 5.5 Experimental study on the pathogenesis of upper central inci- negative intraoral pressure. The weighted sum of incisal and cervical
sor retroclination (Lapatki et al. 2002). (a) Two thin miniature pressure pressure (total) is significantly higher in the class II div. 2 sample. (d) In
sensors were positioned in the incisal and cervical region of the upper the controls showing a physiological lip-to-incisor relationship, rela-
central incisors’ labial crown surfaces. (b) Perioral muscle activity and tively low resting pressure is applied by the upper lip (green arrow). (e)
lip pressure were registered while the lips were in their resting position. In the study group, the high lip line level (LipL) leads to exposure of the
(c) Box plots showing the resting pressure magnitudes registered in the upper centrals to the resting pressure of the lower lip (red arrows) which
incisal and cervical crown areas. Negative pressure values reflect the is approx. 2.5 times higher than those of the upper lip
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 123

the malocclusion is fully manifested, in order to prevent a documented patient examples included in this chapter may at
further exacerbation and to enhance the inherent growth least provide individual clinical evidence.
potential. With regard to class II div. 2 and cover-bite maloc- A review of the literature with regard to the effect of early
clusion, such interception may be particularly effective for class II div. 2 therapy revealed that studies evaluating early
several reasons. Firstly, as described above, the major patho- treatment of class II div. 2 or cover-bite are sparse. Ferrazini
genetic factor of the frontal aspect of the malocclusion is to (2008) studied the outcome of a sole early interceptive
be found in the specific lip-incisor relationship expressed approach. All patients were treated according to the concept
through a high lip line; obviously, this factor is not per se described by Hotz (1974) comprising a three-stage protocol
existing, but it is developing during the eruption of the decid- aiming at (1) protrusion of the upper incisors by means of a
uous or permanent upper incisors (Fletcher 1975; Fränkel maxillary plate with a protruding screw, (2) protrusion and
and Falck 1967). According to a study by Vig and Cohen intrusion of the mandibular incisors by equipping the plate
(1979), the overlap between the upper incisors and the lower with a guide plane, and (3) a subsequent “activator phase.” It
lip is increasing until 13 years of age. Consequently, it may was observed that after approx. 3 years of treatment all typi-
be hypothesized that true intrusion of the upper incisors in cal class II div. 2 features could be successfully corrected
the mixed dentition phase may terminate the pathogenetic without any further therapeutic intervention. Furthermore,
process and prevent the further exacerbation of the frontal literature research indicated that studies evaluating a two-­
malocclusion. Secondly, an early dentoalveolar decompen- phase approach are sparse and focused more on deep over-
sation in the upper anterior region by proclination of the bite correction in general. The corresponding studies of
inverted upper incisors may “unlock” the restrained mandi- Baccetti et al. (2012) and Franchi et al. (2011) included two
ble (Thomson 1986; Litt and Nielsen 1984; Arvystas 1979). patient samples both initially treated with maxillary bite
Such disinhibitory effect on the inherent mandibular growth plates in a two-phase approach—either with an earlier or
potential may significantly contribute to class II correction later treatment start. With regard to class II div. 2 or cover-­
(Woods 2008; Parker et al. 1995). Thirdly, in cover-bite cases bite malocclusion, included patient numbers were relatively
with an extremely deep overbite, early correction of the deep low and results were not separately reported for these
frontal overbite may also eliminate gingival trauma and pre- patients. Generally, we did not identify any study specifically
vent an exacerbation of gingival recessions. These traumatic targeted at comparing the results from larger class II div. 2
effects are related to contacting of the palatal gingiva or man- samples obtained by a two-phase approach with those of a
dibular labial gingiva with incisal edges of lower and upper single-phase protocol in the permanent dentition.
incisors, respectively (see Fig. 5.3). An alternative approach for protrusion of the maxillary
If early intervention in class II div. 2 malocclusion could central incisors and creating the sagittal space for mandibu-
actually intercept the pathogenesis and prevent the exacerba- lar advancement—these are chief tasks of early class II div. 2
tion of the malocclusion, it would be logical that the finaliza- or cover-bite treatment—may be the use of a partial fixed
tion of the treatment in the permanent dentition is confronted appliance comprising the maxillary first molars and incisors.
with a far less manifested malocclusion. In particular, less The utility arch introduced by Ricketts (1979) is the most
active-mechanical palatal root torque for upper incisors and common design of such two-by-two or two-by-four sys-
intrusion of the anterior segments should be required during tems—as explained more detailed below. The great advan-
final fixed appliance treatment. It has to be noted that espe- tage of the use of a partial fixed appliance in the first stage of
cially these treatment tasks are associated with external api- early class II div. 2 treatment is related to the possibility of
cal root resorption (Harris 2000), which is the most common simultaneous protrusion and true intrusion of the maxillary
iatrogenic negative consequence of orthodontic treatment. central incisors. Hence, the treatment may not only address
These aspects might explain why the correction of a class II the sagittal component of the malocclusion but may also be
div. 2 leads to significantly more lower incisor root resorp- directly targeted to the reduction of the lip line level—i.e.,
tions if the treatment occurs in a late one-phase approach the key pathogenetic factor of maxillary incisor
compared to an earlier starting two-phase treatment (Faxén retroclination.
Sepanian and Sonnesen 2018). Another advantage of an In the discussion whether a two-phase treatment approach
early interception in class II div. 2 malocclusion may be comprising an early phase in the mixed dentition may be
related to the partial or even complete correction of the dist- considered efficient or not, two variables are particularly
occlusion during the early treatment phase; this should relevant: (1) the quality of the treatment outcome and (2) the
reduce the need for a dentoalveolar compensation of the treatment time required for achieving this result (von
class II and may avoid corresponding disadvantages. Bremen and Pancherz 2002). As noted by Ferrazini (2008)
Admittedly, not all of these theoretical considerations and also the fundamentally different implications of removable
conclusions are evidence based. However, the well-­ and fixed appliances on treatment costs, requirement of
124 B. G. Lapatki

treatment monitoring, and intervention by the clinician are reported that therapeutical upper incisor proclination by
to be considered. For instance, during activator therapy, 15.2° relapsed only by 2.2° in the 3.5 years posttreatment
monitoring of the treatment by the clinician may be limited interval. Several authors concluded that instability of upper
to 4–6 visits per year, and the patient usually has to use the incisor proclination does not apply to the majority of patients
appliance only at home and mainly at night. Additionally, but in particular to individual cases with an extreme relapse
removable appliances have other obvious advantages such tendency (Kinzel et al. 2002; Kim and Little 1999; Binda
as facilitated oral hygiene and less affected social life com- et al. 1994; Berg 1983).
pared to the use of fixed appliances in combination with The studies mentioned above investigated malocclusion
additional mechanics for class II correction (such as a samples which had undergone fixed appliance therapy in a
Herbst appliance or skeletally anchored appliances for two-phase or one-phase approach. There is only one study of
upper molar distalization). These aspects are also important Ferrazini (2008) investigating long-term stability of class II
in the discussion on whether treatment of class II div. 2 and div. 2 correction comprising a sole early interceptive
cover-bite patients should already be started in the mixed approach corresponding to the concept described by Hotz
dentition. (1974). The author noted remarkable stability of most cor-
In conclusion, according to the opinion of the author of rected dental and skeletal variables 20 years after treatment.
this chapter, the decision whether an early or later treatment An important finding, however, was that the therapeutical
start is preferred in class II div. 2 and cover-bite malocclusion
upper central incisor proclination by approx. 5–6° relapsed
is to be tailored to the individual patient and the available nearly completely. From a pathogenetic viewpoint, this may
therapeutic tools. The basic prerequisite for an early begin ofbe explained by the fact that active-mechanical intrusion of
orthodontic treatment is the patient’s and parent’s willingnessupper incisors has not been an integral component in the
for a longer treatment when compared to a single-­ phase
applied treatment concept. Thus, the high lip line level may
approach in the permanent dentition. Furthermore, intercep- have persisted and, consequently, the pathogenetic mecha-
tive treatment of a class II div. 2 or cover-bite malocclusion nism of upper incisor reclination may have continued to
should be targeted to the pathogenetic key factors—i.e., the exert its effect.
high lip line and the class II tendency (if applicable). Patients Actually, the latter hypothesis could be verified by two ret-
and parents must be involved in the decision-making process rospective investigations on the basis of cephalometric analy-
and have to be informed that an early intervention may pre- ses, evaluation of plaster casts and clinical measurements of
vent the further exacerbation of the malocclusion and, conse- the lip line level after mean post-therapeutic intervals of
quently, may reduce the need for tooth movements associated 2 years (Lapatki et al. 2004) and 9 years (Lapatki et al. 2006).
with a high risk for root resorption and dentoalveolar com- Multiple regression models were calculated in these studies
pensation of the class II. Such informed consent, however, to statistically identify significant relapse determinants. A
must also include that not all of these arguments are based on common finding of both studies was that the relapse of the
very solid scientific evidence and that a controversy discus- therapeutic proclination of the maxillary central incisors
sion regarding the justification of an early treatment of classmainly depends on the amount of therapeutic inclinational
II div. 2 and cover-bite is still ongoing. change as well as the post-therapeutic lip line level. Based on
these results it may be concluded that one of the most impor-
tant objectives when treating patients with cover-bite or class
II div. 2 must be the reduction of increased overlap between
5.4 Stability After Orthodontic Treatment the upper incisors and the lower lip—as demonstrated by the
pre- and posttreatment records of the patient example shown
Many clinicians and authors consider cover-bite and class II in Figs. 5.3 and 5.4. This can be achieved either in an early
div. 2 as relapse-prone malocclusions. For instance, Selwyn-­ treatment phase by active-mechanical intrusion and/or imped-
Barnett (1991) concluded that class II div. 2 therapy is asso- ing the vertical development of the upper anterior segment
ciated with a doubtful prognosis and high relapse probability. (see patient examples below) or in the permanent dentition by
Mills (1973) reported that therapeutic proclination of maxil- active-mechanical intrusion of the upper incisors using seg-
lary incisors by 13° relapsed after >1 year of retention by mented mechanics. Obviously, an increased relapse risk has
approx. 50%. Other authors, however, stated that upper inci- to be taken into account if this aspect is not considered in
sor proclination was relatively stable. Devreese et al. (2007) treatment planning.
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 125

5.5 Early Treatment Phases examples #1 to #4 followed the classical two-stage protocol
and Therapeutical Approaches comprising the intrusion and/or proclination of the upper
central incisors and subsequent functional appliance ther-
5.5.1 Overview apy. Early treatment of patient example #5 skipped the first
main stage for active-mechanical correction of the upper
The treatment of cover-bite and class II div. 2 malocclusion central incisors, and in the treatment of patient example #6
respectively can be subdivided into an early phase in the the second main stage (i.e., functional appliance therapy)
mixed dentition and a late phase beginning after complete was omitted due to the long duration of the initial utility
eruption of the permanent canines and premolars. arch and headgear treatment. In patient example #7, early
The early treatment phase may be further divided into two treatment of the more severe distocclusion was not suffi-
successive main stages. The main focus of the first stage is to cient, which is why an intermediate phase for skeletally
correct the key feature of the malocclusion—i.e., the retro- anchored distalization of upper molars was required between
clination and supraposition of the upper central incisors. The the functional appliance therapy and the final full multi-
decision whether the deep frontal overbite is corrected pri- bracket treatment.
marily through intrusion of the upper incisors or intrusion of
the lower incisors has to consider the lip-incisor relationship.
This analysis should be undertaken with the lips in their rest- 5.5.2 Pretreatment in Patients with Severe
ing posture (e.g., on the lateral cephalogram) and also during Distocclusion
smiling (Zachrisson 2007)—as exemplified by the included
patient examples. In patients with a more severe class II (i.e., As mentioned, the retroclination and supraposition of the
more than half-step distocclusion of first molars), it is advis- upper central incisors is usually the therapeutic key measure
able to first distalize the upper first molars in a preliminary of the first stage of early class II div. 2 and cover-bite treat-
phase before the upper incisor segment is corrected. ment. In those patients, however, with a severe class II first
The use of a removable functional appliance in the second molar relationship (i.e., with distocclusion clearly greater
stage of early treatment enables the retention of the achieved than half-step), it may be reasonable to start the treatment
sagittal and vertical improvements in the upper frontal seg- with distalization of the upper first molars using a cervical-­
ment and further correction of the deep overbite by inhibiting pull headgear, which means that the upper incisors are cor-
the vertical development of the upper and lower anterior seg- rected afterward. Such deviation from the standard procedure
ments (i.e., relative intrusion) and enhancing the eruption of may be justified, because intrusion of upper incisors is diffi-
the first molars. Functional appliances may also stimulate cult to be combined with cervical-pull headgear therapy; this
mandibular growth (Pacha et al. 2016; Perinetti et al. 2015) is related to the extrusive effect on the upper first molars of
which is favorable in the majority of cover-bite or class II div. both of these measures (see also Fig. 5.6); consequently, the
2 patients. In addition, they may guide canine and premolar extrusive effect may be too strong in total. As a cervical-pull
eruption and may contribute to the correction of collateral headgear is more effective in distalizing upper molars than
problems such as anterior crowding or tooth agenesis. the high-pull headgear, the combination of parallel high-pull
If the treatment of a severe cover-bite or class II div. 2 headgear and utility arch treatment (without a previous
malocclusion is started only in the late mixed dentition or in cervical-pull headgear phase) may be insufficient for correc-
the early permanent dentition, it is recommended to replace tion of a severe distocclusion. Another reason for starting the
the functional appliance by a Herbst (or Herbst-like) appli- treatment with upper molar distalization may be that head-
ance (Schweitzer and Pancherz 2001; Obijou and Pancherz gear therapy must be initiated before the second molars
1997) or by a skeletally anchored distalization appliance begin to erupt—simultaneous distalization of first and sec-
(Wilmes and Drescher 2010) for class II correction. ond molars using a headgear has proven to be unrealistic.
Malpositions in the frontal segments are then to be treated It has to be noted that in an initial cervical-pull headgear
subsequently in the permanent dentition, e.g., by using phase only partial correction of the distocclusion is required.
Burstone’s segmented multibracket appliance mechanics The correction of a remaining mild (e.g., quarter-step) dist-
(Burstone 2001) or adaptations of this approach. occlusion may be postponed to the second main stage of
This basic concept for early treatment of cover-bite and early treatment (see corresponding section below).
class II div. 2 malocclusion is described in more detail in the Generally, the collateral extrusion of upper first molars dur-
following sections. Reference is made to seven patient ing cervical-pull headgear therapy is very desirable in class II
examples which are included and described at the end of div. 2 patients with a deep overbite or cover-bite. In this
this chapter; these patients were personally treated by the respect, the anterior bite opening during the initial headgear
author of this chapter. The early treatment phase of patient phase may represent the first measure addressing the vertical
126 B. G. Lapatki

a e
passiv
Utility
tip-back bend posterior tip-back
anterior no torque activation + sufficient torque play
first molars ligated incisors
play Force-moment system statically determinate
posterior distal tip + extrusive
anterior purely intrusive

b
Utility
posterior tip-back
anterior labial crown torque

X
Force-moment system statically indeterminate
X posterior distal tip + weak extrusive
anterior labial tip + weak intrusive

c Utility
posterior tip-back
anterior no torque / retroclined incisors

Force-moment system statically indeterminate

X
X posterior distal tip + weak extrusive
anterior labial tip + weak intrusive

Fig. 5.6 Force-moment systems generated by the utility arch (Ricketts only a very weak curvature of the anterior wire segment—this should
1979) under different conditions. According to Newton’s third axiom, be the case if only the two central incisors are included (so-called two-
the forces and the moments generated by an orthodontic appliance must by-two configuration, see Fig. 5.7a). (b) Activation of the utility arch’s
be balanced in any plane. (a) In an idealized utility arch configuration, anterior segment for labial crown torque. Although labial crown torque
no moment would be applied to the maxillary anterior segment, due to may be favorable in class II div. 2 patients, such anterior torque activa-
sufficient play of the anterior wire segment in the anterior bracket slots. tion is not recommended, because the intrusive effect on the incisors
In this case, the utility arch would reflect a “one-couple configuration” may significantly decrease. To avoid such partial or even complete
generating a “statically determinate system”—which is desirable for elimination of the desired intrusive effect, the utility arch should only
quantitative control of the intrusive force. Practically, this may occur be tied to an anterior underlay wire segment or ligated on top of this
only under the following conditions: (1) wire dimensions are signifi- segment only at the central incisor brackets (see examples in Fig. 5.7b,
cantly smaller in relation to bracket slot height (e.g., 0.016 × 0.016-in. d). (c) Force-­moment system equal to that of (b) resulting from extreme
wire combined with 0.018-in. bracket slot height) and (2) there is no or upper incisor retroclination

component of the malocclusion. It has to be noted that a pre- the malocclusion’s key feature, i.e., the retroclination and
liminary headgear phase may already be combined with the supraposition of the upper central incisors. This task usually
treatment of collateral problems in the lower arch. In particu- requires proclination and intrusion of the upper central (and
lar, a mandibular plate equipped with plane lateral bite plates often also the lateral) incisors, which may be simultaneously
may facilitate the distalization of the upper first molars. This accomplished by means of a partial multibracket appliance
effect is related to the elimination of mesially directed force comprising the fully erupted permanent incisors and the first
components on the upper first molars during occlusion result- molars as posterior support (see patient examples # 1, 2, 3, 6,
ing from occlusal contacts with the lower first molars. 7). In this respect, the so-called utility arch design originally
described by Ricketts (1979) is particularly suitable mainly
for three reasons:
5.5.3 First Main Stage of Early Treatment
1. Provided that there is enough play between the wire and
In most patients, the first main stage of early treatment of the anterior bracket slots, the utility arch induces a “stati-
cover-bite and class II div. 2 is focused on the correction of cally determinate force-moment system” (Proffit et al.
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 127

2007b) which can be easily understood and clinically vector runs above the first molars’ center-of-resistance (Cr)
monitored (Fig. 5.6a). causing the required neutralizing moment with a counter-
2. It allows simple (re-)activation by means of bilateral tip-­ clockwise direction. The remaining distally directed force
back bends mesial to the first molars. vector running above the Cr leads to bodily distalization of
3. The bypass of the deciduous canine and molar crowns at the first molars which is desirable in most patients with max-
their cervical level makes the relatively long free wire illary incisor retroclination due to their class II tendency.
segments less susceptible to plastic deformation during As mentioned, simultaneous application of a maxillary
mastication. utility arch with a cervical-pull headgear is absolutely not
recommended. The relatively strong extrusive effect of both
To increase the patient’s comfort, a silicone tube or dental appliances together with occlusal precontacts exerting forces
flow composite may be used to cover the two upper bends of in opposite direction may lead to “jiggling” of the first molars
the utility arch; in this manner, irritation of the vestibular which may overload the periodontal ligaments.
mucosa is minimized (see also Fig. 5.7a–c). Ricketts originally recommended the use of 0.016 × 0.016-­
Root resorption is a very frequent consequence of tooth in. Elgiloy® blue as wire material. Mechanical in vitro testing
movement, especially intrusion and torquing of incisors in our lab at Ulm University, however, revealed that the force
(Linkous et al. 2020). The study of Goel et al. (2014) com- deflection behavior of 0.016 × 0.016-in. stainless steel is
pared the rate of true intrusion, proclination, and root resorp- quite similar. Therefore, this cheaper alternative may also be
tion of maxillary incisors for three different intrusion recommended.
mechanics. The authors observed that Rickett’s utility arch Depending on the question whether intrusion of only the
was most effective in all three tasks. The higher rate of root upper centrals or all four maxillary incisors is required, the
resorption observed for the utility arch may be related to the utility arch may be designed as two-by-two or two-by-four
higher intrusion rate. appliance (Fig. 5.7). Adequate force magnitudes for different
From a biomechanical point of view, the classical two-by- scenarios can be determined on the following basis: recom-
four utility arch basically reflects a two-couple configuration mended intrusive force magnitudes are 15 cN per maxillary
(Davidovitch and Rebellato 1995), because of the curvature central incisor and 10 cN per maxillary lateral incisor (Proffit
of the incisor segment and the ligation of the rectangular et al. 2007b; Burstone 2001). Thus, adequate intrusive acti-
0.016 × 0.016-in. wire into the anterior brackets. The fact vations of the two-by-two and two-by-four utility arch con-
that in such “statically indeterminate system” moments with figurations are 30 cN and 50 cN, respectively. Own in vitro
unknown magnitudes may be generated at the first molars testing revealed that a 0.016 × 0.016-in. stainless steel utility
and the incisor segment limits the control on therapeutically arch with tip-back bends of only 15° and 25°, respectively,
applied forces and moments (Fig. 5.6). produce such force magnitudes. Unilateral or asymmetrical
Although initial upper incisor retroclination may tempt to activation of the utility arch enables the correction of a
incorporate labial crown torque into the utility arch’s anterior canted anterior occlusal plane.
segment, such combined activation is absolutely not recom- It has to be noted that small deformation of the free seg-
mended. This is related to the generation of a reactive force ments (e.g., occurring during mastication) may easily be
couple consisting of extrusive anterior and intrusive poste- overlooked by the clinician. Such unintended bending may
rior components. These reactive loads may significantly significantly alter the applied force systems leading to
decrease or even completely neutralize the desired intrusive uncontrolled incisor and molar movements. Hence, to avoid
effect on the upper incisors (Fig. 5.6b). A preferable alterna- application of an inadequate intrusive force magnitudes at
tive for enhancement of the protrusive effect of a utility arch least for longer time, it is recommended to detach the ante-
without losing control on its intrusive effect is to slightly rior utility arch segment during each patient appointment
activate the step bends in anteroposterior direction before (see patient examples #1, #6, and #7).
ligation of the anterior segment. Such sagittal activation may Many patients initially require intrusion of the upper cen-
also be performed asymmetrically, if the dental midline has tral incisors before the laterals are to be intruded, as well.
to be corrected (see patient example #2). This aspect might be clinically addressed using first a two-­
Since the sagittal distance between the incisor and molar by-­two appliance for upper central incisor intrusion until the
brackets is several centimeters, the resulting reactive level of the lateral incisors is reached. Subsequently, a sup-
moments exerted to the two first molars have a strong distally plemental underlay wire segment spanning all four incisors
tipping effect. This (often undesired) collateral effect may be may be used. Usually, a superelastic underlay wire (e.g.,
efficiently addressed by applying a high-pull headgear dur- 0.016 × 0.016-in. NiTi) is to be applied (Fig. 5.7b, d), because
ing nighttime with cranial angulation of its extraoral arms lateral incisors often need angulation or rotational
(see patient example #3). In this manner, the extraoral force corrections.
128 B. G. Lapatki

a1 a2

b1 b2

c1 c2

d1 d2

Fig. 5.7 Variants of the utility arch. (a) Two-by-two utility arch con- underlay wire. (d) In this patient, full insertion of a utility arch in all
figuration activated by posterior tip-back bends for generating an intru- four brackets of the reclined incisor segment would cause a proclining
sive force at the central incisor brackets. This configuration largely moment; consequently, the intrusive effect on the incisors would be
avoids anterior torque application which is, as already mentioned, decreased or even eliminated (see also Fig. 5.6c). This problem is mini-
favorable for vertical force control. (b) Example for inclusion of the mized by using an underlay segmental wire and only tying the utility
lateral incisors at a later stage using a superelastic underlay wire. (c) arch to the central incisor brackets
Example of a classical two-by-four utility arch configuration without
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 129

The decision whether combined intrusion and proclination molars) require retention in both the vertical and sagittal
of the upper incisors or only their protrusion is required has to dimensions. From a mechanical point of view, an appli-
consider both pathophysiological and esthetical issues. As ance is needed that supports the incisal edges and palatal
mentioned, a high lip line is the most important causative fac- surfaces of the upper incisors. The vertical force compo-
tor for the retroclination of the upper central incisors (Lapatki nents may also inhibit alveolar growth in the anterior seg-
et al. 2002). From a pure pathophysiological point of view, ments leading to further correction of the deep frontal
elimination of this factor is of utmost importance for achiev- overbite. The prevention of mesial migration of the first
ing a high post-therapeutic stability (Lapatki et al. 2004, molars in the late mixed dentition may be regarded as a
2006). Orthodontic treatment, however, must also meet further important function of the appliance, if a space dis-
esthetical treatment goals. It has to be noted that in the major- crepancy is present.
ity of cover-bite and class II div. 2 patients, the upper central A bimaxillary removable appliance seems particularly
incisors are suprapositioned not only in relation to the occlu- suitable for these therapeutic tasks since the jaw closing
sal plane but also relative to the lip line. The latter is usually muscles (i.e., the masseter and temporalis) are very effective
reflected by the significant appearance of maxillary gingiva in generating the required force components. If the malposi-
during smiling (see initial records of patient examples #1, #2, tion of the upper incisors is accompanied by distocclusion
and #6). Thus, greater compromises between high treatment and/or a skeletal class II jaw base relationship—which
stability and favorable smile esthetics are often avoidable. applies for the majority of cover-bite patients—the bite reg-
A certain part of the patients with retroclined upper incisors, istration required for fabrication of the bimaxillary remov-
however, displays no maxillary gingiva during smiling or able appliance has to be taken in a approx. 4–5 mm protruded
shows even some coverage of the crowns’ cervical regions by mandibular position. Systematic reviews showed that such
the upper lip (see initial records of patient examples #5 and #7). functional appliances may significantly stimulate mandibu-
Provided that also the lip line level is only moderately high in lar growth (Pacha et al. 2016; Perinetti et al. 2015).
these patients, the preferred strategy might be to omit the utility The bite registration for an activator may also address the
arch treatment for active-mechanical intrusion of the upper correction of a skeletally based mandibular midline devia-
incisors and only to protrude the upper incisors. As a conse- tion. It has to be noted, however, that this approach is only
quence, significantly more intrusion is later required in the promising if the transversal occlusion of the buccal segments
lower incisor segment during the final multibracket treatment is adapted in parallel, e.g., by using differential crisscross
phase in the permanent dentition. If these esthetical consider- elastics worn full-time together with the activator (see patient
ations are ignored, it cannot be denied that the smile esthetics is example #3). Otherwise, the neuromuscular training initiated
unfavorable at least in the long term (Zachrisson 2007). by functional appliance therapy would be counteracted by
The simplest approach for protrusion without intrusion of occlusal guidance back into the laterognathic position (when
upper incisors is the use of a maxillary plate with protrusion the activator is not in situ).
springs. This universally applicable orthodontic tool may From the available variations of functional appliances,
effectively address other measures in parallel, such as the Andresen’s “activator” (Graber et al. 1997) or successor ver-
correction of a dental midline shift or transversal arch expan- sions of this appliance seem most suitable for the second
sion in parallel (see patient example #4). main stage of early cover-bite and class div. 2 treatment. This
It is important to note that the correction of the malposi- preference is mainly related to the following aspects:
tion of the upper central incisors using a utility arch or maxil-
lary plate may easily be combined with the treatment of • An activator enables the implementation of anterior bite
collateral problems in the lower arch. For instance, a dental planes in its acrylic basis to inhibit further vertical growth.
midline shift in the mandible can be corrected in parallel • This appliance may also enhance the vertical alveolar
using a mandibular plate with finger springs (see patient growth in the molar region by grinding of the interocclu-
example #4). The therapeutic tasks addressed with a man- sal acrylic to eliminate the vertical support of the molars.
dibular plate may also include uprighting of proclined lower • The wire elements of the activator, together with the rela-
incisors (see patient examples #2 and #3) or transversal tively large extensions of the acrylic basis to the palatal
expansion of the lower dental arch (see patient example #4). and lingual attached gingiva, provide a sufficiently good
fit even in case of a compromised dental support, i.e., dur-
ing eruption of the permanent canines and premolars in
5.5.4 Second Main Stage of Early Treatment the late mixed dentition.
• A standard activator also comprises stop loops mesial to
The results achieved in the preceding early treatment the first molars which prevent the mesial migration of the
phases (i.e., the intrusion and proclination of the upper first molars; in this manner, the leeway space may be pre-
incisors and, if required, the distalization of upper first served for the anterior teeth.
130 B. G. Lapatki

The preservation of the leeway space is to be regarded as to be closed by fixed appliance therapy, often in combination
a highly efficient approach for reducing a space discrepancy with skeletal anchorage.
in the dental arch (see patient examples #2). This is due to According to own clinical experience, clinical monitoring
the possibility of gaining approx. 2.5 mm additional space on of functional appliances in intervals of 2–3 months seems
each side of the lower arch and approx. 1.5 mm per side in sufficient—particularly, in the “resting phase” of the mixed
the upper arch (Proffit et al. 2007a). This measure is to be dentition, i.e., before the permanent canines and premolars
applied to the lower arch more frequently because many begin to erupt. The subsequent eruption guidance in the late
class II patients initially show proclined incisors which mixed dentition requires more careful examination of the
means that additional space is required for incisor uprighting appliance fit and grinding of the activator’s interocclusal
by means of an activated labial bow. The proclination of the acrylic part (see Fig. 5.12a).
lower incisors observed during class II functional appliance
therapy may cause or increase a space discrepancy in the
lower arch. This effect is related to fatigue of the mandibular 5.5.5 Consequences of Later Treatment Begin
protractor muscles after the appliance is in situ for longer in the Final Mixed Dentition Stage
periods. Consequently, the mandible is not any more actively
hold in its therapeutic anterior position and tends to return Particularly if the therapeutic correction of a class II div. 2
back into its original (more posteriorly located) resting posi- or cover-bite is started relatively late, i.e., in the final stage
tion. As a result, the appliance exerts posteriorly directed of the late mixed dentition, the second stage of early treat-
contact forces on the maxillary first molars and incisors (via ment (i.e., the functional appliance phase) may or must be
the stop loops and upper labial bow, respectively) and labi- omitted. This means that the treatment may directly or pro-
ally directed contact forces onto the mandibular teeth (mainly gressively transit from the utility arch to a full multibracket
via the lower frontal acrylic part onto the lower incisors’ lin- appliance. An advantage of omitting functional appliance
gual surfaces). The latter explains the collateral protrusion of therapy in these patients is that total treatment time is not
the lower incisor during class II functional appliance unnecessarily prolonged which is particularly important in
therapy. severe cover-­bite cases requiring excessive and time-con-
The preservation of the leeway space requires the inter- suming further anterior bite opening and upper incisor
vention of the clinician (see patient example #2, Fig. 5.26). torque correction.
More concretely, if the incisors are to be uprighted, the first If in such situation, however, significant distocclusion is
intervention is to grind the deciduous canines mesially. If the present, an intermediate or parallel phase is required for cor-
first deciduous molars are not exfoliating before or during rection of the class II pattern. The same applies to patients
the eruption of the permanent canines, another required which are noncompliant with removable appliances for
intervention is to grind these teeth mesially or to extract class II correction such as the headgear and activator.
them. The same applies for the second deciduous molars dur- Depending on the localization of the problem (i.e., mandib-
ing eruption of the first premolars. To ensure that enough ular retrognathism, maxillary prognathism, or a combina-
enamel is reduced by grinding of deciduous molars and to tion of both) and on the inclination of the lower incisors,
avoid contacting and damaging of erupting or erupted adja- either a Herbst or Herbst-like appliance (Schweitzer and
cent permanent teeth, it is recommended to use a very thin, Pancherz 2001; Obijou and Pancherz 1997) or a skeletally
long diamond bur and to leave a thin, vertical slice of enamel anchorage distalization appliance (Wilmes and Drescher
between the bur and the neighboring tooth (Fig. 5.26b). In 2010) (see patient example #7) may be considered for class
this manner, approx. 1 mm of space may be provided. II correction. The frontal class II div. 2 features, i.e., the
In patients with congenitally missing mandibular second deep frontal overbite and the upper incisor retroclination,
premolar(s), another task performed with an activator during are then to be completely corrected during the subsequent
the mixed dentition phase may be the guidance and enhance- treatment phase, e.g., by using Burstone’s segmented multi-
ment of the mesial migration of the permanent molars into bracket appliance mechanics (Burstone 2001) or adapta-
the second premolar space(s). The remaining spaces are then tions of this approach.
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 131

5.6 Patient-Specific Treatment Concepts cover-bite combined with ¾-step distocclusion and a skeletal
for Successful Class II Div. 2 and class II (Figs. 5.8 and 5.9). Her initial lip-to-incisor relation-
Cover-Bite Correction: ship has been characterized by a high lip line level in the lips’
Seven Patient Examples resting posture and clear maxillary gingiva display during
smiling. Hence, it could be assumed that intrusion of the
If orthodontic therapy of a cover-bite and class II div. 2 maloc- maxillary incisors using a utility arch would not compromise
clusion is initiated in the early mixed dentition, a two-­phase the smile esthetics.
approach comprising the classical two stages of the first phase The course and result of early treatment is documented in
(as described above) and a directly following second multi- Figs. 5.10, 5.11, 5.12, 5.13, and 5.14. Since the correction of
bracket phase may be applicable in most of these patients. Five the distocclusion during the two main early treatment stages
of seven patient examples included in this chapter fall into this has not been fully achieved, distalization of the upper molars
category. In the remaining two patients, treatment was either by means of a cervical-pull headgear has been required before
started with molar distalization with the omission of the first insertion of the full multibracket appliance. Figure 5.15
classical early treatment main stage (patient #5) or significant proves that this measure was successful. The records taken
molar distalization was to be carried out prior to final multi- during the final multibracket phase, directly after debracket-
bracket therapy due to compromised compliance with the ing and after 12 months retention (Figs. 5.16, 5.17, 5.18, 5.19,
functional appliance (patient #7). All patients included were and 5.20) show that all treatment goals could be achieved.
treated personally by the author of this chapter. The observed proclination of the lower incisors in relation to
the lower mandibular border should be considered unprob-
lematic, due to the patient’s horizontal growth pattern. As
5.6.1 Patient Example #1 demonstrated by the frontal image during smiling taken in the
retention period (Fig. 5.20), the smile esthetics was actually
The clinical findings and the treatment approach applied in not compromised by the active-­mechanical intrusion of the
this female patient may be considered as typical for a severe upper incisors. Figure 5.21 shows the buccal and frontal
class II div. 2 (Table 5.1). Her initial records show a complete occlusal relationships prior to and after therapy.

Table 5.1 Problem list and conceptual treatment planning in patient #1. The items (a), (b) etc. are to be interpreted as successive treatment
stages.
Problem list and relevant collateral findings Conceptual treatment planning
1. Class II div. 2 malocclusion with a cover-bite Treatment in mixed + permanent dentition
 • Retroclination of upper centrals by −13°  (a) Early active-mechanical correction of upper centrals
 • Deep frontal overbite of 5.5 mm with (utility arch)
    – Supraposition of upper centrals  (b) Passive incisor intrusion (activator)
    – Supraposition of all 4 lower incisors  (c) Active-mechanical finalization of incisor intrusion, palatal
 • High lip line level of 6 mm root torque for U1
 • Smile with 2 mm maxillary gingiva display
2. Severe distocclusion (¾-step) + skeletal class II pattern (Wits  (a) Functional appliance therapy (activator)
appraisal + 2.7 mm)  (b) (If required) active-­mechanical distalization of upper
molars prior to multibracket therapy
3. Maxillary dental midline deviation (1 mm to right side) Slightly asymmetric protrusive activation of the utility arch
4. Multiple ankylosed deciduous molars Extractions at the necessary times
5. Peg-shaped tooth 22 Composite restauration after finalization of multibracket therapy
Sequence of therapeutic measures Duration
(begin at the age of 9:0 years)
1. Extraction of severely ankylosed tooth 55
2. Utility arch treatment (two-by-two) + high-pull headgear during 8 months
bedtime
3. Activator with mandibular advancement + anterior bite plates 1:04 years
Reevaluation → further distalization of upper first molars was
required
4. Cervical-pull headgear 11 months
5. Multibracket appliance 1:03 years
6. Retention with maxillary and mandibular plates
132 B. G. Lapatki

a b

c d

Fig. 5.8 (a–d)/patient #1. Facial images and cephalogram of patient #1 reveals the characteristic features of a cover-bite, i.e., a high lip line
taken at age 8:11 years prior to treatment. (a) The frontal image shows level, deep frontal overbite, and retroclination of the upper centrals
the significant maxillary gingiva display during smiling. (b) The facial reflected by an SN/U1 angle of 89.0° (reference: 102°). The Wits
profile is concave due to a prominent chin. (c, d) The cephalogram appraisal (+2.7 mm) indicates a skeletal class II pattern
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 133

a b

c d

e f

Fig. 5.9 (a–g)/patient #1. Dental images and panoramic X-ray of deciduous molars are ankylosed except for tooth 54. (e, f) Occlusal
patient #1 associated with the records depicted in Fig. 5.8. (a, b) The views on both arches. Tooth 12 is tipped labially. The infraposition of
frontal and lateral views of the dentition reveal the class II div. 2 maloc- this tooth is related to the position of its incisal edge on top of the lower
clusion with a cover-bite in the early mixed dentition. The lower central lip at rest. In the second quadrant, the deciduous lateral incisor is per-
incisors are nearly completely covered by the retroclined upper cen- sisting. (g) The panoramic X-ray reveals the peg-shaped tooth 22 show-
trals. (c, d) First molars showed nearly full-step distocclusion. All ing also a delayed development
134 B. G. Lapatki

a b

Fig. 5.10 (a, b)/patient #1. The first stage of early treatment comprised with the bracket slots using the tip of a spring balance. Attention must
a utility arch (two-by-two configuration) in the upper jaw. (a) For the be paid that during the measurement that the utility arch contacts only
second reactivation 2 months after treatment start, the wire is detached the probe’s tip. If necessary, the tip-back bends of the utility arch are
from the brackets. For symmetric intrusion, the anterior wire segment adjusted to obtain an adequate total intrusive force of 30 cN (15 cN per
has to run horizontally to achieve uniform loading of both incisors. (b) tooth)
The intrusive force is measured by leveling the anterior wire segment
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 135

a b

c d

e f

g h

Fig. 5.11 (a–h)/patient #1. Situation after 9 months utility arch treat- bite to 3 mm. (e, f) The proclination of the upper central incisors led to
ment. (a, b) The frontal view on the face during smiling shows the a sagittal interincisal distance of 1.5 mm which is to be regarded as a
appearance of the upper centrals’ incisal edges and the absence of max- precondition for the subsequently planned mandibular advancement in
illary gingiva display during smiling. (c, d) Intrusion and proclination the second stage of early treatment. (g, h) Occlusal views indicating
of the upper central incisors resulted in a decrease of the frontal over- that sufficient space is provided in both arches for the permanent teeth
136 B. G. Lapatki

a b

c d

e f

8-12 mm

5-10 mm

Fig. 5.12 (a–f)/patient #1. Construction of the class II activator. (a) A 2 patients with a deep frontal overbite, the anterior acrylic part has to
class II activator with anterior bite blocks is applied to patient #1 in the support the maxillary incisors at their incisal and palatal surfaces for
second early treatment stage. The construction bite has been registered retention of the previously achieved intrusion and proclination of the
during approx. 4 mm mandibular protrusion and approx. 3–4 mm bite upper incisors. (d) The activator’s lower frontal surface contains
opening in the first molar region. (b) During fabrication, the posterior grooves for the mandibular incisors’ incisal edges to inhibit vertical
acrylic part has to be extended so that it supports oral and buccal cusps alveolar growth in this region. (e) The activator’s oral extension has to
of upper and lower buccal teeth. In situ, the interocclusal acrylic part be concave so that the restriction of tongue functions is minimized. This
may locally be ground to enable eruption of the permanent canines and is an important factor regarding the patient’s compliance. (f) The verti-
premolars in the late mixed dentition (see panel (a), white arrows) or to cal extension of the acrylic (usually 8–12 mm in the maxilla and 5–10
enhance alveolar growth in the corresponding region. (c) In class II div. mm in the mandible) has to adapt to individual alveolar bone height
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 137

a b

c d

105.6°

2.9 mm

Wits + 2.1 mm

91.3°

Fig. 5.13 (a–d)/patient #1. Facial images and lateral cephalogram early treatment stage, i.e., proclination of the upper central incisors by
taken after 9 months utility arch treatment and 7 months activator ther- 16.6° and reduction of the lip line level to approx. 3 mm
apy. The lateral cephalogram demonstrates the achievements in the first
138 B. G. Lapatki

a b

c d e

f g

h i

Fig. 5.14 (a–i)/patient #1. Dental images corresponding to the facial eral incisor is shortly before eruption. (f, g) Buccal segments still show
images and cephalogram depicted in Fig. 5.13. (a, b) Activator in situ. distocclusion >½-step. Thus, an additional phase comprising the distal-
A rectangular spring welded to the labial bow is used for palatal move- ization of the upper first molars using a cervical-pull headgear was
ment of tooth 24. (c, d) The original cover-bite characteristics have added to the original treatment plan. (h, i) Occlusal views on the dental
already disappeared. (e) The late developed peg-shaped left upper lat- arches
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 139

a b

c d

e f

Fig. 5.15 (a–f)/patient #1. Dental images taken 12 months after begin extrusive force component of the cervical-pull headgear resulted in a
of cervical-pull headgear therapy. Neutral occlusion of the first molars further reduction of the deep overbite. The peg-shaped tooth 22 is
has been achieved. Maxillary premolars show passive distal drift. The erupting
140 B. G. Lapatki

b c

Fig. 5.16 (a–c)/patient #1. (a) Panoramic X-ray taken 6 months after less steel wire with a 2.5-mm offset bend is inserted. Tooth 22 is now
bracketing for clarification whether the patient has a genetic predisposi- equipped with a bracket and integrated in the appliance using a 0.012-­
tion to severe apical root resorptions (which is not the case). (b) in. NiTi wire. (c) Eight months after bracketing, sufficient extrusion of
Leveling and alignment are completed so that a 0.016 × 0.016-in. stain- tooth 22 is achieved so that a straight archwire can be inserted
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 141

a b

101.4°

Wits + 1.5 mm

102.4°

Fig. 5.17 (a, b)/patient #1. (a) Lateral cephalogram for control of inci- proclined by approx. 10°. The ANB angle (4.1°) is very close to the
sor inclination in the final phase of multibracket therapy. (b) The tracing individualized reference value (3.9°), and the Wits appraisal improved
shows that axial the inclination of the upper central incisors agrees with from 2.7 mm to +1.5 mm. Hence, the mild class II jaw base relationship
the reference value (102°). As a side effect of the class II activator and which was initially present is corrected
class II elastics applied during multibracket therapy, the lower incisors
142 B. G. Lapatki

a b

c d

e f

g h

Fig. 5.18 (a–h)/patient #1. Debracketing after fixed appliance treat- further bite opening due to the persisting viscero-somatic swallowing
ment for only 15 months. (a, b) The deep overbite is slightly overcor- pattern. (f) Occlusal view on lower arch. (g, h) Acrylic plates are used
rected to a value of 1 mm. (c, d) Neutral buccal occlusion is achieved on in both jaws for retention. The patient is instructed to wear the retention
both sides. (e) The spikes bonded to the upper central incisors’ palatal appliances every night
surfaces during multibracket therapy are not yet removed to prevent
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 143

a b

c d

e f

Fig. 5.19 (a–g)/patient #1. Dental images of patient #1 taken tion of the left upper lateral incisor crown by the patient’s general den-
12 months after debracketing. (a–c) The buccal occlusion has settled tist. (f) Occlusal view on the lower dental arch. (g) The panoramic
and the frontal overbite relapsed to a physiological value of 1.5 mm. X-ray shows small root resorptions at teeth 12, 11, 31, and 45. The
The proclination of the upper centrals and the neutral buccal occlusion germs of the third molars are developing and show good axial inclina-
achieved during therapy remained stable. (d, e) Composite reconstruc- tions so that their extraction is not indicated (at least at this stage)
144 B. G. Lapatki

a b

Fig. 5.20 (a, b)/patient #1. Facial images of patient #1 associated with the full upper central incisor crowns during smiling. (b) Lateral view on
the dental records depicted in Fig. 5.19 taken after 12 months retention. the face showing the patient’s inherited concave facial profile
(a) The patient shows a nice smile arc and buccal corridor and displays
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 145

a1 a2

Initial

Final

b1 b2

Fig. 5.21 (a, b)/patient #1. Buccal and frontal occlusal interrelationships prior to (a) and after therapy (b)
146 B. G. Lapatki

5.6.2 Patient Example #2 anterior teeth requires the intervention of the clinician by
means of prevention of the physiological mesial migration of
This patient showed severe upper central incisor retroclination the molars and by grinding or extraction of deciduous canines
related to a high lip line before therapy, but the frontal overbite and molars which enables the eruption of the permanent
was only moderately deep (6 mm), and the class II component canines and premolars more distally. As a result of the
showed relatively slight manifestation (Table 5.2, Figs. 5.22 improved space conditions, transversal arch expansion or inci-
and 5.23). The treatment course in this patient proves the sor protrusion during multibracket therapy and the corre-
effectiveness of the utility arch for upper incisor intrusion and sponding relapse risk can be avoided or at least minimized.
proclination (Figs. 5.24 and 5.25). Moreover, this patient The treatment of this patient has been still ongoing at pub-
example demonstrates how early therapeutic intervention may lication date, so that posttreatment records have not been
easily and effectively address a hereditary space discrepancy available. The latest dental images, however, taken in the
in the dental arch. Such space discrepancy may typically be final mixed dentition phase (Fig. 5.26) already demonstrate
reflected by undermining resorption of the deciduous canines how a mild cover-bite can be effectively treated by early
during eruption of the lateral incisors—as present in the intervention, so that only very limited active-mechanical
patient’s lower dental arch. Utilizing the leeway space for intervention is required in the permanent dentition—if at all.

Table 5.2 Problem list and conceptual treatment planning in patient #2

Problem list and relevant collateral findings Conceptual treatment planning
1. Cover-bite-like malocclusion with Treatment in mixed + permanent dentition
 • Retroclination of upper centrals by −15.5°  (a) Early active-­mechanical correction of upper central
 • Deep frontal overbite of 6 mm with supraposition of upper incisors (utility arch)
centrals only  (b) Passive incisor intrusion (activator)
 • High lip line level of 7 mm  (c) If required, subsequent multibracket therapy for additional
 • Smile with 3 mm maxillary gingiva display incisor intrusion, palatal root torque for upper centrals
2. Mild skeletal class II with physiological distocclusion of first Slight mandibular advancement (activator)
molars
3. Midline deviation of 2 mm, due to combined Midline corrections by
 • Latero-occlusion of 1 mm to right side (precontacts at  • Grinding of 55 distally and 63 palatally for elimination of
55/46 + 63/74) precontacts
 • Dental midline shift in lower arch of 1 mm to right side  • Early correction of the dental midline shift in the lower jaw
4. Space discrepancy in lower jaw with undermined resorption of Utilizing the leeway space for anterior teeth
deciduous canines during eruption of lateral incisors → only 2 mm  • Successive grinding of deciduous molars
space for permanent canines  • Prevention of mesial migration of upper and lower first
molars in the late mixed dentition phase
5. Mild symptoms for a temporo-mandibular disorder Elimination of precontacts for reduction of the dorsal compression
 • Articular pain during compression of stratus superioris on of the right temporo-mandibular joint in habitual occlusion
right side
 • Muscle pain in masseter during palpation
Sequence of therapeutic measures Duration
(begin at the age of 8:06 years)
1. Grinding of teeth 55 and 63 –
2. Maxilla: Utility arch (two-by-two, later two-by-four) 5 months
Mandibula: Plate for midline correction + prevention of leeway
space
3. Activator with Ongoing since 1:06 years
 • Anterior bite plates + stop loops for upper and lower first
molars
 • Slight mandibular advancement
Reevaluation → palatal root torque necessary for upper centrals?
4. Multibracket or aligner therapy (depending on remaining tooth Forthcoming
malpositions and patient’s preference)
5. Retention using maxillary and mandibular plates Forthcoming
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 147

a b

c d
86.5°

Wits + 1.6 mm
7.0 mm

85.8°

Fig. 5.22 (a–d)/patient #2. Initial facial images and cephalogram of severe retroclination of the upper central incisors by 15.5° and the high
patient #2 taken at age 8:02 years. (a) The frontal view of the face dur- lip line level of 7 mm. The mild class II jaw base relationship is indi-
ing smiling shows the significant maxillary gingiva display. (b) The cated by the Wits appraisal of +1.6 mm
facial profile is retrognathic. (c, d) Cephalometric analysis reveals the
148 B. G. Lapatki

a b

c d

e f

Fig. 5.23 (a–g)/patient #2. Dental images of patient #2 associated physiological in this phase as canine relation is neutral. (e, f) Occlusal
with the records depicted in Fig. 5.22. (a, b) Severe retroclination of the images of the dental arches. The early loss of the mandibular deciduous
upper centrals combined with a moderately deep overbite. The midline canines during eruption of the permanent lateral incisors indicates a
deviation of 2 mm is related to mandibular latero-occlusion by 1 mm hereditary crowding pattern. (g) Lateral cephalogram showing physio-
and a dental midline shift in the lower arch by 1 mm to the right side. logical dental development
(c, d) The slight distocclusion of the first molars may be considered
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 149

a b

c d

e f

Fig. 5.24 (a–f)/patient #2. Situation 5 months after insertion of the arch follows the contour of maxillary arch form. (f) The mandibular
mandibular plate and 2 months after begin of utility arch treatment. (a, dental midline has been corrected by successive activation of the finger
b) Upper incisors are partially intruded and proclined, and the midline spring distal to tooth 42. Incisors are partially uprighted by the active
shift is already completely eliminated. (c, d) The clasp retentions of the labial bow
mandibular plate barely interfere with habitual occlusion. (e) The utility
150 B. G. Lapatki

a1 a2

b1 b2

c1 c2

d1 d2

Fig. 5.25 (a–d)/patient #2. Overview over the different stages during ment for 5 months. Active intrusion of the upper central incisors by
intrusion and proclination of the upper central incisors. (a) Situation at approx. 2 mm is clearly recognizable. (d) Insertion of an activator after
insertion of the mandibular plate. (b) Two months later, the utility arch utility arch treatment to retain the correction of the upper incisor seg-
(two-by-two configuration) is inserted. (c) Situation after treatment ment and to address the other treatment tasks planned in the second
with the mandibular plate for 8 months and parallel utility arch treat- main stage of early treatment
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 151

a b1 b3

b2

c1 c2

d1 d2

e2
e1

Fig. 5.26 (a–e)/patient #2. Different stages during the second main Both lower canines have migrated in distal direction so that their over-
stage of early treatment of patient #2 illustrating the utilization of the lap with the lateral incisors is eliminated. The first deciduous molars are
leeway space for the anterior teeth. (a) Activator in situ. The stop loops already exfoliated and the first premolars erupt direct distal to the
located directly mesial to the mandibular first molars prevent mesial canines into the space provided by grinding of the second deciduous
migration of these teeth after subsequent loss of the deciduous molars. molars at their mesial sides. (e) Situation after eruption of the lower
(b) For grinding of deciduous molars adjacent to permanent teeth, it is second premolars. Although treatment has still been ongoing in this
recommended to preserve a slice of enamel for absolute protection of patient at publication date, it is demonstrated that the anterior space
the permanent tooth. (c) Situation after grinding of the first deciduous discrepancy has been completely eliminated by utilizing the leeway
molars which provided space for the erupting permanent canine. (d) space for incisors, canines, and premolars
152 B. G. Lapatki

5.6.3 Patient Example #3 The specific problem in this patient, however, lies in the
combination of the class II div. 2 pattern with mandibular
The class II div. 2 malocclusion in this patient may be char- laterognathism. The course of the treatment demonstrates
acterized as moderate with respect to its vertical and sagittal how the latter problem may effectively be addressed parallel
manifestation (Table 5.3, Figs. 5.27 and 5.28). In Fig. 5.29 it to the correction of the class II div. 2 features using an activa-
is shown how a high-pull headgear has to be designed for tor combined with differential crisscross elastics (Figs. 5.31
achieving bodily distalization of upper first molars during and 5.32). In this manner, it is possible to correct a laterog-
utility arch treatment instead of distal tipping, and how the nathic mandible causally during the growth period. In con-
first early treatment stage may be used for early correction of trast, exclusive treatment in the permanent dentition would
a dental midline shift in parallel to the main intervention in only have enabled the dentoalveolar compensation of the
the maxilla. The images taken at different times during the laterognathism.
initial stage of early treatment (Fig. 5.30) again demonstrate Treatment has been still ongoing at publication date, but
the effectiveness of the utility arch for elimination of the the main aspects of the initial malocclusion are already caus-
typical cover-bite features by means of true incisor intrusion ally corrected by the early intervention in the mixed denti-
and first molar extrusion. More specifically, upper incisors tion phase. Hence after eruption of all permanent teeth, only
are significantly proclined and the overbite is reduced by a short final therapeutic phase using a multibracket appliance
approx. 4 mm in only 4 months of treatment. is to be expected.

Table 5.3 Problem list and conceptual treatment planning in patient #3

Problem list and relevant collateral findings Conceptual treatment planning
1. Class II div. 2 malocclusion with Treatment in mixed + permanent dentition
 • Retroclination of upper centrals by −14.5°  (a) Early active-­mechanical protrusion but limited intrusion of
 • Deep frontal overbite of 6.5 mm upper centrals (utility arch)
 • High lip line level of 7 mm  (b) Passive incisor intrusion + molar extrusion (activator)
 • Smile with full crown display of upper centrals (but no  (c) Multibracket therapy for active-­mechanical incisor intrusion,
maxillary gingiva display) palatal root torque for upper incisors
2. Mandibular retro- and laterognathism  (a) Asymmetric mandibular advancement after adaptation of
 • Asymmetric distocclusion (1/2-step right side/full-step left transversal occlusion of molars (activator)
side)  (b) (If required) further active-­mechanical distalization (using
 • Mandibular midline shift of 3 mm to left side skeletal anchorage)
 (c) (If required) dentoalveolar compensation of mandibular
laterognathism (multibracket appliance + mini screw for
temporary anchorage in third quadrant)
4. Two supernumerous maxillary molars Extraction before treatment start
5. Proclined lower incisors by 6° with fragile labial gingiva and gingiva Utilizing leeway space for anterior teeth
recessions at teeth 31 + 41  • Grinding of deciduous canines and molars mesially
 • Prevention of mesial migration of all 4 first molars in late
mixed dentition phase
Sequence of therapeutic measures Duration
(begin at the age of 9:08 years)
1. Extraction of supernumerous maxillary molars
2. Maxilla: Utility treatment (two-by-­two) + high-pull headgear 4 months
Mandible: Plate for uprighting incisors + prevention of leeway space
3. Activator with asymmetric mandibular advancement, anterior bite 11 months
plates and stop loops for upper and lower first molars; the posterior
acrylic part of the activator is reduced so that it can be combined
with differential crisscross elastics at right and left first molars
4. Standard activator with mandibular advancement and corrected Ongoing since 3 months
midline
Reevaluation → further asymmetric distalization in upper jaw and/or
dentoalveolar compensation of mandibular laterognathism required?
5. Multibracket therapy (with skeletal anchorage if required for further Forthcoming
correction of asymmetry)
6. Retention using maxillary and mandibular plates Forthcoming
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 153

a b

c d
87.5°

Wits +2.3 mm 7.1 mm

95.8°

Fig. 5.27 (a–d)/patient #3. (a, b) Facial images of patient #3 taken at sors (−14.5°) and a high lip line level (7.1 mm). The jaw bases show a
the age of 9:08 years before treatment begin. The patient displays the moderate skeletal class II pattern (Wits appraisal: +2.3 mm, deviation
cervical regions of the upper central incisors’ crowns during smiling but ANB/individualized reference: 2.1°) with a prominent chin. The lower
not their incisal edges. The facial profile is orthognathic. (c, d) incisors are proclined (+5.8°)
Cephalogram showing severe retroclination of the upper central inci-
154 B. G. Lapatki

a b

c d

e f

Fig. 5.28 (a–g)/patient #3. Initial dental images associated with the mandibular laterognathism, the distocclusion is asymmetric (half-step
records depicted in Fig. 5.27. (a) Lateral view on the incisor segment. at right first molars and full-step at left first molars). (e, f) Occlusal
(b) The 3-mm midline deviation before treatment start is related to a views on the dental arches. (g) The panoramic X-ray reveals two super-
laterognathic mandible (2 mm to left side) combined with a dental mid- numerous molars in the first and second quadrants. Deciduous canines
line shift in the maxilla (1 mm to right side). (c, d) As a result of the and molars show insufficient root resorption
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 155

a b

d e

Fig. 5.29 (a–e)/patient #3. First stage of early treatment of patient #3. lower jaw, the deciduous canines are ground mesially to provide space
(a) Intervention in the maxilla comprises the intrusion and proclination for uprighting of the incisors using a plate with an active labial bow.
of upper central incisors using a two-by-two utility arch. (b) The utility Before fabrication of the acrylic part on the cast model, a 2-mm thick
arch is combined with a high-pull headgear (to be worn only during dental wax plate was positioned on the incisor’s lingual crown surfaces.
bedtime) for preventing the distoangulation of the first molars. The Thus, grinding of the plate before insertion is not needed which may
outer headgear bow is angulated in dorso-cranial direction so that the decrease the risk of breakage of the plate. (d, e) The optimal design and
force vector passes above the first molars’ center of resistance (red dot fabrication of the clasps’ retentions minimizes their interference in
on the schematic tooth). In this manner, the utility arch’s distally tipping habitual occlusion
effect on the first molars (see Fig. 5.6) may be neutralized. (c) In the
156 B. G. Lapatki

a1 a2

Initial situation

b1 b2

2.5 months after

utility insertion

c1 c2

4 months after
utility insertion

Fig. 5.30 (a–c)/patient #3. Dental images taken during the utility arch midline shift in the upper jaw. (c) Sufficient correction of the upper
treatment showing the continuous, efficient intrusion and proclination frontal incisors is already achieved after 4 months utility arch treatment.
of the upper central incisors. (a) Initial situation. (b) 2.5 months ongo- The creation of an overjet with sagittal spacing of 3–4 mm between the
ing intrusion and protrusion of upper central incisors. Slight asymmet- upper and lower incisors enabled the subsequently planned mandibular
ric sagittal activation of the utility’s step bends in the first quadrant enhancement
provides space for the erupting tooth 12 and eliminates the slight dental
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 157

a b

c d

e1 e2

e3 e4

Fig. 5.31 (a–h)/patient #3. Second stage of early treatment. (a, b) After elastics in situ without (e1) and with activator (e2 - e4). The activator’s
treatment with the utility arch, buccal occlusion has been neutral on the posterior acrylic part is reduced to avoid interference with the crisscross
right but half-step distocclusion on the left side resulting from a 2-mm elastics to be worn full-time for adaptation of transversal first molar
skeletal mandibular shift to the left side. (c) The deep bite and upper occlusion. Additional grinding of the acrylic lingual to the molars of the
central incisor retroclination are already corrected. (d) The construction second and fourth quadrant is required to allow lingual movement of
bite for fabrication of the subsequent activator was taken in a slightly these teeth; the mesiobuccal cusps of teeth 26 and 36 must maintain
overcorrected mandibular position (1 mm to right side) (e) Criss-cross vertical support to avoid excessive extrusion by the crisscross elastics
158 B. G. Lapatki

a b

c d

Fig. 5.32 (a–d)/patient #3. Situation after parallel neuromuscular stabilization and guided fine adjustment and settling of the transversal
intervention with the functional appliance and active-mechanical adap- occlusion by targeted removal of acrylic. At publication date, functional
tation of transversal first molar occlusion using differential crisscross appliance treatment was still ongoing in this patient. Subsequent multi-
elastics. (a–c) Both, the distocclusion and mandibular midline shift are bracket therapy may comprise differential class II elastics (force on left
largely corrected. (d) A new activator with a centric construction bite side > right side) to stabilize the sagittal and transversal correction of
and complete posterior acrylic extension is inserted for neuromuscular the centric mandibular position
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 159

5.6.4 Patient Example #4 the first stage of early treatment for upper central incisor pro-
clination (Fig. 5.35). Also the concept applied during the
The malocclusion of this patient example is characterized by multibracket phase for correction of the deep frontal overbite
manifestation of cover-bite-like incisor malpositions com- aimed at the preservation of the harmonic lip-incisor rela-
bined with dental midline shifts in both dental arches and a tionship during smiling. This exemplifies that therapeutic
mandibular space discrepancy (Figs. 5.33 and 5.34). Due to planning in patients with a class II div. 2 or a cover-bite has
the fact that the frontal overbite is only moderately increased, to consider both treatment stability and smile esthetics which
and only little maxillary gingiva is displayed during smiling, is not always as easy as in this patient example. Figures 5.36,
active-mechanical intrusion of the upper central incisors 5.37, 5.38, 5.39, 5.40, 5.41, and 5.42 show the records made
using a utility arch was avoided (Table 5.4). Instead, an during and post treatment. Figure 5.43 shows the buccal and
active maxillary plate with finger springs has been used in frontal occlusal relationships prior to and after therapy.

Table 5.4 Problem list and conceptual treatment planning in patient #4

Problem list and relevant collateral findings Conceptual treatment planning
1. Cover-bite-like malocclusion with Treatment in mixed + permanent dentition
 • Retroclination of upper centrals by −5°  (a) Early active-­mechanical protrusion of upper centrals
 • Deep frontal overbite of 4.5 mm with supraposition of both (maxillary plate)
upper centrals  (b) Passive incisor intrusion (activator)
 • Smile with 1 mm maxillary gingiva display and complete  (c) (If required) further active-mechanical intrusion of upper
display of maxillary central incisors and/or lower incisors, palatal incisor root torque
 (lip line level cannot be determined as lateral cephalogram was
taken with a protruded mandible)
2. Midline deviation of 2 mm, due to Early correction of midline shifts in both jaws with maxillary and
 • Slight maxillary dental midline shift of 1 mm to left side mandibular plates
 • Mandibular dental midline shift of 1.5 mm to right side
3. Moderate space discrepancy in lower arch Utilizing leeway space for anterior teeth
 • Grinding of deciduous molars mesially
 • Prevention of mesial migration of upper and lower first molars
in late mixed dentition
Sequence of therapeutic measures Duration
(begin at the age of 8:01 years)
1. Maxillary + mandibular plates for dental midline correction and 1:10 years
proclination of upper central incisors
2. Activator with slight mandibular advancement + anterior bite 1:07 years
plates + stop loops for upper and lower first molars
Reevaluation of lip line level + smile esthetics
→ further incisor intrusion to be performed in maxilla and mandible
3. Multibracket appliance 1:11 years (max.), 1:03 years (mand.)
4. Maxillary and mandibular plates for retention
160 B. G. Lapatki

a b

c d

Fig. 5.33 (a–d)/patient #4. Initial facial images and cephalogram of cephalogram reveals only mild retroclination of the upper central inci-
patient #4 taken at age 7:09 years, 4 months prior to treatment begin. (a) sors, although the cover-bite-like appearance of the front teeth seems
He displays approx. 1 mm maxillary gingiva and the complete upper more severe on the corresponding intraoral images. (The sagittal and
central incisor crowns during smiling. Thus, only minor intrusion of the vertical jaw base relationship is not evaluable on this cephalogram,
upper incisors should be planned. (b) Facial profile. (c, d) The lateral because the patient protruded the mandible during the recording)
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 161

a b

c d

e f

Fig. 5.34 (a–g)/patient #4. Initial dental images of patient #4 associ- dibular component (1.5 mm to the right). The latter is related to an
ated with the records depicted in Fig. 5.33. (a, b) The patient shows the asymmetric space discrepancy in the anterior lower arch of approx.
typical cover-bite-like features in the final phase of the early mixed 4 mm in total. (g) Panoramic X-ray showing physiological dental
dentition. (c, d) First molars and canines are in neutral occlusion. (e, f) development
The dental midline shift has a maxillary (1 mm to the left) and a man-
162 B. G. Lapatki

a b

c d

e f

Fig. 5.35 (a–f)/patient #4. Situation after 9 months treatment with the plate’s left segment, so that it is continuously activated during trans-
maxillary and mandibular plates. (a) The upper central incisors have versal arch expansion. (c, d) The frontal overbite has clearly aggravated
been protruded using a protrusion spring crossing the midline; the when compared to the records prior to treatment (see Fig. 5.34). The
active finger spring distal to tooth 21 has shifted the dental midline to midline shifts in the upper and lower dental arches, however, are already
the right side. Both arches are slightly expanded. (b) The space pro- slightly overcorrected. (e, f) Views on the right and left lateral
vided by grinding of both lower deciduous canines is occupied by the segments
lateral incisors. The finger spring distal to tooth 41 has its retention in
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 163

a b

c d

Fig. 5.36 (a–d)/patient #4. Reevaluation at age 9:11 years after treat- the lower central incisors by +13.6° is related to their integration in the
ment with maxillary and mandibular plates for 1:08 years. (a, b) The dental arch. Consequently, during the subsequently planned activator
smile esthetics and the facial profile are unchanged. (c, d) The Wits treatment, the remaining leeway space in the lower arch has to be pre-
appraisal indicates a very mild skeletal class III jaw base relationship. served for uprighting lower incisors
The lip line level is approx. 4 mm. The very pronounced proclination of
164 B. G. Lapatki

a b

c d

e f

Fig. 5.37 (a–g)/patient #4. Dental images corresponding to the facial anterior region is reduced. (g) The panoramic X-ray shows physiologi-
images and cephalogram depicted in Fig. 5.36. (a–d) The cover-bite cal dental development in the late mixed dentition. All third molar
characteristics are no longer recognizable. (e) All four upper incisors germs can be recognized
are integrated in the dental arch. (f) Anterior crowding in the lower
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 165

a b

c d

Fig. 5.38 (a–d)/patient #4. Facial images and lateral cephalogram for bite by equal intrusion of the upper and lower incisors. (b) Facial pro-
reevaluation of the treatment plan after activator therapy for 1:07 years. file. (c, d) The tracing of the cephalogram shows that the inclination of
The activator’s construction bite has been taken in neutral sagittal man- the upper central incisors agrees with the reference value of 102° (angle
dibular position due to the neutral buccal occlusion and was equipped U1/SN). Successive activation of the labial bow of the activator and
with stop loops for the four first molars to prevent the mesial migration preservation of the lower leeway space respectively resulted in upright-
of these teeth during the late mixed dentition phase. (a) The lip-incisor ing of the lower incisors by 12°
relationship during smiling tolerates correction of the deep frontal over-
166 B. G. Lapatki

a b

c d

e f

Fig. 5.39 (a–f)/patient #4. Dental images associated with the records achieved on both sides. (e) Good alignment of all permanent teeth is to
depicted in Fig. 5.38. (a, b) The frontal overbite shows little improve- be observed in the upper arch. (f) The anterior space discrepancy is
ment as it decreased only by approx. 1 mm when compared to the slightly reduced by occupation of the leeway space by the lower
records before activator insertion. (c, d) Neutral buccal occlusion is incisors
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 167

a1 a2

b1 b2

c1 c2

d1 d2

Fig. 5.40 (a–d)/patient #4. Different stages during multibracket ther- upper incisors and lower incisor brackets. (b) After 4 months leveling,
apy. (a) Due to the slight supraposition of the upper incisors, 1-mm a 0.016 × 0.022 TMA overlay wire is inserted in the upper arch for
steps between upper laterals and canines are bent into the 0.012 and frontal intrusion. (c) One month later, the three segments are replaced
0.016-in. NiTi leveling wires to prevent extrusion of the canines. Steps by a full 0.016 × 0.016 SS wire; the overlay intrusion arch is left for
are fabricated using a “Nice-End-Plier” (Hammacher, Germany). Their another 3 months until lower brackets could be bonded. (d) Situation
height can be precisely adjusted by changing the steps’ angulation after during the finishing phase, after leveling the deep curve-of-Spee in the
bending. Bracketing in the lower arch is planned after slight protrusion lower arch; the deep overbite is already eliminated by equal intrusion of
and intrusion of the upper frontal segment to avoid precontacts between the upper and lower frontal segments
168 B. G. Lapatki

a b

c d

e f

Fig. 5.41 (a–f)/patient #4. Dental images taken 1:01 years after deb- 2 mm) are stable. (c, d) Neutral buccal relationships were achieved with
racketing. (a, b) Both, the corrections of the midline shifts in the upper settling of the occlusion. (e, f) Occlusal views on upper and lower den-
and lower jaw and the deep frontal overbite (to a physiological value of tal arches
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 169

a b

c d

Fig. 5.42 (a–d)/patient #4. Facial images and cephalogram corre- skeletal class III has slightly weakened. The proclination of upper and
sponding to the records depicted in Fig. 5.41. (a) The patients slightly lower central incisors may result from the intrusive mechanics acting
displays the maxillary gingiva so that the smile esthetics is not compro- anterior to the incisor’s center-of-resistance; in the lower arch, the space
mised by the concept of equal intrusion of upper and lower frontal seg- discrepancy contributed to incisor proclination. From the low post-­
ments. (b) The facial profile is harmonic. (c, d) The tendency toward a therapeutic lip line level, high treatment stability is to be expected
170 B. G. Lapatki

a1 a2

Initial

Final

b1 b2

Fig. 5.43 (a, b)/patient #4. Buccal and frontal occlusal interrelationships prior to (a) and after therapy (b)
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 171

5.6.5 Patient Example #5 manent dentition by segmented intrusion of the lower fron-
tal segment (Table 5.5).
This patient exemplifies that in specific manifestations of The decision to start the therapeutic intervention with a
class II div. 2 malocclusions it may be reasonable to omit cervical-pull headgear for upper first molar distalization also
the first main stage of early treatment. In this specific considered the bite-opening effect of this appliance related
patient, the main arguments for this decision were that the to the application of a dorso-caudally directed force
lip-incisor relationship during smiling seemed to be quite (Fig. 5.46). The extrusive effect on the upper first molars led
well-balanced and did not suggest any therapeutical change to the reduction of the frontal overbite without changing the
(Fig. 5.44). Moreover, the sagittal component of the class II well-­balanced lip-incisor relationship present in this patient
div. 2 (i.e., the distocclusion) was obviously more pro- at begin of the treatment. The second stage of early treatment
nounced than the frontal component; concretely, upper cen- was conducted in the classical manner using an activator for
tral incisor retroclination by only 7° and a frontal overbite mandibular advancement and for further overbite reduction
of 5 mm may be considered as a mild cover-bite-like mani- (Figs. 5.46, 5.47, and 5.48).
festation (Fig. 5.45). The deep overbite was mainly due to Figure 5.49 comprising different stages during multi-
the supraposition of the lower anterior segment. Based on bracket therapy shows a consistent and systematic approach
these diagnostic findings, it was concluded that the major for segmented intrusion of the lower frontal segment.
effects of a maxillary utility arch, i.e., significant intrusion Moreover, the treatment results depicted in Figs. 5.50 and
and protrusion of upper incisors, were not needed or were 5.51 demonstrate that asymmetric activation and/or localiza-
even disadvantageous. Consequently, the decision was taken tion of the intrusive force enables the correction of a canted
to focus early treatment of this patient on class II correction, suprapositioned lower anterior segment. Figure 5.52 shows
and to address the deep frontal overbite mainly in the per- the buccal and frontal occlusal relationships prior to and
after therapy.

Table 5.5 Problem list and conceptual treatment planning in patient #5

Problem list and relevant collateral findings Conceptual treatment planning
1. Class II div. 2 malocclusion with Treatment in mixed + permanent dentition
 • Retroclination of upper centrals by −7°  (a) Extrusion of upper molars for bite opening (cervical-pull
 • Deep frontal overbite of 5 mm with headgear)
    – Supraposition of all 4 upper incisors  (b) Passive incisor intrusion + molar extrusion for further bite
    – Deep curve-of-Spee in lower arch opening (activator)
 • Moderately increased lip line level of 3.8 mm  (c) Leveling of mandibular curve-of-Spee + (if required) palatal
 • Smile with full crown display of maxillary central incisors (no root torque of upper incisors and further active-mechanical
maxillary gingiva display) incisor intrusion (multibracket appliance)
2. Significant distocclusion of 2/3-step at first molars  (a) Early active-mechanical distalization of upper first molars
(cervical-pull headgear).
 (b) Mandibular advancement (activator)
3. Mild space discrepancy in lower arch due to proclined lower incisors Utilizing the leeway space for anterior teeth
 • Grinding of deciduous molars mesially
 • Prevention of mesial migration of upper and lower first molars
in late mixed dentition
 • Uprighting of lower incisors
4. Tooth size discrepancy with mesiodistal width of lower teeth 2 mm (If required) Tooth size reduction in lower jaw
larger (acc. to Bolton’s reference values)
Sequence of therapeutic measures Duration
(begin at the age of 10:03 years)
1. Cervical-pull headgear 8 months
2. Activator with slight mandibular advancement + anterior bite 2:03 years
plates + stop loops for upper and lower first molars
Reevaluation of smile esthetics and lip line level
→ overbite correction is to be completed primarily by further
intrusion of lower frontal segment
3. Multibracket appliance 1:05 years
4. Maxillary and mandibular plates for retention
172 B. G. Lapatki

a b

c d

Fig. 5.44 (a–d)/patient #5. Facial images and lateral cephalogram of ing, i.e., right buccal teeth are in a more cranial position in both jaws.
patient #5 taken at age 10:01 years prior to treatment begin. (a) The (c, d) The lip line level is only moderately high and upper centrals show
frontal facial view shows nearly complete display of upper central inci- reclination by 7.0°. Lower incisors are proclined by 7.5°
sor crowns during smiling. (b) The occlusal plane shows a slight cant-
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 173

a b

c d

e f

Fig. 5.45 (a–g)/patient #5. Initial dental images of patient #5 corre- (e, f) The large deciduous lower molars may provide sufficient leeway
sponding to the records depicted in Fig. 5.44. (a, b) The lateral and space for uprighting the proclined lower incisors. (g) Development of
frontal views reveal the typical features of a class II div. 2 in the mixed tooth 25 is delayed
dentition. (c, d) First molars show slight distocclusion (quarter-step).
174 B. G. Lapatki

a b

c d

e f

Fig. 5.46 (a–g)/patient #5. Situation after 8 months cervical-pull distal migration of the deciduous molars and canines can be observed.
headgear treatment. (a, b) The frontal overbite is slightly decreased by (g) At this stage, an activator with anterior bite plates and stop loops for
approx. 1 mm. (c, d) Upper first molars are distalized into neutral occlu- retention of maxillary first molars is inserted
sion. (e, f) Occlusal views on upper and lower dental arches. Passive
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 175

a b

c d

Fig. 5.47 (a–d)/patient #5. Reevaluation during the final early treat- issues. The lower centrals are slightly uprighted (by 4.0°) when com-
ment stage with ongoing activator therapy for 1:10 years; treatment is pared to the initial cephalogram. The initial, mild retroclination of the
monitored only every 3 months. (a, b) The harmonic smile esthetics upper central incisors has only been reduced by 2°, although it has to be
suggests to keep the vertical position of the upper incisal segment at this noted that the remaining deviation from the reference value of 102° is
level. (c, d) The lip line level is only slightly increased so that upper only 5°
incisor intrusion is also not required with respect to treatment stability
176 B. G. Lapatki

b c

d e

Fig. 5.48 (a–f)/patient #5. Dental images corresponding to the records vided by grinding of tooth 85 mesially is already occupied by tooth 44
shown in Fig. 5.47. (a) Frontal view. (b, c) Neutral buccal occlusion has (tooth 85 is to be extracted now). (f) Due to late development of tooth
been achieved by the cervical-pull headgear. (d, e) Subsequent activator 25 and incomplete root development of teeth 35 and 45, the start of
therapy has been successful in the retention of the neutral buccal occlu- multibracket therapy is postponed by approx. 6 months
sion and in preserving the mandibular leeway space. The space pro-
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 177

a1 a2

a3 a4

b1 b2

Fintr.
hook spring

Fig. 5.49 (a–d)/patient #5. Different stages during multibracket ther- by the oblique course of the frontal wire segment and the supraposi-
apy. (a) Situation after separate leveling of the frontal and lateral seg- tioned lower right premolars. (c) The panoramic X-ray shows the
ments using 0.012- and 0.016-in. NiTi wires with step bends (a1 and inserted spring attached to 46 and hooked in between 42/43 to correct
a2). At this stage, leveling wires are replaced by three 0.016 × 0.022-in. the canting by further unilateral intrusion. No significant root resorp-
segment steel wires and a 0.016 × 0.022-in. TMA overlay intrusion arch tions are to be observed which may be also due to the careful monitor-
(a3 and a4) with slightly asymmetric activation (35/25 cN at right/left ing of the intrusion force during reactivation of the mechanics. (d)
sides). (b) Situation after intrusion of the lower anterior segment for Integration of late developed tooth 25 using an underlay NiTi leveling
4.5 months. The mandibular occlusal plane is still canted as indicated wire
178 B. G. Lapatki

a b

c d

e f

g h

Fig. 5.50 (a–h)/patient #5. Dental images of patient #5 taken 2 weeks slight relapse. (c, d) Neutral occlusion of canines and molars and a
after debracketing. The fixed appliance was in situ for 1:07 years. (a, b) physiological incisal occlusion are achieved. (e, f) Occlusal views on
All major problems, i.e., the retroclination of the upper incisors, the the dental arches. (g, h) Maxillary and mandibular plates with acrylic-
deep frontal overbite, the canting of the mandibular occlusal plane, and covered labial bows combined with a flattened 8-braided steel wire in
the midline shift, are successfully corrected. The overbite is even the lower anterior segment are used for retention. Further settling of the
slightly overcorrected to a value of 1.5 mm to account for a possible occlusion is to be expected
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 179

a b

Fig. 5.51 (a, b)/patient #5. Frontal images corresponding to the dental sisting of overbite correction primarily by intrusion of the lower frontal
records shown in Fig. 5.50. The occlusal plane runs now parallel to the segment instead of intrusion of upper incisors. Since, the lip line level
bipupilar line. Cervical regions of the upper central incisors are only prior to multibracket therapy was only barely increased (value: 3.8 mm,
slightly covered by the upper lip and the smile arch appears harmonic. see Fig. 5.47), the proclination of the upper incisors is expected to be
This outcome seems to confirm the concept chosen for this patient con- stable
180 B. G. Lapatki

a1 a2

Initial

Final

b1 b2

Fig. 5.52 (a, b)/patient #5. Buccal and frontal occlusal interrelationships prior to (a) and after therapy (b)
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 181

5.6.6 Patient Example #6 As treatment has begun in the late mixed dentition phase
at the age of 12, and the permanent canines and premolars
The records of this male patient prior to treatment reveal a already erupted during the correction of the upper and lower
severe class II div. 2 combined with a complete cover-bite incisor segments, it was decided to omit the originally
(Table 5.6, Figs. 5.53 and 5.54). Since the extremely deep planned functional appliance treatment. Instead, permanent
overbite of 10 mm and the large interincisal angle was not canines and premolars were integrated step by step into the
only due to supraposition and retroclination of the upper multibracket appliance (Fig. 5.57) so that total treatment
central incisors but also of all four lower incisors, it was duration was not unnecessarily prolonged. Nevertheless,
decided to apply a partial fixed appliance technique for approx. 4.5 years of partial and full-fixed appliance treat-
active-­mechanical intrusion and proclination of the anterior ment were required in total to successfully correct all aspects
teeth not only in the upper arch (Figs. 5.55 and 5.56) but (as of this severe malocclusion (Figs. 5.58 and 5.59). Figure 5.60
soon as bracketing has been possible) also in the lower ante- shows the buccal and frontal occlusal relationships prior to
rior segment. and after therapy.

Table 5.6 Problem list and conceptual treatment planning in patient #6

Problem list and relevant collateral findings Conceptual treatment planning
1. Severe class II div. 2 malocclusion with a complete cover-bite Treatment in mixed + permanent dentition
 • Retroclination of upper centrals by −16.5°  (a) Early active-mechanical intrusion + protrusion of upper incisors
 • Deep frontal overbite of 10 mm with (utility arch)
    – Supraposition of all upper incisors (U1 > U2)  (b) Segmented active-­mechanical intrusion of lower incisors (partial
    – Supraposition (+6 mm) and severe retroclination multibracket appliance)
(−15°) of all 4 lower incisors  (c) (If sufficient time) further passive anterior bite opening (activator)
 • High lip line level of 7 mm  (d) Further active-mechanical incisor intrusion, retraction of upper
 • Maxillary gingiva display of 4 mm during smiling incisors with palatal root torque, lingual root torque for lower
incisors (full multibracket appliance)
2. Severe class II pattern  (a) Early distalization parallel to utility arch (high-pull headgear)
 • Severe asymmetric distocclusion (full-step on right side,  (b) (If sufficient time) mandibular advancement (activator)
1/2-step on left side)  (c) (If required) further distalization of upper molars before
 • Skeletal class II (Wits + 2.8 mm) multibracket phase (skeletally anchored distalslider) OR
correction of remaining small distocclusion (multibracket
appliance + class II elastics)
3. Severe ankylosis of multiple deciduous molars  • Extraction of ankylosed deciduous molars at appropriate times
 • Particularly severe in teeth 55, 84, 85 (begin with tooth 55)
 • Resulting mesial migration/tipping of teeth 16 + 46  • Asymmetric distalization of upper first molars, uprighting of lower
molars as collateral effect of incisor intrusion
Sequence of therapeutic measures Duration
(begin at the age of 12:0 years)
1. Maxilla: Utility arch (two-by-two) 3.5 months
2. Maxilla: Utility arch (two-by-four) 6 months
Reevaluation → decision was taken to omit functional appliance
treatment
3. Maxilla: Step-by-step transition to full multibracket 10 months
appliance + cervical-pull headgear
Mandible: Utility arch (two-by-six)
4. Maxilla: Segmented multibracket appliance + high-pull 3:00 years
headgear during bedtime
Mandible: Transition to full multibracket appliance + overlay
intrusion arch
5. Maxillary and mandibular plates for retention
182 B. G. Lapatki

a b

c d

Fig. 5.53 (a–d)/patient #6. Facial images and lateral cephalogram of upper central incisor retroclination (−14.5°) combined with an
patient #6 taken at age 11:08 years, 4 months prior to treatment begin. extremely high lip line level (9.8 mm). The jaw bases show a clear
(a, b) The significant maxillary gingiva display during smiling is due to skeletal class II pattern (Wits appraisal: +2.8 mm, deviation ANB/indi-
the extreme supraposition of the upper central incisors. The facial pro- vidualized reference: 2.7°). The lower incisors are also retroclined (by
file indicates mandibular retrognathism. (c, d) The lateral cephalogram 12.5°)
reveals the typical characteristics of a severe cover-bite, i.e., pronounced
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 183

a b

c d

e f

Fig. 5.54 (a–g)/patient #6. Initial dental images of patient #6 associ- ankylosis of the second deciduous molars in first and fourth quadrants
ated with the records depicted in Fig. 5.53. (a, b) The lateral and frontal started already in the primary dentition. (e, f) Occlusal views on dental
view reveal a complete cover-bite in the late mixed dentition. (c, d) The arches. (g) The panoramic X-ray taken 6 months before the other initial
cover-bite is combined with asymmetric distocclusion. The severe records reveals insufficient resorption of all second deciduous molars
184 B. G. Lapatki

a b

c d

Fig. 5.55 (a–d)/patient #6. (a–c) The first early treatment stage is tibracket appliance is not combined with a high-pull headgear at this
started after extraction of the two ankylosed deciduous molars in the stage, because some distal tipping of upper first molars is desired (par-
first quadrant. It comprises intrusion and proclination of the maxillary ticularly, in tooth 16). (d) The occlusal view on the upper arch shows
central incisors using a two-by-two utility arch. This arch is designed to the severe alveolar bone loss after extraction of teeth 54 and 55
allow integration of the lateral incisors at a later stage. The partial mul-
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 185

a b c

d e

Fig. 5.56 (a–e)/patient #6. (a–c) The monitoring of the intrusive force of the two lateral incisors 3.5 months after treatment start. Bracketing in
requires detachment of the utility arch’s frontal segment. The tip-back the lower frontal segment is not yet possible at this stage due to the
bends into the most distal part of the bypass wire are slightly increased remaining deep overbite and contacting between upper and lower
on both sides to achieve a total intrusive force of 30 cN. (d, e) Inclusion incisors
186 B. G. Lapatki

a1 a2

b1 b2

c1 c2

d1 d2

Fig. 5.57 (a–d)/patient #6. Intermediate stages of multibracket ther- a 0.016-in. NiTi leveling archwire is combined with a 0.016 × 0.022-in.
apy. (a) Intrusion of the maxillary and mandibular front teeth using two-­ TMA overlay intrusion arch. (c) During subsequent leveling of the fron-
by-­four and two-by-six utility arches in the upper and lower jaw, tal and the two lateral segments in the upper arch using a 0.016 round
respectively. (b) After sufficient intrusion of upper incisors, a seg- NiTi full arch, the incisal part of the 0.016 × 0.016 stainless steel seg-
mented technique was applied for bodily retraction of these teeth using mental wire is maintained as underlay wire to avoid overloading of the
bilateral superelastic coil springs generating force vectors passing lateral incisors. (d) Situation after further bite opening. The remaining
approximately through the incisor segment’s center of resistance and distocclusion has been corrected using class II elastics and a cervical-­
parallel to the occlusal plane. Simultaneously, both upper canines are pull headgear worn during bedtime
intruded and retracted using a segmental T-loop wire. In the lower arch,
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 187

a b

c d

e f

Fig. 5.58 (a–g)/patient #6. (a–f) Dental images taken after 3:00 years root resorptions. Due to compromised space conditions for the upper
full multibracket therapy and subsequent 1:02 years of retention. The and lower third molars and the absence of any restoration, extraction of
extremely deep overbite of 10 mm which was initially present is cor- all third molars is recommended to the patient
rected to 3.5 mm. (g) The panoramic X-ray reveals no sign of apical
188 B. G. Lapatki

a b

c d

Fig. 5.59 (a–d)/patient #6. Facial images and cephalogram of patient Both upper and lower incisors are significantly proclined with some
#6 associated with the dental records shown in Fig. 5.58. (a, b) The over-correction in the upper arch. The skeletal class II pattern is com-
patient’s nice smile is related to the correction of the high lip line to pletely corrected as indicated by the neutral Wits appraisal
only 4 mm (initial level: 10 mm). The facial profile is harmonic. (c, d)
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 189

a1 a2

Initial

Final

b1 b2

Fig. 5.60 (a, b)/patient #6. Buccal and frontal occlusal interrelationships prior to (a) and after therapy (b)
190 B. G. Lapatki

5.6.7 Patient Example #7 segments before multibracket therapy is started—which is

generally the goal.
The original treatment plan of this patient comprised only a Based on the patient’s relatively poor compliance with
short phase for upper incisor proclination using a utility arch removable appliances, the almost completed eruption of the
to create the conditions for subsequent mandibular advance- upper second molars at the time of reevaluation (approx.
ment for causal (and at least partial) correction of the maloc- 1 year after treatment begin) and lower incisor proclination,
clusion’s severe sagittal component reflected by distocclusion it was decided to apply a skeletally anchored distalslider for
of first molars of more than one full step (Table 5.7, Figs. 5.61 correction of the class II molar relationship. Six months
and 5.62). later, the appliance was extended to a full multibracket appli-
The treatment documentation of this patient (Figs. 5.63, ance in both jaws. Concrete tasks were bodily retraction of
5.64, 5.65, and 5.66), however, demonstrates that—e.g., in upper incisors and additional palatal torque of upper incisor
case of severe distocclusion and a relatively late treatment roots using a segmented arch technique and intrusion of the
begin in the final mixed dentition phase combined with lower anterior teeth using an overlay wire. All treatment
insufficient patient compliance—the second stage of early goals were successfully achieved (Figs. 5.67, 5.68, and
class II div. 2 treatment may not always be effective enough 5.69). Figure 5.70 shows the buccal and frontal occlusal rela-
for achieving at least a nearly neutral occlusion of the buccal tionships prior to and after therapy.

Table 5.7 Problem list and conceptual treatment planning in patient #7

Problem list and relevant collateral findings Conceptual treatment planning
1. Severe class II div. 2 malocclusion with Treatment in mixed + permanent dentition
 • Retroclination of upper centrals by −13°  (a) Early active-­mechanical protrusion + limited intrusion of
 • Deep frontal overbite of 6.5 mm with supraposition of upper upper incisors (utility arch)
centrals by 2 mm  (b) Segmented active-mechanical intrusion of lower incisors
 • Incomplete display (ca. ¾) of maxillary incisor crowns during (partial multibracket appliance)
smiling  (c) (If sufficient time) further passive anterior bite opening
 (lip line level cannot be determined on the lateral cephalogram, (activator)
because the interlabial border was not visible)  (d) Further active-mechanical retraction of upper incisors with
palatal root torque, lingual root torque and intrusion of the
lower anterior segment (segmented multibracket appliance)
2. Severe class II pattern with  (a) Mandibular advancement (activator)
 • Distocclusion (1+1/2-step of right first molars, full-step of left  (b) (If required) active-mechanical distalization of upper molars
first molars) (skeletally anchored distalslider)
 • Skeletal class II (Wits appraisal + 2.3 mm)
3. Significant proclination of lower incisors (+13°) Utilizing remaining leeway space in lower arch for incisor
uprighting (mandibular plate parallel to utility arch)
Sequence of therapeutic measures (begin at the age of 11:0 years) Duration
1. Grinding of tooth 75 mesially
2. Maxilla: Utility arch (two-by-­two) + high-pull headgear during 3 months
bedtime
Mandible: Plate with positive labial bow
3. Activator with mandibular advancement + anterior bite 8 months
plates + positive lower labial bow
Reanalysis → headgear + activator were not effective enough due to
poor compliance → non-compliance approach for distalization in
upper arch required
4. Skeletally anchored distalslider with extrusive direction of guiding 4 months
wires + mandibular plate with lateral bite plates for uncoupling the
buccal occlusion and uprighting of lower incisors
5. Full multibracket appliance (with distalslider maintained until 1:11 years
debracketing)
 • Bodily retraction of upper incisors and additional palatal root
torque
 • Overlay intrusion of lower anterior segment
6. Maxillary and mandibular plates for retention
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 191

a b

c d

89.1°

Wits +2.3 mm

102.6°

Fig. 5.61 (a–d)/patient #7. Facial images and cephalogram of patient recognizable on this cephalogram. The clear skeletal class II pattern is
#7 taken at age 10:09 years, 3 months prior to treatment begin. (a, b) reflected by the Wits appraisal of +2.3 mm and the deviation of the
Frontal and lateral facial views. Upper central incisor crowns are ANB angle from the individualized reference by 3.3°. The mandible is
incompletely displayed during smiling. The facial profile is character- retrognathic (SNB 74°) and the maxilla is orthognathic (SNA 80.7°).
ized by the retrognathic mandible. (c, d) The lateral cephalogram indi- The decreased angle between upper and lower jaw bases of 17.4° (refer-
cates retroclination of the upper central incisors by 12.9°, and significant ence: 25°) indicates a skeletal deep bite
proclination of the lower incisors by 12.6°. The lip line level is not
192 B. G. Lapatki

a b

c d

e f

Fig. 5.62 (a–g)/patient #7. Initial dental records associated with the sion of right first molars and full-step distocclusion of left first molars.
facial images and cephalogram depicted in Fig. 5.61. (a, b) The patient (e, f) Eruption of the upper second molars is almost completed and tooth
shows the typical features of a severe class II div. 2 with isolated supra- 75 is the only deciduous tooth present intraorally. Mesial migration of
position and retroclination of the two upper central incisors in the late lower molars into the leeway space did not yet occur. (g) The panoramic
mixed dentition. (c, d) First molars show one-and-a-half-step distocclu- X-ray reveals the composite restoration of tooth 21 after trauma at age 7
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 193

a b

c d

Fig. 5.63 (a–d)/patient #7. (a) Insertion of the utility arch ensure the application of 30 cN in total onto both upper centrals. (c)
(0.016 × 0.016-in. stainless steel) to correct the malposition of the two Occlusal view on the maxillary arch. (d) Reclination of lower front
upper centrals. Since this patient does not display the maxillary gingiva teeth using a plate with active labial bow. Before manufacturing the
during smiling, it was planned to limit active-mechanical intrusion of acrylic part of the plate, 2-mm thick dental wax is applied to the lingual
the upper central incisors to approx. 2 mm. (b) Control measurement to surfaces of incisors and canines to provide the space for uprighting
194 B. G. Lapatki

a b

Fig. 5.64 (a–c)/patient #7. Situation after 3 months early treatment important regarding the planned subsequent mandibular advancement
with the utility arch and the mandibular plate. (a) Intrusion of the upper using an activator with anterior bite blocks. (c) The lower incisors are
central incisors by approx. 2 mm and sufficient proclination of these slightly retruded. Tooth 75 is ground mesially to allow further distal
teeth is achieved. (b) The lateral view on the incisor segment shows the migration of tooth 34
sagittal distance between the upper and lower incisors which is the
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 195

a b

Fig. 5.65 (a, b)/patient #7. (a, b) Cephalometric analysis after finish- and the stable deviation of the ANB angle from the individualized refer-
ing both main stages of early treatment, i.e., 3 months utility arch and 8 ence of 3.2° (compared to 3.3° initially), however, indicate that man-
months activator treatment. The proclination of the upper incisors by dibular growth could not be stimulated sufficiently. This may be
9.4° (initial value: 89.1°) and the uprighting of the lower incisors by explained by the relatively late begin of functional appliance therapy at
3.6° (initial value: 102.6°) demonstrates the significant improvement of the age of 11:09 years and the patient’s poor compliance during this
the frontal features of the malocclusion by the early treatment in the late treatment phase
mixed dentition. The increase of the Wits appraisal from 2.3 to 3.7 mm
196 B. G. Lapatki

a b

c d

e f

g h

Fig. 5.66 (a–h)/patient #7. Dental situation 2 months after the cepha- migrated into the leeway space. (f–h) Insertion of a skeletally anchored
logram depicted in Fig. 5.65 has been taken. (a, b) Lateral and frontal distalslider (Wilmes and Drescher 2010) for distalization of upper
images showing that the deep overbite is only partly corrected. (c, d) molars comprising two mini screws in the anterior palate before multi-
First molars are still in approx. 2/3-step distocclusion after full eruption bracket therapy
of permanent canines and premolars. (e) In the lower arch, these teeth
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 197

a b

c d 96.3°

Wits +0.9 mm

3.9 mm

102.2°

Fig. 5.67 (a–d)/patient #7. Facial images and lateral cephalogram between the ANB angle and its individualized reference indicates an
taken after 6 months skeletally anchored distalization and subsequent almost neutral sagittal jaw base relationship. The distalization of the
1:11 years therapy with a segmented full multibracket appliance. (a, b) complete maxillary dentition by approx. 5 mm comprised bodily retrac-
Frontal and lateral facial views. The patient still displays only incisal tion of the upper frontal segment with additional palatal root torque,
halves of upper central incisor crowns. (c, d) Lateral cephalogram. The i.e., large incisor root movement. This may explain the persisting mild
Wits appraisal of +0.9 mm and the remaining deviation of only 1.2° retroclination of the upper central incisors
198 B. G. Lapatki

a b

c d

e f

g h

Fig. 5.68 (a–h)/patient #7. Dental images after debracketing associ- (g, h) The patient is asked to wear maxillary and mandibular plates at
ated with the records depicted in Fig. 5.67. (a, b) The frontal overbite is night for retention. The distal extensions of the double-loop clasps for
1.5 mm, and upper and lower incisors show good axial inclinations and lower first molars and the recesses in the acrylic coverage of the labial
mutual support. (c, d) Molars and canines show neutral occlusion and bow (mesial to the canines) allow the insertion of light class II elastics
optimum intercuspidation. (e, f) Occlusal views on both dental arches. for retention of the achieved neutral sagittal occlusion
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 199

Fig. 5.69 Patient #7. Panoramic X-ray of patient #7 at the age of 15:06 years (i.e., 1:03 years after debracketing). Angulations of the third molars
seem favorable for eruption, but spatial conditions for teeth 38 and 48 are still unclear

a1 a2
a2

Initial

Final

b1 b2

Fig. 5.70 (a, b)/patient #7. Buccal and frontal occlusal interrelationships prior to (a) and after therapy (b)
200 B. G. Lapatki

References Franchi L, Baccetti T, Giuntini V, Masucci C, Vangelisti A, Defraia

E. Outcomes of two-phase orthodontic treatment of deepbite maloc-
clusions. Angle Orthod. 2011;81:945–52.
Angle EH. Classification of malocclusion. Dent Cosmos. 1899;41:248–
Fränkel R, Falck F. Zahndurchbruch und Vererbung beim Deckbiß.
264, 350–357.
Fortschr Kieferorthop. 1967;28:175–82.
Arvystas MG. Treatment of severe mandibular retrusion in Class II
Godiawala RN, Joshi MR. A cephalometric comparison between Class
Division 2 malocclusion. Am J Orthod. 1979;76:149–64.
II, Division 2 malocclusion and normal occlusion. Angle Orthod.
Ast DB, Carlos JP, Cons NC. The prevalence and characteristics of
1974;44:262–7.
malocclusion among Senior High School Students in Upstate
Goel P, Tandon R, Agrawal KK. A comparative study of different intru-
New York. Am J Orthod. 1965;51:437–45.
sion methods and their effect on maxillary incisors. J Oral Biol
Baccetti T, Franchi L, Giuntini V, Masucci C, Vangelisti A, Defraia
Craniofac Res. 2014;4(3):186–91.
E. Early vs late orthodontic treatment of deepbite: a prospective
Gould MS, Picton DC. A study of pressures exerted by the lips and
clinical trial in growing subject. Am J Orthod Dentofac Orthop.
cheeks on the teeth of subjects with Angle’s Class II Division 1,
2012;142:75–82.
Class II Division 2 and Class 3 malocclusions compared with those
Barbosa LAG, Araujo E, Behrents RG, Buschang PH. Longitudinal
of subjects with normal occlusions. Arch Oral Biol. 1968;13:527–41.
cephalometric growth of untreated subjects with Class II Division
Graber TM, Rakosi T, Petrovic AG, editors. Dentofacial orthopedics
2 malocclusion. Am J Orthod Dentofac Orthop. 2017;151:914–20.
with functional appliances. St. Louis: Mosby; 1997.
Baume LJ. Einfluss der Funktion auf die Topogenese der Zähne.
Harris EF. Root resorption during orthodontic therapy. Semin Orthod.
Fortschr Kieferorthop. 1955;16:310–9.
2000;6:183–94.
Berg R. Stability of deep overbite correction. Eur J Orthod.
Herbst E. Atlas und Grundriss der zahnärztlichen Orthopädie. Hrsg.
1983;5:75–83.
Lehmanns medizinische Handatlanten, Bd. 26. München: J. F.
Binda SK, Kuijpers-Jagtman AM, Maertens JK, et al. A long-term
Lehmann; 1922.
cephalometric evaluation of treated Class II division 2 malocclu-
Hitchcock HP. The cephalometric distinction of Class II, Division 2
sions. Eur J Orthod. 1994;16:301–8.
malocclusion. Am J Orthod. 1976;69:447–54.
Björk A, Skieller V. Facial development and tooth eruption. An implant
Hotz R. Orthodontics in daily practice. Bern: Ed. Hans Huber; 1974.
study at the age of puberty. Am J Orthod. 1972;62:339–83.
Ingervall B, Seeman L, Thilander B. Frequency of malocclusion and
Brezniak N, Arad A, Heller M, et al. Pathognomonic cephalometric
need of orthodontic treatment in 10-year old children in Gothenburg.
characteristics of Angle Class II Division 2 malocclusion. Angle
Sven Tandlaek Tidskr. 1972;65:7–21.
Orthod. 2002;72:251–7.
Isik F, Nalbantgil D, Sayinsu K, et al. A comparative study of cepha-
Bryant RM, Sadowsky PL, Hazelrig JB. Variability in three morpho-
lometric and arch width characteristics of Class II Division 1 and
logic features of the permanent maxillary central incisor. Am J
Division 2 malocclusions. Eur J Orthod. 2006;28:179–83.
Orthod. 1984;86:25–32.
Jonas IE. Therapie der Klasse II/2. In: Diedrich P, editor.
Burstone CJ. Lip posture and its significance in treatment planning. Am
Kieferorthopädie II, Praxis der Zahnheilkunde, Bd. 11/II. München:
J Orthod. 1967;53:262–84.
Urban & Fischer; 2000. p. 315–27.
Burstone CJ. Biomechanics of deep overbite correction: clinical biome-
Kaiser M. Die Bedeutung der (Schneide-) Zahnbreiten in der Ätiologie
chanics. Semin Orthod. 2001;7:26–33.
der Angle-Klasse II/2. Freiburg i.Br: Med Diss; 2002.
Christiansen-Koch S. Familien- und Sippenuntersuchungen zur Frage
Karlsen AT. Craniofacial characteristics in children with Angle Class
der Vererbung des Deckbisses. Berlin: Med Diss; 1981.
II Div. 2 malocclusion combined with extreme deep bite. Angle
Corsten R. Vergleichende Untersuchungen über Kieferanomalien an 22
Orthod. 1994;64:123–30.
Kindern. Köln: Med Diss; 1953.
Kim TW, Little RM. Postretention assessment of deep overbite cor-
Davidovitch M, Rebellato J. Utility arches: a two-couple intrusion sys-
rection in Class II Division 2 malocclusion. Angle Orthod.
tem. Semin Orthod. 1995;1:25–30.
1999;69:175–86.
Delivanis HP, Kuftinec MM. Variation in morphology of the maxillary
Kinzel J, Aberschek P, Mischak I, et al. Study of the extent of torque,
central incisors found in Class II, Division 2 malocclusions. Am J
protrusion and intrusion of the incisors in the context of Class II,
Orthod. 1980;78:438–43.
Division 2 treatment in adults. J Orofac Orthop. 2002;63:283–99.
Demisch A, Ingervall B, Thuer U. Mandibular displacement in Angle
Kloeppel W. Deckbiss bei Zwillingen. Fortschr Kieferorthop.
Class II, Division 2 malocclusion. Am J Orthod Dentofac Orthop.
1953;14:130–5.
1992;102:509–18.
Korkhaus G. Über den Aufbau des Gesichtsschädels beim Deckbiss.
Devreese HO, Dermaut LR, De Pauw GAM. Upper incisor incli-
Fortschr Kieferorthop. 1953;14:162–72.
nation and lip line: an orthodontic relationship? Eur J Orthod.
Lapatki BG, Mager AS, Schulte-Mönting J, Jonas IE. The impor-
2006;28:e10–1.
tance of the level of the lip line and resting lip pressure in Class II,
Devreese H, De Pauw G, Van Maele G, Kuijpers-Jagtman AM, Dermaut
Division 2 malocclusion. J Dent Res. 2002;81:323–8.
L. Stability of upper incisor inclination changes in Class II division
Lapatki BG, Klatt A, Schulte-Mönting J, Stein S, Jonas IE. A retrospec-
2 patients. Eur J Orthod. 2007;29:314–20.
tive cephalometric study for the quantitative assessment of relapse
Droschl H. Die Morphologie des Deckbisses. Fortschr Kieferorthop.
factors in cover-bite treatment. J Orofac Orthop. 2004;65:475–88.
1974;35:209–20.
Lapatki BG, Baustert D, Schulte-Mönting J, Frucht S, Jonas IE. Lip-­
Faxén Sepanian V, Sonnesen L. Incisor root resorption in class II divi-
to-­incisor relationship and postorthodontic long-term stability of
sion 2 patients in relation to orthodontic treatment. Eur J Orthod.
cover-bite treatment. Angle Orthod. 2006;76:942–9.
2018;40:337–42.
Lapatki BG, Klatt A, Schulte-Mönting J, Jonas IE. Dentofacial param-
Ferrazini G. Class II/2 malocclusion: early treatment with remov-
eters explaining variability in retroclination of the maxillary central
able appliances and stability after 20 years. Schweiz Monatsschr
incisors. J Orofac Orthop. 2007;68:109–23.
Zahnmed. 2008;118:814–9.
Lear CS, Decou RE, Ng DH. Threshold levels for displacement of
Fischer-Brandies H, Fischer-Brandies E, Konig A. A cephalometric
human maxillary central incisors in response to lingually directed
comparison between Angle Class II, Division 2 malocclusion and
forces. J Dent Res. 1974;53:942.
normal occlusion in adults. Br J Orthod. 1985;12:158–62.
Leech HL. Angle’s Class II Div. 1 and Class II Div. 2 in identical twins.
Fletcher GG. The retroclined upper incisor. Br J Orthod. 1975;2:207–16.
Trans Br Soc Study Orthod. 1955;42:38–42.
5 Early Treatment of Cover-Bite and Class II Division 2 Malocclusion 201

Linkous ER, Trojan TM, Harris EF. External apical root resorption Ren Y. Very few indications justify early treatment for severe Class II
and vectors of orthodontic tooth movement. Am J Orthod Dentofac malocclusions. Evid Based Dent. 2004;5:100–1.
Orthop. 2020;158:700–9. Ricketts RM. Bioprogressive therapy. Denver: Rocky Mountain/
Litt RA, Nielsen IL. Interceptive treatment of Class II, Division 2. Eur Orthodontics; 1979.
J Orthod. 1984;6:213–30. Ruf S, Pancherz H. Class II Division 2 malocclusion: genetics or
Luffingham JK. Lip and cheek pressure exerted upon teeth in three adult environment? A case report of monozygotic twins. Angle Orthod.
groups with different occlusions. Arch Oral Biol. 1969;14:337–50. 1999;69:321–4.
Luffingham JK. The lower lip and the maxillary central incisor. Eur J Schulze C. Lehrbuch der Kieferorthopädie. Berlin: Quintessenz
Orthod. 1982;4:263–8. Verlags-GmbH; 1993. p. 280–99.
Lux CJ, Conradt C, Burden D, et al. Dental arch widths and mandibular-­ Schweitzer M, Pancherz H. The incisor-lip relationship in Herbst/mul-
maxillary base widths in Class II malocclusions between early tibracket appliance treatment of Class II, Division 2 malocclusions.
mixed and permanent dentitions. Angle Orthod. 2003;73:674–85. Angle Orthod. 2001;71(5):358–63.
Lux CJ, Raeth O, Burden D, et al. Sagittal and vertical growth of the Selwyn-Barnett BJ. Rationale of treatment for Class II Division 2 mal-
jaws in Class II, Division 1 and Class II, Division 2 malocclusions occlusion. Br J Orthod. 1991;18:173–81.
during prepubertal and pubertal development. J Orofac Orthop. Shellhart WC, Moawad MI, Paterson RL, et al. Lip adaptation to
2004;65:290–311. simulated dental arch expansion. Part 1: Reliability and preci-
Maj G, Lucchese FP. The mandible in Class II, Division 2. Angle sion of two lip pressure measurement mechanisms. Angle Orthod.
Orthod. 1982;52:288–92. 1996;66:249–54.
Mayrhofer B. Lehrbuch der Zahnkrankheiten. Jena: G. Fischer; 1912. Themann J. Profil- und Enfacestudien bei Progenie und Deckbiss.
Mills JR. The problem of overbite in Class II, Division 2 malocclusion. Tübingen: Med Diss; 1974.
Br J Orthod. 1973;1:34–48. Thomson JR. Abnormal function of the temporomandibular joints
Myllärniemi S. Malocclusion in Finnish rural children - an epide- and related musculature. Orthodontic implications, Part II. Angle
miological study of different stages of dental development. Suom Orthod. 1986;56:181–95.
Hammaslaak Toim. 1970;66:219–64. Thuer U, Ingervall B. Pressure from the lips on the teeth and malocclu-
Nakasima A, Ichinose M, Nakata S, et al. Hereditary factors in the cra- sion. Am J Orthod Dentofac Orthop. 1986;90:234–42.
niofacial morphology of Angle’s Class II and Class III malocclu- Thuer U, Sieber R, Ingervall B. Cheek and tongue pressures in the
sions. Am J Orthod. 1982;82:150–6. molar areas and the atmospheric pressure in the palatal vault in
Obijou C, Pancherz H. Herbst appliance treatment of Class II, division 2 young adults. Eur J Orthod. 1999a;21:299–309.
malocclusions. Am J Orthod Dentofac Orthop. 1997;112(3):287–91. Thuer U, Grunder J, Ingervall B. Pressure from the lips on the teeth
Pacha MM, Fleming PS, Johal A. A comparison of the efficacy of fixed during speech. Angle Orthod. 1999b;69:133–40.
versus removable functional appliances in children with Class II mal- Trauner R, Byloff-Clar H, Stepantschitz E. Die Vererbung und
occlusion: a systematic review. Eur J Orthod. 2016;38(6):621–30. Entwicklung der Zahn- und Kieferanomalien. Fortschr Kieferorthop.
Pancherz H, Zieber K. Dentoskeletal morphology in children with 1961;22:1–71.
Deckbiss. J Orofac Orthop. 1998;59:274–85. Uysal T, Memili B, Usumez S, et al. Dental and alveolar arch widths in
Pancherz H, Zieber K, Hoyer B. Cephalometric characteristics of Class normal occlusion, Class II Division 1 and Class II Division 2. Angle
II Division 1 and Class II Division 2 malocclusions: a comparative Orthod. 2005;75:941–7.
study in children. Angle Orthod. 1997;67:111–20. Van der Linden FPGM. Gebissentwicklung. Berlin: Quintessenz
Parker CD, Nanda RS, Currier GF. Skeletal and dental changes asso- Verlags-GmbH; 1983. p. 99–110.
ciated with the treatment of deep bite malocclusion. Am J Orthod Van der Linden FPGM. Diagnose und Behandlungsplanung in der
Dentofac Orthop. 1995;107:382–93. Kieferorthopädie. Berlin: Quintessenz Verlags-GmbH; 1988.
Peck S, Peck L, Kataja M. Class II Division 2 malocclusion: a heri- p. 57–60.
table pattern of small teeth in well-developed jaws. Angle Orthod. Vig PS, Cohen AM. Vertical growth of the lips: a serial cephalometric
1998;68:9–20. study. Am J Orthod. 1979;75:405–15.
Perinetti G, Primožič J, Franchi L, Contardo L. Treatment effects of Von Bremen J, Pancherz H. Efficiency of early and late Class II division
removable functional appliances in pre-pubertal and pubertal class 1 treatment. Am J Orthod Dentofac Orthop. 2002;121:31–7.
II patients: a systematic review and meta-analysis of controlled Walkow TM, Peck S. Dental arch width in Class II Division 2 deep-bite
studies. PLoS One. 2015;10(10):e0141198. malocclusion. Am J Orthod Dentofac Orthop. 2002;122:608–13.
Proffit WR. Equilibrium theory revisited: factors influencing position of Weinstein S, Haack DC, Morris LY, et al. On an equilibrium theory of
the teeth. Angle Orthod. 1978;48:175–86. tooth position. Angle Orthod. 1963;33:1–26.
Proffit WR, McGlone RE, Barrett MJ. Lip and tongue pressures related Wilmes B, Drescher D. Application and effectiveness of the Beneslider:
to dental arch and oral cavity size in Australian aborigines. J Dent a device to move molars distally. World J Orthod. 2010;11:331–40.
Res. 1975;54:1161–72. Woods MG. Sagittal mandibular changes with overbite correc-
Proffit WR, Fields HW, Sarver DM. Chapter 3: Early stages of develop- tion in subjects with different mandibular growth directions: late
ment. In: Contemporary orthodontics. 4th ed; 2007a. p. 72–106. mixed-dentition treatment effects. Am J Orthod Dentofac Orthop.
Proffit WR, Fields HW, Sarver DM. Chapter 10: Mechanical principles 2008;133:388–94.
in orthodontic force control. In: Contemporary orthodontics. 4th Zachrisson BU. Facial esthetics: guide to tooth positioning and maxil-
ed; 2007b. p. 383–94. lary incisor display. World J Orthod. 2007;8(3):308–14.
 Early Treatment of Class III
Malocclusions 6
Somchai Satravaha

Class III malocclusions are considered among most diffi-

cult malocclusions to be treated. If it is possible to intercept
early, severity of the malocclusions will be reduced. To treat
early, careful considerations must be taken such as treatment
possibility and limitation in certain cases. Complexities of
Class III malocclusions involve their etiologies which can be
hereditary (Figs. 6.1, 6.2, 6.3, and 6.4) or environment origin
(Figs. 6.5, 6.6, 6.7, 6.8 and 6.9) or both.
Class III malocclusions will become more severe if the eti-
ologies are from both hereditary combined with environment.
According to Rakosi, Class III malocclusions can be
cephalometrically categorized into five types:

1. Dentoalveolar Class III malocclusion (Fig. 6.10).

2. Skeletal Class III malocclusion with fault in the maxilla
(Fig. 6.11).
3. Skeletal Class III malocclusion with fault in the mandible
(Fig. 6.12).
4. Skeletal Class III malocclusion with combination of 2
and 3 (Fig. 6.13).
5. Skeletal Class III malocclusion with pseudo forced bite
(Figs. 6.14 and 6.15).

In many cases, Class III malocclusions are both skeletal

and dental (Rakosi 1985; Graber et al. 1997; Rakosi and
­Graber 2010).

Fig. 6.1 A 9-year-old girl with concave facial profile

6.1 Functional Class III Malocclusion

Function analysis can help in differential diagnosis of Class Therefore, movement of the mandible and joint function
III malocclusions to specify whether the malocclusion is of must be examined (Figs. 6.16 and 6.17).
hereditary or environment or from both origins as stomato- Rakosi mentioned that mandibular movement plays
gnathic system is dynamic not static. The temporomandibu- important clue to the prognosis of skeletal Class III mal-
lar joints are the most used joints in the whole human body. occlusions when treated with his Class III activator, when
the mandible is pushed backward to a new desired posterior
position. He suggested that the mandible normally closes in
S. Satravaha (*) a rotation manner into initial tooth contact, then slide either
Faculty of Dentistry, Orthodontic Department, Mahidol University,
forward or backward into maximum tooth contact. The case
Bangkok, Thailand

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 203
J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_6
204 S. Satravaha

Fig. 6.5 Oral habit as seen here can cause anterior crossbite because
the mandible was dragged forward to a more anterior position to the
maxilla when this patient tried to touch the tip of her nose with her
tongue. Anterior portion of her maxilla was compressed by the force
from the tongue, which could cause anterior crossbite and could develop
Fig. 6.2 Her cephalometric head film showed skeletal Class III into skeletal Class III malocclusion if not intercepted
malocclusion

Fig. 6.3 She had a deep anterior crossbite

Fig. 6.6 An additional habit of making a ribbon with the lips as seen
here can cause narrow upper and lower arches

where the mandible closes with rotation and slide forward

has better prognosis than that of a rotation with a slide back-
ward.
In addition, from doing functional analyses on the
patients, it can be concluded that patients with skeletal Class
III malocclusions have incompetent lips, low tongue posi-
tion with anterior thrust, and visceral or infantile swallow-
ing pattern. The characteristic of the tongue, lips, and their
functions contributes to more severity of the malocclusions
and instability of treatment outcomes (Graber 1963; Rakosi
1985; Graber et al. 1997; Rakosi and ­Graber 2010).

Fig. 6.4 Her photograph with her father showed both of them had con-
cave facial profiles, and her father had also anterior crossbite; which
obviously indicate hereditary cause for the daughter’s malocclusion
6 Early Treatment of Class III Malocclusions 205

Fig. 6.7 Two intraoral

pictures of the same patient in
Figs. 6.5 and 6.6 showed
anterior crossbite with large
negative overjet and bilateral
posterior crossbites. Narrow
upper and lower arches with
linguoversion of posterior
teeth in both arches were
caused by her abnormal oral
habits

Dento-alveolar Class III malocclusion

ANB normal

SNB SNA

Maxilla
a

Anterior

Mandible
e

Fig. 6.8 Polyp seen in the right nostril can obstruct the patient’s upper
airway and cause mouth breathing Fault at axial inclination(s) of upper and/or lower anterior teeth

Fig. 6.10 Dentoalveolar Class III malocclusion with fault at axial

inclination (s) of upper and/or lower anterior teeth

Skeletal Class III malocclusion with fault in the maxilla

ANB = -ve or < normal

SNB SNA

Maxilla

Anterior
Fig. 6.9 Large tonsils can obstruct the patient’s upper airway and
cause mouth breathing and low tongue position. Force from flat tongue
position can cause lower anterior teeth to flare out labially

Mandible

Fig. 6.11 Skeletal Class III malocclusion with fault in the maxilla; the
maxilla is underdeveloped while the mandible is normal
206 S. Satravaha

Skeletal Class III malocclusion with fault in the mandible Skeletal Class III malocclusion with pseudo forced bite

ANB = -ve
ANB = -ve SNB SNA

SNB SNA Maxilla

Anterior
Maxilla

Mandible
Anterior

Proclined upper incisors and retroclined lower incisors, positive

overjet and overbite

Mandible
Fig. 6.14 Skeletal Class III with pseudo forced bite, proclination of upper
anterior teeth, and retroinclination of the lower anterior teeth compensate
skeletal discrepancy resulting in positive overjet and positive overbite
Fig. 6.12 Skeletal Class III malocclusion with fault in the mandible;
the mandible is overdeveloped while the maxilla is normal
Skeletal Class III malocclusion with
pseudo forced bite
Skeletal Class III malocclusion with fault in both, the maxilla
and the mandible ANB= -ve
SNB SNA
ANB = -ve
SNB SNA Maxilla
a

Anterior
Maxilla

Anterior Mandible
le

When upper and lower anterior teeth are upright, skeletal Class III
Mandible
malocclusion, with anterior cross bite can be clearly seen.

Fig. 6.15 When both upper and lower anterior teeth in Fig. 6.14 are
Fig. 6.13 Skeletal Class III malocclusion with fault in both the maxilla
upright, severe skeletal Class III malocclusion is revealed
and the mandible. The maxilla is underdeveloped while the mandible is
overdeveloped

a b

Fig. 6.16 (a, b) A patient at maximum tooth contact or CO showed anterior crossbite
6 Early Treatment of Class III Malocclusions 207

a b

Fig. 6.17 (a, b) The same patient at physiologic rest position; no anterior crossbite was presented

a b

Fig. 6.18 (a, b) If not treated early, the girl on (a) might grow up to become a woman on (b). This certainly has psychological impact on the
patient, especially being teased for having a non-esthetic concave facial profile

6.2 Reasons for Early Treatment ified. There are natural growth and induced growth which
cannot be measured separately. The author believes that the
If not treated, severity of the malocclusions will increase treatment outcomes are the most crucial for the decision
which can cause function problems and have psychological whether to treat early or not. If the treatment outcomes can
impact on the patients (Figs. 6.18, 6.19, and 6.20). reduce severity of malocclusions and are satisfactory to both
There has been a controversy in treatment of Class III patients and orthodontists, then the interception is worth
malocclusions early, especially whether growth can be mod- doing.
208 S. Satravaha

a b

c d

e f

Fig. 6.19 (a–f) Severity of the malocclusion could increase tremendously if not treated

a b

Fig. 6.20 (a, b) An untreated male patient showed a facial asymmetry in a permanent dentition illustrated anterior crossbite and unilateral poste-
rior crossbite on the left side
6 Early Treatment of Class III Malocclusions 209

6.3 To Treat Early: When Is the Right 6.4 In Deciduous Dentition
Time?
It is rather early to treat Class III malocclusions during this
Once we decide to treat the cases, we must begin with the end in stage as Class III malocclusions are rather complex. The
mind knowing the goals and how the finished cases should be. treatment might take a very long time, and patients can get
Treatment objectives should be the same as all orthodon- burnt out. Most cases are to be under growth and develop-
tic treatments which are to achieve good function, acceptable ment observation (Figs. 6.21 and 6.22), and many of the
esthetics, and good stability. The treatment should be at the cases anterior crossbite was corrected through eruption of
right place, at the right time and with proper appliances. permanent upper and lower anterior teeth.

b c

Fig. 6.21 (a–c) Tooth #31 and #41 erupted lingually to tooth #61 and #51; crossbite was self-eliminated

a b c

Fig. 6.22 (a–c) Cephalometric head films of the patient in Fig. 6.21 at age 6, 7, and 8, respectively, showed path of eruptions of upper and lower
anterior teeth. Anterior crossbite was self-corrected through eruption of upper and lower anterior teeth
210 S. Satravaha

6.5 Early Treatment of Dentoalveolar

Class III (Figs. 6.23, 6.24, 6.25, 6.26,
6.27, 6.28, 6.29, 6.30, 6.31, 6.32,
6.33, 6.34, 6.35, 6.36, 6.37, 6.38,
6.39, and 6.40)

6.5.1 In Early Mixed Dentition

Fig. 6.26 Diastema media was seen here

Fig. 6.23 An intraoral picture of an 8-year-old girl in an early mixed

dentition, #11 was in crossbite with #41 and #42. A treatment to correct
the crossbite was needed. If not treated, growth of the maxilla at #11
would be inhibited

Fig. 6.27 An upper plate with two finger springs was used to close the
spaces in the upper anterior region. No raised bite needed here

Fig. 6.24 An upper plate with posterior raised bite and a protrusion
spring were used to correct the crossbite

Fig. 6.28 Spaces were closed

Fig. 6.25 The crossbite was corrected. Upper permanent lateral inci-
sors erupted more into the oral cavity while the lower canines started to
erupt
6 Early Treatment of Class III Malocclusions 211

a b

Fig. 6.29 (a, b) Comparison between before the treatment and sometime after correction of the crossbite and spaces closing in the upper anterior
region

a b

Fig. 6.30 (a, b) An 8-year-old boy with dentoalveolar Class III malocclusion; he showed lower anterior teeth at smile
212 S. Satravaha

a b

Fig. 6.31 (a, b) He had normal facial profile

b c

Fig. 6.32 (a–c) Anterior crossbite was presented

6 Early Treatment of Class III Malocclusions 213

Fig. 6.33 Anterior crossbite was corrected by using an upper plate

with protrusion screw to protrude the upper permanent anterior teeth

a b

Fig. 6.34 (a, b) After correction of the anterior crossbite, the patient showed upper anterior teeth at smile which is esthetically more pleasant than
before the treatment
214 S. Satravaha

a b

Fig. 6.35 (a, b) His profiles remained acceptable

b c

Fig. 6.36 (a–c) Intraoral pictures, 2 years after the beginning of the treatment
6 Early Treatment of Class III Malocclusions 215

a b

Fig. 6.37 (a, b) Cephalometric x-ray of the patient in Figs. 6.30 to 6.36 and the tracing showed that he has a + 2 ANB before the treatment which
indicated no fault in both the maxilla and the mandible. The cause for anterior crossbite was from inclination of upper and lower anterior teeth

a b

Fig. 6.38 (a, b) Cephalometric x-ray of the same patient and the tracing after correction of the anterior crossbite
216 S. Satravaha

a b

Fig. 6.39 (a, b) 2 years after the anterior crossbite was corrected

6.6 Treatment of Skeletal Class III

Malocclusions

6.6.1 The Use of Facemask or Facemask

Combined with Rapid Palatal
Expansion (Figs. 6.41, 6.42, 6.43, 6.44,
6.45, 6.46, 6.47, and 6.48)

Many authors suggested the use of facemask or RPE (rapid

palatal expansion) or facemask combined with RPE to
enhance growth of the maxilla or together with the attempt
to control growth of the mandible. Temporary anchorage
device (TAD) has also been used to protract the maxilla
(Baccetti and McNamara 2004; Cha 2003; Gallagher et al.
1998; Gu et al. 2000; Hass 1980; Kajiyama et al. 2000; Keles
et al. 2002; Liou 2005; McNamara 2000; Mermingo et al.
1990; Ngan 2002; Ngan et al. 2015; Pangrazio-Kulbersh
et al. 1998; Saadia and Torres 2000; Turley 2002; Yüksel et
al 2001).
The author prefers to use RPE not too early as it is eas-
ier to work with the patient, and it was mentioned in many
researches that the results of doing RPE in early or late have
no significant difference.

Fig. 6.40 Superimposition of the tracings at the three timelines, before

treatment (T0), after correction of the anterior crossbite (T1), and
2 years after the treatment began (T2)
6 Early Treatment of Class III Malocclusions 217

6.6.2 The Use of Chincap (Chincup) (Fig. 6.49) use have been done by many authors. Hideo Mitani stated
on his article, “Early application of Chincap therapy to skel-
Chincap have been used to modify growth of the mandible etal Class III malocclusion” that chincap works sufficiently
and the maxilla, and many studies on the effectiveness of its on the first 2 years of the treatment but need long reten-
tion time as the condylar cartilage might gradually become
accustomed to the chincap force, allowing bone formation to
return to the initial level even under compressive force, and
if the chincap therapy is stopped before facial growth is com-
plete, the decreased pressure appears to stimulate and accel-
erate condylar growth, and some recovery growth might take
place. He also added that the improper use of the chincap
can cause temporomandibular disorders and that the chincap
should be used and monitored carefully (Deguchi et al. 1999;
Deguchi et al. 2002; Graber 1977; Ishikawa et al. 1988; Ko
et al. 2004; Mitani 2002; Sugawara et al. 1990; Wendell
et al. 1985).

6.6.3 The Use of Functional Appliances

Functional appliances such as Fränkel’s FR 3, Bimler’s

Bionator, etc. have been used to treat skeletal Class III
­
malocclusions (Fränkel and Fränkel 1989; Graber et al.
­
1997; Levin et al. 2008; Rakosi 1985; Rakosi and Graber
2010; Satravaha 1993; Satravaha and Taweesedt 1996a,
1996b; Satravaha and Taweesedt 1999).

Fig. 6.41 Facemask to protract maxilla and to inhibit growth of the

mandible

a b

Fig. 6.42 (a–f) Extra- and intraoral pictures of a 14-year-old girl, with tongue with low tongue position; the bite was slightly opened. At smile,
a concave facial profile; she had a Class III malocclusion with large a large anterior crossbite appeared and she showed more of the lower
negative overjet and severe crowding in the upper arch. She had a large anterior teeth than the upper anterior teeth
218 S. Satravaha

c d

e f

Fig. 6.42 (continued)

Fig. 6.44 After removal of RPE, fixed appliances were used to correct
Fig. 6.43 RPE was used to expand the upper arch transversally and to upper arch crowding
bring the maxilla forward
6 Early Treatment of Class III Malocclusions 219

a b

c d

Fig. 6.45 (a–d) After removal of the RPE, orthodontic fixed appliances were used during the second phase of treatment; her facial appearance
and lateral profile were esthetically improved
220 S. Satravaha

a b

Fig. 6.46 (a, b) Severe crowding in the upper anterior region was corrected; teeth #34 and #44 were extracted in order to move lower canines
backward and later lower anterior teeth to achieve positive overbite and positive overjet

a b

Fig. 6.47 (a, b) Cephalometric and tracing of the same girl before an RPE was used to expand the upper arch; her SNA angle was 81 degrees
6 Early Treatment of Class III Malocclusions 221

a b

Fig. 6.48 (a, b) After RPE was used, SNA increased from 81 to 82 degrees

6.6.4 The Use of Class III Activator

(Figs. 6.50, 6.51, and 6.52)

The author recommends Class III activator of Thomas Rakosi

(Rakosi 1985; Satravaha 1993; Graber et al. 1997; Rakosi and
Graber 2010) to be used in early stage of treatment of skeletal
Class III malocclusion, and the objectives of using this appli-
ance are as follows:
1. To achieve a more posterior position of the mandible.
2. To protract the maxilla.
3. To get positive overjet.
4. To get positive overbite.
Class III activator of Thomas Rakosi is a bimaxillary
appliance, composed of acrylic part and wire components.
The components and their functions are as follows:
1. Upper labial pads to stimulate bone formation or enhance
growth of the maxilla.
2. Lower labial bow to stabilize the appliance, and the author
recommends not to have any force from the lower labial
bow on the lower anterior teeth. Its distance to the labial
surfaces of the lower anterior teeth should be about 2 mm.
3. Stop loops located mesial to all the 6-year molars to sta-
bilize the appliance.
4. Tongue guard to prevent force from a flat and low tongue
position which exert force upon and flare out the lower
Fig. 6.49 Chincap
anterior teeth.
222 S. Satravaha

a b c

2
4

Fig. 6.50 (a–c) Class III activator

Fig. 6.53 A construction bite

6.7 Construction of Class III Activator

Fig. 6.51 Cephalogram taken before using Class III activator (Figs. 6.53, 6.54, 6.55, 6.56, 6.57,
and 6.58)

A construction bite must be registered to designate a new

position of the mandible which is more posterior to its
original position. Construction bite must be done on the
patient. Its thickness varies according to growth pattern of
the patient but must be thicker than the freeway space of
that patient as activator functions through natural force of
the muscles (Rakosi 1985; Graber et al. 1997; Rakosi and
­Graber 2010; Witt and Gehrke 1981).
In horizontal growth pattern patients, the mandible can be
pushed backward in a more distance than that of the patients
with vertical growth pattern. Patients with horizontal growth
pattern therefore have more favorable prognosis than those
of vertical growth pattern when using Class III activator for
correction of sagittal discrepancy.

Fig. 6.52 Cephalogram of the same patient in Fig. 6.51 showed posi-
tive overjet and positive overbite after the use of Class III activator, and
it can be clearly seen here that the mandible of this patient was pushed
backward into a new position
6 Early Treatment of Class III Malocclusions 223

Fig. 6.55 A cephalogram of a vertical growth pattern patient

Fig. 6.54 A cephalogram of a horizontal growth pattern patient

a b

Fig. 6.56 (a) showed lateral profile of a 9-year-old girl without a con- having construction bite in the mouth, resulting in better proportion of
struction bite in the mouth. Figure (b) shows the same girl with con- the face and improving in esthetics
struction bite in the mouth. Her lower face height increased while
224 S. Satravaha

6.7.1 Checklist when Registering

Construction Bite

1. The patients with the construction bites in the mouth

must be able to close their lips without muscle strain.
2. The patients’ mandibular and facial midlines must coin-
cide. Skeletal midline shift should be corrected through
construction bite registration.
3. As there will be permanent changes in facial appear-
ances of the patients, patients’ and parental approval are
needed.

6.7.2 Patient’s Instruction at Insertion

of Class III Activator
(Figs. 6.59 and 6.60)

1. Inform the patients and their parents that Class III activa-
tor is a bimaxillary appliance, which loosely fit in the
patients’ mouth.
2. The patients should wear the appliances at least 12 hours
a day and mostly at night due to secretion of growth hor-
mone (Funatsu et al. 2006).
3. The patients can wear the activators during doing their
Fig. 6.57 A cephalometric x-ray of a patient at occlusion homework; they can talk while having the appliances in
the mouths.
4. After the insertion, the patients should be able to put the
appliances on and take them off by themselves. At the
first night, when waking up in the morning, the patients
should check whether the appliances are still in the
mouth. If not, they should wear the appliances more dur-
ing the daytime.

Fig. 6.59 Class III activator in situ

Fig. 6.58 A cephalometric x-ray of the same patient with a construc-
tion bite; note that the construction bite brought the mandible backward
into a more posterior position. Lower facial height of the patient
increased and resulted in a better facial proportion and esthetics
6 Early Treatment of Class III Malocclusions 225

6.8 Objectives

1. To achieve positive overbite.

2. To achieve positive overjet.
3. To control tooth eruption.
4. To get good intercuspidation.

6.8.1 Appliance Activation Is

Done by (Fig. 6.61)

1. Adding self-curing acrylic on the appliance at the area

lingually to lingual surfaces of upper anterior teeth to pro-
trude upper anterior teeth.
2. Activate upper labial pads to produce periosteal pull to
enhance growth of the maxilla.
3. Leveling curve of Spee by trimming of the acrylic and
control tooth eruption.
4. Keep the lower labial bow negative as the lower anterior
teeth trend to tip more lingually when use Class III activa-
tor, which might result from contraction of perioral mus-
cle during visceral swallowing and from tongue guard.
Tongue guard prevents opposite force from the tongue
from acting upon lower anterior teeth.

Fig. 6.60 Cephalogram of a patient with Class III activator

The patients with large adenoid/tonsils or mouth

breathers will have difficulties in holding the appliances
in the mouths during sleep. This problem should be elimi-
nated before using Class III activator.
5. The average time for the use of Class III activator is
approximately 1 year.

6.7.3 Patient’s Appointment

The patients should come for appliance adjustment every

4 weeks.

Fig. 6.61 Self-curing acrylic was added to protrude upper anterior

teeth at every appointment in order to achieve positive overjet and
6.7.4 Appliance Adjustment overbite
226 S. Satravaha

6.9 Example of Cases Treated with Class

III Activator (Figs. 6.62, 6.63, 6.64, 6.65,
6.66, 6.67, 6.68, 6.69, 6.70, 6.71, 6.72,
6.73, 6.74, 6.75, 6.76, 6.77, 6.78, 6.79,
6.80, 6.81, 6.82, 6.83, 6.84, 6.85, 6.86,
6.87, 6.88, 6.89, 6.90, 6.91, 6.92, 6.93,
6.94, 6.95, 6.96, 6.97, 6.98, 6.99, 6.100,
6.101, 6.102, 6.103, 6.104, 6.105, 6.106,
6.107, 6.108, 6.109, 6.110, 6.111, 6.112,
6.113, 6.114, 6.115, 6.116, 6.117, 6.118,
6.119, 6.120, 6.121, 6.122, and 6.123)

6.9.1 Case #1 (Figs. 6.62, 6.63, 6.64, 6.65, 6.66,

and 6.67)

a b

c d

Fig. 6.62 (a–g) Extra- and intraoral pictures of a 9-year-old boy showed protrusive profile, Class III molar and canine relationships, and anterior
crossbite. He showed lower teeth at smile
6 Early Treatment of Class III Malocclusions 227

e f

Fig. 6.62 (continued)

a b

Fig. 6.63 (a–g) Extra- and intraoral pictures of the same boy after improved. Anterior crossbite was corrected. Class I molar and canine
treated with Class III activator; his facial profile improved. He showed relationships were achieved
more upper teeth at smile than before the treatment which is esthetically
228 S. Satravaha

c d

e f

Fig. 6.63 (continued)

6 Early Treatment of Class III Malocclusions 229

a b

Fig. 6.64 (a, b) Cephalogram and tracing before the treatment; ANB angle was 0 degree

a b

Fig. 6.65 (a, b) Cephalogram and tracing with Class III activator in situ, showing that the mandible was brought to a more posterior position than
its original position
230 S. Satravaha

a b

Fig. 6.66 (a, b) Cephalogram and tracing after positive overjet and positive overbite were achieved; ANB angle increased from 0 to 2 degrees

6.10 Treatment of Class III Malocclusion

with Pseudo Forced Bite (Figs. 6.68,
6.69, 6.70, 6.71, 6.72, 6.73, 6.74, 6.75,
6.76, 6.77, 6.78, 6.79, 6.80, 6.81, 6.82,
and 6.83)

In many cases of skeletal Class III malocclusion with

pseudo forced bite, the skeletal discrepancies are very severe
(­Pirttiniemi 1994); orthognathic surgery might be required in
later age when mandibular growth ceases.
In some cases when we treat early enough, interceptive
attempt could be made to reduce severity of the malocclu-
sion.

Fig. 6.67 Superimposition of cephalometric tracings before the treatment

(T0) and after positive overjet and positive overbite were achieved (T1)
6 Early Treatment of Class III Malocclusions 231

6.10.1 Case #2

a b

c d

Fig. 6.68 (a–d) Extraoral pictures of a 7-year-old girl showed facial asymmetry at smile, and her chin deviated to the right side
232 S. Satravaha

a b

Fig. 6.69 (a, b) Her lateral profile showed a large body of mandible and prominent chin. Her mandible was obviously too large for her age

b c

Fig. 6.70 (a–e) Intraoral pictures showed moderate crowding of the lower anterior teeth, tooth #32 erupted lingual to tooth #73, positive overjet
and overbite, resulting from retroclined lower anterior teeth. No crossbite presented
6 Early Treatment of Class III Malocclusions 233

d e

Fig. 6.70 (continued)

a b

c d

Fig. 6.71 (a–d) After the use of Class III activator, the mandibular midline was brought to coincide with the facial midline and the facial asym-
metry was eliminated
234 S. Satravaha

a b

Fig. 6.72 (a, b) Lateral profile was esthetically improved after the use of Class III activator; the mandible and the chin appeared to be in good
proportion to the maxilla

a b

Fig. 6.73 (a, b) Comparison of her smiles before the treatment and after the midline correction using Class III activator
6 Early Treatment of Class III Malocclusions 235

a b

c d

Fig. 6.74 (a–d) She maintained a facial symmetry 2 years after the treatment. The treatment result was stable
236 S. Satravaha

b c

d e

Fig. 6.75 (a–e) Intraoral pictures showed crossbite at # 63, #73, and #34; lower anterior teeth were aligned by the use of partial fixed appliances
6 Early Treatment of Class III Malocclusions 237

a b

Fig. 6.76 (a, b) A cephalogram and a tracing before the treatment showed the ANB angle of +1 degree, positive overjet and positive overbite
through retroclined of lower anterior teeth, which fell into category skeletal Class III malocclusion with pseudo forced bite

a b

Fig. 6.77 (a, b) The mandible was pushed backward into a more posterior position through the use of Class III activator; ANB angle became
bigger changing from +1 to +4 degrees
238 S. Satravaha

a b

Fig. 6.78 (a, b) A cephalogram and a tracing 2 years after the treatment with Class III activator and before beginning of partial fixed appliances
to align the crowded lower incisors. The mandible continued to grow fast as the ANB angle decreased from +4 to +3 degree

Fig. 6.79 Superimposition of cephalometric tracing at the three time-

lines, before treatment (T0), 1 years after Class III activator treatment
(T1), and 2 years after the treatment began (T2)
6 Early Treatment of Class III Malocclusions 239

a b

Fig. 6.80 (a, b) Posteroanterior cephalometric x-ray (PA) and tracing of the patient before the treatment showed obvious facial asymmetry with
the mandibular midline shifted to the right side of the patient

a b

Fig. 6.81 (a, b) A PA head film and a tracing of the patient with Class III activator in situ showed the shifted mandibular midline was brought to
a position which coincides with the facial midline. No facial asymmetry presented
240 S. Satravaha

a b

Fig. 6.82 (a, b) A PA head films of the patient and a tracing after the use of Class III activator to correct facial asymmetry, where the mandibular
midline coincides with the facial midline

Fig. 6.83 Superimposition of the PA head films of the patient before

the treatment (T0) and after correction of facial asymmetry with the use
of Class III activator (T1)
6 Early Treatment of Class III Malocclusions 241

6.11 Class III Activator Can be Used

for Treatment of Functional Class III
Malocclusion when the Patient Can
do an Edge-to-Edge Bite (Figs. 6.84,
6.85, 6.86, 6.87, 6.88, 6.89, 6.90, 6.91)

6.11.1 Case #3

a b

c d

Fig. 6.84 (a–d) Extraoral pictures of a 7-year-old girl at rest position and at smile; she showed both upper and lower anterior teeth
242 S. Satravaha

a b

c d

Fig. 6.85 (a–d) Her intraoral pictures showed a very early stage of mixed dentition with a complete block out of upper anterior deciduous teeth.
Tooth #11 was erupting; the patient was able to bite edge to edge

a b c

Fig. 6.86 (a–c) After using Class III activator, the mandible was push into a more posterior position; path of eruption of #11 and #21 were guided;
positive overjet and positive overbite were achieved
6 Early Treatment of Class III Malocclusions 243

a b

Fig. 6.87 (a, b) A cephalogram and tracing before the treatment showed anterior crossbite and the ANB angle of −2 degrees. Both upper and
lower anterior teeth were both retroclined

a b

Fig. 6.88 (a, b) A cephalogram and a tracing with Class III activator in situ showed that the mandible was brought backward into a new
position
244 S. Satravaha

a b

Fig. 6.89 (a, b) A cephalogram and a tracing during the treatment with Class III activator, the ANB angle increased from −2 to +2 degree,
increase in inclination angle of the upper anterior teeth from 100 to 105 degree, and positive overjet and positive overbite were achieved

a b

Fig. 6.90 (a, b) A cephalogram and a tracing during the treatment with Class III activator after positive overjet and positive overbite were
achieved by guided path of eruption of teeth #11 and #21. The mandible continued to grow fast as the ANB angle decreased from +2 to +1 degree
6 Early Treatment of Class III Malocclusions 245

6.12 What to do if the Mandible cannot

be Pushed Backward

Sometimes it is not possible to push the mandible backward

into a more posterior position due to antagonistic forces from
lateral pterygoid muscles, which could come from stress. An
upper removable bite plate is recommended for the patient
to wear more or less 24 × 7 to allow the mandible to move
into its most preferable position. (Figs. 6.92, 6.93, 6.94, 6.95,
6.96, 6.97, 6.98, 6.99, 6.100, and 6.101).

6.12.1 Case #4

In this case, the mandible could not be pushed backward.

Within 1 month after using removable upper bite plate,
Class III activator could be then constructed and used for
the treatment.

Fig. 6.91 Superimposition of the three timelines, before treatment

(T0), after positive overjet and positive overbite were achieved (T1),
and after they were secured by occlusion of posterior teeth (T2)

a b

Fig. 6.92 (a, b) Extraoral and intraoral pictures of a 9-year-old girl, when smiling she showed more lower anterior teeth than upper anterior teeth;
she had anterior crossbite with an open bite tendency
246 S. Satravaha

Fig. 6.93 Her cephalogram obviously showed that she had a very
small maxilla compared to her mandible; she had an anterior crossbite
and protruding lower lip

a b

Fig. 6.94 (a, b) Removable upper bite plate with upper labial pads in situ; when smiling the patient showed more of the upper anterior teeth then,
meaning that the mandible had moved backward while wearing the appliance
6 Early Treatment of Class III Malocclusions 247

a b

Fig. 6.95 (a, b) Removable upper bite plate with upper labial pads

a b

Fig. 6.96 (a, b) Comparison of cephalograms taken on the same day, without (a) and with upper bite plate in situ (b); the mandible could clearly
be seen in a more posterior position and the lateral profile became more pleasing while wearing the upper bite plate
248 S. Satravaha

a b

Fig. 6.97 (a, b) Different smiles on the same day; without and with upper bite plate

Fig. 6.98 Class III activator could be constructed then and was used to
push the mandible into a more posterior position
6 Early Treatment of Class III Malocclusions 249

c d

Fig. 6.99 (a–d) Pictures taken 1 year after using Class III activator; the bite became edge-to-edge, when smiling the patient showed more upper
anterior teeth

a b

Fig. 6.100 (a, b) Comparison of cephalograms at the beginning of the treatment (a) and 1 year after using Class III activator (b) showed improve-
ment of sagittal relationship between the maxilla and the mandible
250 S. Satravaha

c d

e f

Fig. 6.101 (a–f) Her extraoral and intraoral pictures 2 years after arches for all premolars and for retracting lower anterior teeth to
using Class III activator; when smiling she showed only upper anterior achieved positive overjet and positive overbite
teeth which is esthetically good; enough spaces both in upper and lower
6 Early Treatment of Class III Malocclusions 251

6.13 Stability of the Skeletal and Dental 6.13.1 Cause of Dental Instability
Changes after Treatment with Class
III Activator (Figs. 6.102, 6.103, 6.104, As previously mentioned, patient with Class III malocclusions
6.105, 6.106, 6.107, 6.108, 6.109, mostly have large tongue, low tongue position and visceral swal-
6.110, 6.111, 6.112, 6.113, 6.114, lowing pattern. Force from the tongue play major role in the cause
6.115, 6.116, 6.117, 6.118, 6.119, of dental instability (Figs. 6.102, 6.103, 6.104, 6.105, 6.106,
6.120, 6.121, 6.122, and 6.123) 6.107, 6.108, 6.109, 6.110, 6.111, 6.112, 6.113, 6.114, 6.115,
6.116, 6.117, 6.118, 6.119, 6.120, 6.121, 6.122, and 6.123).
Class III activator causes changes in both skeletal and dental.
Clinical research on stability of skeletal changes after activator
6.13.2 Case #5
treatment of patients with Class III malocclusions was done
by Satravaha et al.; they found significant skeletal effects with
The author routinely recommends myofunction exercises
improvement of skeletal profiles and these changes remained
according to Daniel Garliner for all Class III malocclusion
(Satravaha 1993; Satravaha and Taweesedt 1996a; Satravaha
patients and uses in addition Pearlen plate as upper retainer as a
and Taweesedt 1996b; Satravaha and Taweesedt 1999).
reminder and for tongue exercise (Figs. 6.105 and 6.106) (Gar-
liner 1981; Satravaha 1990; Satravaha and Taweesedt 2002).

c d

Fig. 6.102 (a–d) Extra- and intraoral pictures of a 12-year-old girl after using Class III activator, large tongue thrusting anteriorly and laterally.
Her tongue and both upper and lower anterior teeth could be seen at smile
252 S. Satravaha

c d

Fig. 6.103 (a–d) The upper brackets were debonded, despite persistent tongue thrusting at the area in the circle in (d). The father of the patient
and the patient were informed about the risk of having dental relapse
6 Early Treatment of Class III Malocclusions 253

a b

c d

Fig. 6.104 (a–e) A few months after, as a result from large tongue and tongue thrusting, crossbite, open bite, and space can be seen in the intraoral
pictures

a b

Fig. 6.105 (a, b) Rubber ring are used in myofunction exercises

254 S. Satravaha

Fig. 6.106 Pearlen plate

c d

Fig. 6.107 (a–d) Extra- and intraoral pictures at the time of debonding and #44 and at #23, #24, #33, and #34 can be seen in Figs. c and d.
all fixed appliances; the occlusion was improved but the risk of having Pearlen plate was used as upper retainer to help as a reminder and for
relapse was still present. Tendency of having open bites at the #13, #43, tongue training
6 Early Treatment of Class III Malocclusions 255

a b

f
e

Fig. 6.108 (a–f) Extra- and intraoral pictures at recall, 3 years and 1 month after debonding all the fixed appliances; the patient carried on with
myofunction exercises; the treatment outcomes remained stable
256 S. Satravaha

a b
SNA 79
SNB 80
ANB -1
U1 - SN 108
L1 - MP 94

Fig. 6.109 (a, b) Cephalometric head film and tracing at beginning of the treatment; ANB angle was −1 degree

a b

SNA 83
SNB 82
ANB 1
U1 - SN 113
L1 - MP 89

Fig. 6.110 (a, b) Cephalometric head film and tracing after the use of degrees, while lower anterior teeth were more retroclined L1-MP
Class III activator; ANB angle increased from −1 to +1 degree. Upper decreased from 94 to 89 degrees
anterior teeth were more proclined U1- SN increased from 108 to 113
6 Early Treatment of Class III Malocclusions 257

a b

SNA 85
SNB 83
ANB 2
U1 - SN 113
L1 - MP 95

Fig. 6.111 (a, b) Cephalometric head film and tracing before the use of fixed appliances in the second phase treatment; ANB angle was 2 degree.
The upper anterior teeth remained stable while lower anterior teeth became more proclined, and L1-MP increased from 89 to 95 degree

a b

SNA 89
SNB 87
ANB 2
U1 - SN 117
L1 - MP 91

Fig. 6.112 (a, b) Cephalometric head film and tracing at the end of fixed appliances, and ANB angle was 2 degrees; the upper anterior teeth
U1-SN became more proclined from 113 to 117 degree while the lower anterior teeth were more retroclined L1-MP reduced from 95 to 91 degree
258 S. Satravaha

a b

SNA 87
SNB 85
ANB 2
U1 - SN 118
L1 - MP 90

Fig. 6.113 (a, b) Cephalometric head film and tracing 3 years and 1 month after the end of the treatment, ANB angle, and upper and lower anterior
teeth remained stable

Pre Tx
During activator Tx
Begin of fixed appliances
End of Tx
3 years F/U

Fig. 6.114 Superimposition at different timelines

6 Early Treatment of Class III Malocclusions 259

Stability of both skeletal and dental could be achieved 6.13.3 Case #6

after Class III activator treatment combined with myofunc-
tion exercises (Figs. 6.115, 6.116, 6.117, 6.118, 6.119, 6.120,
6.121, 6.122, and 6.123).

a b c

d e

f g

Fig. 6.115 (a–h) Extraoral pictures of a 9-year-old girl showed a concave facial profile; intraoral pictures showed that teeth #11, #21, #42, #41,
#31, and #32 were in crossbite, teeth #12 and #22 were proclined, and she had Class III molar relationships
260 S. Satravaha

b c

Fig. 6.116 (a–c) Pictures showed positive overjet and positive overbite during Class III activator treatment

a b c

d e f

g h

Fig. 6.117 (a–h) Extra- and intraoral pictures at recall; 5 years after the well aware of the relapse risk, and she continued with myofunction
end of second phase treatment with fixed appliances showed good stabil- exercises
ity of the treatment outcomes. The patient had large tongue but she was
6 Early Treatment of Class III Malocclusions 261

a b

SNA 75
SNB 79
ANB -4
U1 - SN 104
L1 - MP 85

Fig. 6.118 (a, b) Cephalometric head film and tracing at beginning of the treatment, and ANB angle was −4 degrees

a b

Fig. 6.119 (a, b) A cephalogram and a tracing with Class III activator in situ
262 S. Satravaha

a b

SNA 81
SNB 80
ANB 1
U1 - SN 110
L1 - MP 87

Fig. 6.120 (a, b) A cephalogram and a tracing during the treatment degrees, and lower anterior teeth from 85 to 87 degrees. Positive overjet
with Class III activator; the ANB angle increased from −4 to +1 degree, and positive overbite were achieved
increase in inclination angle of the upper anterior teeth from 104 to 110

a b

SNA 79
SNB 77
ANB 2
U1 - SN 110
L1 - MP 96

Fig. 6.121 (a, b) Cephalometric head film at the end of the treatment; ANB angle was 2 degrees
6 Early Treatment of Class III Malocclusions 263

a b

SNA 79
SNB 76
ANB 3
U1 - SN 106
L1 - MP 96

Fig. 6.122 (a, b) Cephalometric head film and tracing 9 years after the end of the treatment; the treatment results both skeletal and dental were
stable

6.14 Conclusion

As mentioned before that Class III malocclusions are one of

the most difficult malocclusions to be treated. Anyhow, early
Class III treatment could be done successfully when proper
diagnosis and proper treatment plan are carefully carried out
and the treatments are done following the concept of treating
at the right place, at the right time with the right appliances.
The purposes of early treatment can be causative treatment,
in case of dentoalveolar Class III malocclusion. In case of
skeletal Class III malocclusions, growth modification can
be done with awareness of limitation in severe cases where
orthognathic surgery is required in the later stage.
Most skeletal Class III malocclusions exhibit discrepan-
Pre Tx cies in all dimensions, in the sagittal, transversal, and vertical
During activator Tx
End of fixed appliances Tx
dimension. Therefore, second phase treatment is required in
9 years F/U many cases. Anyhow, early treatment of Class III malocclu-
sions when carefully done help reduce severity of the maloc-
clusions, and it can help prevent major surgery. Therefore,
Fig. 6.123 Superimposition of cephalometric tracings at different it can be concluded that Class III activator maybe a viable
timelines
mode for initial stage of Class III treatment in conjunction
with fixed or removable therapy.
264 S. Satravaha

References Mermingos J, Full CA, Anderson G. Protraction of the maxillofacial

complex. Am J Orthod Dentofac Orthop. 1990;98:47–55.
Mitani H. Early application of chincap therapy to skeletal class III mal-
Baccetti T, Franchi L, McNamara JM Jr. Cephalometric variables pre-
occlusion, presented at the international symposium on early orth-
dicting the long-term success or failure of combined rapid maxillary
odontic treatment, February 8-10, 2002; Phoenix. Ariz Am J Orthod
expansion and facial mask therapy. Am J Orthod Dentofac Orthop.
Dentofacial Orthop. 2002;121:584–5.
2004;126:16–22.
Ngan P. Biomechanics of maxillary expansion and protraction in class
Cha KS. Skeletal changes of maxillary protraction in patients exhibit-
III patients, presented at the international symposium on early
ing skeletal class III malocclusion: a comparison of three skeletal
orthodontic treatment, February 8-10, 2002; Phoenix. Ariz. Am J
maturation groups. Angle Orthod. 2003;73:26–35.
Orthod Dentofacial Orthop. 2002;121:582–3.
Deguchi T, Kuroda T, Hunt NP, Graber TM. Long-term application of
Ngan P, Wilmes B, Drescher D, Martin C, Weaver B, Gunel
chincup force alters the morphology of the dolichofacial class III
E. Comparison of two maxillary protraction protocols: tooth-borne
mandible. Am J Orthod Dentofac Orthop. 1999;116:610–5.
versus bone-anchored protraction facemask treatment. Prog Orthod.
Deguchi T, Kuroda T, Minochima Y, Graber TM. Craniofacial features
2015;16:26. https://doi.org/10.1186/s40510-­015-­0096-­7.
of patients with class III abnormalities: growth-related changes and
Pangrazio-Kulbersh V, Berger J, Kersten G. Effects of protrac-
effects of short-term and long-term chincup therapy. Am J Orthod
tion mechanics on the midface. Am J Orthod Dentofac Orthop.
Dentofac Orthop. 2002;121:84–92.
1998;114:484–91.
Fränkel R, Fränkel C. Orofacial orthopedics with the function regulator.
Pirttiniemi PM. Association of mandibular and facial asymmetry-a
Basel, München, Paris, London, New York, Tokyo: Sydney; Karger;
review. Am J Orthod Dentofac Orthop. 1994;Aug:191–200.
1989.
Rakosi T. Funktionelle Therapie in der Kieferorthopädie. München
Funatsu M, Sato K, Mitani H. Effect of growth hormone on cra-
Wien: Hanser; 1985.
niofacial growth. Angle Orthod. 2006;76(6):970–6. https://doi.
Rakosi T, Graber T. Orthodontic and Dentofacial orthopedic treatment.
org/10.2319/011905-­17.
Stuttgart New York: Thieme; 2010.
Gallagher RW, Miranda F, Buschnang PH. Maxillary protraction: treat-
Saadia M, Torres E. Sagittal changes after maxillary protraction with
ment and posttreatment effects. Am J Orthod Dentofac Orthop.
expansion in class III patients in the primary, mixed, and late mixed
1998;113:612–9.
dentitions: a longitudinal retrospective study. Am J Orthod Dentofac
Garliner D. Myofunctional therapy. 1981 ISBN 75–14781.
Orthop. 2000;117:669–80.
Graber TM. The “three M’s” Muscles, malformation, and malocclu-
Satravaha S. Combined therapy with appliances and myofunc-
sion. AJO-DO 1963 Jun 418–450.
tional exercises in an adult with periodontal involvement. Prakt
Graber LW. Chincup therapy for mandibular prognathism. Am J
Kieferorthop. 1990;4:49–52.
Orthod. 1977;72:23–41.
Satravaha S. Frühbehandung bei Progeniefällen in Thailand. Prakt
Graber T, Rakosi T, Petrovic A. Dentofacial orthopedics with functional
Kieferorthop. 1993;7:23–30.
appliances (second edition). Mosby; 1997.
Satravaha S, Taweesedt N. Skeletal and dental changes follow-
Gu Y, Rabie A. Treatment effects of simple fixed appliance and reverse
ing activator therapy on class III patients. Mahidol. Dent J.
headgear in correction of anterior crossbites. Am J Orthod Dentofac
1996a:31–9.
Orthop. 2000;117:691–9.
Satravaha S, Taweesedt N. Changes in maxillary and mandibular body
Hass AJ. Long-term posttreatment evaluation of rapid palatal expan-
lengths following class III activator therapy. Mahidol. Dent J.
sion. Angle Orthod. 1980;50(3):189–217.
1996b:40–7.
Ishikawa H, Nakamura S, Kim C, Iwasaki H, Satoh Y, Yoshida
Satravaha S, Taweesedt N. Stability of skeletal changes after activa-
S. Individual growth in class III malocclusions and its relation-
tor treatment of patients with class III malocclusions. Am J Orthod
ship to the chin cap effects. Am J Orthod Dentofac Orthop.
Dentofac Orthop. 1999;116:196–206.
1988;114:337–46.
Satravaha S, Taweesedt N. Nonsurgical orthodontic treatment of ante-
Kajiyama K, Murakami T, Suzuki A. Evaluation of the modified max-
rior open-bite in adult: a case report. J Tha A O. 2002;1:25–31.
illary protractor applied to class III malocclusion with retruded
Sugawara J, Asano T, Noriaki E, Hideo M. Long-term effects of chin-
maxilla in early mixed dentition. Am J Orthod Dentofac Orthop.
cap therapy on skeletal profile in mandibular prognathism. Am J
2000;118:549–59.
Orthod Dentofac Orthop. 1990;98:127–33.
Keles A, Cetinkaya Tokmak E, Erverdi N, Nanda R. Effect of verify-
Turley PK. Commentary: managing the developing class III maloc-
ing the force direction on maxillary orthopedic protraction. Angle
clusion with palatal expansion and facemask therapy. Am J Orthod
Orthod. 2002;72:387–96.
Dentofac Orthop. 2002;122:349–52.
Ko YL, Baek SH, Mah J, Yang WS. Determinants of successful chincap
Wendell PD, Ravinda N, Sakamoto T, Nakamura S. The effect of chin
therapy in skeletal class III malocclusion. Am J Orthod Dentofac
cup therapy on the mandible: a longitudinal study. Am J Orthod
Orthop. 2004;126:33–41.
Dentofac Orthop. 1985;87:265–74.
Levin AS, McNamara JA, Franchi L, Beccetti T, Fränkel. Short-term
Witt E, Gehrke ME. Leitfaden der kieferorthopädischen Technik.
and long-term treatment outcomes with the FR-3 appliance of
Berlin, Chicago: Rio de Janeiro und Tokio; Quintesseny Verlags-­
Fränkel. Am J Orthod Dentofac Orthop. 2008;134:513–24.
GmbH; 1981.
Liou JWE. Tooth borne orthopedic maxillary protraction in class III
Yüksel S, Ücem TT, Keykubat A. Early and late facemask therapy. Eur
patients. JCO. 2005;39:68–75.
J Orthod. 2001;23:559–68.
McNamara JA. Maxillary transverse deficiency. Am J Orthod Dentofac
Orthop. 2000;117:567–70.
 Early Treatment of Open Bite Problems
7
Julia Harfin

The normalization of functional disturbances is one of the Also, there is a significant link between the respiration
main objectives that need to be achieved during early orth- mode, the direction of the facial growth, and the development
odontic treatment. of the malocclusions (posterior crossbite and anterior open
There is a close relationship between anterior open bite in bite), due to abnormal contraction of the cheek muscles.
young patients and abnormal habits that are some of the Hypertrophic lymphoid tissues and nasal obstruction in
main etiologic factors of malocclusion. combination with large adenoids and tonsils are the most
Among the most common habits are thumb-sucking, lip/ common cause of nasal obstruction and mouth breathing as
nail biting, tongue-thrusting, and mouth breathing mode. they push the tongue forward due to pain and decrease in the
Normally all of these habits could cause interferences amount of posterior space for the tongue.
with the circumoral musculature and tongue pressure bal- This atypical swallowing pattern and the anterior posture
ance and as a consequence, they develop unaltered maxillary of the tongue at rest prevents the eruption of the incisors and
and mandibular arch forms (Urzal et al. 2013). increases the anterior open bite with lower lip interposition
Of course, the duration, frequency, and intensity of these every time the patient swallows.
habits play an important role, not only in the diagnosis and In general these young patients are sent to the speech
treatment plan but also during the whole retention phase. therapist in order to improve the pronunciation of certain
Since there is not only one reason for digital sucking or words but it is important to remember that the anterior open
the prolonged use of pacifiers, there is not only one treatment bite is the consequence not the cause.
for all of them. It is important to control the habit after It has been demonstrated that tongue dysfunction plays an
2 years of age. In some patients, the help of a psychologist is important role not only in the etiology of the open bite but
valuable (Dugoni). also in the relapse of treated open bite patients.
Digital sucking is responsible for causing significant changes Also, orofacial and speech dysfunction could be combined
in the maxilla and in the mandible during the growth period. with problems at the TMJ that could worsen in the future.
In general the maxilla becomes narrow and V shaped, the In addition to TMJ problems, episodes of sleep apnea
mandible tends to be retrognathic, and as a consequence, a could be added. The child could stop breathing several times
significant open bite is developed with proclined upper inci- during the night (20–40 times per hour of sleep). As a conse-
sors and retruded lower incisors. quence, he or she would feel daytime sleepiness, headaches,
Due to the excessive proclination of the upper incisors, fatigue, obesity, changes in personality, lack of attention at
lips become incompetent and the tongue is placed between school in the morning, etc.
the upper and lower incisors during the swallowing process Since sleep apnea is a progressive disorder, the consulta-
worsening it. tion with the specialist is very important from the first day in
There is a close relationship between lip and tongue posi- order to perform a multi- and interdisciplinary treatment
tion and action during speech and swallowing, and they may plan and avoid relapse (Pascually et al.)
interfere with normal facial growth. It is important to remember that sleep-walking in young
children and enuresis are commonly related to open bite
problems.
J. Harfin (*)
Department of Orthodontics, Maimonides University, The real question is who, when, why, and how to treat.
Buenos Aires, Argentina The higher the percentage of environmental factors in
Health Sciences Maimonides University, relation to the genetic ones, the better the prognosis. Among
Buenos Aires, Argentina the deleterious habits, the prolonged use of pacifiers, mouth

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 265
J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_7
266 J. Harfin

breathing, or thumb-sucking are the determinants. In some In general anterior open bite in temporary or early mixed
patients, the help of a psychologist is fundamental to control dentition is associated with digital sucking habit and tongue
these habits. anterior interposition.
Unfortunately, there is not only one type of appliance to Its correction is very important since otherwise the prob-
treat all these patients. The appliance selection has to be lem could worsen and turn into a skeletal alteration.
related to the etiology, age of the patient, seriousness of the The size and length of the lips are also important to main-
problem, etc. The orthodontist is responsible for the appro- tain a proper lip seal during day and night. Also it is neces-
priate selection. sary to normalize the position and function of the tongue.
The decision of whether to use a removable, fixed appli- Normally children who breathe through their mouth have
ance or a combination of both is related to the etiology and a narrow maxillary arch, protrusive incisors, Class II occlu-
the skeletal maturity in order to maximize the effectiveness sion, convex facial profile, bags under the eyes, open mouth
of the orthodontic treatment. posture, and narrow nostrils.
The normalization of the vertical dimension is extremely The importance of the multidisciplinary treatment cannot
challenging for the orthodontist to control, especially in high be denied.
angle patients with mouth breathing. Treatment strategies are in close relationship with etiol-
If problems leading to an open bite could be identified and ogy, facial biotype, age of the patient, and clinical
treated early, it might be possible to minimize or even elimi- experiences.
nate an undesirable pattern of growth. The management of the tongue thrust and mouth breath-
According to the structures affected, anterior open bite ing involves the interception of the habit. First of all, the doc-
can be divided into three main categories: dental, dentoalve- tor has to determine that the patient can use his/her nose to
olar, and skeletal. breathe normally.
Dental and dentoalveolar open bite develop as a result It is important to remember that mouth breathing is abnor-
of prolonged mechanical blockage of the normal vertical mal and can affect the whole stomatognathic system, body
development of anterior teeth and alveolar process posture, etc. and not only the position of the teeth.
(Torres). As soon as this problem is corrected, fewer consequences
The skeletal form, in turn, is characterized by a significant appear.
vertical skeletal discrepancy, with features such as counter- Different appliances could be used according to the age of
clockwise rotation of the palatine process, increased lower the patient and his/her medical history, in order to establish a
anterior facial height and gonial angle, short mandibular new neuromuscular pattern.
ramus, and increased posterior dentoalveolar height in both According to the etiology and the importance of the prob-
the mandible and maxilla. lem, removable, fixed, or a combination of both types of
The diagnosis process has to include medical and dental appliances can be used.
analysis, patients’ chief complaint, evaluation of growth, The orthodontist has the final decision.
functional analysis, etc. The following examples will describe each option in
The treatment goals should include the removal of the detail.
etiologic and environmental factors to permit the normaliza- This 6-year, 8-month-old patient was sent to the office by
tion of the anterior growth development. her family dentist in search of a second opinion regarding her
No consensus has been reached until now to determine anterior open bite.
the best time to initiate the orthopedic/orthodontic treatment. An adenoidectomy was performed 4 months earlier.
Nonetheless, it is totally accepted that the earlier the correc- Nonetheless, mouth breathing and tongue thrusting continued.
tion of the open bite begins, the better the results will be. It was difficult for her to close and maintain the lips sealed.
Also, early treatment helps decrease chances of relapse or She used a pacifier until 4 years of age (Fig. 7.1a and b).
avoid it completely. Her profile was convex and the nasolabial angle was
Myofunctional therapy is the best option to normalize reduced.
mouth breathing. Even though she was only 6 years and 8 months of age,
Control and reduction of the extrusion of the molars are she had a double chin.
fundamental to allow a counterclockwise rotation of the Hyperactivity of the musculature of the lips in combina-
mandible to maintain the results. tion with tongue thrust was observed during the clinical
Failure to control bad habits may be the most important exam with abnormal tongue posture during speech.
reason of relapse. The front photograph showed a significant open bite in
The role of the otolaryngologist to improve and normalize the anterior region in combination with a midline deviation.
nasal breathing during the diagnosis process and speech Only the central upper and lower incisors were erupting at
pathology is of prime importance. that time (Fig. 7.2a and b).
7 Early Treatment of Open Bite Problems 267

a b

Fig. 7.1 (a and b) Pretreatment frontal and lateral smile. The tongue was clearly visible between the front teeth

No posterior crossbite was present. Normal eruption of It is recommendable that at the beginning this appliance
the upper and lower incisors was affected due to the position be used few hours during the day (2–3 hours) and then all
of the tongue. Due to the presence of large cavities, some night (Fig. 7.5a and b).
stainless steel crowns were placed on the temporary molars After 9 months, a significant improvement of the maxillo-­
(Fig. 7.3a and b). mandibular relationship was clearly observed. The anterior
The treatment objective (Phase I) was to normalize over- open bite was totally closed and midlines were almost nor-
bite and overjet, maintain Class I molar, control tongue malized (Fig. 7.6a and b).
thrust, improve the activity of the lips, and enhance her The transverse development observed in some patients
profile. could be due to the buccal shields of the functional appliance
To achieve this objective, the use of a functional appli- that stimulates the lateral muscles using the same principles
ance is decided on. Of all the possible choices, a prefabri- that Frankel regulator does.
cated functional appliance also known as Trainer System The treatment goals were totally achieved without the use
TM (Myofunctional Research Co. Australia) was chosen. of any other appliance.
It is fabricated with a special type of polyurethane and When analyzing the front and lateral photographs, a sig-
helps the correction and normalization of the muscular nificant improvement in the lower third of the face was
dysfunction. achieved. The patient could close her lips without tension,
The appliance is especially designed to stimulate anterior and the tongue was located in its right position not only at
and lateral muscles and help to achieve normal nasal breath- rest but in active position too (Fig. 7.7a and b).
ing. Since the material is soft, no major problems of adapta- These were the results 18 months later. Class I canine was
tion are present (Fig. 7.4a and b). achieved and Class I molar was maintained. Overjet and
268 J. Harfin

a b

Fig. 7.2 (a, b) The lateral photograph showed a convex profile with a double chin. The front dental photograph confirmed the anterior position of
the tongue

a b

Fig. 7.3 (a and b) Pretreatment lateral views with the tongue between the upper and lower incisors

a b

Fig. 7.4 (a and b) Trainer System TM (Myofunctional Research Co. Australia)

7 Early Treatment of Open Bite Problems 269

a b

Fig. 7.5 (a and b) Functional appliance in place

a b

Fig. 7.6 (a and b) Frontal and lateral results after 9 months using the functional appliance

overbite were normalized and midlines were normal. Oral The comparison between the pre- and posttreatment front
hygiene was fairly good. Gingival line and occlusal plane dental photographs showed evidence of the normalization of
were parallel (Fig. 7.8a and b). the anterior open bite and the parallelism between the occlu-
The profile and smile lateral photographs confirmed the sal and gingival plane.
results. The lips were relaxed and the double chin was absent. No brackets were required to achieve the expected results.
A 6-month control was highly recommended (Fig. 7.9a and b). Ideally an overcorrection of the overjet and overbite is
It is advisable that open bites be treated as early as possi- highly recommended (Fig. 7.10a and b).
ble and in this way reinstate normal oral and breathing func- A 6-month control was recommended until all the second
tions with least the possible relapse. molars erupted.
The type of Trainer (T4K) or Myobrace is a valid alterna- Upon analyzing the lower third of the face and the nasola-
tive to treat open bite patients at an early age. It also helps to bial angle, a significant improvement was confirmed.
improve dental arch development during the early and late Moreover, the lips were more relaxed and the double chin
mixed dentition, and most importantly, this appliance helps was normalized (Fig. 7.11a and b).
normalize bad habits. Further studies should be conducted to analyze whether
Also, other types of functional appliances can be used in the use of this treatment protocol could have a skeletal effect
accordance with the orthodontist’s preferences. As always, in patients with anterior open bite.
correct diagnosis is more important than the type of the In general, patients with anterior open bite have a high
appliance used. angle facial pattern and also have discrepancies in the
270 J. Harfin

a b

Fig. 7.7 (a and b) Frontal and lateral photograph after 9 months of treatment

a b

Fig. 7.8 (a and b) Results 18 months later. Class I molar and canine was achieved
7 Early Treatment of Open Bite Problems 271

a b

Fig. 7.9 (a and b) The profile and smile lateral photographs confirmed the results

a b

Fig. 7.10 (a and b) Comparison pre- and posttreatment front dental photographs
272 J. Harfin

a b

Fig. 7.11 (a and b) The comparison pre- and posttreatment photographs clearly confirmed the excellent results achieved after correcting the bad
habits. The double chin was no longer present and the patient was able to close her lips effortlessly

anteroposterior and transverse dimensions. The retention The panoramic Rx confirmed that no agenesis were pres-
protocol has to include a strict control of the position and ent and the lateral radiograph showed normal development
function of the tongue and the normalization of the breath- according to her age. The anterior open bite was clearly vis-
ing pattern. ible (Fig. 7.15a and b).
This 9-year, 2-month-old patient was sent by her family The treatment objectives were as follows:
dentist due to her significant midline deviation and slight
Class III tendency. 1. Align and level the arches.
Her profile was straight with a normal nasolabial angle. 2. Normalize transverse dimension.
She snored loudly at night very often (Fig. 7.12a and b). 3. Normalize overjet and overbite.
The dental front photograph clearly showed the ante- 4. Achieve Class I molar and canine.
rior open bite and the important deviation of the midlines 5. Control tongue thrust.
(3 mm). She presented a V-shaped maxilla (Fig. 7.13a 6. Long-term stability.
and b).
The right second temporary molars had a Class III ten- To achieve these objectives, the following treatment plan
dency, and there was a significant lateral crossbite on the left was designed:
side that was maintained in central relation. Phase I
No TMJ symptoms were present until then, but she pre-
ferred to eat only soft food. 1. Rapid maxillary expansion to normalize the transverse
He dental hygiene was fairly good and no cavities were problems.
present (Fig. 7.14a and b). 2. Speech therapy treatment to control tongue thrust.
7 Early Treatment of Open Bite Problems 273

a b

Fig. 7.12 (a and b) Pretreatment lateral and smile photographs

a b

Fig. 7.13 (a and b) Considerable frontal open bite with a significant midline deviation to the left and a V-shaped upper maxilla
274 J. Harfin

a b

Fig. 7.14 (a and b) Pretreatment lateral views with a significant lateral left molar crossbite

Fig. 7.15 (a and b)

Pre-panoramic and lateral a b
radiograph

Phase II. The lateral and smile posttreatment photographs con-

If necessary, esthetic brackets, 0, 22″ slot in order to nor- firmed the results that were achieved. The lips closed
malize dental positions, would be used. smoothly without tension and the nasolabial angle was nor-
To correct the transverse deficiency, a modified hyrax mal (Fig. 7.19a and b).
appliance was suggested. The protocol of activation was The patient returned to the office seeking improvement of
twice a day. The lateral arms were bonded with composite to the position of the canines 20 months later. To achieve these
the temporary molars to improve stability. After 2 weeks, the results, esthetic brackets slot 0.022″ were bonded in con-
inter-incisal diastema between the central incisors confirmed junction with a 0,016” SS wire (Fig. 7.20a and b).
that the central suture was open (Fig. 7.16a and b). A nickel-titanium open coil spring was placed on the left
The correction of maxillary constriction is very often a side to improve the position of the first upper left bicuspid
target for treatment in open bite patients (McNamara). (Fig. 7.21a and b).
As usual, 1 month later, the diastema closed on its own The orthodontic brackets were removed and the tongue
and a monthly control was suggested. The anterior open bite thrusting habit was totally corrected 7 months later
was totally normalized with the help of a speech therapist. (Fig. 7.22a and b).
Midlines were almost corrected. Front photographs at the end of the second phase treat-
In these cases, it is highly recommendable that RME ment. The face was symmetrical with balanced proportions
appliance be kept in place a minimum of 6 months to prevent and normal exposure of the maxillary teeth. The smile and
relapse (Fig. 7.17a and b). tongue position were totally normalized (Fig. 7.23a and b).
At the end of the first phase of treatment, all the objectives The lateral photographs confirmed the results. The patient
were achieved. The overjet and overbite were normalized as was able to close her lips gently in concordance with a nice
well as the position of the first molars. A removable retainer and pleasant profile and a passive lip seal (Fig. 7.24a and b).
used during the night was recommended to maintain the cor- The comparison pre- and posttreatment dental front pho-
rection of the transverse dimension, until the second molars tographs confirmed that the treatment objectives were totally
and upper canines erupted (Fig. 7.18a and b). achieved.
7 Early Treatment of Open Bite Problems 275

a b

Fig. 7.16 (a and b) Upper rapid maxillary expander in place

a b

Fig. 7.17 (a and b) Rapid maxillary expander in place 1 month after the expansion was completed

a b

Fig. 7.18 (a and b) Frontal and upper arch at the end of the first phase of treatment. Considerable expansion was achieved
276 J. Harfin

a b

Fig. 7.19 (a and b) Lateral and smile posttreatment photographs

a b

Fig. 7.20 (a and b) Esthetic brackets slot 0.022″ were bonded in conjunction with a SS 0.016″ wire to correct the position of the canines
7 Early Treatment of Open Bite Problems 277

a b

Fig. 7.21 (a and b) A nickel-titanium open coil spring was placed on the left side to improve the position of the first upper left bicuspid

a b

Fig. 7.22 (a and b) Final dental photographs at the end of the active orthodontic treatment

Dental midlines were corrected and overjet and overbite Frequently she had colds with fever and was medicated
were normalized. with corticoids and antibiotics (Fig. 7.26a and b).
The gingival and occlusal planes were parallel, and the It is important to remember that abnormal tongue posture
oral hygiene was fairly good (Fig. 7.25a and b). is associated with enlarged adenoids and tonsils in addition
Several environmental factors can be associated with the to sucking habits and tongue thrust. All of these affect the
development of a complex skeletal malocclusion as the ante- development of the normal function and consequently dental
rior tongue posture (Quiroga Souki). occlusion.
The importance of the normalization of the functional Thus, the early treatment of complex malocclusions that
problems specially the influence of respiration and its rela- compromise dental and facial esthetics can have important
tion on the nasomaxillary complex is clearly demonstrated psychosocial implications for some patients since they are
when the following patient is analyzed. considered less attractive by their peers (Kijak). These were
She was 7-year, 3 months of age and was sent to the office the most important reasons to determine a two-phase
by her pediatric doctor due to her loud night snoring that treatment.
disturbed not only her sister but also her parents’ sleep. The stability of these open bite treatments might increase
She had a convex profile, difficulty to achieve lips clo- when the parafunctional habits were corrected.
sure, and double chin which are typical in all mouth breath- The front dental photographs clearly confirmed the ante-
ers in conjunction with a larger lower third face and the rior position of the tongue at rest and a considerable open
presence of circles under their eyes. bite of 7 mm in the incisor region (Fig. 7.27a and b).
278 J. Harfin

a b

Fig. 7.23 (a and b) Final frontal photographs

The lateral views showed Class II molar on the right side The activation was a quarter twice a day for 2 weeks.
and Class I molar on the left side. The temporary right At the same time she was sent to the speech therapist to
canine, first and second molar, and permanent first molar normalize the position of the tongue and in this way help to
were in crossbite occlusion. close the anterior open bite (Fig. 7.30a and b).
The oral hygiene was good and no cavities were observed After 2 weeks, the expansion was completed. It is highly
(Fig. 7.28a and b). recommendable that the expander be maintained in place for
The panoramic radiograph confirmed that all the perma- a minimum of 6 months to have better control over relapse
nent teeth were present in different stages of development in (Fig. 7.31a and b).
accordance to her age. The open bite was confirmed on the The speech therapist had to continue working until the
lateral radiograph, and it was clearly visible that the respira- overjet and overbite were normalized.
tory airway was obstructed (Fig. 7.29a and b). A follow-up 2 months later confirmed the improvement
After the consultation with the specialist, the following achieved. The inter-incisal diastema was closing normally,
treatment plan was decided: and the position of the central incisors was normalized.
Different types of RME can be used but it is preferable to
1. Normalize the mouth breathing pattern. use those without acrylic plates, not only on the palatal tis-
2. Improve the position of the tongue at rest. sues but also on the occlusal surfaces of the molars.
3. Normalize the position of the right canine and molars. The protocol of activation is determined by the ortho-
4. Achieve normal overjet and overbite. dontist but twice a day is usually sufficient (Fig. 7.32a
5. Long-term stability. and b).
The patient was gone for 2 years and then she returned
In order to correct the transverse problem, a fixed bonded without the RME.
rapid maxillary expander was suggested. The design included The anterior occlusion was edge to edge and some open
bands on the right and left temporary second molars to pro- bite was still present. Cuspids and bicuspids were almost
tect the permanent first molars. erupted (Fig. 7.33a and b).
7 Early Treatment of Open Bite Problems 279

a b

Fig. 7.24 (a and b) Lateral photographs at the end of the active orthodontic treatment

a b

Fig. 7.25 (a and b) Comparison pre- and posttreatment. Midlines were totally corrected and overjet and overbite were normalized
280 J. Harfin

a b

Fig. 7.26 (a and b) 7 years, 6 months pretreatment photographs. A severe open bite was present along with a double chin

a b

Fig. 7.27 (a and b) A severe 7 mm open bite was present

7 Early Treatment of Open Bite Problems 281

a b

Fig. 7.28 (a and b) Pretreatment lateral views. Right lateral cross bite was present along with a considerable frontal open bite

Fig. 7.29 (a and b)

Panoramic and pretreatment a b
lateral radiographs. Anterior
open bite is clearly confirmed

a b

Fig. 7.30 (a and b) Rapid maxillary expander in place (a) and after 2 weeks activation (b)
282 J. Harfin

a b

Fig. 7.31 (a and b) Rapid maxillary expansion in place after the expansion was completed

a b

Fig. 7.32 (a and b) Follow-up 1 month later

The lateral photographs showed slight lateral open bite in align and level the arches. No extraction of bicuspids was
the lateral. planned at that time.
Incisor and canine region, and tongue interposition was Midlines are almost coincident (Fig. 7.37a and b).
still present in this area (Fig. 7.34a and b). No brackets were bonded on the second lower temporary
After a long conversation with the parents and the patient, molars. However, manual stripping was performed on the
they accepted a Phase II treatment with fixed appliances in mesial side in order to achieve Class I canine on the left and
order to improve her dental occlusion and prevent any type right side (Fig. 7.38a and b).
of relapse of the anterior open bite (Fig. 7.35a and b). The upper and lower arches showed great improvement.
New panoramic and lateral radiographs showed normal The lower second right and left temporary molars were still
eruption of the cuspids and bicuspids with no evidence of in place (Fig. 7.39a and b).
root resorption. The dentoalveolar changes were significant with a greater
According to Ricketts, she had a dolichofacial pattern improvement in the incisor position and inclination. Vertical
with some protrusive incisors and a moderately increased control was very important in order to avoid an increase of
lower anterior facial height and gonial angle (Fig. 7.36a the lower facial height, during the growth period.
and b). These were the results 2 years after debonding. Midlines
Esthetic preprogrammed 0.022″ slot brackets were were coincident. Overbite and overjet were almost normal
bonded on the upper and lower teeth with SS 0.016″ wires to and the oral hygiene was fairly good (Fig. 7.40a and b).
7 Early Treatment of Open Bite Problems 283

a b

Fig. 7.33 (a and b) Frontal photographs after 2 years without follow-up. The anterior position of the tongue was still present

a b

Fig. 7.34 (a and b) Lateral views after 2 years without follow-up

Right and left Class I canine and molar were obtained no gingival smile. The dental midline was coincident with
with good interdigitation in the bicuspid area. The gin- the facial one (Fig. 7.43a and b).
gival line and the occlusal plane were parallel The profile photographs clearly showed a muscle equilib-
(Fig. 7.41a and b). rium. The profile was still straight and the nasolabial angle
A fixed retention wire was bonded on the upper and lower was normal (Fig. 7.44a and b).
arches to maintain the position of the incisors. Long-term reten- The patient returned 3 years later for a control of her
tion in addition to a removable appliance was recommended to retention wires.
control the function of the tongue (Fig. 7.42a and b). Her smile was better than ever and the oral muscles were
The final photographs after the orthodontic treatment completely relaxed. At the end she presented a symmetrical
showed a significant improvement in the lower third of the face with balanced proportions (Fig. 7.45a and b).
face. She could close the lips without tension and there was
284 J. Harfin

a b

Fig. 7.35 (a and b) Frontal and profile photographs at the beginning of the second phase of treatment

Fig. 7.36 (a and b)

Panoramic and lateral a b
radiograph 2 years later
without orthodontic control
7 Early Treatment of Open Bite Problems 285

a b

Fig. 7.37 (a and b) Esthetic 0.022″ slot preprogrammed brackets were bonded on the upper and lower arches along with SS 0.016″ arches

a b

Fig. 7.38 (a and b) Lateral views after bonding the brackets

a b

Fig. 7.39 (a and b) Upper and lower arches at the beginning of the second phase of treatment
286 J. Harfin

a b

Fig. 7.40 (a and b) Control 2 years after treatment. Midlines were coincident

a b

Fig. 7.41 (a and b) Right and left Class I canine and molar were achieved

a b

Fig. 7.42 (a and b) Fixed upper and lower retention was bonded on the upper and lower arch
7 Early Treatment of Open Bite Problems 287

a b

Fig. 7.43 (a and b) Final frontal and frontal smile photograph at the end of the treatment
288 J. Harfin

a b

Fig. 7.44 (a and b) Lateral and smile profile photograph at the end of the treatment
7 Early Treatment of Open Bite Problems 289

a b

Fig. 7.45 (a and b) Follow-up 3 years later

290 J. Harfin

The nasolabial angle was more open even though no

extractions were performed in the upper arch nor in the man-
dible. A nice and broad smile was achieved.

When analyzing the front photographs 3 years later, a

slight relapse in the anterior region was observed. With this
in mind, it was advisable to finish the case with bigger over-
bite in order to relapse.
7 Early Treatment of Open Bite Problems 291

Class I canine and molar were maintained. A 6-month

follow-up was highly advisable in order to maintain or
improve the results that were achieved.

The observation of the pre- and postfrontal dental photo-

graphs showed that the treatment objectives were achieved.
The gingival line and the occlusal plane were parallel and the
hygiene was very good.
This confirmed that to obtain an efficient therapeutic result,
correct diagnosis and treatment timing are very important.
292 J. Harfin

The comparison of the pre- and postfrontal photographs

clearly demonstrated how the soft tissues were improved as
a consequence of the correction of the bad habits. Now, the
patient closes her lips normally.
The importance of tongue posture and tongue function
cannot be denied.
7 Early Treatment of Open Bite Problems 293

The results were similar from the lateral side. She had a theory that early treatment in conjunction with the normal-
straight profile and closed her mouth in a normal way with ization of functional habits prevents asymmetric alveolar
reduction of the lip protrusion and decreased mentalis strain. bone growth that affects the permanent dentition.
The nasolabial angle was less protrusive even though no There is considerable evidence to support the benefits of
bicuspid extractions were performed. early orthodontic treatment to correct parafunctional habits
There was a significant improvement in vertical skeletal as well as to improve oral function in a growing child, thus
and dentoalveolar relationships due to the elimination of the contributing to better skeletal and occlusal development
tongue thrust and mouth breathing. This patient confirms the (Quiroga Souki).
294 J. Harfin

The present clinical case clearly demonstrates that if course, habit elimination is mandatory to prevent open bite
proper diagnosis is obtained and orthodontic biomechanics relapse.
are well designed, stable results can be achieved in a patient Ideally the treatment has to begin when the children are
with severe anterior open bite. 4–6 years old as most of the functional and dentofacial prob-
The post-retention stability of open bite treatment is a lems begin at this age and also there is a reduction in the risk
controversial topic in orthodontics. Relapse is of trauma of the upper front teeth.
unpredictable. The prevention of apnea is more important than the cor-
The etiology could be tongue thrust, its size or posture, rection of the snoring. Remember that snoring in children in
respiratory problems, sucking habits, condylar resorption, conjunction with poor concentration at school and behav-
direction of growth, etc. ioral problems are the most typical signs of sleep apnea epi-
Habit elimination is mandatory to prevent open bite sodes in children.
relapse. Relapse is unpredictable since the etiology could be mul-
How can relapse be prevented? Better diagnosis and an. tifactorial (condylar resorption, respiratory problems, con-
Individualized treatment and retention plan. tinuous tongue thrust, direction of growth, habits, etc.).
It is well-known that the stability after retention of the open
bite treatment is a controversial issue for the orthodontists.
7.1 Conclusions The effectiveness and efficiency of an early orthopedic/
orthodontic treatment, based on a correct individualized and
Ideally, open bite patients should be treated as early as exhaustive diagnosis, is undeniable.
possible. Long-term control is fundamental to confirm the achieved
Unfortunately there is no specific bracket or archwire to results (Huang).
help the normalization of the position of the tongue. The normalization of the anterior open bite is imperative tak-
These three patients were treated with different appli- ing into account the health problems that can occur later on.
ances since the etiologic reasons at the beginning were dif- Also, it is important to take into account that these patients
ferent: the first one used a pacifier until 4 years of age and are prone to having mild-to-moderate obstructive sleep apnea
had an adenoidectomy, the second one had a persistent (OSA). This problem includes a disorder of breathing during
tongue thrusting habit until 9 years of age and the third one sleep, and these children can present nocturnal snoring, sleepi-
was a combination of both. ness during the day, and nightmares and could or are likely to
From a clinical point of view, early treatment with remov- develop some type of craniomandibular dysfunction.
able or fixed appliances is more effective and reduces the Unfortunately there is not a specific bracket or wire to
length of treatment in the permanent dentition with less sur- treat all these patients nor to help in the normalization of the
gical procedures and more stability. tongue position.
It is well-known that environmental and neuromuscular The parents and the young patients have to be aware that
influences may alter the position of the teeth and the direc- the earlier the correction of the dysfunctional habits begin,
tion of the maxilla and mandibular growth. the better and more effective the results will be.
It is important to determine the presence or absence of A complete multi- and interdisciplinary early treatment
anos- or oropharyngeal obstructions that can alter the posi- plan is the key to correct the anterior open bite and the func-
tion of the tongue and the mandibular posture. tional disturbances associated with it.
Dentofacial changes associated with mouth breathing and
its relation with some types of malocclusions that involve the
presence of long face syndrome are well recognized (Linder-­
Reference
Aronson and Woodside).
The role of the otolaryngologist and speech therapist is Urzal V, Braga AC, Ferreira AP. Oral habits as risk factors for anterior
unquestionable in the diagnosis and treatment procedures. openbite in the deciduous and mixed dentition-cross sectional study.
There is strong evidence that the earlier the open bite mal- Eur J Pediatric Dent. 2013;14:299–302.
occlusion is corrected, the better the prognosis will be and of
 Correction of the Transverse Problems
8
Julia Harfin

Normalization of the upper arch has always been one of the Dr. Emelson C. Angell in 1860 described this treatment
most important issues in the treatment of young children for the first time. He is considered the father of the rapid
with constricted maxillary arch with uni- or bilateral maxillary expansion. In 1950, Korhauss and Andrew Hass
crossbite. reintroduced this appliance, and now its use is highly recom-
The etiology is multifactorial and the functional problems mendable no matter what type of other appliances is
play an important role. The environmental factors are deter- combined.
minant not only in the beginning but also in the maintenance Rapid maxillary expansion (RME) is considered as dento-
of the malocclusion. It can be present in Class I, II, or III facial orthopedic appliance that produces a splint at the mid-
patients with or without crowding. dle palate suture. Teeth are generally used as anchorage units
It is acknowledged worldwide that transverse problems (Hass), but in the last years bone-teeth or skeletal anchorage
have to be normalized in temporary or early mixed dentition appliances are described with very interesting results
to allow a normal eruption of the bicuspids and cuspids. (Wilmes).
It is well accepted that the younger the patient, the easier Indications for maxillary rapid expansion include uni- or
it is to achieve excellent results with fewer chances of bilateral posterior or anterior crossbite, constricted maxillary
relapse. The most appropriate timing for treatment appears arches with mouth breathing tendency, tooth size-arch length
to be before the eruption of the permanent lateral incisors. discrepancy, etc.
The recovery of the normal maxillary width not only Moreover, limited information is available about the long-­
allows the gaining of space in the lateral areas but also gives term stability of the changes of the airway produced by RME
the tongue more space to function in the correct position and (McNamara). Some studies have shown that maxillary con-
maintain the results until adulthood. striction has a very close relationship with apnea in children,
After the treatment not only is the normalization of the arch and this is an important issue to take into account.
perimeter achieved but in most of the cases the patients recover To maintain the results, a fixed quad-helix appliance is
normal nose breathing (day and night) and stop snoring. suggested in almost all the young patients until the complete
Expansion is one of the noninvasive methods of gaining growth period is finalized.
or recover space in the transverse dimension. When the diagnosis indicates that a skeletal expansion is
It can be classified in slow or rapid expansion according recommendable, it has to be performed by a fixed appliance,
to the rate of activation and also it can be uni- or bilateral and the result is the movement of the maxillary shelves away
according to its direction. from each other (Fig. 8.2a and b). The pre- and post-occlusal
Dentoalveolar expansion produces dental expansion radiographs after 2 weeks of activation of a rapid palatal
without any skeletal change and in general a removable expander showed the expansion that was produced in the
appliance is used. This type of appliance is able to tip the midpalatal suture very clearly.
teeth buccally but are not able to open the midpalatal suture It is highly recommendable that this procedure be initi-
(Fig. 8.1a and b). ated prior the ossification of the midpalatal suture. There
is an individual variation among all the patients but it is
recognized that in general girls complete their growth
J. Harfin (*)
Department of Orthodontics, Maimonides University, period between 12 and 14 years of age and boys a little
Buenos Aires, Argentina later (14–17 years old).
Health Sciences Maimonides University, This procedure is always used in order to increase
Buenos Aires, Argentina maxillary arch perimeter, correct uni- or bilateral cross-

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 295
J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_8
296 J. Harfin

a b

Fig. 8.1 (a and b) Example of a removable appliance to correct a slight transverse problem

a b

Fig. 8.2 (a and b) Pre- and post-occlusal radiographs after the use of a rapid maxillary expander for 2 weeks

bite, improve anterior crossbite, and in some cases essary. Very few difficulties in speech and mastication could
improve airway flow. be present during the first 3–4 days.
According to the diagnosis and treatment plan, all the It is advisable to give the patient an instruction sheet list-
appliances have a similar design with bands on the first ing the schedule of activation and all the cares to take into
molars or metallic crowns on the first and second temporary account during the whole procedure. The parents’ help is
molars. Different designs were described by different authors invaluable.
(bonded or cemented) but all of them include a central expan- Normally the suture will open between 6 and 10 days.
sion screw. An important interincisal diastema is always present
The activation protocol involves the generation of ortho- when the midpalatal suture is set apart and then closes spon-
pedic forces that could split the midpalatal suture. The screw taneously after 2–3 weeks due to the action of the supra-
has to be activated 1, 2, or 3 times a day (one quarter turn) crestal fibers. The patient has to be controlled once a week to
according to the individualized treatment objectives. No pain monitor the treatment during the expansion phase.
and little discomfort could be present during the first days. The lack of space in the anterior region is also an indi-
The parents and the patients have to be instructed on the cation for using RME during the early mixed dentition
maintenance of the appliance and strict oral hygiene is nec- period (Rosa). This procedure does not require any patient
8 Correction of the Transverse Problems 297

cooperation and allows the increase of the perimeter of the the upper arch was present at the beginning of the treatment
upper arch. (Fig. 8.4a and b).
In general, raising of the bite is not necessary in meso-, To increase the transversal width of the upper arch, a stan-
braqui-, or dolichofacial patients. The results are very pre- dard rapid maxillary expander was bonded with bands on the
dictable in a relatively short period of time. second temporary upper molars in order to protect the first
Different types of RME can be used (Fig. 8.3a and b). molars and avoid eventual decalcifications or cavities. A dis-
The following patients are a clear example of the results tal extension wire was welded to the screw toward the right
that can be achieved using this protocol. and left first molars and a mesial one until the temporary
The first one is an 8-year-old patient that was sent to the canines (Fig. 8.5a). The screw was activated twice a day
office by the family dentist due to lack of space for the erup- (once in the morning and again after dinner). The results
tion of the upper lateral incisors. The mother was worried were achieved in two weeks and, as always, the interincisal
about the central interincisal diastema. Mild constriction of diastema became wider (Fig. 8.5b).

a b

Fig. 8.3 (a and b) Different types of RME can be used with the same protocol of activation

a b

Fig. 8.4 (a and b) Pretreatment intraoral photographs. The lack of space for the upper lateral incisors was evident
298 J. Harfin

a b

Fig. 8.5 (a and b) Results after 14 days of activation. A wider diastema was clearly visible

a b

Fig. 8.6 (a and b) After 3 weeks the diastema was almost closed. The expander screw was fixed with composite

As was expected 3 weeks later, the diastema was almost of relapse and permit a complete reorganization of the suture
closed and the upper lateral incisors began to erupt. The and all the surrounding tissues. This time is also important to
expander’s screw was fixed with composite. In these cases, it is allow the adaptation of the facial muscles to the new trans-
highly recommendable that the same appliance be used as a verse dimension of the maxillary arch.
fixed retainer for a period of 6 months at least (Fig. 8.6a and b). Otherwise, relapse will be the consequence. It is impor-
For personal reasons the patient returned 3 years later, and tant to keep in mind that muscles play an important role in
no other orthodontic treatment had been performed in that maintaining the results achieved in the transverse
span of time. The upper lateral incisors erupted and the dimension.
interincisal diastema was closed. The occlusal photograph In general, when the RME appliance is placed on the tem-
showed that the bicuspids erupted in their right position, and porary molars, a slight normalization of the position of the
the width of the upper arch was maintained (Fig. 8.7a and b). incisors is achieved as result of the anterior expansion of the
This patient is a clear example of the importance of the upper arch perimeter in the early mixed dentition.
normalization of the arch perimeter in the early mixed There is no doubt about the effectiveness of the RME
dentition. when it is cemented on the temporary molars with a wire
In cases where the extraction of bicuspids is necessary, it welded to the palatal surfaces of the first permanent molars.
is important that they be postponed until the rapid maxillary In general expansion is achieved in the first permanent molar
expansion process is concluded. area too (Mutinelli) (Fig. 8.8).
In general, a retention period of 6 months with the appli- The efficacy of this appliance is well acknowledged by all
ance in place is recommendable in order to control any type the orthodontists. The relationship between arch perimeter
8 Correction of the Transverse Problems 299

a b

Fig. 8.7 (a and b) Results 3 years later without any orthodontic treatment. All the treatment objectives were achieved

a b

Fig. 8.8 (a and b) An example of an RME bonded on the temporary molars. The use of crowns on the temporary molars is advisable for better
retention

and arch expansion was very well studied by Adkins and canines to correct their position with a SS 0,016″ archwire
coworkers. They concluded that an average of 0,7 mm arch for a 6-month period (Fig. 8.10a). Excellent results were
perimeter is increased after 1 mm of transpalatal width achieved 7 months later. The cuspids and bicuspids erupted
enlargement, but these proportions could vary according to in the correct position without any additional appliance. The
the age and patient facial biotype. arch width was maintained and a removable retention was
The next 8-year-old patient was sent to the office by her placed (Fig. 8.10b).
mother, a pediatric neumonologist, who was worried about The comparison between the pre- and posttreatment smile
the triangular shape of her maxillary arch (Fig. 8.9a). The clearly showed its improvement. This is one of the best pro-
child was a mouth breather until 6 years of age, and after a tocols to obtain a broad smile in a very controlled procedure
1 year treatment with a speech therapist, she was able to cor- (Fig. 8.11a and b).
rect this habit. To normalize the shape of the upper arch and The lateral smile photographs confirmed how the thick-
at the same time make sufficient space for the upper incisors, ness of the upper lip changed. Since the facial biotype plays
an RME was placed with bands on the first molars and exten- an important role in the maintenance of the results, it is
sion wires bonded to the temporary canines. The activation important to determine an individualized treatment plan. A
protocol was two turns a day. The interincisal diastema was 6-month follow-up was recommended until the second
visible after the first week of treatment (Fig. 8.9b). molars fully erupted (Fig. 8.12a and b).
After 8 months, metal preprogrammed brackets (0.022″) Silva and coworkers describe that after RME, the maxilla
were bonded on the rotated upper incisors and temporary is displaced downward and backward. Meanwhile, Hass
300 J. Harfin

a b

Fig. 8.9 (a and b) Pretreatment occlusal photograph and 1 week after the activation of an RME

a b

Fig. 8.10 (a and b) Occlusal photographs during the second phase of treatment and at the end of the active procedure

a b

Fig. 8.11 (a and b) Comparison of pre- and posttreatment frontal smile. A significant improvement was achieved

showed that the result is a slight bite opening and a forward Trainers (myofunctional appliances). There is no specific
displacement of Point A. It is very difficult to compare all period of time for all patients but a minimum of 12 months is
these studies. required in order to give the reorganization of the soft and
The retention protocol could change according to various hard tissues enough time to avoid relapse.
circumstances and includes a removable palatal plate such as The following case is another interesting example of cor-
a Hawley or Scwartz appliance or functional appliances like rection of transverse problems. The following patient was
8 Correction of the Transverse Problems 301

a b

Fig. 8.12 (a and b) The improvement in the thickness of the upper lip in concordance with a broadened smile was more than satisfactory

a b

Fig. 8.13 (a and b) Pretreatment frontal and occlusal photographs of a 7-year and 6-month-old patient

7 years and 6 months of age in the first consultation. He was To fulfil the treatment objectives, a two-phase treatment
the youngest of four children, three of them with class III was suggested. During the first phase, a Haas expander was
molar and canine. placed with metallic bands on the second temporary molars
No important medical history was present. and extension wires bonded on the temporary canines. An
She had difficulties with the pronunciation of some conso- activation twice a day was recommended along with a
nants due to the absence of the upper incisors in conjunction weekly control. This protocol has been demonstrated to be
with the anterior position of the tongue (Fig. 8.13a and b). efficient at this age (Fig. 8.16a and b). No brackets were
Upon analyzing the lateral views, a slight compression in placed on the lower arch to correct the anterior crowding
the temporary canine and molar region was present. The during this phase of treatment.
right canines were in crossbite position (Fig. 8.14a and b). One of the disadvantages of the RME is that in some clin-
The panoramic radiograph showed that there were no ical cases the anterior open bite can be increased when the
agenesis nor supernumerary teeth (Fig. 8.15a), and the lat- molars are crossed to the labial position (Fig. 8.17a). To
eral radiograph confirmed that the patient would have a monitor the position of the tongue, a removable functional
mesofacial growth. The lips were closed without tension appliance (Trainers) was used to enhance tongue position
with a normal nasolabial angle (Fig. 8.15b). and nasal breathing. Its use was recommended 3–4 hours
The treatment objectives were as follows: during the day and all night (Fig. 8.17b).
A 3 –month follow-up later showed the improvement in
1. Normalize the transverse dimension. the position of the upper incisors while the RME was still in
2. Normalize overjet and overbite. place as a retention appliance. No molar tipping was observed
3. Maintain Class I canine and molar. (Fig. 8.18a and b). The patient had to continue using the
4. Long-term stability. Trainer to control the position of the tongue.
302 J. Harfin

a b

Fig. 8.14 (a and b) Lateral views at the beginning of the treatment. A crossbite relationship was present on the right side

Fig. 8.15 (a and b)

Pretreatment panoramic and a b
lateral radiograph

a b

Fig. 8.16 (a and b) First phase of treatment. RME in place with bands on the temporary upper second molars

The patient was ready for the second phase of treatment, right and left side with more activation on the left quarter to
1 year later. The open bite was totally closed. Esthetic brack- correct midlines (Fig. 8.19a and b).
ets (0,022″ slot) with an esthetic 0,016” SS archwire were Since there was enough room for the eruption of the canine
placed in the upper and lower arches. To recover the space on the right side, but not on the left side, additional activation
for the upper canines, an open coil spring was placed on the of the left open coil spring was necessary. To correct anterior
8 Correction of the Transverse Problems 303

a b

Fig. 8.17 (a and b) The use of a removable functional appliance to normalize nasal breathing and tongue position is highly advisable (Trainer
Myofunctional Research)

a b

Fig. 8.18 (a and b) A 3-month follow-up later with the RME in place as a retention device in conjunction with the use of the Trainer to normalize
the position of the tongue

a b

Fig. 8.19 (a and b) At the beginning of the second phase of treatment, the upper and lower 0.022″ esthetic brackets were bonded. An activated
coil spring on the left side was placed to achieve the space for the left canine
304 J. Harfin

a b

Fig. 8.20 (a and b) Right and left side at this stage of the treatment. A coil spring was placed on the left side and activated more

a b

Fig. 8.21 (a and b) Follow-up 3 months later. The anterior lower crowding was almost corrected

crowding, the same type of brackets were bonded on the Final front photographs. All the objectives were fulfilled:
lower arch with bands on the temporary second molars along midlines were almost coincident, gingival line was parallel
with a 0,014” NI-Ti wire (Fig. 8.20a and b). to the occlusal plane, and overjet and overbite were within
Follow-up 3 months later showed a considerable improve- the normal values (Fig. 8.24a and b).
ment. Overjet and overbite were almost normal. The oral The lateral views corroborated that all the treatment
hygiene was fairly good (Fig. 8.21a and b). objectives of the second phase of treatment were achieved.
Although the patient was 11 years old, the upper canines The normalization of the occlusal plane as well as the gingi-
began to erupt before the second bicuspids. To improve ante- val line was achieved with Class I canine and molar
rior torque, the upper coil springs along with a 0,016″ × 0,022” (Fig. 8.25a and b).
SS esthetic archwire were maintained until the eruption of all The retention plan included upper and lower fixed
the bicuspids. A 0.018” Ni-ti lower archwire with an open retention wires at least until the third molars erupted
coil spring was placed on the left side to gain space for the (Fig. 8.26a and b).
left canine and first bicuspid (Fig. 8.22a and b). The final radiographs confirmed the parallelism of the
The evaluation of the upper and lower arch confirmed that roots. Also, the second and third upper and lower molars
all the first bicuspids erupted and no crowding was present. were erupting normally (Fig. 8.27a and b).
Lower bands were still in place on the temporary second The comparison of the front photographs pre- and post-
molars (Fig. 8.23a and b). treatment showed the significant improvement that was
8 Correction of the Transverse Problems 305

a b

Fig. 8.22 (a and b) Lateral views at this stage of treatment. Right and left upper canines began their eruption path before the second bicuspids

a b

Fig. 8.23 (a and b) Upper and lower occlusal photographs. The second upper and lower temporary molars are still in place

a b

Fig. 8.24 (a and b) Frontal photographs at the end of the orthodontic active treatment. Midlines were almost coincident with overjet and overbite
within normal ranges
306 J. Harfin

a b

Fig. 8.25 (a and b) Lateral views at the end of the second phase of treatment

a b

Fig. 8.26 (a and b) Upper and lower occlusal views with the retention wires bonded between upper and lower right and left canines

Fig. 8.27 (a and b)

Panoramic and lateral a b
radiograph at the end of the
treatment

achieved during the second-phase orthodontic treatment Follow-up 30 months after the finalization of the active
(Fig. 8.28a and b). treatment showed that there was a little relapse in the anterior
Similar results were observed from the occlusal point of region, regarding overjet and overbite. A consultation with the
view. A fixed retention wire was bonded from the right to the speech therapist was recommended to improve the position of
left canine to maintain the position of the upper anterior teeth the tongue and certain swallowing habits in order to maintain
(Fig. 8.29a and b). the results in the vertical dimension (Fig. 8.30a and b).
8 Correction of the Transverse Problems 307

a b

Fig. 8.28 (a and b) Comparison pre- and posttreatment front photographs. The improvement was noticeable. Overjet and overbite were normal.
Occlusal and gingival lines were parallel

a b

Fig. 8.29 (a and b) A significant change in the upper arch was evident. The final photograph showed the retention wire bonded between the
canines

a b

Fig. 8.30 (a and b) A slight relapse was visible in the anterior region during the 30-month follow-up. It was important that the patient continue
going to the speech therapist to control the anterior position of the tongue
308 J. Harfin

a b

Fig. 8.31 (a and b) Lateral views confirmed a slight relapse in the anterior region

a b

Fig. 8.32 (a and b) Occlusal photographs 30 months later with the retention wires in place

Similar conclusions were observed after analyzing the Rapid maxillary expansion performed in temporary or
right and left side. Class I canine and molar were perfectly mixed dentition did not produce undesirable root resorption
maintained but slight changes were observed in the anterior or side effects on the periodontal bone tissues (Garib) when
region (Fig. 8.31a and b). the appliance was bonded on deciduous molars. Also, it pro-
Fixed retention wires were placed and the upper and tects the first permanent molars from undesirable side effects.
lower dental arch forms were maintained (Fig. 8.32a and b). The use of an RME appliance is a procedure that was used to
The treatment objectives were fulfilled with a very conserva- split the midpalatal suture and widen the dental arches. Its
tive and efficient protocol. action has a more skeletal effect with less dental tipping than
To conclude, the best time to normalize the transverse the removable ones.
width of the maxilla is during late primary or early mixed Ideally it has to be used prior to the ossification of the
dentition. This procedure provides better and more stable midpalatal suture and long-term results are confirmed. Of
results. course there is variability in the amount of changes accord-
ing the age, facial biotype, and etiology of the problem.
The protocol of activation has to be determined by the
8.1 Conclusions orthodontist but during the early or late mixed dentition two
turns a day is the most commonly used.
Slow or rapid maxillary expansion is one of the noninvasive Since there is a considerable correlation between the
methods of gaining space at any age or facial biotype. transverse, anteroposterior, and vertical discrepancies, the
8 Correction of the Transverse Problems 309

early normalization of the transverse dimension discrepancy Garib DG, Ockle Menezes MH, da Silva Filho G, Bittencourt Dutra
dos Santos P. Immediate periodontal bone plate changes induced by
is very important. It was widely demonstrated that maxillary
rapid maxillary expansion in the early mixed dentition: CT findings.
arch constriction produces insufficient maxillary arch width Dental Press J Orthod. 2014;19:36.43.
causing anterior crowding and lack of the space for the Hass A. Rapid expansion of the maxillary dental arch and the nasal cav-
canines (Bahreman). ity by opening the mid palatal suture. Angle Orthod. 1961;31:73–90.
Hass A. Treatment of the maxillary deficiency by opening the mid pala-
Rapid maxillary expansion is useful in correcting poste-
tal suture. Angle Orthod. 1965;65:200–17.
rior crossbites, increasing arch length, facilitating Class II Hass A. Long term post-treatment evaluation of rapid palatal expan-
and III correction, improving space for canine eruption, sion. Angle Orthod. 1980;50:189–217.
improving nasal breathing, and broadening the smile Haas A. Palatal expansion. Just the beginning of dentofacial orthope-
dics. AJODO. 1997:219–55.
(McNamara).
Lima Filho RM, de Oliveira Ruella AC. Long term maxillary changes
Different types of RME can be used but to avoid caries or in patients with skeletal class II malocclusion treated with slow and
enamel decalcifications it is preferable to use those without rapid palatal expansion. AJODO. 2008;134:383–8.
acrylic plates not only on the palatal tissues but also cemented McNamara JA Jr, Brudon WL. Orthodontic and Dentofacial orthope-
dics. Needham Press Inc 2001.
on the occlusal surfaces of the molars.
McNamara JA Jr. Early intervention in the transverse dimension. Is it
This protocol creates optimal conditions for the normal worth the effort? AJODO. 2002;121(6):572–4.
growth of the craniofacial skeleton and helps to develop a McNamara JA Jr, Lione R, Franchi L, Angelier F, Cevidanes L,
normal stomatognathic system. Darendeliler A, Cozza P. The role of rapid maxillary expansion in
the promotion of oral and general health. Prog Orthod. 2015;16:33.
In general, no significant secondary effects were observed
Mutinelli S, Cozzani M, Manfredi M, Bee M, Siciliani G. Dental arch
in patients in either genders. changes following rapid maxillary expansion. EJO. 2008;30:469–76.
Rosa M, Lucchi P, Mariani L, Captioglio A. Spontaneous correction of
anterior crossbite by RME anchored on deciduous teeth in the early
mixed dentition. Eur J Pediatric Dentistry. 2012;13:176–80.
Suggested Reading Clarenbach T-H, Wilmes B, Ihssen B, Vasudavan S, Drescher D. Hybrid
hyrax Distalizer and Mentoplate for rapid palatal expansion, class
Adkins MD, Nanda RS, Cuurrier GF. Arch perimeter changes on rapid III treatment, and upper molar Distalization JCO. J Clin Orthod.
palatal expansion. AJODO. 1990;97:194–9. 2017;6:317–21.
Angell EC. Treatment of irregularities of the permanent or adult teeth. Wilmes B, Nienkemper M, Drescher D. Application and effectiveness
Dental Cosmos. 1860;1:540–4. of a mini-implant- and tooth-borne rapid palatal expansion device:
Bahreman A. Early–age orthodontic treatment. Quintessence Books; the Hybrid Hyrax. World J Orthod. 2010;11(25):323–30.
2013.
Da Silva Filho OG, Capelloza BMC, Filho L. Rapid maxillary expan-
sion in the primary and mixed dentition: a cephalometric evaluation.
AJODO. 1991;100:171–9.
 Management of Dental Asymmetries
9
Julia Harfin

Facial symmetry is an important goal in orthodontic treat- skeletal and dental deviations, and the younger the patient,
ment. Smiling involves not only the teeth but also the sur- the easier the normalization.
rounding soft tissues. This is very important during the Etiology could be multifactorial. The genetic factors
diagnostic process and treatment planning procedures since involve craniofacial syndromes such as cleft palate, hemifa-
patients view themselves from the frontal perspective and no cial microcrosomias, craniosynostosis, ankylosis, and facial
coincidence of midlines is very evident. clefts, as shown in Fig. 9.2a and b.
Treatment strategies include growth modification and The following patient had an important left deviation due
occlusal guidance. They have to be applied in growing chil- to a fibrous ankylosis on the same side. She also had limited
dren during primary or mixed dentition to minimize dentoal- mouth opening, only 29 mm instead of 40 mm as the norm
veolar and skeletal disharmonies that can affect normal indicates. Unilateral condyle ankylosis affects normal growth
growth. on one side in conjunction with facial asymmetry due to defi-
Facial symmetry means balance throughout all the struc- cient growth on the affected side (Fig. 9.3a and b).
tures of the face. There is a very thin line to determine when Significant differences were seen when skeletal or dental
asymmetry really begins. asymmetries were analyzed. Skeletal asymmetries may
A thorough diagnosis is the basis for success. A detailed involve the maxilla, mandible, or both and can be accompa-
medical and dental history along with radiographic and func- nied with muscular or functional imbalances (McNamara).
tional studies that help determine the real reason of the asym- Dental asymmetries can be caused by proximal caries,
metry is important. loss of temporary molars, agenesis, discrepancies in the
The digital panoramic radiograph is very useful in deter- mesiodistal size of the anterior teeth, compression of the
mining bone and dental discrepancies between the right and upper arch with molars in crossbite position, etc.
left structures. A midsagittal reference plan is also useful to Both types of asymmetries can cause uni- or bilateral pos-
determine not only the quantity but also the place of the terior dental or skeletal crossbite. Posterior crossbite is one
discrepancies. of the most prevalent malocclusions in primary and early
Normally, there are differences between the right and left mixed dentition and is reported to occur in 8% to 22% of the
side of the face. Unfortunately, there is not a critical number cases (Kutin and Egermark). The functional factors most fre-
of measurement that can delimit it, and it is often determined quently found are premature contacts that deviate the path of
“by the clinician’s sense of balance and the patient’s percep- occlusion when the patient’s mouth closes in centric
tion of the imbalance” (Bishara). occlusion.
Asymmetries can be classified as dental, skeletal, or func- A close relationship between unilateral posterior cross-
tional or their combination. Soft tissues play an important bite in centric occlusion and body posture was observed
role since they can make asymmetries more evident or, con- (Zurita-Hernandez). Since unilateral posterior crossbite with
trary to this, hide them (Fig. 9.1a and b). It is important to functional shift is one of the most common malocclusions in
remember that abnormal muscle function often results in mixed dentition, the early correction of this condition is
highly recommendable in order to avoid asymmetric muscu-
lar activity and, as a result, an abnormal mandibular growth.
J. Harfin (*)
Diagnosis is the most important stage to determine the
Department of Orthodontics, Maimonides University,
Buenos Aires, Argentina correct treatment plan. In general, some patients with early
mixed dentition have a shifted midline in addition to a unilat-
Health Sciences Maimonides University,
Buenos Aires, Argentina eral crossbite when they bite in centric occlusion. However,

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 311
J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_9
312 J. Harfin

a b

Fig. 9.1 (a and b) Patient with an asymmetric smile due to temporary paralysis after a car accident and fracture of the left ramus

a b

Fig. 9.2 (a and b) Patients with cleft lip and palate, respectively. The facial asymmetry in the middle and lower third of the face is evident

when the patient is in centric relation, the occlusion changes duces an abnormal initial tooth contact and a midline devia-
completely: midlines coincide and the crossbite is bilateral tion in centric occlusion as a consequence.
(Fig. 9.4a and b). Treatment mechanics are chosen in correlation with a cor-
These functional deviations may be caused by a narrow rect diagnosis and treatment plan. Some clinical cases need
maxilla or an upper or lower tooth in a malposition that pro- asymmetric mechanics, while with others, surgery is the best
option.
9 Management of Dental Asymmetries 313

a b

Fig. 9.3 (a and b) Facial asymmetry due to condyle ankylosis

a b

Fig. 9.4 (a and b) Patient with a functional deviation. The centric occlusion and centric relation occlusion is quite different. Midlines are coinci-
dent in centric relation

It is mandatory to begin the treatment as soon as possible. the lateral crossbite was totally corrected (Fig. 9.6a and b). It
Otherwise, this unilateral posterior crossbite can produce is clear that mandibular function is essential to normalize
alterations in the dental, muscular, or skeletal development maxilla and mandibular growth and development.
of the face and body. The comparison between pre- and posttreatment lateral
As always, some patients tend to chew more on one side photographs clearly demonstrates that all treatment objec-
and can develop more asymmetries that are very difficult to tives in the frontal and lateral areas were achieved (Fig. 9.7a
correct in adolescence or adulthood. and b).
This is a case of a 5-year-old patient with significant uni- The following patient clearly demonstrates the importance
lateral crossbite on the left side along with a considerable in performing an accurate diagnosis in centric relation. This
frontal and lateral overbite. In occlusion, the mandibular 8-year, 6-month-old patient was sent to the office by her fam-
dental midline is deviated to the left (Fig. 9.5a and b). ily dentist to correct the posterior right crossbite. No TMJ
A complete correction of the frontal and lateral crossbite problems were present up to this moment (Fig. 9.8a and b).
was achieved after 2 years and 6 months of treatment with These crossbites develop early and are not self-correcting.
functional appliances. The midline was almost normal and Some of the suggested etiologic factors of crossbites include
314 J. Harfin

a b

Fig. 9.5 (a and b) Considerable lateral crossbite on the left side along with a significant overbite

a b

Fig. 9.6 (a and b) Frontal and lateral photos after treatment

prolonged retention of deciduous teeth, crowding, premature The treatment plan was grinding the cuspids of the left
loss of the deciduous teeth, and arch deficiencies. upper and lower canines until centric occlusion and centric
The first issue is to attain a correct diagnosis to identify relation were coincident.
the real problem. When the lateral crossbite is accomplished In general, unilateral posterior crossbite is due to an
with a midline deviation, a diagnosis in centric relation is asymmetric mandibular shift from the OC to the RC. The
mandatory to determine if the patient has a skeletal asym- mandible is usually symmetric but markedly positioned
metry or if it is a posterior crossbite with a functional shift. asymmetrically. However, if this position is not corrected,
The treatment and retention plan would be completely skeletal asymmetry would result (Fig. 9.11a and b).
different in each case. The midline was typically deviated to the crossbite side,
The lateral photos showed that the right first and second and the patient had Class III on one side and Class II on the
temporary molars as well as the permanent right first molar other side, but in centric relation, the midlines were
were in a complete crossbite position on the right side and coincident.
“normal” occlusion on the left side with fairly good oral Due to the fact that neuromuscular guidance of the man-
hygiene (Fig. 9.9a and b). dible is generated by the central nervous system, as soon as
However, when the patient was in centric relation, the it is diagnosed, it helps prevent the asymmetrical positioning
occlusion changed dramatically. Now, midlines were coinci- and growth of the condyles.
dent and an anterior and lateral open bite was present. The It was demonstrated that children with posterior crossbite
sole contact point was between the left upper and lower tem- can have reduced bite force and asymmetrical muscle
porary canines (Fig. 9.10a and b). ­function where the anterior temporalis is more active and the
9 Management of Dental Asymmetries 315

a b

Fig. 9.7 (a and b) The significant left crossbite occlusion was totally normalized, as was the negative overbite

a b

Fig. 9.8 Front dental photographs in (a) centric occlusion and (b) centric relation

masseter less active on the crossbite side. Moreover, there is facial pattern of the patient is necessary to complete the final
a significant association between crossbite and TMJ prob- treatment and retention plan.
lems (da Silva Andrade). Early normalization is very important because it is very
The patient returned when she was 14 years old without difficult to achieve spontaneous correction, and posterior
having had any other orthodontic treatment. Midlines were crossbite could be transferred from primary to permanent
centered, and the occlusion was almost normal but with a dentition, with long-term effects on the growth and develop-
reduced overjet and overbite. A second phase of orthodontic ment of the stomatognathic system. The condyles on the
treatment was suggested, but the patient refused (Fig. 9.12a crossbite side are positioned relatively more superiorly and
and b). posteriorly in the glenoid fossa than those on the non-­
After analyzing the right and left dental photographs, nor- crossbite side, and this position has a great influence on the
mal Class I canine and molar relationship was confirmed development of the mandible.
without any other orthodontic treatment (Fig. 9.13a and b). The following patient is a clear example of this pattern.
The comparison between the pre- and posttreatment fron- An 11-year, 8-month-old boy was sent to the orthodontic
tal photographs clearly demonstrated that the treatment department for a second opinion due to a significant asym-
objectives were achieved with a very simple and conserva- metry in the lower third of the face. He lived 850 km from
tive protocol (Fig. 9.14a and b). As always, diagnosis is the the city. The chin was deviated to the right, and apparently,
most important tool to identify these asymmetries and to dif- the left side of the mandible was longer than that on the right
ferentiate between dental, dentoalveolar, or skeletal cause side. Although he was almost 12 years old, nearly all teeth
(Burstone). Also, an overall evaluation of the skeletal and had erupted. The first diagnosis was to wait until he was
316 J. Harfin

a b

Fig. 9.9 (a and b) Lateral views in the first appointment. The right side shows a crossbite occlusion, while a normal one can be seen on the left
side

a b

Fig. 9.10 (a and b) Occlusion in centric relation. Only one contact point in the left canines was observed

20–22 years old and correct the problem through an orthog- When the lateral photographs were observed in centric
nathic surgery procedure. occlusion, Class II canine and Class I molar on the right side
As always, the first step is to identify the problems in were present. Meanwhile, on the left side, Class III canine
order to determine the cause or causes of the asymmetry and and Class I molar were seen (Fig. 9.17a and b).
then decide the most realistic treatment plan for this patient In centric relation, a significant lateral open bite was pres-
at this age (Fig. 9.15a and b). A close clinical examination in ent, leading to a completely different treatment plan. It is
concordance with radiographs are required to make a reliable important to observe the mesiodistal axial inclination of the
diagnosis. Ideally, radiographic images have to be taken in posterior teeth before brackets are bonded (Burstone). The
the centric relation to determine the exact position of the normalization of the axial inclination of the anterior and pos-
mandible. Also, it is necessary to determine the percentage terior teeth should be obtained during the first phase of treat-
of dental and skeletal influence in the anterior or posterior ment (Fig. 9.18a and b).
crossbites. Radiographic images are very useful to confirm the clini-
Analyzing the frontal dental photographs in centric occlu- cal findings. Panoramic radiography is the most commonly
sion, a significant midline deviation was observed used, which shows the potential differences in size and shape
(Fig. 9.16a), but when the patient was in centric relation of the condyles, as well as the ramus and corpus of the
(Fig. 9.16b), the midlines coincided and a large anterior and ­mandible (Fig. 9.19). Patients with unilateral posterior cross-
lateral open bite was present. bite had more asymmetric condyles than in those with sym-
9 Management of Dental Asymmetries 317

a b

Fig. 9.11 (a and b). Lateral photos in centric relation. A significant open bite was present along with a premature contact in the canine region

a b

Fig. 9.12 (a and b) Five years later without any orthodontic treatment. Midlines were coincident with reduced overjet and overbite

a b

Fig. 9.13 (a and b) Lateral occlusion at 14 years of age. Class I molar and canine were present. No brackets or other removable appliance was
used
318 J. Harfin

a b

Fig. 9.14 (a and b) Pre- and posttreatment frontal photographs without any active orthodontic treatment

a b

Fig. 9.15 (a and b) Pretreatment frontal photographs The asymmetry is visible with the chin deviated to the right

metric condyles. In addition, condylar, ramus, and asymmetric mandibular growth, facial disharmony, and sev-
condylar-plus-­ramal heights on the crossbite side were eral functional changes in the masticatory muscles and TMA
smaller than in those on the non-crossbite side (Kilic). as seen in the following patient (Fig. 9.21a and b). A large
The lateral and frontal radiographic images confirm the difference between the two photos can be observed in only
asymmetry in centric occlusion (Fig. 9.20a and b). In this 3 years without treatment. To determine the best treatment
patient. The deviation of the mandible to the right is very plan, it is mandatory to know if the asymmetry is stable or
evident. Another radiograph in centric relation would have progressive and distinguish the real etiology of the problem
been helpful to confirm these findings. before the treatment plan is defined.
It was demonstrated that the adaptation of the neuromus- An individualized and profound diagnosis is mandatory
cular area to the acquired mandibular position can cause to determine the real causes of such asymmetry. Without a
9 Management of Dental Asymmetries 319

a b

Fig. 9.16 (a and b) A significant difference between centric occlusion and centric relation is observed. In centric relation, the midlines were
almost coincident

a b

Fig. 9.17 (a and b) Lateral views in centric occlusion. Class II canine on the right side and Class III canine on the left side were observed

a b

Fig. 9.18 (a and b) Lateral views at centric relation. A significant right and left open bite was present
320 J. Harfin

real and comprehensive diagnosis, it is not possible to Positional asymmetries might have immediate morphologi-
achieve the treatment goals. cal influence in the mandibular growth.
Studies have shown that crossbites, especially when asso- These characteristics were shown in the following patient
ciated with a lateral shift, play an important role in cranio- that was sent to the orthodontic department for a second
mandibular disorders. Since posterior crossbite generally opinion since her doctor at that time realized that she had a
causes dual bite with a lateral mandibular shift, an asym- lateral deviation to the left when she opened her mouth. The
metrical condylar movement pattern can develop (Schmid). asymmetry was barely noticeable when the mouth was
Changes in condylar movement might induce asymmetrical closed. The left side was a little more rounded than that on
mandibular growth. Schmid et al. indicated that morphologi- the right side (Fig. 9.22a and b). Her medical record pro-
cal asymmetry in growing children is the result of mandibu- vided insight as to why this happened. When she was 2 years
lar displacement consequent to occlusal alterations. old, she had fallen from a high place and fractured her con-
dyle. No surgical intervention nor other treatment was
offered at that time. She was able to open her mouth nor-
mally (40 mm). Moreover, no dysfunction (clicking, pop-
ping) or pain was present in the TMJ at that time. To decide
on a correct diagnosis, it is important to determine the ana-
tomic level of the fracture. No previous radiographic images
were available.
The frontal dental photographs showed a very slight den-
tal deviation and a compression in the upper arch. A prema-
ture contact between the upper and lower incisors was visible
in conjunction with an edge to edge occlusion and anterior
open bite (Fig. 9.23a and b).
Fig. 9.19 The panoramic radiographic image clearly showing the
asymmetry between the right and left side of the condyle and ramus Class I molar was present along with the crossbite posi-
areas tion of the right and left temporary molars (Fig. 9.24a and b).

a b

Fig. 9.20 (a and b) Lateral and frontal radiographic images where the asymmetry is clearly evident
9 Management of Dental Asymmetries 321

a b

Fig. 9.21 (a and b) Frontal photographs with a 3-year difference without any kind of treatment

a b

Fig. 9.22 (a and b) The asymmetry was clearly confirmed when the patient opened her mouth, although she could open it for up to 40 mm, which
is the average

The premature contact between the upper and lower central The patient returned 1 year later with the same pathology;
incisors was clearly visible. a significant deviation to the left side when the mouth was
The panoramic radiographic image confirmed the fracture opened without any pain or clicking. The TMJ specialist
on the neck of the condyle. In addition, there was a signifi- described an anteromedial disc displacement and mild mus-
cant difference between the right and left ramus and coro- culature atrophy on that side (Fig. 9.26a and b).
noid process. The eruption of the permanent teeth seemed to The frontal dental photographs at this stage showed that
be normal according to her age (Fig. 9.25a). the midlines were almost coincident with a significant open
The lateral radiographic image confirmed the mandibular bite on the right side. The tongue was interposed between the
asymmetry and showed a double image in the lower and dis- maxilla and the mandible at rest and in function. Oral hygiene
tal borders of the mandible (Fig. 9.25b). was fairly good (Fig. 9.27a and b).
322 J. Harfin

a b

Fig. 9.23 (a and b) Pretreatment frontal dental photographs. A premature contact was clearly seen between the upper and lower central incisors
with noncoincident midlines

a b

Fig. 9.24 (a and b) Noticeable compression of the upper arch

a b

Fig. 9.25 (a and b) Pretreatment panoramic and lateral radiographic images. The fracture of the condyle and a significant mandibular asymmetry
were confirmed
9 Management of Dental Asymmetries 323

a b

Fig. 9.26 (a and b) The significant deviation to the left side when the mouth was opened remained. No pain or clicking was present

a b

Fig. 9.27 (a and b) Frontal photographs one year later without treatment. The midlines are almost coincident, but a significant right open bite was
present

It is well known that form and function are intimately he/she is diagnosed (Tavares). A conservative orthodontic
related. With this in mind, a functional appliance was treatment was recommended with an Andreasen-Haulp
designed in order to improve musculature function. activator that was controlled every 6–8 weeks. The patient
Clinical observations have shown large adaptive cooperated very well by using it almost all day (Fig. 9.28a
changes in condyle fractures that can cause functional dis- and b).
turbances and alterations during the growth period. For Upon detailed analysis of the following X-ray images, an
this reason, it is important to treat the patient as soon as improvement of the shape of the left condyle was observed
324 J. Harfin

a b

Fig. 9.28 (a and b) An Andreasen-Haulp activator was recommended that was controlled every 6–8 weeks

Fig. 9.29 (a and b) A

significant remodelling in the a b
condylar area was visible

with satisfactory remodelling of the condylar fracture region. The use of triangular elastics (1/8 heavy) was important to
The second left lower molar continued its eruption path normalize the occlusal plane and help maintain the correct
(Fig. 9.29a and b). position of the tongue. Ideally, elastics have to be used
To correct the lateral open bite, metallic preprogrammed 22–23 hours a day. When the expected results were achieved,
brackets (0.022″ slot) with bands on the first molars were reinforcement was recommended during the night for
bonded on the upper arch with a 0.016” Ni-Ti-Cu archwire. 4–6 months (Fig. 9.33a and b).
Slow and controlled forces were recommended to extrude At the end of the orthodontic treatment, excellent func-
the right side with bone and not through it. The help of the tional and esthetic results were achieved. The midlines were
speech therapist was essential to normalize tongue function coincident and the gingival line and occlusal plane were par-
and position (Fig. 9.30a and b). allel. Overjet and overbite were within the normal range
The lateral views corroborate the beginning of the align- (Fig. 9.34a and b).
ment of the upper arch (Fig. 9.31a and b). A 6-week control Intraoral examination revealed Class I canine and molar
was advisable. No brackets were bonded on the canines until on the right and left sides. Overjet and overbite were within
that point. the normal ranges and there was no pain or clicking in the
When the alignment and leveling of the arches were com- TMJ (Fig. 9.35a and b). It was important to continue the
pleted, a rectangular wire SS 0.016″ × 0.022″ was placed on treatment with the speech therapist to control the position of
the upper arch and a 0.017″ × 0.025″ turbo-wire was ligated the tongue at rest and in function in order to avoid any type
in the lower arch (Fig. 9.32a and b). of relapse.
9 Management of Dental Asymmetries 325

a b

Fig. 9.30 (a and b) A Ni-Ti-Cu 0.016″ archwire was placed to begin alignment and leveling in the upper arch with preprogrammed 0.022″
brackets

a b

Fig. 9.31 (a and b) Lateral views at the beginning of the treatment with a 0.016” Ni-Ti-Cu archwire in place

a b

Fig. 9.32 (a and b) To achieve better torque control, rectangular wires were placed in the upper and lower arches
326 J. Harfin

a b

Fig. 9.33 (a and b) Triangular elastics were recommended to improve lateral occlusion (1/8 heavy)

a b

Fig. 9.34 (a and b) Frontal and occlusal view at the end of the active orthodontic treatment. Midlines, overjet, and overbite were normalized

a b

Fig. 9.35 (a and b) Lateral views at the end of the active orthodontic treatment
9 Management of Dental Asymmetries 327

a b

Fig. 9.36 (a and b) Frontal and smiling photographs at the end of orthodontic treatment

Fig. 9.37 (a and b)

Panoramic and lateral a b
radiographic images at the
end of the treatment. All
measurements were within
the normal ranges

At the end of the treatment, facial proportions and natural with the reestablishment of the function (Chatzistaurou)
lip closure improved (Fig. 9.36a and b). (Fig. 9.38a and b).
The radiographic images at the end of the treatment dem- The comparison among the pre-, mid-, and posttreatment
onstrated the results obtained. No disturbances in dental radiographic images confirmed that improvement in the con-
development were found. All teeth were well aligned and dylar region was better than expected at the beginning of the
there was an evident improvement in the condyle zone. On treatment (Fig. 9.39a, b, and c). Long-term control with
the lateral radiographic image, a considerable asymmetry functional appliances was necessary to maintain or even
was confirmed in the mandibular region in the inferior and improve the excellent results achieved.
posterior borders of the mandible (Fig. 9.37a and b). It is very interesting to highlight that remodelling of the
The comparison between the pre- and posttreatment fron- condylar fracture was highly satisfactory. In addition,
tal photographs showed that facial asymmetry seemed to be improvement of the occlusion was also obtained.
enhanced. A conservative treatment approach for unilateral Similar results were desired in a 7-year, 6-month-old
condylar fracture using a functional appliance during the patient that was sent to the orthodontic department due to a
growth period can lead to the restoration of the fracture area great latero-deviation while opening the mouth. The chin
328 J. Harfin

a b

Fig. 9.38 (a and b) Comparison between pre- and posttreatment frontal photographs

a b c

Fig. 9.39 (a, b, and c) Comparison of the pre-, mid-, and posttreatment radiographic images in the condyle area. The results were better than
expected at the beginning

was shifted toward the right side and TMJ evaluation did not The frontal dental photographs showed a considerable
show pain or clicking during function (Fig. 9.40a and b). midline deviation in conjunction with a significant overbite.
Facial asymmetry was visible in the middle and lower third Gingival margins were uneven (Fig. 9.41a and b).
of the face. The mother did not remember when this problem Class I canine and molar were present on the right side,
began, but the teacher at school was worried about the whereas on the left side, Class II molar with a normal erup-
patient’s situation. The lips were incompetent, and a day and tion process was seen (Fig. 9.42a and b).
night mouth breathing habit was present. No other important Upper and lower dental arches showed an ovoid shape
issues were present in the medical history. with very slight crowding. No cavities or gingivo-­periodontal
9 Management of Dental Asymmetries 329

a b

Fig. 9.40 (a and b) Important latero-deviation at rest and when opening the mouth was observed in the pretreatment photographs. Day and night
mouth breathing was present

a b

Fig. 9.41 (a and b) Pretreatment frontal and overbite photographs. An important overbite was present along with the overlapping of the upper
central incisors

problems were observed. The upper and lower second tem- dic treatment, and as expected, no major changes were
porary molars were still present (Fig. 9.43a and b). observed (Fig. 9.44a and b). Clinically, the midline shift
Unfortunately, no radiographic images were taken at this when opening the mouth remained.
time. The mother consulted a traumatologist who recom- The most important treatment objective was the reestab-
mended some physical exercises, twice a week. The patient lishment of normal skeletal and muscle growth. A functional
returned 14 months later without any orthodontic or orthope- appliance was suggested to improve patient’s problems,
330 J. Harfin

a b

Fig. 9.42 (a and b) Lateral views at the beginning of the treatment. A significant overbite was present in the anterior and canine regions

a b

Fig. 9.43 (a and b) The upper and lower dental arches. The upper and lower second temporary molars were present

bearing in mind that oral physiologic function such as masti- The panoramic radiographic image confirmed the normal
cation, swallowing, or speech is highly coordinated with eruption of the permanent teeth, and no agenesis or supernu-
neuromuscular function. An individualized double activator merary teeth were present. Moreover, no root resorption was
was specially designed for the patient (Fig. 9.45a and b). It observed (Fig. 9.48).
was highly recommended that the patient use the appliance The asymmetry was clearly confirmed in the frontal
20–22 hours a day. radiographic image where the differences between the right
Ideally, this appliance should be used nearly 20 hours a day and left sides were evident. The lateral radiographic image
but the patient was uncooperative. The arguments were diffi- confirmed that the patient had a mesofacial biotype with sig-
culties in speech and swallowing, and she was supported by her nificant protrusion of the upper incisors (+11°) and a dimin-
parents. After 10 months, the decision to perform an orthodon- ished interincisal angle (112°). The lower facial height was
tic treatment was permitted by the parents, and the patient’s normal (47°) (Fig. 9.49a and b).
intraoral photos at the beginning of the orthodontic treatment Since in this patient the asymmetry was a combination of
were obtained. The midlines were not coincident and a consid- skeletal, muscular, and soft tissue discrepancies, an individu-
erable overbite was still present (Fig. 9.46a and b). alized treatment protocol had to be designed in order to
The lateral photographs confirmed Class I canine and achieve the best results. Metallic preprogrammed brackets
molar on the right side and Class II canine and molar on the with 0.022″ slots were bonded with 0.016” SS archwires to
left side. All permanent teeth had erupted (Fig. 9.47a and b). align and level the arches (Fig. 9.50a and b).
9 Management of Dental Asymmetries 331

a b

Fig. 9.44 (a and b) Frontal photographs 14 months later without any orthopedic/orthodontic treatment

a b

Fig. 9.45 (a and b) An individualized activator was designed to improve muscle activity

a b

Fig. 9.46 (a and b) Frontal photographs before the beginning of the orthodontic treatment
332 J. Harfin

a b

Fig. 9.47 (a and b) Right and left occlusion before orthodontic treatment

overbite were within the normal ranges. Occlusal plane and

gingival lines were parallel (Fig. 9.53a and b).
Perfect Class I canine and molar were achieved on the
right side and, as expected, Class II on the left side. Good
oral hygiene was maintained (Fig. 9.54a and b).
Upper and lower fixed retention wires were bonded in
order to maintain the position of the upper and lower inci-
sors. To maintain the achieved results, another functional
appliance similar to the one made by Trainers was
­recommended for a long period (4–5 years) since the nor-
malization of the musculature activity takes several years
Fig. 9.48 Panoramic radiographic image preorthodontic treatment (Fig. 9.55a and b).
Subtle soft tissue facial asymmetry can be observed at the
Class II elastics were suggested to improve lateral occlu- end of the active orthodontic treatment (Fig. 9.56a and b). A
sion. Overjet and overbite were in within the normal range functional appliance was recommended as a retainer for a
and the midlines were still noncoincident. According to the long period of time.
clinical and radiographic diagnosis, it was very difficult to After a careful analysis of the panoramic radiographic
achieve Class I molar and canine on the left side due to the images, a good parallelism of the roots without resorption
presence of a skeletal asymmetry (Fig. 9.51a and b). was observed. The second molars had completely erupted
The upper and lower occlusal arches were well rounded and the third molars were in their normal process of eruption
and all the rotations were corrected. In general, it is advis- (Fig. 9.57a). The lateral radiographic image confirmed the
able that the last archwire be maintained in place for at least substantial improvement in the profile (Fig. 9.57b).
5–6 months to obtain mature bone around the new position The comparison between the pre- and posttreatment pho-
of the teeth (Fig. 9.52a and b). tographs clearly showed that the treatment objectives were
Photographs at the end of the treatment showed that all reached. Although some asymmetry was observed, it was
objectives were fulfilled in the 2-year, 6-month orthodontic less visible (Fig. 9.58a and b). No TMJ pain or dysfunction
treatment. The midlines were coincident, and overjet and was present.
9 Management of Dental Asymmetries 333

a b

Fig. 9.49 (a and b) Pretreatment frontal and lateral radiographic images. The asymmetry and the protrusion of the upper incisors were evident

a b

Fig. 9.50 (a and b) Frontal view after 20 months in active orthodontic treatment with preprogrammed 0.022″ metal brackets. Gingival line was
parallel to the occlusal plane

a b

Fig. 9.51 (a and b) Class II elastics were recommended 20 hours a day to improve occlusion
334 J. Harfin

a b

Fig. 9.52 (a and b) Upper and lower arches before the end of the orthodontic treatment

a b

Fig. 9.53 (a and b) Posttreatment frontal photographs. All objectives were fulfilled with no extractions

a b

Fig. 9.54 (a and b) Lateral views at the end of the orthodontic treatment
9 Management of Dental Asymmetries 335

a b

Fig. 9.55 (a and b) Upper and lower fixed retainers were bonded on the anterior teeth along with a functional appliance to maintain the results

a b

Fig. 9.56 (a and b) Frontal and smiling photos at the end of the treatment. The asymmetry is less noticeable
336 J. Harfin

Fig. 9.57 (a and b)

Panoramic and lateral a b
radiographic images at the
end of the active orthodontic
treatment

a b

Fig. 9.58 (a and b) Frontal photographs pre- and post-orthodontic treatment. A substantial esthetic and functional improvement were achieved

9.1 Conclusions asymmetries have to be diagnosed in centric relation. A pan-

oramic radiograph is useful to survey dental and bone struc-
One of the biggest challenges for the orthodontist is the treat- tures of the maxilla and the mandible and to determine the
ment of dentoalveolar and skeletal asymmetries. It is crucial presence of gross pathologic condition or the shape of the
to determine the real factors that cause the asymmetry and, in mandibular ramus and condyles on both sides. Clinical
this way, to define the best treatment and long-term retention observations have shown large adaptive changes in fractured
plan. condyles than can cause functional disturbances and altera-
The treatment of asymmetries in temporary and early tions in dentofacial growth.
mixed dentition requires a detailed study of all the available The retention plan has to be individualized for each
records (radiographic images, cast models, tomographic patient and be determined at the same time as the treatment
images, photographs, etc.) to determine the location, extent, plan. A long-term retention plan with functional appliances
and causes that produce these results (Thilander). To obtain is always recommendable in all patients. Unfortunately,
an accurate diagnosis, all the frontal, transverse, and lateral there is no particular bracket or wire that can solve all the
9 Management of Dental Asymmetries 337

different types of asymmetries that could be present in all shift is responsible for some asymmetries in the temporo-
patients. Taking into account that unilateral posterior cross- mandibular region and can change the normal growth pat-
bite can alter the stomatognathic system, it could be interest- tern, as observed in adolescents or young adults.
ing to study the relationship between this problem, the size As a result, it is highly recommended to correct unilateral
of the condyles, and the height of the ramus. posterior crossbite in temporary or early mixed dentition since
Normally, in temporary dentition, there is premature con- it is not self-corrected during growth. Further studies should
tact in the temporary canine area (Fig. 9.8b) in centric rela- be conducted to analyze whether the use of this treatment pro-
tion since a functional mandibular shift is the consequence tocol for a longer period of time would have a significant skel-
not the cause (primary etiology). Moreover, this mandibular etal effect in growing patients with asymmetries.
 Mandibular Incisor Agenesis
10
Julia Harfin

Upper and lower incisor agenesis is one of the most common A 9-year, 10-month-old patient was referred to the orth-
anomalies in children with permanent dentition (Ingervall odontic department due to malposition of the lateral incisors.
et al., 1972). The most common congenitally missing inci- The frontal photograph showed mild asymmetry along with
sors are the upper lateral ones and then one or two central a straight profile and a thin upper lip. He can close his mouth
lower incisors (Davis, 1987). Niswander, Sujaku, and Davis without effort (Fig. 10.2a and b).
showed that the mandibular incisors were the most com- The frontal dental photograph showed a significant over-
monly missing teeth in Japanese as well as Chinese popula- bite of approximately 100% at the central incisal area and an
tions (Niswander & Sujaku, 1963). Till date, it is not clear uneven gingival line. Analyzing the lower arch, only three
whether a close relationship exists between craniofacial mor- incisors have erupted (Fig. 10.3a and b).
phology and lower incisors agenesis, and this etiology is The panoramic radiographic image confirmed that only 3
totally uncertain. lower incisors were present, and no dental agenesis was seen.
Moreover, hereditary, environmental, and endocrine pat- Since the Panorex image was taken in the occlusion site, the
terns can play an important role. More clinical trials are nec- important overbite was clearly visible (Fig. 10.4).
essary to confirm these theories. Since tooth eruption plays a In order to align and level the upper arch, preprogrammed
critical role in the continuous growth of the mandibular sym- brackets were bonded on the upper incisors along with bands
physis, the absence of mandibular central incisors can exhibit on the first molars and a low deflection arch as the first arch
a smaller mandibular symphysis area with a greater incisor (Fig. 10.5a and b).
retroclination than that in normal patients. When the right and left sides were examined, significant
In contrast, the absence of the lower central incisors can gingivitis was observed. No brackets adhered to the tempo-
cause some disturbances in the tongue position in conjunc- rary canines and molars (Fig. 10.6a and b).
tion with a significant anterior deepbite, as observed in the These were the results after 11 months of treatment.
first example. As first reported by Newman in 1967, the man- Excessive overbite was almost normalized and oral hygiene
dibular central incisors are frequently prone to bilateral improved. A Ni-Ti coil spring was added to gain space for
agenesis (Newman & Newman, 1998) (Fig. 10.1a and b). the second right bicuspid eruption, not only has it rotated, but
Lower incisor agenesis can be diagnosed using orthodon- it was also in a palatal position (Fig. 10.7a and b).
tic records, including orthopantomographic and periapical Eight months later, overbite and overjet were completely
radiographic images. restored. Gingival line and occlusal plane were parallel. An
The real dilemma is to close or open the space to replace upper and lower SS 0.016″ × 0.022″ was used to complete
uni- or bilateral absent teeth by implants or fixed or remov- alignment and maintain torque (Fig. 10.8a and b).
able prosthesis. A multidisciplinary approach is important to The lateral views showed that even though one lower inci-
provide the most appropriate and comprehensive treatment sor was missing, Class I canine and molar were achieved. No
and retention plan. stripping was performed on the upper arch (Fig. 10.9a and b).

J. Harfin (*)
Department of Orthodontics, Maimonides University,
Buenos Aires, Argentina
Health Sciences Maimonides University,
Buenos Aires, Argentina

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 339
J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_10
340 J. Harfin

a b

Fig. 10.1 (a and b) Agenesis of the lower central incisors

a b

Fig. 10.2 (a and b) Pretreatment frontal and profile photographs

10 Mandibular Incisor Agenesis 341

a b

Fig. 10.3 (a and b) Pretreatment frontal and lower arch photographs

His frontal and profile photographs demonstrated that his

facial biotype was maintained (Fig. 10.15a and b).
Five years later, the position of the teeth was totally main-
tained and a new retention wire was bonded (Fig. 10.16a and b).
The case of a 7-year-old patient is a clear example of how
congenitally central lower incisors agenesis should be man-
aged. He was sent to the office by the dentist’s family. No
relevant medical history and no trauma or infections in the
anterior region were present, and there was no history of
Fig. 10.4 Pretreatment panoramic radiographic image lower incisor agenesis in the family.
The frontal pretreatment photographs showed a symmet-
rical face, but when he smiled, the absence of the central
The normalization of the anterior and posterior teeth posi- lower incisors was visible (Fig. 10.17a and b).
tion was confirmed when the upper and lower arches were The lateral photographs exhibited a convex profile that was
analyzed (Fig 10.10a and b). almost normal in a 7-year-old patient (Fig. 10.18a and b).
Frontal and upper arch photographs at the end of the treat- Analyzing the frontal dental photographs, a significant
ment show that since the patient presented with one lower overbite and the absence of the lower central incisors were
incisor agenesis, the midlines were not coincident, but the confirmed (Fig. 10.19a and b).
other treatment objectives were achieved (Fig. 10.11a and b). Despite the agenesis of the lower central incisors, Class I
A fixed retention wire was bonded between the right and molar on the right and left sides was confirmed (Fig. 10.20a
left canines. The periapical radiographic image confirmed and b).
the parallelism of the lower incisor roots (Fig. 10.12a and b). The pretreatment panoramic radiographic image con-
Lateral views at the end of the active orthodontic treat- firmed the agenesis of the lower central incisors and the
ment. Class I canine was maintained as well as a normal lower right second bicuspid (Fig. 10.21).
occlusal plane (Fig. 10.13a and b). Considering the age of the patient, a control every
The final photographs posttreatment showed that facial 6 months was decided. However, the patient returned 4 years
features were maintained with a clear improvement on the later without any type of treatment. Analyzing the panoramic
lower third of the face (Fig. 10.14a and b). radiographic image, agenesis of the second lower right
The patient returned 5 years later to control the fixed wire bicuspid was confirmed. The canines erupted following its
retainers. normal path (Fig. 10.22).
342 J. Harfin

a b

Fig. 10.5 (a and b) Brackets bonded on the upper incisors with a low deflection arch to align the upper arch

a b

Fig. 10.6 (a and b) Lateral views at the beginning of treatment

a b

Fig. 10.7 (a and b) Alignment after 11 months of treatment

10 Mandibular Incisor Agenesis 343

a b

Fig. 10.8 (a and b) Frontal and overbite view after 15 months of treatment

a b

Fig. 10.9 (a and b) Lateral views at this stage of treatment

a b

Fig. 10.10 (a and b) Upper and lower arches

344 J. Harfin

a b

Fig. 10.11 (a and b) Final photographs. All objectives were achieved

Fig. 10.12 (a and b)

Retention wire in place and a b
radiographic image of the
final lower incisors

a b

Fig. 10.13 (a and b) Final lateral photographs. Class I canine was achieved despite the agenesis of a lower incisor
10 Mandibular Incisor Agenesis 345

a b

Fig. 10.14 (a and b) Frontal and profile photographs at the end of active treatment

a b

Fig. 10.15 (a and b) Control 5 years later

346 J. Harfin

a b

Fig. 10.16 (a and b) Five-year follow-up images

a b

Fig. 10.17 (a and b) Pretreatment frontal photographs

10 Mandibular Incisor Agenesis 347

a b

Fig. 10.18 (a and b) Profile photographs at the beginning of treatment

a b

Fig. 10.19 (a and b) Pretreatment frontal and lower arch photographs

348 J. Harfin

a b

Fig. 10.20 (a and b) Pretreatment lateral views

Four years later, the facial photographs showed a straight

profile and the patient can close his lips without effort
(Fig. 10.23a and b).
The frontal dental photograph confirmed the presence of
a significant overbite. The gingival line and the occlusal
plane were not parallel. More extrusion on the left side was
present The lower lateral incisors were partially mesialized
on its own (Fig. 10.24a and b).
In spite of the agenesis of the central lower incisors, Class
I molar was maintained. An important diastema between the
lower right canine and first bicuspid was present (Fig. 10.25a
Fig. 10.21 Pretreatment panoramic radiographic image
and b).
To normalize the increased anterior overbite, the treat-
ment plan included lingual brackets on the upper arch.
Among all the lingual brackets, those with a bite plane were
the most recommendable.
The front photograph demonstrated the normalization of
the deepbite 2 months later (Fig. 10.26a and b).
When the lateral views were examined, Class I molar on
the right and left sides was maintained. The gingival line and
occlusal plane were almost parallel (Fig. 10.27a and b).
To close all the remnant anterior space, labial prepro-
grammed esthetic brackets (0.022″ slot) were used along
with a Ni-Ti coil open spring to mesialize the lower canines
Fig. 10.22 Panoramic radiographic image 4 years later without any (Fig. 10.28a and b).
type of treatment
10 Mandibular Incisor Agenesis 349

a b

Fig. 10.23 (a and b) Facial photographs 4 years later

a b

Fig. 10.24 (a and b) Frontal dental and lower arch photographs 4 years later without treatment
350 J. Harfin

a b

Fig. 10.25 (a and b) Pretreatment lateral views

a b

Fig. 10.26 (a and b) Lingual brackets were bonded on the upper arch

a b

Fig. 10.27 (a and b) Lateral views after 2 months with lingual brackets
10 Mandibular Incisor Agenesis 351

a b

Fig. 10.28 (a and b) Esthetic lower brackets with a Ni-Ti open coil spring to mesialize the lower canines

a b

Fig. 10.29 (a and b) Right and left dental photographs 4 months later

Lateral views at this stage of treatment. Mesialization of maintained. On the right side, some relapse on the canine
the right and left Class I canines was accomplished zone was observed (Fig. 10.35a and b).
(Fig. 10.29a and b). Taking into account that long-term retention was the best
A fixed retention wire was bonded on the upper arch option when agenesis of one or two lower incisors was pres-
between the right and left first bicuspids, while the left first ent, fixed retention wires were bonded on the upper and
bicuspid was mesialized in order to close the lateral diastema lower arches (Fig. 10.36a and b).
(Fig. 10.30a and b). The control panoramic radiographic image confirmed the
The facial photographs at the end of active orthodontic upper and lower fixed retention wires and the complete clo-
treatment confirmed a relaxed smile (Fig. 10.31a and b). sure of the interincisal lower space (Fig. 10.37).
Profile photographs at the end of treatment. Facial biotype Complete closure of the anterior space due the agene-
was maintained (Fig. 10.32a and b). sis of the central lower incisors was confirmed when pre-
At the end of treatment, all spaces were closed, although and posttreatment lower arch photographs were
the midlines were not completely centered. A long-term compared. No implants were required in the lower arch
fixed retention wire was recommended (Fig. 10.33a and b). (Fig. 10.38a and b).
A 3-year follow-up later confirmed that the results were The comparison of the pre- and posttreatment frontal pho-
stable. Good oral hygiene was maintained (Fig. 10.34a and b). tographs confirmed the significant improvement achieved.
Lateral views at 3 years of follow-up show that the right Overbite and overjet were completely normalized (Fig. 10.39a
and left Class I molars as well as the Class I left canine were and b).
352 J. Harfin

a b

Fig. 10.30 (a and b) Upper and lower occlusal photographs at this stage of treatment

a b

Fig. 10.31 (a and b) Final facial photographs

10 Mandibular Incisor Agenesis 353

a b

Fig. 10.32 (a and b) Final profile photographs

a b

Fig. 10.33 (a and b) Frontal dental and lower occlusal photographs at the end of treatment
354 J. Harfin

Fig. 10.34 (a and b) After

the 3-year follow-up a b

a b

Fig. 10.35 (a and b) Right and left views

a b

Fig. 10.36 (a and b) Fixed retention wires were bonded to the upper and lower arches
10 Mandibular Incisor Agenesis 355

Fig. 10.37 Panoramic radiographic image at the control stage

a b

Fig. 10.38 (a and b) Comparison of pre- and posttreatment photographs

a b

Fig. 10.39 (a and b) Comparison of pre- and posttreatment photographs

356 J. Harfin

10.1 Conclusions plan included the installation of a lower fixed retention wire
for a long period of time.
The number of patients exhibiting congenitally missing
mandibular incisors is low. Although the exact etiology of
congenital agenesis is unknown, several factors such as References
heredity, infections, or endocrine alterations are possible
causes (Endo et al., 2007). Davis PJ. Hypodontia and hyperodontia of permanent teeth in
Hong Kong schoolchildren. Community Dent Oral Epidemiol.
There are few studies of lower incisor agenesis in tempo- 1987;15:218–20.
rary dentition. Endo T, Ozoe R, Kojima K, Shimooka S. Congenitally missing mandib-
In some cases, hypodontia can affect the anterior man- ular incisors and mandibular symphysis morphology. Angle Orthod.
dibular growth, particularly at the symphysis area. 2007 Nov;77(6):1079–84.
Ingervall B, Seeman L, Thilander B. Frequency of malocclusion and
An individualized treatment plan is mandatory for each need of orthodontic treatment in 10-year old children in Gothenburg.
patient according the number of absent teeth, facial and gin- Swed Dent J. 1972;65:7–21.
gival biotype, and amount of remaining growth. In spite the Newman GV, Newman RA. Report of four familiar cases with con-
improvement of implants during the last decade, closing genitally missing mandibular incisors. AJODO. 1998;114:195–207.
Niswander JD, Sujaku C. Congenital anomalies of teeth in Japanese
space during mixed or early permanent dentition continued children. J Phys Anthropol. 1963;21:569–74.
to be the best option until now. Consistently, the retention
 Impacted Central Incisors: Different
Options for Treatment 11
Julia Harfin

According to the literature, the prevalence of impacted cen-

a b
tral incisors is less than 1% (Machado); however, for the
patient, it is quite disturbing from an esthetic and functional
point of view. Normally, the upper incisors erupt between 6
and 10 years of age. Nevertheless, when a lateral incisor
erupts before the central incisor, impaction of the central
incisor could result (Kurol).
Tooth impaction may result as a consequence of different
conditions, such as mesiodens, supernumerary teeth, ectopic
position of the tooth bud, odontoma, cysts, local tumor, scar
tissue, lack of space ankylosis of the primary teeth, trauma
on the deciduous incisors, loss of or inadequate space, and
delayed resorption of the primary roots.
Trauma in primary dentition, especially traumatic incisor
intrusion, may result in the crown or root dilaceration of the
developing permanent incisors (Uematsu) (Fig. 11.1a, b), as Fig. 11.1 (a, b) Root and crown dilaceration after primary incisor
shown in the following radiographic images. The conse- trauma
quence will depend on the stage of development of the root
at the moment of trauma. The angulation between the crown
and the root will determine the prognosis of the result. In CT to accurately define the position of the incisor and its
general, pulp vitality is preserved but in some cases necrosis relation with the roots of the adjacent teeth.
is the consequence. A careful treatment plan is required to obtain a reasonable
Traumatic intrusion is a dental injury that involves the result. It is important to consider the angle between the
upper anterior teeth and is often associated with a comminu- crown axis and the root. Sometimes, one of the major prob-
tion or fracture of the alveolar bone (Turley). Some accidents lems is the recovery of the space for the incisor, in conjunc-
during early childhood can have consequences due to the tion with the elimination of functional interferences that can
proximity to the temporary incisor roots on the permanent alter the path of the eruption.
teeth. An early diagnosis is very important for the clinician, In general, the prognosis is the result of several factors
the parents, and, above all, the patient. If the contralateral such as etiology, quantity of bone, root length and shape, and
incisor erupts 6–8 months earlier, a panoramic radiograph is dilaceration of the crown. Treatment timing also plays an
mandatory. Some patients require complementary studies important role. Different orthodontic techniques can be used,
such as a periapical and occlusal radiograph and a cone beam and in some cases, spontaneous eruption can be observed
when the space is recovered (Becker), but in other patients,
orthodontic traction may be required.
In 28% to 60% of cases, mesiodens and odontomas cause
J. Harfin (*)
incisor impaction (Suri.Batra). Their extraction is necessary
Department of Orthodontics, Maimonides University,
Buenos Aires, Argentina before initiating the extrusion process. If an impacted incisor
is associated with a cyst, a conservative approach is preferred
Health Sciences Maimonides University,
Buenos Aires, Argentina to prevent the loss of the incisor. When the preservation of

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 357
J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_11
358 J. Harfin

the tooth is desired in a young patient where the lesion is The following patients are clear examples of some of
isolated, marsupialization is the treatment of choice. When these circumstances. The parents of this 9-year-old patient
the intrusion is severe, ankylosis of the tooth could result. asked for a second opinion regarding the right upper central
Till now, orthodontic treatment to move the tooth to its cor- incisor that had not erupted. The family dentist told them that
rect position is not possible. Moreover, attempts show the they had to wait until the patient was 12 years old, but they
undesirable movement of the adjacent tooth. were worried about waiting so long.
Determining the duration of treatment is difficult since it The left central incisor erupted 20 months earlier without
depends a lot on circumstances, such as residual eruption any inconvenience, and now a mild crown mesial inclination
potential, localization of the impacted tooth, bone density, was present without enough room for the right intruding
surgical procedures, root dilaceration, and missed appoint- incisor (Fig. 11.2a, b). The occlusal view confirmed that
ments. The higher the position of an impacted incisor, the there was no room for the right incisor and the buccal-palatal
longer the duration of the orthodontic treatment (Tanaka). width was diminished.
The treatment plan includes three steps: presurgical ortho- Lateral views showed Class I right and left canine and
dontics, exposure and bonding, and postsurgical orthodontics. molar with a normal path of eruption. The mesio-inclination
During the surgical procedure, at least one-half or two-­ of the left upper central incisor was clearly evident. There
thirds of the crown has to be uncovered. Gingivectomy would was a significant overbite in the left central incisor region.
be the most conservative procedure when a normal attached The patient had a good oral hygiene (Fig. 11.3a, b).
gingiva is present, but when its width is compromised, an api- According to studies by Becker and Chaushu, the first
cally positioned flap is required (open eruption) (Vermette). phase of treatment is to achieve sufficient mesiodistal space
However, in some patients, a close eruption technique to have room for the intruding incisor. Esthetic brackets at
would be the best option. During this procedure, the attached 0.022″ were bonded on the upper laterals and the left central
gingiva is raised, and after placement of a button or a bracket incisor along with an esthetic Ni-Ti 0.014″ archwire. To have
on the impacted incisor, it is fully replaced to its original better anchorage, brackets were also placed on the temporary
position. Studies have shown less recession, better bone sup- canines (Fig. 11.4a).
port, and superior periodontal parameters with the closed-­ The periapical X-ray images showed the position and
eruption method (Becker). inclination of the right central incisor and an open coil spring
The patient should be aware that some problems can to recover the right central incisor space (Fig. 11.4b).
appear during the surgical-orthodontic treatment, such as After 5 months of treatment, the space was achieved and
some root canal obliteration, devitalization of the tooth, or the midlines were normalized. A 0.016″ × 0.016″ Elgiloy
ankylosis (Chaushu). Unfortunately, there is no single and archwire was placed and a control radiographic image was
specific bracket available to treat all of these patients. taken (Fig. 11.5a, b).
Nonetheless, a controlled and light force is highly recom- Since the intruding incisor did not erupt by itself, the
mended to erupt the tooth with bone and normal gingivo-­ patient was referred to an oral surgeon for a closed surgical
periodontal tissues. In addition, controlled oral hygiene is procedure and bracket bonding at the same time. However,
fundamental for this purpose. the surgeon decided to perform an open procedure. When the
patient returned 3 weeks later, an esthetic bracket was bonded

a b

Fig. 11.2 (a, b) Impaction of the right maxillary central incisor caused by trauma on the primary incisor
11 Impacted Central Incisors: Different Options for Treatment 359

a b

Fig. 11.3 (a, b) Pretreatment lateral views. Class I molar was observed along with lack of space for the eruption of the right central incisor

Fig. 11.4 (a, b) Esthetic

brackets were bonded on the a b
upper anterior teeth. X-ray
image showed the impacted
right central incisor and the
coil spring to recover the
space

Fig. 11.5 (a, b) Frontal

a b
photograph and periapical
X-ray image after 5 months of
treatment
360 J. Harfin

a b

Fig. 11.6 (a, b) Frontal and occlusal photographs 1 month after the surgical incisor exposure

a b

Fig. 11.7 (a, b) A second arch (Ni-Ti 0.012″) was placed to control eruption with very low forces

on the labial surface of the central incisor along with a liga- The following were the results after 23 months of treat-
ture to the main arch. The occlusal photographs confirmed the ment. All treatment objectives were completed: the upper right
recovered space and the biomechanics used (Fig. 11.6a, b). central incisor and midlines were corrected (Fig. 11.10a, b).
Taking into account that it is very important to maintain No important root resorption was seen and the upper right
healthy gingivo-periodontal tissues, a controlled extrusion central incisor pulp was still vital. Since there was a slight
force was applied. A second Ni-Ti 0.012″ archwire was difference in the gingival height, no further mucogingival
placed between the upper canines. An 8-week activation surgery was recommended. A fixed retainer wire was recom-
period was recommended (Frank) (Fig. 11.7a, b). mended for a long period of time, in conjunction with a night
Four months later, the incisor was extruded very slowly. vacuum maxillary retainer.
When analyzing the frontal photograph, a ligature-of-eight The bilateral Class I canine and molar relationship with
was placed on the left side to correct the midline to the left. normal overjet and overbite were achieved. Gingivo-­
Moreover, the bracket on the right central incisor had to be periodontal tissues were almost normal (Fig. 11.11a, b).
repositioned to improve its alignment (Fig. 11.8a, b). The patient returned after 30 months for a control of the
To control leveling and alignment, a 0.018″ SS archwire was retainer. The results were almost maintained although the
placed. No brackets were bonded on the bicuspids until that point fixed retention wire was lost 1 year earlier. The gingival tis-
(Fig. 11.9a, b). A slight difference was still present on the gingival sues were normal and a subtle relapse could be observed on
margin of the incisors along with a mild inflammation on the right the right upper central incisor (Fig. 11.12a, b).
side. The interincisal diastema had to be closed very smoothly to
achieve complete closure with normal dental papillae.
11 Impacted Central Incisors: Different Options for Treatment 361

a b

Fig. 11.8 (a, b) Frontal and occlusal photographs 4 months after the open flap surgery

a b

Fig. 11.9 (a, b) Frontal and occlusal photographs at the end of the phase I treatment

a b

Fig. 11.10 (a, b) Final records after 23 months of treatment. The upper and lower midlines were almost normal and no significant root resorption
was seen
362 J. Harfin

a b

Fig. 11.11 (a and b) Lateral views at the end of treatment. Class I molar was maintained

a b

Fig. 11.12 (a, b) A control 12 months later. The results were almost maintained

a b A comparison between the pre- and posttreatment radio-

graphic images confirmed the achieved results. No important
root resorption was visible (Fig. 11.13a, b).
Delayed eruption has to be monitored very closely to
avoid major inconveniences that can produce impactation or
ankylosis of the incisor and can have direct effects on the
development of the occlusion.
The next case provides a visible example. A 10-year,
10-month-old girl was sent for a second opinion since her
upper central right incisor was absent. She was in good health
and no history of supernumerary teeth, mesiodens, or odon-
toma. Although she had a history of dental trauma when she
Fig. 11.13 (a, b) Pre- and posttreatment periapical radiographic was 4 years old and she had the habit of nail biting from the age
images. No root resorption was visible of 5, the etiology of the impacted incisor was mainly due to
11 Impacted Central Incisors: Different Options for Treatment 363

Fig. 11.14 (a, b) Frontal

photograph and X-ray image a b
showing the right impacted
incisor with a rounded and
short root

a b

Fig. 11.15 (a, b) Lateral views at the beginning of the treatment. Class I molar and cuspid are present

trauma. The periapical radiographic image showed the difficult for the patient to maintain good oral hygiene in this
impacted incisor with a short and rounded root (Fig. 11.14a, b). zone (Fig. 11.16a, b).
Upon analyzing the lateral views, a skeletal Class I mal- After 7 months, the incisor erupted but in a rotated posi-
occlusion with a balanced facial pattern was observed. tion. A 0.016″ × 0.016″ TMA archwire with some bends was
Although she was almost 11 years old, all the canines and placed to normalize the position of the right incisor. The
bicuspids had erupted. Intraoral examination revealed a periapical radiographic images confirmed that the extrusion
Class I molar relationship with an overbite of 2 mm and an was performed with no more root resorption (Fig. 11.17a, b).
overjet of 1.5 mm. A mild diastema distal to the right and left The following photographs show the results of orthodon-
lateral incisors was present (Fig. 11.15a, b). tic treatment. A slight recession was present on the gingival
The surgeon decided on an open flap surgery, and the margin of the upper central right incisor. Overjet and over-
bracket was bonded 2 weeks after the surgery. Ideally, bond- bite were almost normal, and at the end of treatment, the
ing has to take place during the surgical procedure, but if for midlines were coincident (Fig. 11.18a, b).
any reason it is not possible, a wide exposure must be per- The comparison between the pre- and posttreatment fron-
formed and a surgical pack may be placed, to prevent wound tal photographs demonstrated that the results obtained were
closure. It is important to prevent damage to the cementum-­ excellent. All treatment objectives were achieved: extrusion
enamel junction (Becker). An open coil spring was placed to of the impacted central right incisor, normalized overjet and
open the space and, at the same time, to hold a metallic liga- overbite, and an occlusal plane parallel to the gingival plane
ture. The extrusion has to be performed very slowly to pro- (Fig. 11.19a, b). It is very interesting to see how the interin-
tect the rounded root and to obtain normal gingivo-periodontal cisal papillae were totally recovered with normal color and
tissues. Due to the high position of the tooth, it was very shape. Moreover, the periodontal status of the exposed inci-
364 J. Harfin

Fig. 11.16 (a, b) Frontal

a b
photograph and X-ray image
2 weeks after the open flap
surgery

Fig. 11.17 (a, b) Seven

months of treatment. Root a b
resorption was not present

a b

Fig. 11.18 (a, b) Frontal photographs with the last archwire and at the end of treatment

sor after orthodontic treatment showed a normal gingival incisor had fallen 6 months earlier and the permanent incisor
contour. No further mucogingival surgery was recommended. had not erupted. The panoramic radiographic images con-
The following case was a 12-year-old patient and the firmed distal inclination of the crown and lack of space.
most challenging in reference to impacted incisors. He was Some mild crowding in the lower arch was also present
worried about his smile. The temporary upper right central (Fig. 11.20a, b).
11 Impacted Central Incisors: Different Options for Treatment 365

a b

Fig. 11.19 (a, b) Pre- and posttreatment comparison. The gingival line is almost normal

a b

Fig. 11.20 (a, b) Pretreatment frontal photograph and panoramic radiographic image. An important disto-inclination of the right central impacted
incisor is visible

Preprogrammed brackets were bonded on the upper arch When the upper right central incisor reached the occlusal
along with a Ni-Ti Cu 0.016″ broad arch to begin the align- plane, a bracket was bonded on the upper right lateral incisor
ment and to obtain sufficient space for the impacted incisor. along with an open coil spring to recover enough space for
The surgeon decided on an open flap surgery and the bracket the central and lateral incisors (Fig. 11.23a). A 0.016″ SS
was placed on the right central incisor in the same proce- archwire was placed to finish the leveling and alignment of
dure. No bracket was bonded on the upper right lateral inci- the upper arch. At the same time, brackets were bonded on
sor to protect it. A wire ligature between the right central the lower teeth to correct the mild lower anterior crowding
incisor and the left canine was placed to improve its posi- (Fig. 11.23b).
tion. An activation was recommended every 3 weeks Six months later, lower anterior crowding as well as the
(Fig. 11.21a, b). midlines was normalized (Fig. 11.24a). Since the patient
These are the results after 6 and 9 months of treatment. A decided to continue his studies abroad, two fixed retention
0.014″ Ni-Ti archwire was ligated and light forces were used wires were bonded between the canines (Fig. 11.24b). Oral
with the intention of extruding the incisor with bone and not hygiene needed improvement.
through it (Fig. 11.22a). There were significant results after Although the patient was 12 years old, at the beginning of
3 months (Fig. 11.22b). treatment, the normalization of the position of the upper
366 J. Harfin

a b

Fig. 11.21 (a, b) A control 2 and 6 weeks postsurgery. Very low forces were recommended to move the incisor with bone

a b

Fig. 11.22 (a, b) A Ni-Ti 0.014″ was placed to extrude the incisor very slowly with bone

a b

Fig. 11.23 (a, b) A bracket was bonded on the upper right lateral incisor when enough space was achieved with brackets on the lower arch to
correct mild crowding
11 Impacted Central Incisors: Different Options for Treatment 367

a b

Fig. 11.24 (a, b) Frontal photographs before and after debonding. Oral hygiene had to be improved

a b

Fig. 11.25 (a, b) Comparison of pre- and posttreatment panoramic radiographic images. Root resorption was not present

right central incisor was clearly demonstrated when the pre- extruded with a normal quantity of attached gingiva and the
and posttreatment radiographic images were compared. No maintenance of excellent oral hygiene is crucial to obtain
major root resorption was observed but a slight mesio-­ normal interincisal papillae.
inclination of the root of the upper right lateral incisor was It is important to consider that the preservation of the
present (Fig. 11.25a, b). vitality of the tooth during the surgical and orthodontic pro-
cedures is mandatory. The duration of the surgical-­
orthodontic treatment of an impacted maxillary incisor varies
11.1 Conclusions widely since the etiology as well as the position and inclina-
tion of the impacted incisor could be different.
Early diagnosis is critical for the success of the treatment. Unfortunately, there are no specific brackets or wires
Each clinical case must be treated with an individualized available to treat these patients. The most important issue to
treatment plan to achieve the best functional and esthetic consider is to apply light and continuous forces during the
result. Light and controlled extrusive forces are mostly rec- entire active treatment. It is highly recommended that the last
ommended to bring the tooth down to the occlusal plane. A arch be maintained a minimum of 6 months before the finish-
careful soft-tissue management is necessary to achieve a suc- ing process begins. A long-term fixed retention wire is also
cessful long-term esthetic outcome. The incisor has to be recommended in all clinical cases.
 How Orthodontic Movement Can Avoid
Future Periodontal Problems 12
in Children

Julia Harfin

Patients with a nice and attractive smile, white teeth, and prevalence of this recession ranges from 4% to 8% in chil-
normal gingivo-periodontal tissues are the gold standard for dren between 7 and 12 years old (Seehra). The etiology is
all orthodontists. To obtain this goal, a complete and pro- multifactorial, but ectopic tooth eruption may play an impor-
found understanding of the histology and physiology of peri- tant role in conjunction with localized gingivitis in this zone.
odontal tissues is fundamental. It is essential to be aware of Patients with thin periodontal biotype are more prone to this
its pathology, especially in young patients. problem than those with thick periodontal biotype. It is
The periodontium is a complex tissue that includes the mostly prevalent in the central mandibular incisors as the lat-
gingiva and the gingival attachment to the tooth, cementum, eral incisors tend to erupt more lingually (Vasconcelos).
periodontal ligament, and alveolar bone. It is important to It is important to establish the difference between true and
take into account that these tissues constantly change during pseudo-recession. True recession is an exposure of cemen-
the growth period and its health maintenance is crucial tum with apical migration of the junctional epithelium
before, during, and after all the orthodontic movements. (Song). The predisposing factors include excessive labial
Clinical observation demonstrates that teeth in lingual position of the lower incisors, minor width of the attached
position have wider bands of keratinized and attached gin- gingiva, gingiva trauma, and poor oral hygiene. On the con-
giva than teeth in facial position. Labial displacement of the trary, lingually positioned incisors have more keratinized
central lower incisors during eruption is more predisposed to gingival width and reduced crown length. Crowding is an
having localized gingival recession and loss of periodontal important factor that can accelerate this process and its asso-
attachment in concordance to an uneven gingival line. ciation with occlusal trauma can lead to an important gingi-
A complete and exhaustive diagnosis is fundamental in val recession (Fig. 12.1a, b). In these circumstances, this
every patient. It is well known that gingivitis is a gingival recession never improves by itself, but worsens every year
inflammation without loss of connective tissue attachment and can lead to the loss of the tooth.
(Armitage). Although it is a reversible process, it could eas- Careful oral hygiene plays an important role in the main-
ily lead to periodontitis with apical migration of the junc- tenance of the results, and it has to be reinforced constantly
tional epithelium and loss of the connective tissue and through distribution of patient leaflets as well as verbal
alveolar bone. The presence of gingivitis and local reces- instructions. A close relationship between the orthodontist
sions in the lower anterior region is a challenging condition. and periodontist is crucial in order to minimize and control
In general, it is more prevalent in older patients than that in the lower incisor recession. It was demonstrated that the nor-
children and frequently observed in mandibular teeth than malization of the position of the upper and lower incisors can
that in maxillary teeth. It also has a close relationship with improve and/or normalize the position and height of the
alveolar bone dehiscences. Approximately 80% of the man- gingivo-­periodontal tissues (Seehra).
dibular incisors with recession are positioned labially When necessary, the surgical treatment choice is a free
(Andlin-Sobocki). It can negatively affect the smile and may gingival graft and it is recommended that this graft be placed
cause pain and hypersensitivity on the affected teeth. The after the orthodontic treatment when the position of the
lower incisors returns to normal. In some adult patients and
in certain circumstances, a previous free gingival graft is
J. Harfin (*)
Department of Orthodontics, Maimonides University, suggested but is not recommended in young patients since
Buenos Aires, Argentina some normalization is achieved when the position of the
Health Sciences Maimonides University, teeth is corrected. A long junctional epithelium attachment is
Buenos Aires, Argentina the most common result. Predisposing factors include the

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 369
J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_12
370 J. Harfin

a b

Fig. 12.1 (a, b) Examples of gingival recession in labially positioned lower incisors during early mixed dentition with less width of attached
gingiva

a b

Fig. 12.2 (a, b) Significant lower anterior gingival recession in an 8-year-old boy along with mild crowding in the upper and lower gingival line

prominent anterior position of the lower incisors and the plaint was the position of the central upper incisors. No rel-
minor width of the gingival attachment. The position of the evant medical history was present. He also had 5 mm of
localized lower anterior recession in conjunction with a crowding at the lower arch and an uneven upper and lower
plaque-induced gingival inflammation due to the malposition gingival line.
of the incisors acts as a determining factor in these patients The lateral photographs confirmed the anterior position of
(Parfit and Mjör). the lower central incisor with significant loss of periodontal
It is important to consider that dental hygiene plays an attachment and the absence of the right first temporary molar
important role in the maintenance and improvement of the that was extracted due important caries (Fig. 12.3a, b). The
gingivo-periodontal status. Long-term observations of early patient’s oral hygiene was fairly good. The right and left
correction of this condition demonstrate that normalization Class I molar was present although the right one was in
of the anterior crossbite should be constantly maintained. crossbite position.
Some patients will need a second phase of treatment, but oth- After analyzing the models, X-ray images, and photos,
ers will not. There is no doubt that these problems should be the treatment objectives for the first phase of treatment were
treated as early as possible to avoid more complex as follows:
problems.
The following two patients clearly demonstrate these con- 1. Align and level the arches.
cepts. The first patient is an 8-year-old boy with severe local- 2. Maintain Class I molar.
ized gingival recession in conjunction with anterior crossbite 3. Achieve Class I canine.
in the incisor region (Fig. 12.2a, b). His mother’s chief com- 4. Improve gingival conditions at the lower anterior region.
12 How Orthodontic Movement Can Avoid Future Periodontal Problems in Children 371

a b

Fig. 12.3 (a, b) Pretreatment lateral views. The anterior position of the right central incisor and the periodontal attachment loss were confirmed

a b

Fig. 12.4 (a, b) Brackets were placed on the central upper incisors with a utility arch (0.016″ × 0.016″ Elgiloy wire) to normalize overjet and
overbite

5. Normalize overjet and overbite. No brackets were bonded to the lower teeth since normal
6. Long-term stability. eruption of the cuspids and bicuspids was expected. Due to
work-related reasons, his parents moved abroad for approxi-
To achieve these objectives, a utility arch (0.016″ × 0.016″ mately 24 months.
Elgiloy wire) was placed with preprogrammed brackets with Two years after debonding, the position and inclination of
0.022″ slot. No brackets were bonded to the lower arch dur- the upper and lower incisors were almost normal. The mid-
ing this phase of treatment (Fig. 12.4a, b). lines were coincident, the occlusal plane was parallel to the
Seven months later, the position of the central and lateral gingival plane, and overjet and overbite were normalized.
upper incisors was normalized. An exhaustive dental plaque con- The recovery of the gingiva in the lower central incisor area
trol was recommended with special emphasis at the lower ante- was noticeable. No type of gingival graft was necessary
rior region, in order to improve gingival condition. No brackets (Fig. 12.7a, b).
were bonded to the lower arch until that point (Fig. 12.5a, b). The lateral photographs confirmed that Class I molar and
The lateral photographs confirmed the actual status. A canine were achieved with acceptable overjet and overbite
fixed lower inner arch (SS 0.036″) with two mesial loops was not only in the front region but also in the lateral areas
placed to maintain the anteroposterior position of the first (Fig. 12.8a, b).
lower molars and to avoid the mesialization of the right first The occlusal views confirmed the obtained results. A
molar. A 0.016″ × 0.022″ SS wire was placed on the upper fixed retention wire was bonded on each tooth in the lower
arch to control the inclination and torque of the upper inci- arch to prevent any kind of relapse, even though no brackets
sors (Fig. 12.6a, b). had been bonded on them. A long-term follow-up was rec-
ommended every 6 months (Fig. 12.9a, b).
372 J. Harfin

a b

Fig. 12.5 (a, b) After 7 months of treatment, the position of the upper incisors was normalized with a 0.016″ SS archwire

a b

Fig. 12.6 (a and b) Lateral views with a lower inner arch to maintain the anteroposterior position of the lower molars

a b

Fig. 12.7 (a, b) Two years after the end of treatment, the results were maintained or even improved. The midlines were coincident and overjet and
overbite were within normal ranges
12 How Orthodontic Movement Can Avoid Future Periodontal Problems in Children 373

a b

Fig. 12.8 (a, b) Lateral views at the end of treatment. Class I canine and molar were achieved

a b

Fig. 12.9 (a, b) Upper and lower occlusal views 2 years after the end of treatment

a b

Fig. 12.10 (a, b) Follow-up 4 years and 9 months later. The results were maintained and the gingival tissues were totally normalized
374 J. Harfin

The patient returned for follow-up after 4 years and recommended waiting for the eruption of the second molars,
9 months for the retention wire. The results were maintained another suggested the extraction of the left central lower
or even improved. The gingival margin was still normal incisor to improve occlusion, and another proposed that the
(Fig. 12.10a, b). only way was the use of micro-implants (Fig. 12.13a, b).
The lateral views confirmed that Class I canine and To lower her mother’s anxiety, some similar clinical cases
molar were maintained with normal overjet and overbite were shown to her and her daughter to explain different alter-
(Fig. 12.11a, b). natives of treatment. It was very important that the parents
The comparison of the pre- and posttreatment frontal pho- understand the importance of early correction of the position
tographs clearly demonstrates the huge improvement not of the incisors to prevent more dental and periodontal com-
only of the left central lower incisor gingival position but plications in the future.
also of the occlusion plane. Bone recession at the central It is essential that patients and their parents be fully aware
lower incisor was self-corrected, and no further periodontal that excellent oral hygiene is fundamental to achieve and
treatment was required. The gingival status of the upper and maintain normal gingivo-periodontal tissues. It is important
lower incisors was totally normal (Fig. 12.12a, b). to highlight that this patient had diastemas in the upper teeth
The next case is yet another good example of why it is due a positive discrepancy with an uneven gingival line
important to begin treatment early. The second patient was a (Fig. 12.13a, b).
9-year, 8-month-old girl who was sent to the office by her The lateral views confirmed Class I canine and molar and
pediatric dentist who wanted a second opinion regarding the excessive proclination of the left central lower incisor.
best time to begin the correction of the palatal position of the Although she was a very young girl, some loss of periodontal
upper right central incisor. Her mother was confused by the attachment was seen in this area. The upper left central inci-
completely different opinions she received. Some of them sor was palatinized and extruded (Fig. 12.14a, b).

a b

Fig. 12.11 (a, b) Right and left side occlusion after 4 years and 9 months of active orthodontic treatment

a b

Fig. 12.12 (a, b) Comparison of pre- and posttreatment images. Upper and lower midlines and gingival margins are totally normal
12 How Orthodontic Movement Can Avoid Future Periodontal Problems in Children 375

a b

Fig. 12.13 (a, b) Pretreatment frontal photographs. The labial position of the central left lower incisor is clearly observed

a b

Fig. 12.14 (a, b) Class I molar along with an excessive labial position of the central left lower incisor was present

a b

Fig. 12.15 (a, b) Pretreatment images of the upper and lower arches. The malposition of the lower left central incisor was confirmed
376 J. Harfin

The occlusal photographs showed a positive discrepancy maintained their normal position (Fig. 12.17a, b). Oral
of 2.5 mm in the upper arch and + 2 mm in the mandible hygiene was checked regularly.
(Fig. 12.15a, b). Oral hygiene was fairly good and no cavities A figure-of-eight ligature was placed between the central
were seen. incisors to close the anterior diastema. Overjet and overbite
After analyzing the models, X-ray images, and photos, were almost normal and bicuspids were erupting normally
the treatment objectives for the first phase of treatment were (Fig. 12.18a, b).
as follows: When all the bicuspids and right canine erupted, a 0.018″
SS archwire was used to complete alignment and leveling of
1. Normalize the position of the right upper and lower cen- the upper arch with an open coil spring to obtain sufficient
tral incisor. space for the left canine. A 0.014″ NiTi wire as a double arch
2. Align and level the arches. was suggested to level the canine without alterations of the
3. Maintain Class I canine and molar. adjacent teeth (Fig. 12.19a, b).
4. Improve gingiva-periodontal condition. Esthetic brackets with a 0.022″ slot were also bonded to
5. Long-term stability. the lower arch and a 0.016″ SS archwire was placed to cor-
rect anterior crowding in the anterior region and rotations in
To achieve these treatment objectives, 0.022″ esthetic pre- the bicuspid area (Fig. 12.20a, b).
programmed brackets were bonded to the upper incisors in The following were the results at the end of the active
conjunction with a SS 0.014″ wire and bands on the upper orthodontic treatment: The midlines were coincident
first molars (Fig. 12.16a, b). and the gingival line and occlusal plane were parallel.
The lateral views confirmed the achieved results after Overjet and overbite were within the normal parameters
5 months of treatment. Temporary right and left molars (Fig. 12.21a, b).

a b

Fig. 12.16 (a, b) Esthetic preprogrammed brackets with a 0.016″ SS wire at the beginning of treatment

a b

Fig. 12.17 (a, b) Lateral photographs with a 0.016″ SS arch in place

12 How Orthodontic Movement Can Avoid Future Periodontal Problems in Children 377

a b

Fig. 12.18 (a, b) A figure-of-eight ligature was placed between the central incisors to close the anterior diastema

a b

Fig. 12.19 (a, b) Frontal and occlusal photos with an open coil spring and a 0.014″ NiTi wire as a double arch

a b

Fig. 12.20 (a, b) Frontal and occlusal photographs at this stage of treatment. The upper left canine has totally erupted
378 J. Harfin

a b

Fig. 12.21 (a, b) End of the active orthodontic treatment. All treatment objectives were fulfilled

a b

Fig. 12.22 (a, b) At 18-month follow-up. The results were maintained and the lower gingival margin continued to be normal

A follow-up 18 months later showed that the results were The comparison between the pre- and posttreatment out-
maintained. Overjet and overbite in the upper and lower cen- comes with frontal photographs clearly showed enhance-
tral and lateral incisor regions were almost normal. The oral ment of the occlusion in the anterior region. All treatment
hygiene was much better (Fig. 12.22a, b). objectives were achieved and normalization of the gingivo-­
The lateral photographs confirmed that Class I canine and periodontal tissues was noticeable (Fig. 12.25a, b).
molar were maintained. The position of the incisors as well Similar results were achieved in this 9-year-old patient
as the gingival recession at the left lower central incisor was with the same problem. The comparison between the
improved (Fig. 12.23a, b). pre- and 5-year posttreatment frontal photos was the best
Improvement in the position and inclination of the upper example after using the same treatment protocol without
and lower incisors was noticeable. A long-term fixed reten- the aid of any surgical procedures. The malposition of the
tion wire on the lower arch was advisable (Fig. 12.24a, b). anterior teeth was normalized and the interincisal papil-
lae were totally recovered. Dental occlusion was signifi-
12 How Orthodontic Movement Can Avoid Future Periodontal Problems in Children 379

a b

Fig. 12.23 (a, b) Right and left occlusion 18 months after ending the active treatment. Class I molar and canine were maintained

a b

Fig. 12.24 (a, b) A long-term fixed retention on the arch was recommended

a b

Fig. 12.25 (a, b) Comparison of pre- and posttreatment frontal photographs. Improvement of the position of the central incisors and the gingival
tissues was clearly visible
380 J. Harfin

a b

Fig. 12.26 (a, b) Comparison of pre- and 5-year posttreatment frontal photos using a similar protocol. The normalization of the gingival tissues
was remarkable

cantly improved and the gold standard was achieved only sary before orthodontic treatment since the total recovery of
through the use of orthodontic movements. No signs of the gingival tissues is clearly visible. It is advisable to nor-
relapse was seen during the 5-year follow-up and the gin- malize the proclination of the lower incisors as soon as pos-
gival and periodontal tissues were completely normalized sible, since the improvement in their position helps in the
(Fig. 12.26a, b). normalization of the gingival tissues.
A multi- and interdisciplinary treatment is the only way to
achieve optimal results for a long period of time. There is no
12.1 Conclusions doubt that the gold standard is to keep the gingiva as healthy as
possible during and after the orthodontic treatment. Strict
It is well accepted that proclined incisors have a higher inci- plaque control is important to maintain and improve the
dence of severe labial gingival recession when compared to achieved results as gingivo-periodontal inflammation is a very
that of less proclined ones. The results showed that signifi- important detrimental factor that causes irreversible loss of
cant alterations in the widths of the keratinized and attached periodontal attachment. Special attention should be given to the
gingiva took place when the teeth changed positions in facial zone of attached gingiva and its relationship with the proclina-
or lingual directions (Bimstein). tion of the lower incisors since it could be an etiologic factor in
The clinical cases presented in this chapter demonstrated the development of mucogingival recessions in this area. There
that excellent results can be achieved using fixed orthodontic is no doubt about the treatment efficiency (result vs. treatment
appliances at an early age and, in this way, reverse the reces- time), and the long-term results confirm this approach.
sion process. No reparative surgical procedures are neces-
 Early Orthodontic Treatment
in Cleft Lip / Palate Patients 13
Somchai Satravaha

It is well-known among orthodontists that cases with cleft achieve good function, good esthetics, and good stability for
lip/palate (CLP) are unique and difficult to treat (Figs. 13.1, the individual cases.
13.2, 13.3, 13.4, 13.5, and 13.6). The treatment could be There are many problems associated with CLP cases
complicated with multifactorial causes and require much (Fig. 13.7):
more different approaches than in non-CLP patients. The
treatment time could take a long, long time. Anyhow, like all 1. Collapse maxilla segments.
other orthodontic treatments, the treatment objectives are to 2. Protruded premaxilla.
3. Nasal deformity.
4. Malocclusions.
5. Esthetic problem.
6. Speech problem.
7. Ear problem.
8. Other associated problems, e.g., psychological problem.

These problems should be dealt by interdisciplinary team;

orthodontist belongs to this team.

Fig. 13.1 A 12-year-old boy with bilateral cleft lip and cleft palate

Fig. 13.2 He had a large cleft site both at alveolar ridge and palate
S. Satravaha (*)
Faculty of Dentistry, Orthodontic Department, Mahidol University,
Bangkok, Thailand

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 381
J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_13
382 S. Satravaha

Fig. 13.5 A 10-year-old girl with unilateral cleft lip and cleft palate
Fig. 13.3 A 9-year-old-boy with unilateral cleft lip and cleft palate

Fig. 13.4 He had anterior crossbite. Cleft site can be seen in the Fig. 13.6 A cleft site and a decayed #63 can be seen in her intraoral
picture picture
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 383

Fig. 13.7 Multiple problems associated with CLP

384 S. Satravaha

Fig. 13.7 (continued)

Most CLP cases exhibit both skeletal and dental problems

(Figs. 13.8, 13.9, 13.10, 13.11, and 13.12). Sagittal discrep-
ancy between the maxilla and the mandible is the most prom-
inent problem of all problems in three dimensions (Fig. 13.13).
Treatment objectives in CLP treatment are the same as the
treatment objectives of other orthodontic treatment, which are
to achieve good function, good esthetics, and good stability. We
must then begin with the end in mind, knowing the treatment Fig. 13.8 A 9-year-old boy with a unilateral cleft lip/palate
result before starting of the treatment. Therefore, we must care-
fully do comprehensive analysis, diagnosis, and treatment plan-
ning and then start with proper treatment with proper appliances
and retain the treatment outcome to obtain stability.
As mentioned previously that sagittal discrepancy
between the maxilla and the mandible is the most prominent
problem of all problems in three dimensions, correction of
sagittal discrepancy should be done first as at the early age
facial growth can still be modified. To correct sagittal dis-
crepancy in CLP patients, Class III Activator of Thomas
Rakosi (Figs. 13.14 and 13.15) is recommended for early
Class III treatment (for details, see Chap. 6) (Rakosi 1985;
Graber et al. 1997; Rakosi and Graber 2010; Satravaha 1993;
Satravaha and Taweesedt 1996a; Satravaha and Taweesedt
1996b; Satravaha and Taweesedt 1999).

Fig. 13.9 He had a concave facial profile

13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 385

Fig. 13.10 He had anterior crossbite

Fig. 13.11 Crowding and malalignment of upper teeth

Fig. 13.12 Crowding of teeth in the lower arch and bifid uvula
386 S. Satravaha

Fig. 13.13 A 9-year-old boy and 10-year-old girl with cleft lip/palate, both had concave facial profiles resulting from sagittal discrepancy between
the maxilla and the mandible

13.1 Example of Treated CLP Cases

Case #1 (Figs. 13.16, 13.17, 13.18, 13.19, 13.20 and 13.21)

3 Types of Smile

1. Children smile, showing gum (Fig. 13.22).

2. Teenager smile, showing upper teeth (Fig. 13.23).
3. Elderly smile, showing lower teeth (Figs. 13.24).

Fig. 13.14 Class III Activator for non-CLP patient

Fig. 13.15 Class III Activator for CLP patient

13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 387

Fig. 13.16 A 9-year-old boy presented at our CLP center with a unilateral cleft lip/palate. The lip was already repaired alio loco. He was in the
early mixed dentition, and he had anterior crossbite; cleft site could be seen in the intraoral picture
388 S. Satravaha

Fig. 13.17 He had obviously protruding lower lip, which is esthetically not good

Fig. 13.18 At smile he showed mostly his lower anterior teeth

13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 389

Fig. 13.21 Cleft site can be seen here

Fig. 13.19 His cephalometric head film showed large negative overjet,
negative overbite, and positive lip step (protruding lower lip)

Fig. 13.20 He had two missing upper lateral incisors

Fig. 13.22 Children smile

390 S. Satravaha

Fig. 13.23 Teenager smile

Fig. 13.24 Elderly smile

Class III Activator was used to minimize sagittal dis- It would have been easier to achieve positive overjet
crepancy between the maxilla and the mandible (Fig. 13.25). and positive overbite if we can do extraction in the lower
Class III Activator are often used in combination with other arch but the patient was not a good cooperative, having
orthodontic appliances in attempt to achieve positive overjet loosed brackets at almost every visit and did not follow
and positive overbite (Figs. 13.26, 13.27, 13.28, 13.29, 13.30, instructions. It was decided not to do extraction in the
13.31, 13.32, 13.33, 13.34, 13.35, 13.36, and 13.37). lower arch, being afraid of not being able to close the
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 391

Fig. 13.27 Additional 2 × 4 fixed appliance was used to close spaces

at the lower anterior region

Fig. 13.25 Class III Activator in situ. Mandible was pushed backward
into a new position. It is clearly seen that his lower lip became less
protrusive

Fig. 13.28 Combined usage of Class III Activator and 2 × 4 fixed

appliance

Fig. 13.26 Class III Activator was used to correct sagittal discrepancy
in this case
392 S. Satravaha

a b

Fig. 13.29 (a and b): Facial change after the use of Class III Activator

a b

Fig. 13.30 (a and b): Change in lateral profile was obvious, the lower lip became less protrusive
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 393

a b

Fig. 13.31 (a and b): After achieving positive overjet and positive overbite, brackets were placed on #11 and #21, and C-chain was used to close
the gap and to clear paths of eruption for #13 and #23

Fig. 13.32 1 year and 9 months after starting of the treatment, it was difficult to maintain positive overjet and positive overbite due to the large
tongue which forcefully push the lower anterior teeth forward. Cleft site was still present
394 S. Satravaha

a b

Fig. 13.33 Comparison of the cephalograms at start of the treatment (a) and after treatment with Class III Activator, the mandible was in a more
posterior position after the treatment (b)

Fig. 13.34 At age 11 years 2 months, his cephalogram showed miss-

ing of teeth #12 and #22; teeth #53 and #63 were present. Tooth #13
was about to erupt and #23 was seen at root apex of #63

Fig. 13.35 Alveolar bone graft was done at age 11 years 2 months;
tooth #63 was extracted before bone grating
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 395

Fig. 13.36 3 years after start of the treatment, positive overjet and positive overbite were achieved. #13 erupted into occlusion, #15 palatally
erupted, and #23 not yet seen in the oral cavity
396 S. Satravaha

Fig. 13.37 Comparison of intraoral pictures at start of treatment and 3 years after, positive overjet and positive overbite were achieved

extraction spaces due to lack of patient cooperation. Inter The patient was informed that the open bite at #23 and
proximal reduction (IPR) of the lower anterior teeth and #33 could lead to relapse and instability of the treatment out-
of lower canines was the only mean to correct tooth size comes. The debonding of the brackets was a must as the
discrepancy (Figs. 13.38, 13.39, 13.40, 13.41, 13.42, patient did not maintain good oral hygiene and he had to
13.43, 13.44, 13.45, 13.46, 13.47, 13.48, 13.49, 13.50, move to another city to further his education (Figs. 13.62,
13.51, 13.52, 13.53, 13.54, 13.55, 13.56, 13.57, 13.58, 13.63, 13.64, 13.65, 13.66, 13.67, 13.68, 13.69, 13.70, 13.71,
13.59, 13.60 and 13.61). 13.72, 13.73 and 13.74).
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 397

a b

Fig. 13.38 (a and b): Comparison of cephalograms at start of the treatment (a) and 3 years after (b)

Fig. 13.39 Cephalogram 3 years after start of the treatment, #13 was
already present in oral cavity. #23 had unfavorable path of eruption

Fig. 13.40 From the upper occlusal film, it was obvious that #23 had
unfavorable path of eruption
398 S. Satravaha

Fig. 13.41 Intraoral pictures 3 years and 5 months after start of the treatment; #23 not yet erupted into oral cavity
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 399

a b

Fig. 13.42 (a and b): Large tongue combined with abnormal oral habit can play role in preventing eruption of tooth #23 into occlusion, the patient
was instructed to do myofunction exercises. (Graber 1963; Garliner 1981; Satravaha 1990)

Fig. 13.44 Bracket was placed on #23

Fig. 13.43 Surgically assisted mobilization of #23

400 S. Satravaha

Fig. 13.45 Extraoral pictures taken at 4 years and 5 months after start of the treatment, 1 year after mobilization of #23
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 401

a b c

Fig. 13.46 (a–c): At smile he showed both upper and lower anterior teeth

Fig. 13.47 After 1 year of mobilization, #23 was mobilized into oral
cavity

a Fig. 13.49 Lingual buttons were placed on #23, #24, and #25 to help
correct posterior crossbite

Fig. 13.50 Spikes were also built on #33 and #34 to eliminate tongue
thrusting habit

Fig. 13.48 Bilateral posterior crossbites could be clearly seen as well

as his large flat tongue in (a) when the patient was unaware about his
tongue position but not seen in (b) when he was aware
402 S. Satravaha

Fig. 13.51 Extraoral pictures at age 15; 6 years after the start of the treatment, the pictures showed improvement of both frontal and lateral facial
profiles. At smile, he showed mostly upper teeth resulting from the treatment and smile training
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 403

Fig. 13.51 (continued)

Fig. 13.52 Intraoral pictures at age 15; #13 and #23 were not reshaped.
Positive overbite and positive overjet were achieved at minimal due to
missing of teeth #12 and #22 Fig. 13.53 Crossbite at posterior right was present. #13 and #43 region
had open bite tendency
404 S. Satravaha

Fig. 13.54 Open bite at #23, #33

Fig. 13.56 Cephalogram at age 15 showed slight open bite tendency

Fig. 13.57 In the orthopantomogram, all teeth were present; accept

teeth #12, #22, #38, and #48. Teeth #38 and #48 were surgically
removed
Fig. 13.55 Intra oral pictures at age 15, missing teeth #12 and #22
were replaced by eruption of #13 and #23. No teeth in the lower arch
was extracted
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 405

Fig. 13.58 Extraoral pictures at age 17, at rest position and at smile after debonding of the brackets

Fig. 13.59 At age 17, after debonding of the brackets in both upper
and lower arches, teeth #13 and #23 replaced missing teeth #12 and
#22. Slight open bite at #23 and #33 Fig. 13.60 No open bite at #13 and #43; right posterior crossbite was
corrected
406 S. Satravaha

Fig. 13.61 Open bite was clearly seen at #23 and #33

Fig. 13.64 Cephalogram at the end of the treatment

Fig. 13.62 Upper arch after debonding of brackets; malformed teeth

#15 and #25 could be clearly seen here

Fig. 13.65 Orthopantomogram at the end of the treatment

Fig. 13.63 Lower arch after debonding

13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 407

Fig. 13.66 Extraoral pictures at recall; 8 months after the end of the treatment, at rest and at smile
408 S. Satravaha

Fig. 13.67 Intraoral picture at recall, 8 months after the end of the
treatment. The treatment result was stable; the open bite at #23 and #33
improved

Fig. 13.70 Stable result in the upper arch

Fig. 13.68 Stable result

Fig. 13.71 Stable result; picture was taken unaware, note the tongue
position!

Fig. 13.69 Improvement of the open bite at #23 and #33 due to more
patient awareness of tongue thrusting habit and myofunction therapy
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 409

a b

Fig. 13.72 (a and b): Extraoral pictures, taken before start of the treatment (a) and at recall (b)

a b

Fig. 13.73 (a and b): At smile; before the treatment he showed only lower anterior teeth, which was less esthetic (a), compared to the more beauti-
ful smile at recall showing just only his upper teeth (b)
410 S. Satravaha

a b

Fig. 13.74 (a and b): Closer look at his smiles before start of the treatment (a) and at recall (b)

Case #2 (Figs. 13.75, 13.76, 13.77, 13.78, 13.79, 13.80, 13.106, 13.107, 13.108, 13.109, 13.110, 13.111, 13.112,
13.81, 13.82, 13.83, 13.84, 13.85, 13.86, 13.87, 13.88, 13.89, 13.113, 13.114, 13.115, 13.116, 13.117, 13.118, 13.119,
13.90, 13.91, 13.92, 13.93, 13.94, 13.95, 13.96, 13.97, 13.98, 13.120, 13.121, 13.122, 13.123, 13.124, 13.125, 13.126,
13.99, 13.100, 13.101, 13.102, 13.103, 13.104, 13.105, 13.127, 13.128 and 13.129)
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 411

Fig. 13.75 A 10-year-old girl presented at our CLP center with unilateral cleft lip/palate; the lip was already repaired alio logo. She had concave
facial profile
412 S. Satravaha

Fig. 13.76 At smile she showed mostly lower anterior teeth

Fig. 13.77 Intraoral picture at start of the treatment, she was in the mixed dentition. She had deep anterior crossbite. Cleft site was present
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 413

a b

Fig. 13.78 (a and b): Upper arch at start of the treatment; early loss of some deciduous teeth, carious #63 was present. Cleft site was also
present

Fig. 13.79 Lower arch at start of the treatment

Fig. 13.80 Her cephalogram at start showed anterior crossbite, protru-

sive lower lip
414 S. Satravaha

Fig. 13.81 All teeth were present. Cleft site was clearly seen

Fig. 13.83 Class III Activator was used to correct sagittal

discrepancy

Fig. 13.82 Cleft site could be seen from the upper occlusal film

Fig. 13.84 Class III Activator in situ, mandible was push backward
into a new position, and lower lip became less protrusive
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 415

a b

Fig. 13.85 (a and b): Difference of smiles at start of Class III Activator treatment (a) and 1 month after (b). She smiled showed more upper teeth
after 1 month of Class III Activator treatment

Fig. 13.86 At smile; 9 months after Class III Activator treatment, she
showed more upper anterior teeth than at start of the treatment
416 S. Satravaha

Fig. 13.87 She could almost bite edge to edge; teeth #11, #12, and #21 were still retroclined

Fig. 13.88 Cleft site was clearly seen here

13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 417

a b

Fig. 13.89 (a and b): Comparison of the upper arch at start of the treatment (a) and 9 months after Class III Activator treatment (b)

a b

Fig. 13.90 (a and b): Upper protrusion plate with raised bite and protrusion screw was used to procline upper anterior teeth (a). Upper labial pad
was added to the plate to create periosteal pull at the cleft site to stimulate bone formation (b)
418 S. Satravaha

Fig. 13.92 Orthopantomogram taken before alveolar bone grafting; all

teeth were present including tooth #63. #22 was still located very high
in the alveolar bone near cleft site

Fig. 13.91 Cephalograms taken 9 months after Class III Activator

treatment

a b

Fig. 13.93 (a and b): Cleft site, teeth #22, and #63 were present; tooth #63 was extracted during alveolar bone grafting
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 419

Fig. 13.94 Alveolar bone graft was performed in the operative theater

Fig. 13.95 Preparation of the donor site

420 S. Satravaha

Fig. 13.96 Bone was taken from the iliac crest

Fig. 13.98 Alveolar bone graft, ready for suture

Fig. 13.97 Cleft site filled with bone from the iliac crest
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 421

a b

Fig. 13.99 (a and b): Comparison of cleft site before bone graft (a) and after bone graft where new bone formation could be seen (b)

Fig. 13.100 Fixed appliance was used to align the upper teeth as well as to procline upper anterior teeth; tooth #22 erupted into cleft site
422 S. Satravaha

Fig. 13.101 Tooth #22 erupted into cleft site, #13 was about to erupt. Fig. 13.102 Tooth #35 not yet erupted, raised bites on #36 and #46
All the upper premolars were present and palatally inclined

a b

Fig. 13.103 (a and b): Comparison intraoral conditions before start of the treatment (a) and 2 years and 9 month afterward (b)

a b

Fig. 13.104 (a and b): Before the start of the treatment (a). Bite was raised in effort to gain positive overjet and positive overbite with fixed appli-
ances during the treatment (b)
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 423

a b

Fig. 13.105 (a and b): Cleft site was present at start of the treatment (a) and closed by alveolar bone grafting; #22 erupted gradually into the cleft
site (b)

a b

Fig. 13.106 (a and b): Cleft site was present at start of the treatment (a) and was closed during the treatment, #22 erupted into the cleft site, #13
was erupting, and upper premolar teeth almost fully erupted

a b

Fig. 13.107 (a and b): Comparison of lower arch at start of the treatment and 2 years and 9 months afterward
424 S. Satravaha

Fig. 13.110 Tooth #22 erupted into cleft site

Fig. 13.108 Cephalogram at 2 years and 9 months after the treatment

started

Fig. 13.109 Orthopantomogram at 2 years and 9 months after the

treatment started
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 425

a b

Fig. 13.111 (a and b): Filler injection on the upper lip done by a dermatologist

a b c

Fig. 13.112 (a, b and c): 7 months after filler injection on the upper lip; the upper lip became very thick and only lower anterior teeth could be
seen at smile

a b c

Fig. 13.113 (a, b, and c): Thick upper lip as a result from filler injection
426 S. Satravaha

a b

Fig. 13.114 (a and b): Changes at the a la of nose and upper lip before (a) and 7 months after the filler injection (b)

a b

Fig. 13.115 (a and b): Change of smile before (a) and 7 months after the filler injection (b), she showed both upper and lower anterior teeth at
smile before receiving the filler injection on the upper lip; later she could only show the lower anterior teeth when smiled
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 427

a b

Fig. 13.116 (a and b): Tooth #22 erupted more into oral cavity, linguoversion of all upper premolar teeth

a b

Fig. 13.117 (a and b): Tooth #22 erupted into cleft site, bilateral posterior crossbites, bite was opened due to raised bites at molars

a b

Fig. 13.118 (a and b): Tooth #22 erupted into the cleft site, linguoversion of all upper premolars, raised bite on #36 was lost
428 S. Satravaha

a b

Fig. 13.119 (a, b and c): Comparison of the upper arch forms at different timelines; at start of the treatment (a), 9 months after Class III Activator
treatment (b) and 2 years and 9 months after start of the treatment when alveolar bone graft was done and # 22 erupted into cleft site (c)

a b

Fig. 13.120 (a and b): Engaged #22 to arch wire to bring it into occlusion
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 429

a b

Fig. 13.121 (a and b): Tooth #22 was engaged to arch wire; posterior bilateral crossbites were still present

a b

Fig. 13.122 (a and b): Teeth #15 and #25 were not bonded yet; raised bite on #36 was lost due to occlusal force from mastication
430 S. Satravaha

Fig. 13.123 Extraoral pictures of the patient at rest and at smile at the end of dentofacial orthopedic and orthodontic treatment; she was 16 years
old. The treatment time was 6 years
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 431

Fig. 13.123 (continued)

Fig. 13.124 Intraoral pictures at the end of dentofacial orthopedic and orthodontic treatment, acceptable treatment results
432 S. Satravaha

a b

Fig. 13.125 (a and b): Comparison of cephalograms at start of the treatment (a) and at the end of the treatment (b)

Fig. 13.126 (a and b): Comparison of orthopantomograms of the

patient at start (a) and at the end of the treatment (b)
13 Early Orthodontic Treatment in Cleft Lip / Palate Patients 433

a b c

Fig. 13.127 (a, b and c): Comparison of upper lip at rest and a la of nose at start (a), at the end of the treatment (b) and after the upper lip surgery (c)

a b c

Fig. 13.128 (a, b and c): Straight facial profiles at start (a), at the end of the treatment (b) and after the upper lip surgery (c); note esthetic
improvement at the upper lip and a la of nose

a b c

Fig. 13.129 (a, b, and c): At smile; at start of the treatment (a), at the end of the treatment (b) and after surgery on the upper lip (c)
434 S. Satravaha

13.2 Conclusion References

Cleft lip/cleft palate (CLP) cases are caused by multifactorial Garliner D. Myofunctional therapy. 1981. ISBN 75-14781.
Graber TM. The “three M’s” muscles, malformation, and malocclusion.
factors. All cases are unique; the problems are both skeletal AJO-DO 1963:418–50.
and dental and in three dimensions. Therefore, the treatment Graber T, Rakosi T, Petrovic A. Dentofacial orthopedics with functional
is more complicated than in the non-CLP cases. An interdis- appliances. 2nd ed. Mosby; 1997.
ciplinary team composes of gynecologist, pediatrician, Rakosi T. Funktionelle Therapie in der Kieferorthopädie. München
Wien: Hanser; 1985.
nurse, dentist, orthodontist, oral-maxillofacial surgeon, plas- Rakosi T, Graber T. Orthodontic and dentofacial orthopedic treatment.
tic surgeon, ENT doctor, audiologist, otolaryngologist, Stuttgart: Thieme; 2010.
speech therapist, psychiatrist, social worker, and patient’s Satravaha S. Frühbehandung bei Progeniefällen in Thailand. Prakt
family, play important role in giving CLP care and treatment. Kieferorthop. 1993;7:23–30.
Satravaha S, Taweesedt N. Skeletal and dental changes following acti-
Clinical Practice Guidelines (CPG) will indicate how the vator therapy on class III patients. Mahidol. Dent J. 1996a:31–9.
team works. Satravaha S, Taweesedt N. Changes in maxillary and mandibular
Orthodontists can start dentofacial orthopedic and orth- body lengths following class III activator therapy. Mahidol Dent J.
odontic treatment in CLP patients during active growth 1996b:40–7.
Satravaha S, Taweesedt N. Stability of skeletal changes after activa-
period. To treat early and if successfully will be advanta- tor treatment of patients with class III malocclusions. Am J Orthod
geous as major surgeries such as orthognathic surgery and Dentofac Orthop. 1999;116:196–206.
distraction osteogenesis can likely be avoided. These major Satravaha S. Combined therapy with appliances and myofunc-
surgeries certainly cause much pain to the patients and cost a tional exercises in an adult with periodontal involvement. Prakt
Kieferorthop. 1990;4:49–52.
lot of money. The author suggests the use of Class III
Activator of Thomas Rakosi in the initial stage of the treat-
ment in combination with the use of removable and/or fixed
appliances in later stage.
 Diabetes in Childhood and Adolescents
14
Olga Ramos

14.1 Introduction Gestational DM, is characterized by the appearance of

hyperglycemia during pregnancy and should be treated
Diabetes mellitus (DM) is a group of metabolic diseases immediately (Mayer-Davis et al. 2018).
characterized by hyperglycemia, resulting from defects in
insulin secretion, insulin action in tissues, or both. Diabetes
mellitus (DM) is the most common endocrine disease and 14.2 Type 1 Diabetes: Diagnostics
one of the most common chronic conditions in children.
Diabetes mellitus is classified into type 1 diabetes mellitus Type 1 diabetes is characterized by the chronic immune-­
(T1DM), type 2 diabetes mellitus (T2DM), other types of mediated destruction of pancreatic B-cells, leading to partial
DM, and gestational diabetes. T1DM is the most common or absolute insulin deficiency. This destruction occurs at a
form of DM in children and adolescents and the presentation variable rate and becomes clinically symptomatic when
age start from the first year of life that increases during approximately 90% of pancreatic B-cells are destroyed.The
puberty. illness progresses through three stages at variable rates:
T1DM is an autoimmune illness, characterized by multi-
ple autoimmune markers even in the preclinical period, with • Stage 1: autoimmunity with normoglycemia and without
partial or total destruction of the pancreatic islet B-cell and clinical symptoms.
deficiency in insulin secretion. Consistently, genetic markers • Stage 2: dysglycemia, but asymptomatic.
(HLA) are present, increasing or decreasing the risk of • Stage 3: the symptomatic phase of the disease (Insel et al.
patients and their families. Potential triggers are environ- 2015).
mental factors such as congenital rubella, enteroviral infec-
tions, casein, and cereals. Insulin is the treatment of choice to Type 1 diabetes mellitus in young people is usually shows
be given immediately upon diagnosis (American Diabetes characterized by polyuria, polydipsia, nocturia, enuresis,
Association 2018). weight loss with polyphagia, and blurred vision. A plasma
T2DMis an emerging disorder in children and adoles- blood glucose level (BGL) measurement on laboratory glu-
cents, leaving large gaps in knowledge on the pathophysiol- cose oxidase estimation is required to confirm the diagnosis,
ogy and treatment optimization. Patients with T2DM have rather than a capillary blood glucose monitor. In the absence
insulin resistance and non-autoimmune B-cell failure. of unequivocal hyperglycemia, diagnosis must be confirmed
Familial T2DM, obesity, and physical inactivity are the prin- by repeat testing with an oral glucose tolerance test (OGTT)
cipal risk factors. and the diabetes-associated autoantibodies glutamic acid
There are other multiple types of DM: neonatal DM, decarboxylase 65 (GAD), tyrosine phosphatase-like insulin-
endocrine and genetic illnesses, etc. oma antigen 2 (IA2), insulin autoantibodies (IAA), and

O. Ramos (*)
Medicine Faculty, Buenos Aires University Argentina,
Buenos Aires, Argentina

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 435
J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_14
436 O. Ramos

B-cell-specific zinc transporter 8 (ZnT8). The presence of 14.3.3 Epidemiology of Type 1 Diabetes
one or more of these antibodies confirms the diagnosis of
type1 diabetes (Watkins et al. 2014). In its more severe form, Overall, approximately 96,000 children under 15 years of
ketoacidosis may develop and lead to stupor, coma, and, in age are estimated to develop type 1 diabetes annually
the absence of treatment, death. worldwide.
The incidence varies between different countries, within
countries, and between ethnic populations with the highest
14.3 Criteria for the Diagnosis of Diabetes incidence rates observed in Finland (50/100,000), Europe
Mellitus (10–20/100,000), Northern Europe (30/100,000), and
Canada (45/100,000). In Asia, the incidence is very low in
14.3.1 Glycemic Diagnostic Values (OGTT) Japan (2/100,000) and China (1/100,000) (Harjutsalo et al.
2013; Karvonen et al. 2000).
Fasting blood Glycated
glucose level 2 h postload hemoglobin
(BGL) glucose level (HbA1c) level 14.4 Treatment of Children
Normal ≤100 mg/dL <140 mg/dL <5.6%
and Adolescents with Diabetes
Prediabetes >100 to >140 to 5.7% to 6.4%
IFG and/or <126 mg/dL <200 mg/dL
IGT 14.4.1 Treatment Consists of Insulin,
Diabetes ≥126 mg/dL ≥200 mg/dL HbA1c ≥6.5% Nutrition, Education, Exercise,
mellitus + ≥200 mg/dL and Psychosocial Support
Polyuria, casual
polydipsia,
weight loss 14.4.1.1 Insulin
Information source: Diabetes Care, 2018 (American Diabetes Children and adolescents with type 1 diabetes are dependent
Association 2018) on insulin for survival and should have access to adequate
IFG: impaired fasting glucose amounts of at least regular insulin (short acting) and NPH
IGT: impaired glucose tolerance insulin (intermediate-acting insulin).
OGTT test: The test should be performed using a glucose load contain-
ing the equivalent of 1.75 g/kg of body weight to a maximum of 75 g Human insulins. Currently, children are administered
human insulins instead of porcine or bovine insulin due to
their low immunogenicity.
Regular insulin (short acting). Usually identical to human
14.3.2 Impaired Glucose Tolerance (IGT) insulin, it is still used as premeal bolus injections, given
and Impaired Fasting Glucose (IFG) 20–30 min before meals together with intermediate-acting
Levels (American Diabetes Association insulin NPH, twice daily (Danne et al. 2002).
2018)
14.4.1.2 Insulin Analog: Basal Insulin and
Impaired glucose tolerance and impaired fasting glucose levels Rapid Acting Insulin
are intermediate stages in the natural history between normal Basal insulin analogs include glargine and detemir. They
glucose homeostasis and diabetes. Patients with IFG levels have a more predictable effect compared to that of NPH,
and/or IGT are referred to as having “prediabetes,” indicating with less variations in its effect, but they are more expensive
their relatively high risk for the development of diabetes: (50% to 100%). In general, it is possible to use them once or
twice daily.
• FPG <100 mg/dL: normal fasting glucose. Rapid-acting insulin analogs include aspartic, glulisine,
• FPG >100 mg/dL to 125 mg/dL: IFG. and lispro. They have a rapid and shorter duration of action
• FPG >126 mg/dL (provisional diagnosis of diabetes). than that of regular insulin.
They can be used immediately before or after meals, and
• 2-hour post-load plasma glucose level: 140 mg/dL, nor- nocturnal hypoglycemia may also be reduced due to its short
mal glucose tolerance. duration of action.
• 2-hour post-load plasma glucose level: 140–200 mg/dL, IGT. Regular and rapid-acting insulins can be given subcutane-
• 2-hour post-load plasma glucose level: >200 mg/dL, ously or intravenously, but NPH and basal analogs should
diabetes. only be administered subcutaneously.
14 Diabetes in Childhood and Adolescents 437

Injection Site. The usual sites of injection are the lateral foods from the four food groups (grain products, vegetables,
aspect of the arm, buttocks, lateral thigh, and abdomen. The fruits, milk and alternatives, and meat and alternatives).
abdomen has faster absorption, but lipohypertrophy (accu- Appropriate matching of insulin to carbohydrate content
mulation of fat) is very frequent. may allow increased flexibility and improved glycemic con-
Storage of Insulin. Unused insulin should be stored in a trol (Cameron et al. 2013).
refrigerator (4–8 °C) and never be frozen or receive direct Nutrition therapy should be individualized based on the
sunlight or warming. child’s nutritional needs, eating habits, and lifestyle and
Devices for Insulin Administration. Disposable insulin must ensure normal growth and development without com-
syringes and pen injectors containing insulin in prefilled car- promising glycemic control.
tridges, in small size (5–6 mm), are available. Features suggestive of eating disorders and celiac disease
Continuous subcutaneous insulin infusion is possible should be systematically studied.
with the use of external pumps (DCCT 1994). This method Evidence suggests that it is possible to improve diabetes
permits a more physiological insulin replacement therapy. outcomes through attention to nutritional management and
Motivation appears to be the most important factor for the an individualized approach to education (Martin et al. 2012).
success of this form of therapy (Danne et al. 2018).
Daily insulin dosage depends on several factors: age, 14.4.1.4 Education
weight, puberty, monitoring of blood glucose and glycated Children with new-onset type 1 diabetes and their families
hemoglobin levels, nutritional intake and distribution, exer- require education regarding diabetes. Education must include
cise, intercurrent illness, etc. insulin action and administration, blood glucose and ketone
Initially, the total daily insulin dose is often <0.5 IU/kg/ testing, dosage adjustment, prevention of diabetic ketoacido-
day, prepubertal children require 0.6–1 IU/kg/day, and during sis, and preventive treatment of hypoglycemia, nutrition
puberty, requirements are above 1–2 IU/kg/day. The “best” therapy, and exercise.
dose of insulin is that which achieves the best glycemic con- Health care providers should initiate conversations with
trol (70–180 mg/dL) without hypoglycemia and good growth, children and their families about school, career choices, psy-
weight, and height according to the children’s chart. chological issues, etc.
There are different regimens of distributing the insulin dose Interdisciplinary teams providing education should
in relation to the type of insulin, lifestyle (diet, exercise, school, include, as a minimum, a pediatric endocrinologist/diabe-
work, commitments, etc.), and residual insulin secretion. tologist, diabetes specialist nurse, a dietician, and a psychol-
The most frequently used regimens are as follows: one or ogist (Komatsu et al. 2005).
two injections of human insulin such as intermediate-action
NPH or long-acting insulin analogue, glargine or detemir, 14.4.1.5 Exercise
and human regular or analogue rapid-acting insulin, such as Physical activity is an essential component of treatment.
lispro and aspartic, before each main meal (breakfast, lunch, Playing games and sports offer psychological benefits for all
and main evening meal). age groups with type 1 diabetes. Unfortunately, exercise can
Insulin adjustments should be made until target blood glu- increase the risk of hypoglycemia. The management of
cose (BG) and HbA1c levels are achieved (Neu et al. 2015). hypoglycemia during and after doing exercise adds to the
Hypoglycemia should be avoided in children <6 years complexity of the treatment (Braatvedt et al. 1997).
old, which could induce severe cognitive impairment. The goal of hypoglycemia treatment is to prevent it, reducing
Children with persistently poor glycemic control (HbA1c the doses of insulin or consuming more carbohydrates. In mild
>9%) should be assessed by a specialized pediatric diabetes or moderate hypoglycemia, some juice or liquid with sugar is
team aimed at improving glycemic control should be con- enough to restore the blood glucose level to 100 mg/dL.
sider to enhance chronically poor metabolic control and pre- Diabetes should not limit the patient’s ability to excel in a
vent acute and chronic complications. (Canadian Diabetes chosen sport. Many famous athletes have proved this. Camps
Association Clinical Practice Guidelines Expert Committee) for children with diabetes that include counseling on nutri-
(Delahanty and Halford 1993). tion and insulin adjustment for exercise can result in
improved glycemic control (Hilliard et al. 2013).
14.4.1.3 Nutrition
Nutritional management is one of the cornerstones of diabe- 14.4.1.6 Psychosocial Support
tes care and education. Children with type 1 diabetes should Psychosocial support must be provided at diagnosis and reg-
follow a healthy diet; this involves consuming a variety of ularly thereafter. The treatment will only be effective if the
438 O. Ramos

family and patient are able to implement it. For the impact of and the treatment repeated if there is no response. Milder
psychosocial factors on the treatment plan, it is necessary to hypoglycemia should be treated with oral glucose (10–15 g)
work with the individual and family to overcome barriers or or 100 mL of sweet drink or juice, followed by additional
redefine goals as appropriate, especially as the youth grows, carbohydrates (bread, cookies) (Willi et al. 2003). New tech-
develops, and acquires the need for greater independent self-­ nologies including continuous glucose monitoring (CGM)
care (Reynolds and Helgeson 2011). and pump therapies offer the potential to reduce the impact
Young people with DM appear to have a greater incidence of hypoglycemia (Bui et al. 2010).
of depression, anxiety, psychological distress, and eating dis-
orders compared to their healthy peers (Young et al. 2013; 14.5.1.2 Ketoacidosis (DKA)
Winkley et al. 2006). Diabetic ketoacidosis (DKA) is the leading cause of morbid-
Mental health professionals should be available not only ity and mortality in children with type 1 diabetes mellitus
to interact with patients and families at clinic visits to con- (T1DM). Among the different types of diabetes, the preva-
duct screening and more complete assessment of psychoso- lence of type 1 diabetes in youth did not significantly change
cial functioning, but also to support the diabetes team in the over time (30.2%). The overall prevalence was highest in the
recognition and management of mental health and behavior 0- to 4-year age group and lowest in the 15- to 19-year age
problems (Cryer 2008). group. The high prevalence at diagnosis in many countries
indicate a need for increased awareness of the signs and
symptoms of type 1 diabetes and better access to health care
14.5 Complications (Neu et al. 2009).
Mortality is predominantly related to the occurrence of
14.5.1 Acute Complications cerebral edema; only a minority of deaths in DKA is attrib-
uted to other causes. Cerebral edema occurs in 0.3% to 1% of
14.5.1.1 Hypoglycemia all episodes of DKA, and its etiology, pathophysiology, and
Hypoglycemia is the most common acute complication of ideal method of treatment are poorly understood.
type 1 diabetes. Its risk presents a major physiological and
psychological barrier to achieving optimal glycemic control Definition
(Rewers et al. 2014). A blood glucose of 65 mg/dL has been Diabetic ketoacidosis (DKA) is a metabolic derangement
accepted as a level for defining hypoglycemia; however, characterized by the triad hyperglycemia, acidosis, and keto-
70 mg/dL is used as the threshold value for initiating treat- sis that occurs in the presence of very low levels of effective
ment because of the potential for glucose to fall further insulin action, together with elevations in counterregulatory
(Jones 2018). hormones including glucagon, catecholamine, cortisol, and
Hypoglycemia is classified as symptomatic and asymp- growth hormone (Roche et al. 2005). This leads to increased
tomatic, mild, moderate, or severe. The symptoms result glucose production by the liver and kidney and impaired
from adrenergic activation (shakiness, pounding heart, and peripheral glucose utilization resulting in hyperglycemia and
sweatiness) and neuroglycopenia (headache, drowsiness, hyperosmolarity. The increased lipolysis, with ketone body
and difficulty concentrating), and behavioral changes (irrita- production, causes ketonemia, metabolic acidosis, and loss
bility, agitation, quietness, and tantrums). In children, severe of electrolytes and water that can lead to dehydration, shock,
hypoglycemia is most often defined as an event associated and death.
with a seizure or loss of consciousness (Karges et al. 2017).
Common clinical precipitants for hypoglycemia are exces- Diagnosis
sive insulin doses, missed meals, exercise in adolescents, and Early recognition of the classical triage of polydipsia, poly-
alcohol ingestion. Risk factors include young age, previous uria, and polyphagia with weight loss is essential; vomiting,
severe hypoglycemic events, and hypoglycemic awareness. pain in the stomach, and rapid breathing (Kussmaul),
A lower HbA1c level is a risk factor, but now is less common together with compromised circulation and decreased level
with contemporary therapy (Clarke et al. 2008). Severe of consciousness, are early signs. The biochemical criteria
hypoglycemia requires urgent treatment in a hospital with for the diagnosis of DKA include hyperglycemia >200 mg/
intravenous glucose administration (10% glucose, 2–3 mL/ dL, with bicarbonate level < 15 mmol/L, and/or pH <7.30
kg). At home, IM or SC glucagon injection should be given (venous). DKA is generally categorized by the severity of the
(<12 years old, 0.5 mg; >12 years old, 1 mg). If the blood acidosis, varying from mild pH <7.30 and bicarbonate level
glucose level is nearly 70 mg/dL, glucose control can be 15 mmol/L to moderate pH <7.2 and then severe pH <7.1
accomplished by giving glucose tablets or sweetened fluids. and bicarbonate level < 5 mmol/L, associated with glycos-
In 10 or 15 min, the blood glucose level should be retested uria, ketonuria, and ketonemia (Savage et al. 2011).
14 Diabetes in Childhood and Adolescents 439

Treatment be evaluated initially and then based on age, diabetes dura-

In general, it is necessary to use 0.9% saline during the first tion, and treatment.
2 h but at different infusion rates, from 10 mL/kg/L to 20 mL/
kg/h. After the first 2 h, the amount of fluids to be infused
should not exceed 3 L/m2/day. The fluid infused is saline, 14.6.2 Treatment
either 0.9% or 0.45%, and 5%–10% glucose solution, corre-
sponding to the glycemic value. Potassium supplementation When persistently elevated, urinary albumin to creatinine
is performed at different rates at 20–40 mEq/L. Bicarbonate ratio (>30 mg/g) should be evaluated with at least two or
is exceptionally used according to the pH DKA severity three urine samples, and treatment with an ACE inhibitor
(Metzger 2010). should be considered and the dose titrated to maintain blood
Regular or rapid-acting insulin analogue is infused using pressure within the age-appropriate normal range.
an automated syringe injected directly in the fluid solution
starting from the second to third hour, mostly according to
the DKA severity. The insulin infusion rate is 0.05–0.1 U/k/h 14.6.3 Retinopathy
to rate DKA severity and to evaluate DKA management fol-
low-­up needs. The administration of insulin could also be Adolescents have a higher risk of progression to vision-­
done subcutaneously (Control and Complications Trial threatening retinopathy (severe nonproliferative retinopathy
Research Group 1994). or proliferative retinopathy) compared with that of adults
(Bragge et al. 2011). The progression may be rapid, espe-
cially in those with poor glycemic control. Biomicroscopy
14.6 Microvascular and Macrovascular fundus slit examination through dilated pupils by an ophthal-
Complications mologist and mydriatic seven-field stereoscopic retinal pho-
tography and fluorescein angiography OCT specifically
Childhood and adolescence are periods during which inten- reveal macular edema (Mohamed et al. 2007).
sive education and treatment may prevent or delay the onset Once sight-threatening retinopathy is detected, laser ther-
and progression of complications in later adult life (Mogensen apy consists of multiple discrete outer retinal burns through-
et al. 1995). Clinically evident diabetes-related vascular out the mid- and far peripheral area, sparing the central
complications are rare in childhood and adolescence. macula (Šimunović et al. 2018). Diabetic cataracts have been
However, early functional and structural abnormalities may reported in patients with type 1 diabetes close to or even pre-
be present a few years after the onset of the disease. Longer ceding diagnosis. Surgical removal may be required (Russell
duration of diabetes at older age and puberty are risk factors and Zilliox 2014).
for complications.
The long-term complications of diabetes include micro-
and macrovascular complications. The microvascular com- 14.6.4 Neuropathy
plications are nephropathy, retinopathy, and neuropathy.
Neuropathy is a polyneuropathy caused by diffused damage
to all peripheral nerve fibers—motor, sensory, and auto-
14.6.1 Nephropathy nomic. Patients usually complain of numbness, prickling,
burning, and/or paresthesia of the hands or feet (Guy et al.
Nephropathy is defined as persistent proteinuria >500 mg/24 h 2009).
or albuminuria >300 mg/24 h and is usually associated with
hypertension and a diminishing glomerular filtration rate
(GFR). End-stage renal failure may occur many years later 14.6.5 Macrovascular Disease (CVD)
and requires dialysis or kidney transplantation. Early detec-
tion of diabetic nephropathy and timely treatment of blood The mortality and morbidity of CVD are markedly increased
pressure have a pivotal role in the prevention of end-stage in diabetic individuals compared with that in the nondiabetic
renal failure in young people and adults with diabetes (Schultz population. Hypertension has a greater impact on CVD, and
et al. 2000). blood pressure control to <130/80 mmHg reduces cardiovas-
Annual screening for albuminuria with a random spot cular morbidity. Atherosclerosis starts in childhood and ado-
urine sample for albumin to creatinine ratio should be con- lescence and cardiovascular events are strongly associated
sidered once the child has type1 diabetes for 5 years (Hietala with poor glycemic control. Cholesterol plays an important
et al. 2010). The estimated glomerular filtration rate should role in the initiation and progression of atherosclerosis. High
440 O. Ramos

a b

Fig. 14.1 (a, b) The following case is a 12-year-old patient diagnosed with type 1 diabetes since she was 6 years old

a b

Fig. 14.2 (a and b) Although the periodontal inflammation of the gums was constantly controlled, it was present throughout the entire treatment

LDL cholesterol is defined as >100 mg/dL and triglycerides since, in diabetic patients, gingival tissues respond, with dif-
>150 mg. If present, then interventions to improve metabolic ficulty, to pathogens that are normally present in the mouth
control, dietary changes, and increased exercise should be (Fig. 14.1).
instituted. If the above interventions do not lower the LDL Gingivitis is typically observed in this type of patient.
cholesterol to <130 mg/dL, statins should be considered in This particular case is worse since there is a lack of space for
children aged >10 years (42). proper tooth eruption.
After 18 months of treatment, the objectives, sought from
the orthodontic perspective, were achieved. What needs to be
14.6.6 Orthodontic Procedures kept in mind is that, in spite of the parents’ efforts, many
adolescent patients rebel against treatment for diabetes as
It is possible to achieve normalization of tooth position as well as orthodontics (Fig. 14.2).
well as improvements in functional problems in children or From the orthodontic point of view, the objectives
teenagers with any type of diabetes. As described previously, decided at the beginning of treatment have been accom-
this endocrine disorder is typically associated with gingivitis plished: ­correction of dental midline and placement of the
and periodontitis. It is for this reason that a thorough control upper canines and normalization of crossbite, overjet, and
of dental hygiene is required to lessen the risk of infections gingival line.
14 Diabetes in Childhood and Adolescents 441

a b

Fig. 14.3 Final photographs confirm the excellent results achieved, even though in a diabetic patient (a, b)

Monthly periodontal follow-up was recommended in DCCT. Effect of intensive diabetes treatment on the development and
progression of long-term complications in adolescents with insulin-­
order to normalize gingival tissues (Fig. 14.3). dependent diabetes mellitus: diabetes control and complications
trial. Diabetes control and complications trial research group. J
Pediatr. 1994;125:177–88.
References Delahanty LM, Halford BN. The role of diet behaviors in achiev-
ing improved glycemic control in intensively treated patients
in the diabetes control and complications trial. Diabetes Care.
American Diabetes Association. 2. Classification and diagnosis of dia- 1993;16:1453–8.
betes: standards of medical care in diabetes—2018. Diabetes Care. Guy J, Ogden L, Wadwa RP, et al. Lipid and lipoprotein profiles in
2018;41(Suppl 1):S13–27. youth with and without type 1 diabetes: the SEARCH for diabetes in
Braatvedt GD, Mildenhall L, Patten C, Harris G. Insulin requirements youth case-control study. Diabetes Care. 2009;32:416–20.
and metabolic control in children with diabetes mellitus attending a Harjutsalo V, Sund R, Knip M, Groop PH. Incidence of type 1 diabetes
summer camp. Diabet Med. 1997;14:258–61. in Finland. JAMA. 2013;310(4):427–8.
Bragge P, Gruen RL, Chau M, Forbes A, Taylor HR. Screening for Hietala K, Harjutsalo V, Forsblom C, Summanen P, Groop PH. On
presence or absence of diabetic retinopathy: a meta-analysis. Arch behalf of the FinnDiane study group. Age at onset and the risk
Ophthalmol. 2011;129:435–44. of proliferative retinopathy in type 1 diabetes. Diabetes Care.
Bui H, To T, Stein R, Fung K, Daneman D. Is diabetic ketoaci- 2010;33:1315–9.
dosis at disease onset a result of missed diagnosis? J Pediatr. Hilliard ME, Holmes CS, Chen R, Maher K, Robinson E, Streisand
2010;156(3):472–7. R. Disentangling the roles of parental monitoring and family con-
Cameron FJ, de Beaufort C, Aanstoot H-J, et al. The Hvidoere flict in adolescents’ management of type 1 diabetes. Health Psychol.
International Study Group. Lessons from the Hvidoere International 2013;32(4):388–96.
Study Group on childhood diabetes: be dogmatic about outcome Insel RA, Dunne JL, Atkinson MA, et al. Staging presymptomatic
and flexible in approach. Pediatr Diabetes. 2013;14:473–80. type 1 diabetes: a scientific statement of JDRF, the Endocrine
Clarke W, Jones T, Rewers A, Dunger D, Klingensmith GJ. Assessment Society, and the American Diabetes Association. Diabetes Care.
and management of hypoglycemia in children and adolescents with 2015;38(10):1964–74.
diabetes. Pediatr Diabetes. 2008;9:165–74. Jones TW. Defining relevant hypoglycemia measures in chil-
Effect of intensive diabetes treatment on the development and pro- dren and adolescents with type 1 diabetes. Pediatr Diabetes.
gression of long-term complications in adolescents with insulin-­ 2018;19(3):354–5.
dependent diabetes mellitus: diabetes control and complications Karges B, Kapellen T, Wagner VM, et al. Glycated hemoglobin A1c as
trial. Diabetes Control and Complications Trial Research Group. J a risk factor for severe hypoglycemia in pediatric type 1 diabetes.
Pediatr 1994;125:177–188. Pediatr Diabetes. 2017;18:51–8.
Cryer PE. Hypoglycemia: still the limiting factor in the glycemic man- Karvonen M, Viik-Kajander M, et al. Incidence of childhood type 1
agement of diabetes. Endocr Pract. 2008;14:750–6. diabetes worldwide. Diabetes Mondiale (diamond) project group.
Danne T, Deiss D, Hopfenmuller W, von Schutz W, Kordonouri Diabetes Care. 2000;10:1516–26.
O. Experience with insulin analogues in children. Horm Res. Komatsu WR, Gabbay MA, Castro ML, et al. Aerobic exercise capac-
2002;57(Suppl 1):46–53. ity in normal adolescents and those with type 1 diabetes mellitus.
Danne T, Phillip M, Buckingham BA, et al. ISPAD clinical practice Pediatr Diabetes. 2005;6:145–9.
consensus guidelines 2018: insulin treatment in children and adoles- Martin D, Lange K, Sima A, et al. On behalf of the SWEET group.
cents with diabetes. Pediatr Diabetes. 2018;19(Suppl. 27):115–35. Recommendations for age-appropriate education of children and
442 O. Ramos

adolescents with diabetes and their parents in the European Union. Russell JW, Zilliox LA. Diabetic neuropathies. Continuum (Minneap
Pediatr Diabetes. 2012;13(Suppl. 16):20–8. Minn). 2014;20:1226–40.
Mayer-Davis E, Kahkoska AR, ISPAD Clinical Practice Consensus Savage MW, Dhatariya KK, Kilvert A, et al. Joint British diabetes soci-
Guidelines. Definition, epidemiology, and classification of diabe- eties guideline for the management of diabetic ketoacidosis. Diabet
tes in children and adolescents. Pediatric Diabetes October 2018. Med. 2011;28(5):508–15.
2018;19(Suppl. 27):7–19. Schultz CJ, Neil HA, Dalton RN, Dunger DB. Oxforn regional prospec-
Metzger DL. Diabetic ketoacidosis in children and adolescents: an tive study group. Risk of nephropathy can be detected before the
update and revised treatment protocol. BC Med J. 2010;52:24–31. onset of microalbuminuria during the early years after diagnosis of
Mogensen CE, Keane WF, Bennett PH, et al. Prevention of diabetic type 1 diabetes. Diabetes Care. 2000;23:1811–5.
renal disease with special reference to microalbuminuria. Lancet. Šimunović M, Paradžik M, Škrabić R, Unić I, Bućan K, Škrabić
1995;346:1080–4. V. Cataract as early ocular complication in children and adolescents
Mohamed Q, Gillies MC, Wong TY. Management of diabetic retinopa- with type 1 diabetes mellitus. Int J Endocrinol. 2018;2018:6763586.
thy: a systematic review. JAMA. 2007;298:902–16. Watkins RA, Evans-Molina C, Blum JS, Dimeglio LA. Established and
Neu A, Hofer SE, Karges B, et al. Ketoacidosis at diabetes onset is still emerging biomarkers for the prediction of type 1 diabetes: a system-
frequent in children and adolescents: a multicenter analysis of 14,664 atic review. Transl Res. 2014;164:110–21.
patients from 106 institutions. Diabetes Care. 2009;32(9):1647–8. Willi SM, Planton J, Egede L, Schwarz S. Benefits of continuous
Neu A, Lange K, Barrett T, et al. Classifying insulin regimens--dif- sub- cutaneous insulin infusion in children with type 1 diabetes. J
ficulties and proposal for comprehensive new definitions. Pediatr Pediatr. 2003;143:796–801.
Diabetes. 2015;16(6):402–6. Winkley K, Landau S, Eisler I, Ismail K. Psychological interventions to
Rewers MJ, Pillay K, de Beaufort C, et al. ISPAD clinical practice con- improve glycemic control in patients with type 1 diabetes: system-
sensus guidelines 2014. Assessment and monitoring of glycemic atic review and meta-analysis of randomised controlled trials. BMJ.
control in children and adolescents with diabetes. Pediatr Diabetes. 2006;333(7558):65.
2014;15(Suppl 20):102–14. Young V, Eiser C, Johnson B, et al. Eating problems in adolescents
Reynolds K, Helgeson V. Children with diabetes compared to peers: with type 1 diabetes: a systematic review with meta-analysis. Diabet
depressed? distressed? Ann Behav Med. 2011;42(1):29–41. Med. 2013;30(2):189–98.
Roche EF, Menon A, et al. Clinical presentation of type 1 diabetes.
Pediatr Diabetes. 2005;6(2):75–8.
 Orthodontics in Hemophilia Patients
15
Eduardo Rey

15.1 Introduction The diagnosis of postpartum hemophilia is based on the

measurement of the plasma level of FVIII/FIX collected
Hemophilia is a rare bleeding disorder caused by mutations from a sample of umbilical cord blood, or a sample of periph-
in the X chromosome, which brings about a decrease or eral venous blood from a newborn.
absence of activity in factors VIII or IX. About a third of Arterial, jugular, and femoral punctures and circumcision
these mutations are spontaneous, lacking family history. It are contraindicated until the patient has an adequate level of
causes the appearance of internal and/or external bleeding of the deficient factor. According to the plasma level of FVIII or
variable severity depending on its location. FIX, hemophilia is classified as follows:
The frequency of FVIII deficiency (hemophilia A) is approxi- Severe hemophilia
mately 1 in 5000 to 10,000 births in boys, and for FIX deficiency
(hemophilia B), it is approximately 30,000–50,000 births. –– 1% factor.
The clinical expression of hemophilia is bleeding in dif- –– Bleeding can be spontaneous.
ferent locations in the body: joints, muscles in the lower and –– Very frequent bleeding episodes.
upper limbs, internal bleeding, the digestive and urinary sys- –– Commitment of various joints.
tems, and others, but less frequently. Among the aforemen-
tioned, bleeding in the central nervous system is the most Moderate hemophilia
severe form of hemorrhage in patients with hemophilia that
causes the highest morbidity and mortality. –– Between 1% and 5%.
Ninety percent of people with severe hemophilia A or B –– Bleeding from insignificant trauma can be seen.
have bleeding episodes that begin at an early age. The most –– Less frequent bleeding. They may present joint
affected joints are the ankles, knees, and elbows. This causes compromise.
a characteristic pathology called hemophilic arthropathy,
characterized by the presence of progressive joint lesions, Mild hemophilia
which lead to a severe limitation of joint function, arthral-
gias, and serious disabling sequelae. Due to its frequency –– 5% factor.
and chronic evolution, hemophilic arthropathy is the compli- –– They can bleed from severe trauma, surgeries, etc.
cation with the highest morbidity, and thus, the main aim of –– Very infrequent hemorrhages. Joint involvement is rare.
its treatment is the prevention of its development.
The early detection of female carriers is based on a lin- Treatment of patients with hemophilia consists of intrave-
eage analysis. DNA-based diagnosis is the most accurate nous administration of FVIII or FIX concentrates in order to
one, but it does not provide full information about this group raise the plasma levels of these factors (replacement ther-
of patients. Prenatal diagnosis can be made by chorionic vil- apy). Treatment can be on demand for the bleeding episodes
lus biopsy between weeks 9 and 11 of gestation, or by amnio- that occur, or prophylactically so as to prevent bleeding. In
centesis between weeks 15 and 20, by extracting DNA from patients with mild hemophilia A, desmopressin is a therapeu-
fetal cells for a genetic diagnosis. tic alternative.
Patients with hemophilia may present, as a treatment
complication, the development of an inhibitor (an antibody
E. Rey (*) that blocks the coagulant action of FVIII or FIX). The hema-
School of Dentistry, University of Buenos Aires, tological management of these patients is a great challenge.
Buenos Aires, Argentina

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 443
J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_15
444 E. Rey

Bleeding is treated with so-called bypassing or bridging Intrapapillary technique: it is only used as a coadjutant of
agents (recombinant activated FVII and activated prothrom- terminal techniques.
bin complex concentrate). Intraligamentous technique: it is effective in short-term
treatments only.
Substitution therapy is vitally important for the regional
15.1.1 Overview: General Facts technique which usually blocks the inferior alveolar and lin-
gual nerve. In general, the application of antihemophilic fac-
In dentistry, bleeding can be caused by multiple practices. tor concentrates is not essential in other anesthetic
Under normal circumstances, the techniques performed can be techniques.
carried out without major complications. However, the risk of The liquid administration of the anesthetic must be slow
intra- and postoperative bleeding is potentially higher in to prevent bruises. The concentrate should be administered
patients with hereditary bleeding disorders such as hemophilia, to increase the level of FVIII/FIX to ≥50%, 10 min before
a relatively uncommon disorder, but complex in terms of diag- anesthesia, regardless of the type of anesthesia used.
nosis and treatment. The first clinical sign of the disease such In other types of anesthesia, the hematologist, in consulta-
as hemorrhage is usually manifested in oral and maxillofacial tion with the dentist, can indicate a dose of FVIII/FIX to
trauma as well as routine dental care in early childhood. reach levels ≥30%.

15.1.3.1 Surgical Treatment

15.1.2 Is Orthodontic Treatment a Trauma? Patients with hemophilia may have hemorrhagic problems,
the most severe at the oral level, in terms of bleeding.
It is not. In the case of soft tissue trauma in children, local action
This chapter aims to provide recommendations to health (suture) must be carried out with special care so as not to
professionals in different types of orthodontic treatments in cause greater trauma and bleeding.
order to achieve an optimal state of oral health. Substitute treatment such as FVIII or FIX is often
The idea is to reduce dental surgeries as much as possible. necessary.
However, it is known that sometimes, dental extraction is Spontaneous oral bleeding episodes are usually caused by
necessary to continue with the orthodontic treatment. In mobility of temporary tooth. The pericoronary sac of a per-
cases when surgery is fundamentally important, such as in manent dental piece is the major problem. Thus, the extrac-
third molar extraction, this kind of indications must be stud- tion of temporary tooth is necessary. In order to stop the
ied carefully in order to continue with the procedure. bleeding, a caustic agent (30% trichloroacetic acid) or bis-
Uncontrolled dental hemorrhages can eventually threaten muth subgallate is used for local treatment (Rey et al. n.d.,
the patient’s life. Thus, it is known that people with hemo- 2000) [21].
philia or other bleeding disorders are a priority group for oral Working with the hematologists is essential for planning
and maxillofacial preventive care. surgical treatment in order to prevent bleeding
For a better understanding of these procedures in this kind complications.
of patients, several things about local anesthesia need to be To protect the largest amount of bone wall, atraumatic
analyzed. technique should be carried out.

15.1.3.2 Emergencies
15.1.3 Local Anesthesia
• Upper lip frenulum injury.
Local anesthesia technique in patients with hemophilia for • Lower lip frenulum injury.
pain control has been a challenge for dentists. In fact, infil- • Tongue frenulum injury.
tration of different types of anesthetics can be performed • Dorsal tongue face injury.
locally and slowly. Moreover, in order to cause less pain, • Dental replacement.
local anesthesia should be warmed. The techniques that can
be used are the following: What Can We Do?
Infiltrative technique: Local compression, placing ice over the region outside the
mouth, cold diet, and calling the professional should be car-
• Terminal: it requires slow infiltration to avoid bruising. ried out.
• Troncular of the lower jaw: it requires the administration As for soft tissue traumas, such as the tongue, braces, and
of substitution treatment to avoid bruising and/or hemor- lips, their dimension should always be evaluated to deter-
rhage which can cause respiratory problems. mine if suture is essential.
15 Orthodontics in Hemophilia Patients 445

Local Hemostatic Agents proteins that obliterate the light of the glasses of small
Local hemostasis is an important pillar in the surgical treat- caliber.
ment of patients with hemophilia. It is a matter of using the It is economical and easy to be prepared by drug-
most convenient method from all points of view: low cost, stores. Its mode of intrasurgical preparation is also sim-
easy instrumentation and application, low infectious risk, ple; it consists of making a mixture of bismuth subgallate
etc. In cases of minor surgery, these hemostats are some- with anesthetic liquid with a vasoconstrictor until a
times used as the only prophylactic measure, while in mass consistency is obtained, and this preparation is
medium or major surgeries, they are used in combination compacted in the bleeding site on the surgical bed. From
with systemic therapy. here arises the need for a conservative exodontia of
Local hemostats are drugs that participate directly in the alveolar cavities. It is rapidly eliminated, showing
mechanism of coagulation. The reason why they stop the absence of radiological evidence after approximately
bleeding is twofold: they produce an artificial clot or they 30 days.
create a mechanical matrix that facilitates blood clotting (C) Plasma Enriched in Platelets.
when applied directly to the site of the hemorrhage. It is At present, there is a great boom in the field of maxil-
important to highlight that local action is effective. lofacial surgery, especially in reconstructive and regen-
The application of anesthesia has two benefits. Firstly, it erative surgeries. Once obtained by means of special
avoids pain on the patient, and secondly, it facilitates to see blood centrifugation techniques, the extracorporeal
where the bleeding is coming from. coagulation of plasma is improved by the application of
calcium chloride and thrombin in preestablished con-
Examples of Local Hemostatics centrations. This technique should only be performed in
specialized medical centers and under strict measures of
(A) Biological Tissue Adhesives. biosafety and blood control. Among its observed advan-
They are commercial preparations of two compo- tages are the following:
nents: one is composed of protein concentrates (coagu- (a) It provides adhesion and tensile strength for the sta-
lable proteins, fibrinogen, FXIII, plasminogen) and bilization of the coagulum.
aprotinin and the other of a solution of thrombin and (b) It provides safety since it uses autologous plasma.
calcium chloride. (c) It is biologically acceptable for tissues.
These two components mix and give rise to the trans- (d) It contains important healing factors released by
formation of fibrinogen into fibrin in situ, which rapidly platelets.
transforms into a foaming white elastic coagulum that (e) It promotes angiogenesis.
adheres firmly to the tissues. This fixation, which imi- (f) It has a high concentration of leukocytes, which
tates the last phase of normal human coagulation, is reduces the risk of infections.
what allows the hemostatic, sealing, and adhesive activ- (g) It contains a mesh rich in fibrin, which is
ities that characterize the product. During wound heal- osteoconductive.
ing, total resorption of the biological adhesive takes (D) Microfibrillary Collagen.
place. The commercial preparation is provided with a They are commercial preparations that act as a
fast-acting thrombin and a slow-acting one. The rapid mechanical matrix to trigger coagulation. Their func-
one is used for hemostasis and the slow one to adhere to tion is to attract platelets to trigger aggregation when
the tissues. applied directly to the bleeding site.
(B) Bismuth Subgallate [28–30]. (E) Lyophilized Swine Skin.
It is a chemical compound that has been used for several It is a commercial preparation, whose high content of
decades by many branches of medicine such as dermatol- collagen mimics the action of microfibrillary collagen.
ogy, gastroenterology, and especially otorhinolaryngology (F) Oxidized Cellulose.
where it is used in tonsillectomies. It allows the formation of a matrix that stops the
It is an intense yellow odorless powder, which is deposition of fibrin and the propagation of the blood
insipid and opaque to the Radiographic study (Rx) clot.
(which allows its visualization in radiographic images (G) Trichloroacetic Acid 30%.
until its total elimination). Also, it is recognized as an It is a caustic of local action. It is indicated especially
antibacterial and hemostatic. in capillary hemorrhages in mucous membranes. It has
Its hemostatic principles were studied in vivo and the advantage that since it is a self-limiting acid (it is
in vitro and are found in the activation of factor Hageman inactivated when combined with a certain amount of
or FXII, accelerating the coagulation cascade and in its substrates), it does not act on the depth of the tissues.
local astringent action, that is, precipitating vascular (H) Antifibrinolytic Preparations [25–27].
446 E. Rey

Antifibrinolytic agents act in molecular form by occu- Postsurgical controls of these patients are carried out as
pying the sites of plasminogen activation and the plasmin often as possible, to follow their evolution and prevent hemo-
receptor for fibrin. This slows the lysis of the clot and static alterations.
improves its hemostatic properties. The most recognized
drugs are aminocaproic acid and tranexamic acid.
15.2 Hemophilia Clinical Case
Tranexamic acid: The use of 10-mL mouthwash, with
tranexamic acid 5%, four times a day, for 7–10 days, as well This 9-year-old patient was sent to the orthodontic depart-
as 25 mg/kg orally every 6 h for 5–10 days, is recommended ment by his clinical doctor in search of a second opinion.
to prevent posttreatment hemorrhages. In children, doses The previous orthodontist suggested applying the serial
should be adjusted according to the age and weight. extraction protocol. However, considering that the patient
Ε-Aminocaproic acid (EACA): It can be indicated orally at was diagnosed with hemophilia when he was 5 years old,
50–75 mg/kg of weight every 6 h or 2 or 3 ampoules orally this protocol was not considered the best option.
every 6 h (Machado de Sousa et al. 1995; Martinez Lage et al. Up until that moment, he had been treated by the same
1983; Marquez et al. 1982; Mulkey 1977; Rey et al. 2002). hematologist, and to date, no major dental bleeding episodes
Postsurgical suture is performed routinely, without excep- have been observed.
tion, since it offers great advantages in hemostasis and post- Her mother was worried about the position of the upper
operative evolution, preventing the consequent edema and lower central incisors. A significant gingival retraction
separating the lips from the wound. was confirmed on the labial side of the lower central incisors
In the case of outpatient surgery, the patient must remain along with an uneven gingival margin (Fig. 15.1a, b).
at rest for a few minutes before leaving once the surgery has The upper discrepancy was −4 mm (Fig. 15.2).
been completed, in order to check the definitive hemostasis A nonextraction protocol was decided and the treatment
and explain the postsurgical care. These differ from those plan included aligning and leveling the arches with very low
given to a normal patient, since all that has been indicated forces.
aims for the stability of the clot. When treating patients with hemophilia, it is important to
It is indicated that the temperature of the food to be maintain a careful hygiene protocol to avoid swollen gums.
ingested must be of natural temperature or cold, neither hot It is highly recommended to use rounded brackets and a
nor warm. This type of feeding should be followed for strict control of wires to avoid gingival injuries during the
approximately 6 or 7 days with controls of the wound by the whole active treatment.
surgeon. Due to his medical conditions, low-load deflection arches
The gauze dressing that is placed on the wound to protect were recommended during the entire treatment (Figs. 15.3,
it should remain in place between 5 and 7 h (by that time, the 15.4, 15.5, 15.6, 15.7 and 15.8).
clot will probably be stabilized). The comparison between the pre- and posttreatment fron-
Suction as well as smoking is contraindicated, but the tal photographs shows a significant improvement in the posi-
hygiene of the remaining dental pieces is indicated. tion and inclination of the teeth.

a b

Fig. 15.1 (a and b) Frontal and upper occlusal pretreatment photographs

15 Orthodontics in Hemophilia Patients 447

a b

Fig. 15.2 (a, b) Class I molar was observed on the lateral views

a b

Fig. 15.3 (a, b) A utility arch that was made with a TMA wire was the best option

a b

Fig. 15.4 (a, b) These were the results 12 months later when the first phase of treatment was finished
448 E. Rey

a b

Fig. 15.5 (a, b) The lateral views confirmed that Class I canine and molar were achieved

a b

Fig. 15.6 (a, b) These were the results at the end of the active treatment. All objectives were achieved: central incisor midlines were coincident
and gingival line and occlusal plane were parallel with normal overjet and overbite

a b

Fig. 15.7 (a, b) The lateral photographs confirmed Class I molar and canine
15 Orthodontics in Hemophilia Patients 449

a b

Fig. 15.8 (a, b) Also, the gingival tissues were clearly improved particularly in the lower incisor area

It is important to highlight that no important bleeding epi- Fenton JE, Blayney W, Dwyer O, T. Bismuth Subgallate – its role in
sodes were observed during the entire active orthodontic tonsillectomy. J Laryngol Otol. 1995;109:203–5.
Grady B, Leibold D, Triplett R. Hemophilic pseudotumor of the
treatment. mandible: report of a case. Oral Surg Oral Med Oral Pathol.
1990;69:550–3.
Halfpenny W, Fraser J, Adlam D. Comparison of 2 haemostatic agent
15.3 Conclusions for the prevention of postextraction hemorrhage in patients on anti-
coagulants. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2001;92:257–9.
It is possible to treat patients with hemophilia and all types Johnson W, Leary J. Management of dental patient with bleeding
of malocclusions when control and low forces are used. disorders: review and update. Oral Surg Oral Med Oral Pathol.
Clearly, dental extractions and minor dental surgeries have 1998;66:297–303.
Machado de Sousa S, Piratininga J, Pinto D, et al. Hemophilic pseu-
to be minimal. Also, treatment objectives may need to be dotumor of the jaws: report of two cases. Oral Surg Oral Med Oral
modified to certain limits according to the severity of the Pathol Oral Rad End. 1995;79:216–9.
disease. Marquez J, Vinageras MD, Dorantes S, et al. Hemophilic pseudotumor
of the inferior maxilla. Rep Case Oral Surg. 1982;53:347–9.
Martinez Lage J, Sanchez H, Garcia J, et al. A pseudo-tumor of the
mandible in a haemophiliac patient: a case report. J Max-fac Surg.
References 1983;11:171–3.
Médicos Tratantes de personas con Hemofilia. Guía de Tratamiento de
Adrew Brewer MEC. Guidelines for dental treatment of patients with la Hemofilia. Consenso de Médicos especialistas en Hemofilia de la
inherited Bleeding disorders. Treatment of Hemophilia. N°40 May República Argentina. Fundación de la Hemofilia; 1° Edición Julio
2006. 2011.
Axelssoon P. Preventive materials, methods and programs. Slovakia: Mulkey T. Hemophilic pseudotumor of the mandible. J Oral Surg.
Quintsence Publishing; 2004. 1977;35:561–8.
Brook AH, Bedi R, Chan LW. Haemophilic pseudotumours of the man- Rey MP, Puia S, Castillo W. Como abordar el tratamiento quirúrgico
dible: report of a case a one year old child. Br J Oral Maxillofacial bucal en pacientes considerados de alta complejidad. Revista
Surg. 1985;23:47–52. del Ateneo Argentino de Odontología. Año: 2000. Agosto.
Callanan V, Curran A, Smyth D. The influence of bismuth subgallate XXXIX(2):6–10.
and adrenaline paste upon operating time and operative blood loos Rey E, Puia S, Parreira M, Perez Bianco R, Tezanos Pinto M. Evaluation
in tonsillectomy. J Laryngol Otol. 1995;109(3):206–8. of haemostatic effectivity with a local biological tissue adhesive and
Campbell J, Alvarado F, Murria A. Anticoagulation and minor oral bismuth subgallate in oral surgery in haemophilia patients: com-
surgery: Should the anticoagulation regimen be altered? J Oral parative study. Haemophilia. 2002;8(4):23 Po 16.
Maxillofac Surg. 2000;58:131–5. Rey E, Castillo W, Puia S, Parreira M. Dental Extraction in patients
Conley S, Ellison M. Avoidance of primary post-tonsillectomy with haemophilia and inhibitors. En libro “Inhibitors in patients
(Hemorrhage in a teaching program.): 109-2. Arch Otolaryngol with Haemophilia” de Rodríguez Marchan, C and Lee, C. 1 Edicion
Head Neck Surg. 1999;125:330–3. Part 7. Chapter 29. Oxford : Blackwell Science Company. p. 183–4.
Eduardo R, Miryam P. Guia para el tratamiento odontológico de paci- Shirley García de Valente M. Adolescencia y salud bucal. http://ral-­
entes con hemofilia. adolec.bvs.br/pdf/ral/v1n3/a06v01n3.pdf
 How to Avoid Long Term Relapse
in Early Orthodontic Treatment 16
Julia Harfin

Open bite is one of the most difficult types of malocclusions to Sometimes, the child’s psychological state plays an impor-
treat not only in early or mixed dentition but also in permanent tant role during this whole process and the help of a special-
dentition. The real issue is how to avoid long-term relapse. ist is invaluable. Different alternatives (removable or fixed
There is no doubt that there is a close interrelationship appliances) can be used but the parents’ help is priceless.
between breathing, facial musculature, and the tongue that The frequency and duration of thumb-sucking and tongue
affects not only facial growth but also the position of the thrust swallowing are determinants during deciduous and
teeth and TMJ function. early mixed dentition. It is important to remember that
The position of the tongue at rest and the normalization of finger-­sucking is one of the worst oral habits present in chil-
breathing play an important role not only during treatment dren, and sometimes, it appears during the intrauterine life
but also during the retention period. Additionally, they are (English 2002). When it is prolonged, past the age of 2–3
responsible for all types of relapse (Fig. 16.1a, b). years, it can alter the normal path of facial growth and dental
Since these anomalies are not self-corrected and are the occlusion (Torres et al. 2012) due to the abnormal force
result of multifactorial issues, the advantages of early treat- applied on the orofacial muscles and the frontal teeth.
ment cannot be denied. Anterior open bite with maxillary incisor flaring and
Environmental factors during primary and mixed denti- retrusion of the lower anterior teeth are the common charac-
tion play an important role in the development of this prob- teristic clinical signs, in addition to a long anterior face,
lem (Cozza et al. 2005). For this reason, the sooner these snoring, eye bags, and sleepiness.
factors are controlled, the less relapse is present. The early elimination of these habits is fundamental to
Early recognition of the etiology can prevent ongoing recover normal growth. For this reason, parents play an
problems and the development of worse abnormalities in the important role in this phase of treatment by accompanying
future (Fig. 16.2a, b). children during this whole process.
The most common local causes of anterior open bite in There are several appliances that can be used to achieve
children are related to tongue thrusting, sucking habits, and good results, but it is important to recommend a child-­
mouth breathing (Hepper et al. 2005). friendly one to obtain the willingness of the child to stop the
Normally, they are accompanied by a downrotation of the habit (Huang 2002). The orthodontist has the final decision.
mandible with extrusion of the molars and intrusion of the The following examples describe the step-by-step
upper and lower incisors (Fig. 16.3a, b). treatment.
All these habits could cause interferences with the cir- This 7-year, 6-month-old patient was sent to the office
cumoral musculature and, of course, cause the abnormal due to speech problems (Fig. 16.4a, b).
position of the tongue. The sooner they are corrected, the Adeno- and tonsillectomy was performed 8 months ear-
better the results (Castilho and Rocha 2009). lier, but tongue thrust and abnormal tongue posture were not
The main strategy is to eliminate these abnormalities as self-corrected as was visible on the frontal and profile smile
soon as possible (Ramirez Yañez and Paulo 2008). photographs.
During spring, she regularly suffered from asthma that
was treated with corticoids.
J. Harfin (*) The dental frontal photograph showed a significant open
Department of Orthodontics, Maimonides University,
Buenos Aires, Argentina
bite, with no midline dental deviation. The anterior position
of the tongue is clearly visible. Negative overjet and overbite
Health Sciences Maimonides University,
Buenos Aires, Argentina were present (Fig. 16.5a, b).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 451
J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_16
452 J. Harfin

a b

Fig. 16.1 (a, b) Position of the tongue at rest

a b

Fig. 16.2 (a, b) Anterior open bite in deciduous dentition (3 years old)

a b

Fig. 16.3 (a, b) Severe open bite due to thumb sucking. Flaring of the upper incisors and retrusion of the lower incisors are clearly visible
16 How to Avoid Long Term Relapse in Early Orthodontic Treatment 453

a b

Fig. 16.4 (a, b) Pretreatment frontal and profile smile photographs

a b

Fig. 16.5 (a, b) Pretreatment frontal dental photographs where the anterior position of the tongue is clearly visible

Class I molar and no posterior crossbite were observed on It is fabricated with a special type of polyurethane and helps
the lateral views (Fig. 16.6a, b). the correction and normalization of the muscular and tongue
The phase I treatment objective was to normalize overjet dysfunction (Fig. 16.7a, b). Since the material is soft, no
and overbite, maintain Class I molar, normalize tongue major problems of adaptation were present.
thrust, improve the activity of the lips, and enhance her pro- It is recommended that the appliance be used 2–3 h during
file (Torres et al. 2012). the day and then all night.
To achieve this objective, the use of a functional appliance These were the results after 7 months of treatment. No
was decided. The Myobrace System (Myofunctional more asthma attacks were reported by the mother 4 months
Research Co., Australia) was the best option for this patient. prior to that checkup.
454 J. Harfin

a b

Fig. 16.6 (a, b) Pretreatment lateral views with no posterior crossbite

a b

Fig. 16.7 (a, b) Myobrace System in place

The speech problems noticeably improved as well as the maintained. No other orthodontic appliance was recom-
anterior position of the tongue during swallowing and in mended during this phase of treatment.
resting position. Facial photographs taken 2 years after treatment during a
These results were confirmed when the smile photograph follow-up appointment showed that the patient could close
was observed (Fig. 16.8a, b). her lips without tension and a relaxed smile was present
Class I molar and lateral occlusion were maintained. The (Fig. 16.12a, b).
anterior open bite had improved and midlines were coinci- The profile and lateral smile photographs confirmed the
dent (Fig. 16.9a, b). results, and a double chin was not present (Fig. 16.13a, b).
Four months later (11 months of treatment), less interinci- It is important to highlight that all treatment goals were
sal diastema was present. Overjet and overbite were improved achieved: midlines were coincident with a beautiful smile.
and nasal breathing was totally recovered (Fig. 16.10a, b). Oral hygiene was still good (Fig. 16.14a, b).
The patient continued using the functional appliance Gingival and occlusal planes were parallel and no gingi-
(Myobrace) for 2–3 h a day and all night plus respiratory and val recessions were present (Fig. 16.15a, b). The treatment
tongue exercises. This appliance is very child-friendly and goals were totally achieved without the use of other
the results are predictable (Fig. 16.11a, b). Class I molar was appliances.
16 How to Avoid Long Term Relapse in Early Orthodontic Treatment 455

a b

Fig. 16.8 (a, b) After 7 months of treatment

a b

Fig. 16.9 (a, b) Lateral views after 7 months of treatment

All permanent teeth erupted in a normal position at the was recommended during the whole retention period
end of the treatment period (20 months). Upon analyzing the (Fig. 16.18a, b) (Ramirez Yañez and Paulo 2008).
upper and lower occlusal photographs, rounded and normal The comparison between the pre- and posttreatment pho-
arcades were confirmed. No cavities were present tographs clearly demonstrated that all objectives were
(Fig. 16.16a, b). obtained. The success achieved is based on the control and
The comparison between the pre- and posttreatment fron- monitoring of the breathing difficulties and tongue position
tal dental photographs demonstrates the normalization of the in concordance with the establishment of the neuromuscular
position of the tongue and the correction of the anterior open function (Fig. 16.19a, b).
bite (Fig. 16.17a, b). It is important to treat the causes of the malocclusion
No other appliance or brackets were required to achieve rather than only the symptoms. The patient and the parents
the expected results. A similar appliance (Myobrace System) must understand the real magnitude of the problem, and their
456 J. Harfin

a b

Fig. 16.10 (a, b) Frontal and upper occlusal views after 11 months of treatment

a b

Fig. 16.11 (a, b) Lateral views at this time of treatment

cooperation is a key factor in obtaining stable results and a The smile photograph confirmed a significant contraction
complete habit control. of the masseter muscles, more evident on the right side.
In our everyday clinical practice, deep bites are other Overbite was almost 100% in the incisor area in conjunction
very common types of malocclusion. The relationship with an uneven gingival line (Fig. 16.21a, b).
between significant deep bites in children with TMD distur- The pretreatment lateral views confirmed Class II molar
bances is acknowledged worldwide. This cause-effect rela- and canine. Retrusion of the upper central incisors were
tionship might cause posterior and superior displacement of clearly visible. The gingival line and occlusal plane were not
the condyle and, as a consequence, dysfunction and head- parallel (Fig. 16.22a, b).
aches, in conjunction with muscular and joint pain (Du and No crowding was present in the upper and lower arches,
Hagg 2003). although some dental rotations were present in the upper
The following patient is a clear example. He is a 7-year, arch (Fig. 16.23a, b).
9-month-old boy who was sent to the office due to some pain The treatment objectives included different aspects. It is
and TMJ clicking. important to consider not only the position of the teeth but
The frontal and profile photographs confirmed a reduced also the muscles and gingival and occlusal plane asymme-
lower third of the face compared to that in the middle side of try. Since TMD disturbances have a multifactorial etiology,
the face. The right side of the face was wider than that on the an exhaustive clinical exam is mandatory (Ramirez-Yañez
left side. The chin seemed to be retruded (Fig. 16.20a, b). et al. 2007).
16 How to Avoid Long Term Relapse in Early Orthodontic Treatment 457

a b

Fig. 16.12 (a, b) Final facial frontal photographs

a b

Fig. 16.13 (a, b) Profile and lateral smile photographs 2 years after treatment
458 J. Harfin

a b

Fig. 16.14 (a, b) Smile and frontal dental photographs after 2 years in retention

a b

Fig. 16.15 (a, b) Lateral views at the end of treatment. Gingival and occlusal planes were parallel

a b

Fig. 16.16 (a, b) Occlusal photographs at the end of treatment

16 How to Avoid Long Term Relapse in Early Orthodontic Treatment 459

a b

Fig. 16.17 (a, b) Comparison of frontal dental photograph pre- and posttreatment

a b

Fig. 16.18 (a, b) Myobrace System for the retention period

a b

Fig. 16.19 (a, b) Comparison of pre- and posttreatment photographs

460 J. Harfin

a b

Fig. 16.20 (a, b) Pretreatment frontal and profile photographs

a b

Fig. 16.21 (a, b) Smile and dental frontal photographs

16 How to Avoid Long Term Relapse in Early Orthodontic Treatment 461

a b

Fig. 16.22 (a, b) Pre lateral views. Retrusion of the central upper incisors was remarkable

a b

Fig. 16.23 (a, b) Pretreatment photographs of the upper and lower arches

Sometimes, the uneven occlusal plane is the consequence These are the results after 4 months of treatment: No more
and not the cause of the dental and facial asymmetries. pain or TMJ disturbances were present. Improvement in the
The panoramic and lateral radiographs confirmed the front area was clearly visible (Fig. 16.26a, b).
clinical observations: The patient had a severe brachyce- When analyzing the right and left sides, some modification
phalic pattern with reduced lower anterior height (35 in the molar and incisor areas were observed (Fig. 16.27a, b).
mm), Class II molar and canine, and significant overbite Some improvement was visible when the frontal and pro-
(7 mm) with no agenesis or supernumerary teeth file photos were analyzed (Fig. 16.28a, b).
(Fig. 16.24a, b). In order to continue his dental alignment and to normalize
In order to achieve the treatment objectives, a his overjet and overbite, the Trainer for Alignment Phase 2
Myofunctional protocol was advisable. The use of the was recommended. The time of use was similar to that of the
Myobrace System is highly recommended since it allows first case: 2–3 h a day and all night (Fig. 16.29a, b).
treatment of the main causes of these disorders. The following photographs explain how the appliance
The time schedule included 2 h during the day and all should be used very clearly. The frontal and lateral shields
night. This type of appliance is very child-friendly for the are useful to exercise the orofacial muscles and can improve
patient (Fig. 16.25). the potential of growth (Fig. 16.30a, b).
462 J. Harfin

a b

Fig. 16.24 (a, b) Pretreatment radiographic images

Fig. 16.25 Myobrace at the first stage

a b

Fig. 16.26 (a, b) Frontal and occlusal photographs after 4 months of treatment
16 How to Avoid Long Term Relapse in Early Orthodontic Treatment 463

a b

Fig. 16.27 (a, b) Lateral views after 4 months of treatment

a b

Fig. 16.28 (a, b) Frontal and profile photographs after 4 months of treatment
464 J. Harfin

a b

Fig. 16.29 (a, b) Trainer for Alignment (Myofunctional Research Co.)

a b

Fig. 16.30 (a, b) Frontal and lateral views with the T4A appliance in place

The following photographs showed the improvement The lateral facial photographs showed a significantly concave
after 12 months of treatment. Clinical enhancement of the profile with tension of the upper lip when the patient smiles. The
vertical dimension was advisable (Fig. 16.31a, b). lower third of the face was almost normal (Fig. 16.33a, b).
The following photographs showed improvement after 20 At this time, a new appliance was recommended in order
months of treatment using the same time protocol: 2–3 h dur- to maintain the results and control the musculature. The
ing the day and all night (including phase I and phase II). occlusion was stable (Fig. 16.34a, b).
Complete normalization of the overjet and overbite was The lateral views confirmed that Class I canine and molar
achieved (Fig. 16.31a, b). were maintained as well as a normal overjet and overbite
Since his family had moved, the patient returned to the (Fig. 16.35a, b).
office 3 years later. He had lost his last appliance weeks The occlusal photographs showed a normal arch form
­earlier. Although mild asymmetry was visible, TMJ prob- with no cavities nor periodontal problems (Fig. 16.36a, b).
lems nor important headaches were not present (Fig. 16.32a, It is interesting when pre- and 3 years’ posttreatment
b). Normalization of the overjet and overbite was main- frontal photographs are analyzed. Complete correction of the
tained. In order to maintain these positive results, a new uneven gingival line was achieved and a significant overbite
Myobrace appliance was suggested (Bakke and Moller and midlines were normalized with the use of the
1991) (Fig. 16.32a, b). Myofunctional appliances (Fig. 16.37a, b).
16 How to Avoid Long Term Relapse in Early Orthodontic Treatment 465

a b

Fig. 16.31 (a, b) Posttreatment frontal and occlusal maxillary photographs

a b

Fig. 16.32 (a, b) Front and smile photographs 3 years posttreatment

466 J. Harfin

a b

Fig. 16.33 (a, b) Lateral and smile photographs 3 years after treatment

a b

Fig. 16.34 (a, b) An adult Myobrace stage 1 was recommended to maintain the results
16 How to Avoid Long Term Relapse in Early Orthodontic Treatment 467

a b

Fig. 16.35 (a, b) Follow-up 3 years later

a b

Fig. 16.36 (a, b) Upper and lower occlusal arcades

a b

Fig. 16.37 (a, b) Comparison pre- and 3 years’ posttreatment photographs

468 J. Harfin

16.1 Conclusion alized for each patient. Long-term control is fundamental to

confirm the achieved results (Ramirez Yañez and Paulo
Ideally, open bite should be treated as early as possible. It is 2008).
important to consider that reminder therapy has to be applied
during the whole treatment and also during the retention
period (Graber 1963). References
Patients with open bite also have TMJ problems, episodes
of snoring, and sleep apnea disorders. The child can stop Bakke M, Moller E. Occlusion, malocclusion and craniomandibular
function. In: Melsen B, editor. Current controversies in orthodon-
breathing several times during the night (20–40 times per tics. Chicago: Quintessence; 1991. p. 77–102.
hour). As a consequence, he or she would feel daytime Castilho SD, Rocha MA. Pacifier habit: history and multidisciplinary
fatigue, sleepiness, headaches, changes in personality, lack view. J Pediatr. 2009;85:480–9.
of attention at school in the morning, etc. Cozza P, Mucedero M, Baccetti T, Franchi L. Early orthodontic treat-
ment of skeletal openbite malocclusion: a systematic review. Angle
Since sleep apnea is a progressive disorder, consultation Orthod. 2005;75:707–13.
with the specialist is very important from the first day in Du X, Hagg U. Muscular adaptation to gradual advancement of the
order to perform a multi- and interdisciplinary treatment and mandible. Angle Orthod. 2003;73:525–31.
avoid relapse. English JD. Early treatment of skeletal openbite malocclusions.
AJODO. 2002;121:563–5.
There is no doubt that early intervention of all oral habits Graber TM. The “three Ms”: muscles, malformation and malocclusion.
can reduce or prevent major problems in the future. It is AJO. 1963;49:418–50.
advisable that open bites be treated as soon as possible to Hepper PG, Wells DL, Lynch C. Prenatal thumb sucking is related to
reinstate normal breathing function and reduce the possibil- postnatal handedness. Neuropsychologia. 2005;43:313–5.
Huang GL. Long term stability of anterior open bite therapy: a review.
ity of relapse (Urzal et al. 2013). The parents and the chil- Semin Orthod. 2002;8:162–72.
dren have to be aware and cooperate to achieve excellent Ngan P, Fields HW. Openbite: a review of etiology and management.
results. There is no complete evidence between the relation- Pediatr Dent. 1997;19:91–8.
ship of deepbite malocclusion and TMD problems, but clini- Posen AL. The influence of maximum perioral and tongue force on the
incisor teeth. Angle Orthod. 1972;42:285–309.
cal association is inevitable. Ramirez Yañez G, Paulo F. Early treatment of Class II division 2 maloc-
Despite the type of appliance used, the orthodontist has to clusion with the Trainer for Kids T4K: a case report. J Clin Pediatr
bear in mind the importance of the multifactorial etiology of Dent. 2008;32:325–30.
temporomandibular problems and to normalize its function Ramirez-Yañez G, Sidlauskas A, Junior E, Fluter J. Dimensional
changes in dental arches after treatment with a prefabricated func-
to achieve long-term results (Posen 1972). tional appliance. J Clin Pediatr Dent. 2007;31:279–83.
There is strong evidence that the earlier the open bite Torres FC, Rodriguez de Ameida R, Rodriguez de Ameida Pedrin R,
and deep bite problem is corrected, the better the prognosis Pedrin F, Paranhos RL. Dentoalveolar comparative study between
will be. removable and fixed cribs, associated to chin cup, in anterior open
bite treatment. J Appl Oral Sci. 2012;20:531–7.
Habit elimination is mandatory to prevent not only open Urzal V, Braga AC, Ferreira AP. Oral habits as risks factors for anterior
bite but deep bite relapse (Ngan and Fields 1997). It is impor- openbite in the deciduous and mixed dentition-cross section study.
tant to look for an effective protocol that should be individu- Eur J Paediatr Dent. 2013;14:299–302.
 Controversies in Cleft Lip / Palate
Patients 17
Julia Harfin

Different controversies are present during the cleft lip palate required and expected long-term results are achieved (Yen
treatment. Some are related to pre- and postsurgical issues et al. 2005). This new protocol is recommended as the first
and others to the individualized treatment plan. option to avoid failures when different surgeries to close
Treatment alternatives for uni- or bilateral missing lateral important palatal clefts with a secondary bone graft were
incisors in patients with cleft palate are space closure or performed.
opening for their replacement by fixed or removable prosthe- The following clinical case is presented to illustrate this
sis. Due to the lack of bone in this, area implants without protocol. A 14-year-old patient was sent to the office in
bone graft are not always the best option. Closing the alveo- search of a second opinion to improve the substantial palatal
lar bone defect is a necessary step in order to restore the cleft. His dental clinical records showed five previous sur-
alveolar arch and achieve a normal occlusal pattern. An geries: at 5 months, 14 months, 4 years, 6 years, and 12 years
exhaustive and individualized diagnosis and treatment plan of age, including two bone grafting procedures. Two months
significantly improves the results with more predictable earlier, another soft palatal tissue surgery was performed and
outcomes. some sutures were still in place (Fig. 17.1a).
It is recognized that secondary alveolar bone grafting is Figure 17.1a shows the situation at that time: the upper
usually done before the eruption of the permanent maxillary midline was completely displaced to the left along with the
lateral incisor or canine in order to achieve alveolar continu- central and lateral upper incisors.
ity and adequate closure of the fistula. The rate of success The lateral photograph confirmed the significant cleft
varies between 35 and 86%. The rate of complications present on the right side (Fig. 17.1b).
includes exposure of the graft associated with infections or A new treatment plan was designed taking into account
resorption, and more than 50% of patients require a reopera- studies from Allan Fontanelle and Bjorn Zachrisson about
tion procedure (Meireles Borba et al. 2014; Feichtinger moving teeth into an edentulous region. Bearing in mind that
et al. 2007). teeth can move with bone when lower forces are used and
This new protocol was designed to avoid another surgery through bone when high forces are planned and considering
such as iliac crest bone or other types of grafts using the that some bone was present mesial to the upper right canine,
same concepts periodontists use to gain osseous height and the following biomechanics was decided.
width before implants are placed (Zachrisson 2003). A Ni-Ti coil spring on a TMA rectangular wire
This procedure also increases the efficiency of treatment (0.016″ × 0.022″) was placed with a very low load activation
by reducing the number of surgeries. Bearing in mind that to promote its mesialization along with bone (Fig. 17.2a, b).
closing the alveolar bone defect is one of the outcomes to A very low 2-month activation was recommended.
achieve and knowing all the consequences that these surgical Analyzing the occlusal photo, it is easy to observe that new
procedures can produce, the new protocol plays an important bone is formed distal to the canine with new soft tissue that
role. This protocol is very easy to manage and control in all is clearly recognizable due to its texture and color. Despite
patients no matter the age or sex. No further surgeries are some canine mesialization, a substantial palatal cleft is still
present. Brackets were bonded on the lower arch to align the
occlusal plane (Fig. 17.3a, b).
J. Harfin (*) Using the same biomechanics, the canine continued mov-
Department of Orthodontics, Maimonides University,
Buenos Aires, Argentina
ing mesially after 10 months of treatment. The gingivo-­
periodontal tissue accompanied the mesial canine movement,
Health Sciences Maimonides University,
Buenos Aires, Argentina and as a result, the cleft size decreased (Fig. 17.4a, b).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 469
J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_17
470 J. Harfin

a b

Fig. 17.1 (a, b) Significant palatal cleft with a severe midline displacement to the left side

a b

Fig. 17.2 (a, b) Use of a coil spring to mesialize the canine

a b

Fig. 17.3 (a, b) Occlusal and lateral views after 5 months of treatment
17 Controversies in Cleft Lip / Palate Patients 471

a b

Fig. 17.4 (a, b) After 10 months in treatment

a b

Fig. 17.5 (a, b) Occlusal and lateral views after 15 months

After 15 months of treatment, the canine is near the lateral It should be noted that orthodontic tooth movement is a
incisor and there is a significant improvement in the palatal process by which the tooth is moved by the application of a
cleft area (Fig. 17.5a, b). force that induces bone deposition on the tension side and
Four months later, almost the whole alveolar cleft was resorption on the compression side.
closed, and new bone, surrounded by normal gingivo-­ These results are clearly visible when pre- and posttreat-
periodontal tissue, was created (Fig. 17.6a, b). ment panoramic radiographic images are compared. It is
The comparison between pretreatment and current palatal interesting to observe the shape of the roots of the right and
photographs clearly demonstrates how the palatal cleft was left upper lateral incisors. A complete alignment and leveling
closed. Also, it confirms the total mesialization of the right of the occlusal plane was achieved (Fig. 17.8a, b).
canine and the new bone that was developed distally. This Normal bone width and height were created distal to the
new bone has an ideal height and width that are necessary for upper right canine without any other bone graft procedure
future implants or prosthesis. A new soft tissue surgery was and in a very predictable way. The following radiographic
performed to close the remaining cleft (Fig. 17.7a, b). images confirm the results (Fig. 17.9a, b).
472 J. Harfin

a b

Fig. 17.6 (a, b) After 14 months, the alveolar cleft was closed

a b

Fig. 17.7 (a, b) Occlusal view of pre- and post-mesialization of the canine and after the last soft tissue surgery

a b

Fig. 17.8 (a, b) Comparison pre- and posttreatment panoramic radiographic images. The alignment and levelling of the occlusal plane were
accomplished
17 Controversies in Cleft Lip / Palate Patients 473

a b

Fig. 17.9 (a, b) Posttreatment radiographic images. The achieved new bone distal to the upper right canine as well as the closure of the right cleft
was confirmed

It is important to highlight all the improvements seen gingivo-periodontal tissues that otherwise are very difficult
when the right and left side clefts were compared. Closure of to obtain. Long-term follow-up is needed to maintain the
the right cleft is almost complete. The cone bean clearly achieved results.
showed the amount of bone distal to the canine.

References
17.1 Conclusions
Feichtinger M, Mossbock R, Karcher H. Assessment of bone resorption
after secondary alveolar bone grafting using 3 D computer tomogra-
This new protocol is very useful to treat patients with severe phy. Cleft Palate Craniofac J. 2007;44:142–8.
cleft palate deformities along with large cleft spaces. There Meireles Borba A, Borges AH, Da Silva CSV, Brozoski A, Miloro
are few complications and many benefits. No morbidity B. Predictors of complication for alveolar bone graft. Br J Maxillofac
associated with grafting large alveolar clefts and new and Surg. 2014;52:174–8.
Yen SL, Yamashita DD, Gross J, et al. Combining orthodontic tooth
healthy bone is generated. movement with distraction osteogenesis to close cleft spaces
The treatment of patients with cleft lip and palate requires and improve maxillary arch form in cleft lip and palate patients.
a multidisciplinary team beginning at pregnancy and con- AJODO. 2005;127:224–32.
tinuing during childhood and adolescence. This approach Zachrisson BU. Implant site development by horizontal tooth move-
ment. World J Orthod. 2003;4:266–72.
introduces a new paradigm in treating this type of patients,
since it is possible to create new bone surrounded by normal
 Controversies Concerning Early
Treatment 18
Julia Harfin and Kurt Faltin Jr

Why are controversies in early treatment a continuous topic that can suit all patients alike. Nonetheless, different
in all worldwide meetings after more than 100 years? Will it approaches of treatment are available depending on etiologi-
be solved in the next 10 years? The first question to answer cal factors.
would be: Is it really an efficient and effective method of What are the risks, costs, and benefits of early orthodontic
treatment? Yes, it is, respecting the biological sequence of treatment? The answer for this question is a correct diagnosis
priorities stablished through a complete diagnosis. and a profound knowledge of craniofacial and dental devel-
Unfortunately, there is not only one answer, since every opment. It is important to remember that some malocclu-
patient is unique. Their malocclusion is the result of the devi- sions are best treated early for biological, functional, and
ation of skeletal, dental, and neurophysiological problems social reasons. The normalization of function and the possi-
along with different directions and amount of growth. bility to redirect growth is the best option. One of the most
An individualized diagnosis is the criteria of decision for common controversies in the early mixed dentition is how,
which type of cases should be treated by the clinician to offer when, and why patients should be treated in one, two, three,
the best option for each individual patient. Since a consider- or more phases.
able amount of growth occurs during the transitional period, The problem in orthodontics is to move teeth in harmony
it is a real advantage to begin skeletal correction during this with the face and keep them stable after treatment. (Horn)
period and avoid worsening of the problem, especially when The transition from mixed to permanent dentition is an
craniofacial dysfunctions are present. important period in orthodontic decision-making. This stage
It is important to emphasize that the early treatment stage is the most important due to the unique opportunity in using
does not avoid a second phase of treatment but surely reduces the prepubertal growth spurt.
its length and complications. Therefore, many incipient mal- There are no doubts about the early correction of anterior
occlusions could be prevented since they are affected by or posterior crossbite in order to prevent further and more
environmental factors. The interaction between the perioral complicated malocclusions. The normalization of the posi-
musculature and orofacial structures determines the future tion and inclination of the incisors and molars are closely
occlusion. related to the direction of growth of the maxilla and mandi-
The need to control oral habits such as mouth breathing, ble, no matter the type of appliance used. Numerous papers
tongue thrust swallowing, and finger or lip interposition dur- confirmed this approach, (Mandal, Sugawara) although oth-
ing rest or function plays an important role. Cooperation ers suggested waiting until the post-peak of growth to solve
between the patient and the parents in combination with the all problems in only one stage. More extractions or orthogna-
speech therapist is fundamental when the treatment plan has thic procedures would be the answer.
to be determined. Unfortunately, there is no single appliance Before deciding on the final treatment plan, it is important
to determine the etiology, severity, and nature of the prob-
J. Harfin (*) lem. It is important to determine how long the child has had
Department of Orthodontics, Maimonides University, this habit, when the habit took place (day, night, or all day),
Buenos Aires, Argentina
and the willingness of the child to correct it. The following
Health Sciences Maimonides University, examples show the importance of beginning the treatment as
Buenos Aires, Argentina
soon as possible and, in this way, to reduce further inconve-
K. Faltin Jr niences and, in some cases, avoid extractions and/or orthog-
Department of Orthodontics and Face Orthopedics, University
nathic surgery, no matter the severity of the initial Class II or
Paulista (UNIP), Sao Paulo, Brazil
e-mail: [email protected]; http://www.faltin.odo.br III problem.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 475
J. Harfin et al. (eds.), Clinical Cases in Early Orthodontic Treatment, https://doi.org/10.1007/978-3-030-95014-9_18
476 J. Harfin and K. Faltin Jr

The next clinical case is a clear example of the impor- was fairly good. The lower lateral incisors were lingually
tance of a two-stage treatment. She was 8 years, 9 months positioned in the lower arch.
old and was sent to the office for a second opinion regarding The lateral photographs confirmed a significant overjet
the best moment to begin the correction of her occlusion. She (8 mm), which is an important risk factor in the fracture of
had recurring colds in concordance with episodes of high maxillary incisors at school or at home (Fig. 18.3a, b). A
fever and asthma attacks. The odontopediatrician recom- considerable overbite was also present. The lower incisors
mended that the best time to begin orthodontic treatment was were in contact with the palatal tissues.
when the second molars have erupted, and with this protocol, The pretreatment occlusal photographs showed rounded
only one phase would be needed. Early consultation with the arcades with diastemas in the upper arch and slight crowding
maxillofacial surgeon was also recommended. in the lower arch. No caries or periodontal problems were
The facial photographs showed a convex profile with a present (Fig. 18.4a, b).
short upper lip and the impossibility to close her mouth at rest The panoramic radiographic image demonstrated normal
position. The lower lip was behind the upper incisors. The sequence of eruption of the permanent teeth according to her
nasolabial angle was acute and the mandible was totally age. No agenesis or supernumerary teeth were present
retruded. An early consultation with the otorhinolaryngologist (Fig. 18.5a). The lateral radiographic image clearly showed
is strongly advisable, since oral respiration and nasal obstruc- considerable protrusion of the upper incisors in concordance
tion are common findings among orthodontic patients. An with the protrusion of the upper lip (Fig. 18.5b).
abnormal respiratory function can affect craniofacial growth Taking into account that functional problems had to be
and produce or enhance malocclusions. Early intervention is normalized first, the following treatment plan was designed:
mandatory to reduce the risk of fracture of the upper incisors (a) normalization of the position of the first molar since it is
and from the psychological aspect too (Fig. 18.1a, b). easier before the eruption of the second molar and (b) correc-
The upper and lower incisors had fully erupted and some tion of habits as soon as possible to facilitate tooth eruption
diastemas were present in the upper arch. The interincisal in a normal position and allow the normal development of
upper papillae was absent (Fig. 18.2a, b) and oral hygiene the mandible. Habits needed to be corrected as early as pos-

a b

Fig. 18.1 (a, b) Pretreatment frontal and profile photographs. A significant convex profile with a short upper lip was confirmed in concordance
with the position of the lower lip behind the upper incisors
18 Controversies Concerning Early Treatment 477

a b

Fig. 18.2 (a, b) Frontal photographs at the beginning of treatment. An upper interincisal diastema was present

a b

Fig. 18.3 (a, b) Significant overjet and overbite were confirmed along with Class I molar and a significant overbite with retroposition of the lower
incisors

a b

Fig. 18.4 (a, b) Upper and lower pretreatment rounded arches

478 J. Harfin and K. Faltin Jr

a b

Fig. 18.5 (a, b) Pretreatment panoramic and lateral radiographic images. The protrusion of the upper incisors was confirmed as well as the signifi-
cant overbite

a b

Fig. 18.6 (a, b) A pendulum was bonded to normalize the position of the first molars in conjunction with esthetic brackets on the central incisors
to close the interincisal diastema

sible to reestablish the normality in the maxilla and mandib- 0.016″ SS archwire to normalize their position and inclina-
ular direction of growth, as well as reduce the length of the tion (Fig. 18.7a, b).
second phase of treatment. Among all the factors that had to In order to maintain the anteroposterior position of the
be considered, the most significant were determining the best upper first molars, a Nance button was recommended. Upper
treatment plan and the enhancement of the profile with facial and lower utility arches (Elgiloy 0.016″ × 0.016″) were
balance and long-term stability. placed to normalize overjet and overbite. All anterior diaste-
It is well known that normalization of the position of mas were closed and the position and inclination of the upper
the first molar is easier before the eruption of the second incisors improved (Fig. 18.8a, b).
molar. To achieve this objective, a pendulum was bonded After the eruption of the bicuspids, two lingual brackets
along with esthetic brackets on the central incisors to close were bonded on the palatal surfaces of the upper central inci-
the interincisal diastema that was one of her parents’ con- sors along with an 0.018″ SS archwire with two vertical
cerns. An 8-week activation period was suggested loops distal to the upper lateral incisors to improve the pre-
(Fig. 18.6a, b). treatment overjet and overbite (Fig. 18.9a, b).
After the distalization of the second temporary molars, Lateral views with the same arch in place. Class I molar
brackets were bonded on the upper lateral incisors with a and canine were achieved. To maintain Class I canine and
18 Controversies Concerning Early Treatment 479

a b

Fig. 18.7 (a, b) The second temporary molars were completely distalized and the anterior diastemas were closed with a ligature-of-eight on a
0.016″ SS archwire

a b

Fig. 18.8 (a, b) A Nance button in place to maintain the new position of the right and left first molars with upper and lower utility arches to help
the normalization of the overjet and overbite

a b

Fig. 18.9 (a, b) An 0.018″ SS archwire with two vertical loops was placed to achieve normal overjet and overbite after the eruption of the bicus-
pids. Also, two lingual brackets were bonded on the palatal surfaces of the central incisors
480 J. Harfin and K. Faltin Jr

molar, ligature-of-eight was used between the cuspids and of the lower third of the face was remarkable (Fig. 18.14a, b).
first molars (Fig. 18.10a, b). All treatment objectives were fulfilled.
The results after the active orthodontic treatment con- The same results were observed when the profile photo-
firmed the normalization of the overjet and overbite. All the graphs were compared. Since the orofacial functions were
diastemas were closed and midlines were coincident. The normalized, the change in the position and length of the
gingival line and occlusal plane were parallel (Fig. 18.11a, b). upper lip was remarkable (Fig. 18.15a, b).
Class I canine and molar were achieved with normal occlu- The pre- and posttreatment lateral radiographic images
sion in the bicuspid area. The patient maintained good oral confirmed the theory that when function is normalized, the
hygiene during the entire treatment process (Fig. 18.12a, b). soft and hard tissues will develop in the normal direction.
At final frontal and lateral photographs taken 2 years after Since the radiographic images were taken in different insti-
treatment, the patient was able to close her lips without any tutes, it was impossible to compare the tracings of the two
muscular strain. She had a straight profile with a normal cephalographic images (Fig. 18.16a, b).
nasolabial angle, as a consequence she became a nose It is highly recommended to correct deepbite malocclu-
breather (Fig. 18.13a, b). sion early on because the unfavorable consequences of an
The comparison of the pre- and posttreatment photo- untreated deepbite include an increase in lower anterior
graphs clearly demonstrates the importance of early treat- crowding, maxillary dental flaring, and associated periodon-
ment with better patient and parent compliance. Improvement tal breakdown. (Franchi) In this patient, the normalization of

a b

Fig. 18.10 (a, b) Right and left sides with the double-loop arch in place. Class I canine and molar were maintained

a b

Fig. 18.11 (a, b) Final frontal and occlusal photographs. All treatment objectives were fulfilled, and midlines were almost coincident
18 Controversies Concerning Early Treatment 481

a b

Fig. 18.12 (a, b) Right and left Class I molar and canine at the end of the active treatment

a b

Fig. 18.13 (a, b) Frontal and profile photographs 2 years after treatment. The patient was able to close her lips without any strain

the deepbite and the correction of lower anterior crowding After 24 months, the frontal and lateral dental photo-
were noticeable (Fig. 18.17a, b). graphs confirmed that all treatment objectives were fulfilled:
Follow-up 2 years later confirmed that the achieved results the overjet and overbite as well as the frontal and lateral
were maintained. As expected, the profile was slightly occlusion were normalized (Fig. 18.19a, b).
straighter and she could easily close her mouth. Not only was One of the main objectives of early treatment is the cor-
there a significant improvement in function, but also in facial rection of abnormal oral habits since oral function and the
esthetics (Fig. 18.18a, b). growth and development of the face are closely interrelated.
482 J. Harfin and K. Faltin Jr

a b

Fig. 18.14 (a, b) Comparison of frontal photographs pre- and posttreatment. The normalization of the lip seal, as well as the musculature in the
lower third of the face, was significant

a b

Fig. 18.15 (a, b) Pre- and posttreatment profile photographs. There was considerable improvement in the middle and lower third of the face
18 Controversies Concerning Early Treatment 483

a b

Fig. 18.16 (a, b) Pre- and posttreatment lateral radiographic images. The changes in the anterior occlusion and profile were evident

a b

Fig. 18.17 (a, b) Class I molar and canine were maintained and overjet and overbite were clearly normalized

(Bahreman) It has been shown that many deformities caused The following patient is a clear example of this protocol.
by muscle dysfunction during primary and mixed dentition She was an 8-year, 3-month-old girl who was sent to the
are not self-corrected and become worse during permanent office looking for an appliance to protect her upper incisors
dentition. since they had been chipped in a bicycle-related accident. No
It is important to remember that the early elimination of significant medical history was present until that point. One
bad habits is one of the most significant treatment objectives of the most important things to consider was the interposi-
to achieve during this stage. Finger- and lip-sucking habits tion of the lower lip behind the upper incisors along with a
have to be corrected as soon as possible. Their persistence convex profile. Also, she was a mouth breather with a short
beyond 4 years of age is considered a chronic nonnutritive upper lip and a slight facial asymmetry (Fig. 18.20a, b). It is
habit and needs to be corrected before it causes a negative well known that mouth breathing can have an adverse effect
impact on dental occlusion and facial esthetics (Bahreman). on the maxillary structure and its relation with the position of
484 J. Harfin and K. Faltin Jr

a b

Fig. 18.18 (a, b) Results 2 years after treatment. The patient easily closed her mouth and the lip seal was totally relaxed

a b

Fig. 18.19 (a, b) Follow-up after 24 months corroborated that all treatment objectives were maintained

the mandible. Also, the reduction of the protrusion of maxil- The frontal dental photographs confirmed a consider-
lary incisors reduces the chance of incisor trauma. Dry lips able overbite and proclination in the central incisor region
and dark circles under the eyes are also visible. The ­treatment and extrusion of the lower incisors. Midlines were not
plan was determined considering the correction of bad hab- coincident (Fig. 18.21a, b). Excessive anterior overlap of
its, improvement in oral function, and facial esthetics. the incisors is a common malocclusion that is difficult to
18 Controversies Concerning Early Treatment 485

a b

Fig. 18.20 (a, b) Pretreatment frontal and profile photographs. Mouth breathing and the interposition of the lower lip behind the upper incisors
were visible

a b

Fig. 18.21 (a, b) A considerable overbite and overjet were confirmed in the central incisor region with no coincident midlines

solve and causes delays in treatment as well as skeletal lower canine was suggested to normalize the position of the
problems. lower right lateral incisor (Fig. 18.22a, b).
Upon observing the periapical radiographic image, the To improve the position of the partially transposed right
transposition of the lower lateral incisor and temporary right lateral incisor, a Ni-Ti open coil spring was used with bands
canine was confirmed. Extraction of the temporary right on the temporary second molars and preprogrammed brack-
486 J. Harfin and K. Faltin Jr

a b

Fig. 18.22 (a, b) The transposition of the right lateral and right canine is clearly visible

a b

Fig. 18.23 (a, b) To mesialize the crown of the lateral right lower incisor, an open coil spring was placed on the lower right side in conjunction
with an upper quad helix to improve the position of the upper left lateral incisor

ets were placed on the lower incisors (Fig. 18.23a). An upper The posttreatment facial photographs clearly showed
quad helix was placed to normalize the upper arch size and how the soft tissues accompanied the positive upper and
the position of the upper left lateral incisor, with a monthly lower dental changes. The patient could close her lips prop-
activation (Fig. 18.23b). erly and her profile was straight (Fig. 18.26a, b). The
Six months later, preprogrammed 0.022″ brackets were advantage of early treatment is to enable the normal erup-
used along with upper and lower utility arches (Elgiloy tion of the upper and lower canines and bicuspids in order
0.016″ × 0.016″) to correct incisor protrusion and excessive to minimize the dentoalveolar discrepancies that can affect
overbite (Fig. 18.24a, b). normal growth and development. No extraction was needed
These were the results 9 months later. Class I canine and to achieve Class I molar and canine with a normal overjet
molar were achieved and overjet and overbite were normal- and overbite.
ized. Midlines were coincident and occlusal plane and gingi- There were no major changes in follow-up 3 years later.
val lines were parallel (Fig. 18.25a, b). Also, oral hygiene Overjet and overbite, as well as Class I canine and molar,
improved. were maintained stable (Fig. 18.27a, b). The gingival line
18 Controversies Concerning Early Treatment 487

a b

Fig. 18.24 (a, b) Upper and lower utility arches (0.016″ × 0.016″ Elgiloy wire) to normalize anterior overjet and overbite

a b

Fig. 18.25 (a, b) Results at the end of the active orthodontic treatment. All treatment objectives were achieved including the parallelism of the
occlusal plane

and occlusal plane maintained their parallelism and excellent The Rickets cephalometric superimposition demonstrated
oral hygiene was present. the differences pre- and posttreatment (Fig. 18.30).
The facial photographs accompanied the normal growth Anterior crowding is another malocclusion that should be
according to her age and facial biotype (Fig. 18.28a, b). treated in mixed dentition, especially when it is present in the
The comparison between the pre- and posttreatment pro- lower arch. One of the primary reasons could be a negative
files demonstrated the significant reduction in lip protrusion discrepancy between the primary and permanent teeth, which
and decreased mentalis strain. Another benefit of early orth- could be the result of different morphologic and etiological
odontic intervention in these patients is improved self-esteem factors.
(Fig. 18.29a, b). The space deficiency can be divided into slight, mild, or
These findings clearly demonstrated that excellent long-­ severe and is the result of the tooth size-arch size discrep-
term results were achieved when orthodontic treatment was ancy. One of most common situations is when a temporary
provided to patients who were 6–9 years old and had promi- canine falls out as a consequence of the distal eruption of the
nent front teeth. The best time for early intervention is during lateral incisor. The lower incisors erupt without apparent
the early mixed dentition. crowding but result in the shifting of the midline to the side.
488 J. Harfin and K. Faltin Jr

a b

Fig. 18.26 (a, b) Frontal and profile photographs at the end of the active orthodontic treatment. The patient could close her lips without any
tension

a b

Fig. 18.27 (a, b) Frontal and right lateral photographs during a follow-up 3 years later

Controversy exists on the best time to begin treatment, to opment is vital for timing interceptive procedures. (Graber)
avoid major problems such as the mesialization of the poste- It is recommended that every child have orthodontic appoint-
rior teeth in combination with the distalization of the anterior ment at 7 years of age for the diagnostic assessment of a
teeth and the consequent loss of space for the permanent potential malocclusion. As soon the lack of space is detected,
canines and bicuspids. it is important to determine the best treatment option for the
A guided eruption protocol would be the best option patient.
according to the individual facial biotype and quantity of The next patient is a clear example of this protocol. He
growth. Soft tissue analysis plays an important role too. The was sent to the orthodontic office for left temporary canine
decision is always based on what is best for the patient with extraction for the central midlines to coincide. Lack of space
efficient mechanotherapy and long-term stable results. for the eruption of the right lower canine was clearly observed
Moreover, through knowledge on tooth formation and devel- in the panoramic radiographic image (Fig. 18.31) along with
18 Controversies Concerning Early Treatment 489

a b

Fig. 18.28 (a, b) Facial photographs 3 years later confirming normal maxillary and mandibular development

a b

Fig. 18.29 (a, b) Significant changes were achieved in the dentoskeletal and soft tissues. The results were better than expected. No upper extrac-
tions were needed to improve the profile
490 J. Harfin and K. Faltin Jr

a significant overbite. A careful study of the leeway space

(difference between the primary and permanent teeth in the
lateral region) was performed.
The right lateral and lower occlusal photographs showed
Class I molar on the right side with midline displacement of
the permanent mandibular incisors to the right (Fig. 18.32a, b).
In order to recover the necessary space for the lower right
canine and bicuspids, sequential stripping of the temporary
molars helped control the leeway space. The second tempo-
rary molars were banded to protect the permanent first molars
(Fig. 18.33a). Three months later, the right canine and first
bicuspid began their path of eruption (Fig. 18.33b). A 0.016″
SS archwire was placed to maintain the lower arch length.
There are several approaches to improve or maintain the
lower arch length and, as a consequence, to avoid future per-
manent extractions. The following protocol was chosen since
it is considered to be the most conservative in this particular
patient. To normalize the discrepancy between the temporary
Fig. 18.30 Pre- and posttreatment Ricketts superimposition where the and permanent bicuspids and canine, a 0.016″ × 0.016″ SS
changes were clearly visible archwire with active Ni-Ti coil springs was placed on the
right and left sides (Fig. 18.34a, b). A 6-week activation was
highly recommended.
Six months later, all the lower cuspids and bicuspids
erupted and bands were placed on the permanent first molars
in conjunction with brackets on the canines to normalize
their position (Fig. 18.35a, b).
Class I molar and canine were achieved 6 months later.
Overjet and overbite were within normal parameters. No
brackets were bonded to the upper arch during the whole
treatment (Fig. 18.36a, b). It is advisable to place a fixed
retainer wire between the right and left lower canines and
Fig. 18.31 Pretreatment panoramic radiographic image. The lack of maintain it in place for a long period of time in order to avoid
space for the eruption of the lower right canine was confirmed anterior crowding relapse.

a b

Fig. 18.32 (a, b) Pretreatment lateral and lower occlusal photographs. The lack of space for the eruption of the right lower canine was evident
18 Controversies Concerning Early Treatment 491

a b

Fig. 18.33 (a, b) Comparison between the two stages of treatment. Bands on the secondary temporary molars were placed to maintain the lower
initial arch length. Right canine and first bicuspid during their eruption path

a b

Fig. 18.34 (a, b) A 0.016″ × 0.016″ SS archwire with a right and left Ni-Ti coil spring activated every 6 weeks was placed to maintain lower arch
length

a b

Fig. 18.35 (a, b) Esthetic brackets were bonded on the right and left canines to normalize their position
492 J. Harfin and K. Faltin Jr

a b

Fig. 18.36 (a, b) Lateral and lower occlusal photographs at the end of treatment. Class I molar and canine with normal overjet and overbite were
achieved

a b

Fig. 18.37 (a, b) Pre- and posttreatment panoramic radiographic images. All treatment objectives were fulfilled

The comparison between the pre- and posttreatment pan- 18.1 Conclusions
oramic radiographic images clearly demonstrated the
obtained results. All spaces for the right canine were recov- It is widely accepted that early treatment does not avoid a sec-
ered and midlines normalized (Fig. 18.37a, b). ond phase of treatment. However, it reduces its length and
Treatment planning is the result of a profound diagnosis complications. The timing of treatment interventions was
for each particular patient. Some crowding can be corrected influenced by the severity of the malocclusion and the age and
with occlusal guidance and space supervision. The real maturation of the patient at the start of treatment. (JANG)
­question is how to identify the problem and manage the dif- Although some support the idea that all treatment goals can be
ferent situations to effectively obtain the best result. The accomplish in only one phase of treatment, it was demon-
preservation of the e-space to maintain or even improve the strated by the authors that in some clinical cases, early inter-
length of the lower arch and guide the eruption of the cuspids vention may reduce treatment time and the need for complex
and bicuspids is highly essential. The protocol has to be indi- orthodontic treatment, which includes permanent tooth extrac-
vidualized for each patient according the facial biotype and tion or orthognathic surgery. Unfortunately, there is no single
amount of skeletal and dental discrepancies in concordance bracket that produces more growth than others, and it is con-
with facial esthetics. The early mixed dentition period plays firmed that early treatment is the best option to improve some
an important role in the first phase of treatment since major malocclusions from a functional and esthetic point of view.
changes occur during this period. There are no doubts about Orthodontists need to understand that the timing to initiate
the importance of the normalization of the direction of orthodontic treatment is different based on the type of maloc-
growth during this phase of treatment. clusion and in this way maximize the effectiveness of the long-
18 Controversies Concerning Early Treatment 493

term results. (DiBiase) There are no “recipes” that can be used Franchi L, Baccetti T, Giuntini V, Masucci C, Vangelisti A, Defraia
E. Outcomes of two-phase orthodontic treatment of deepbite maloc-
for all patients alike, since the answer is an individualized
clusions. Angle Orthod. 2011;81:945–52.
treatment plan no matter the type of appliance that is chosen Gianelli A. One-phase vs two-phase treatment. AJODO.
by the orthodontist. More consensus among clinicians about 1995;108:556–9.
one- or two-stage treatment is necessary, but it is important to Graber T. Mixed dentition guidance of occlusion. Serial extrac-
tion procedures in Bishara Samir. In: Textbook of orthodontics.
remember that the answer is an accurate diagnosis. It is impor-
Philadelphia: WB Saunders; 2001. p. 257–89.
tant to note that over the past three decades, parents are more Horn A, Thiers-Jegou I. Class II deep bite faces One phase or two-phase
involved and more interested in early treatment, especially in treatment? WJO. 2005;2:171–9.
orthodontic patients. The family dentist has a substantial role Jang JC, Fields HW, Vig KW, Beck FM. Controversies in the timing of
orthodontic treatment. Semin Orthod. 2005;11(3):108–11.
during this challenging phase. The keys to success in early
King GJ, McGorray SP, Wheeler TT, Dolce C. Taylor Comparison of
treatment include a correct diagnosis, comprehensive treat- peer assessment ratings (PAR) from 1-phase and 2-phase treatment
ment plan, and continued active supervision until the eruption protocols for Class II malocclusions. AJODO. 2003;123(5):489–96.
of the permanent dentition (Dugoni).The more dentition is Littlewood S, Nute S, Stivaros N, McDowall R, et al. Is early Class
III protraction facemask treatment effective? A multicentre,
monitored, the better long-term results can be achieved.
randomized, controlled trial: 15-month follow-up. J Orthod.
2010;37:149–61.
Mandall N, DiBiase A, Littlewood S, Nute S, Stivaros N, McDowall
Suggested References R, et al. Is early Class III protraction facemask treatment effective?
A multicentre, randomized, controlled trial: 15-month follow-up. J
Orthod. 2010;37:149–61.
Bahreman A. Early age orthodontic treatment. Chicago: Quintessence;
Sugawara J, Asano T, Endo N, Mitani H. Long-term effects of chin-
2013.
cap therapy on skeletal profile in mandibular prognathism. AJODO.
DiBiase A. The timing of orthodontic treatment. Dental Update.
1990;98:127–33.
2002;29:434–41.
Dugoni S, Lee J, Varela J, Dugoni A. Early mixed dentition treatment:
post-retention evaluation of stability and relapse. Angle Orthod.
1995;65:311–20.