Ortho Management of Adult Anterior Open-bite Part 1

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Posted on By Maurice Salama In Orthodontics

Patient presents with Class 2 bi-maxillary protrusion, anterior open-bite and tongue thrust. Some perio issues remain. Patient told by other dentist to have all maxillary teeth removed and full arch implants performed to replace her teeth in correct and esthetic positions. Thoughts and concerns? regards Dr. Salama

Preop Smile
Right Lateral view Face

Left Lateral View Face
Cephalometric film


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14 Comments

Dr Salama,

Wow, tough case !
Not sure how to tackle this, but I do not believe that extraction is the solution here.
Looking forward to your solution :)

Best regards,
Ehab


Reply

Either segmental osteotomies if extractions are planned or TAD`s in the upper posterior segments to intrude molars and change occlusal plane with IPR as needed.
Retention will be key to long term success as these cases often have high relapse rates because of tongue thrust. I would retain with fixed lingual wires plus Vivera nightime plus refer to Orthophonist to try to kick tongue thrust habit. Very difficult case indeed!


Reply

I have done a very similar case with 2 segmental osteotomies in the upper and lower arch with extractions of first upper and lower premolars at surgery. For sure get my OMFS Dr. Jorge Ravelo involved. Tongue habit considerations into retention


Reply

Mo,

What is status of joints-how old is patient- Mouth breather-lip incompetence- inc Mandibular plane angle- Is there a cant in maxilla? do you have Pano
level and align- can crossbite be corrected -or minimized- Surgically - possibly 3 piece maxilla to widen w differential impaction posterior max depending on tooth to lip ratio- maybe lip lenghtening
Address Nasal tip
Advance mandible- if chin ends up prominent then manage
Skin looks- thin CT disease?
Airway?
decomp tongue

just my 3 cents

Cheers,

Richard


Reply

Maurice nice, interesting and difficult case!
The inclination of maxillary teeth is excessive in both upper and lower arches. Looking at her nasolabial angle I would think that extraction of upper and lower first bicuspids, with maximum anchorage using either TAD's or plates might be an option. Now the tongue thrust makes me think that there might be an airway obstruction problem. If that would be the reason extractions combined with Orthognatic surgery might be the answer.
If there is no respiratory obstruction problem, we could work this case with extractions and TAD's.
Question: What is the position of the upper incisor to upper lip vertically?
Of course always paying special attention to the tongue thrust habit and retention.
Looking forward to your treatment proposal, as always surely very complete.
Best regards,
Manuel


Reply

Manuel; Upper incisor to lip at rest is displayed on the lateral images. regards Mo


Reply

I believe the most important piece of information is "What are the patients goals". Then an appropriate TP can be developed to best address those desires of the patient. I see that a surgical solution would be best long term, stabile solution and retains the patients own dentition. I agree with Richard work up for the TMJ,airway and tongue thrust then a 3 piece maxillary osteotomy to impact the posterior to close the open bite and widen the arch to address the x-bite, clockwise rotation of anterior segment, with bone grafting, to correct lip support and change lip line. Then mandibular advancement to correct the class 2 dental relationship. A possible genioplasty procedure if the profile warrants it. Whether you remove the 1st bicuspids would require more information or you may need to make that decision once the presurgical ortho tx has been initiated. The implant option may be a consideration if the patient eliminates the more time consuming ortho/surgery TP, but I would be very uncomfortable removing teeth that are not terminal or poor prognosis.


Reply

Great comments and discussion from all. The patient desired a functional and esthetic result. She desired to have more teeth in contact to properly masticate her food and reduce the proclination of her teeth in the anterior region. She also wanted to maintain the periodontal health of her dentition. She did not complain of any TMJ related issues, snoring or sleep apnea issues and the airway space tested WNL. Dr. Salama


Reply

Mo,

Show us what was done! Suspense!

Richard


Reply

Richard; No more suspense. Just posted Part 2 with Treatment. regards Mo


Reply

Patient shows adequate anterior teeth when smiling. Intrude the maxillary buccal segments with TADs when you are in rectangular wire; 18x 25 NITi. That will cause auto rotation of the mandible. She will probably need 4 bicuspids extracted as well to correct the bimaxillary protusion and the lower facial convexity.


Reply

Only 2 Maxillary bicuspids and one single lower incisor were extracted. Occlusal adjustment of gross premature contacts, retraction and tongue placement exercises during treatment. Dr. Salama


Reply

Jerome; Please take a look at Part 2 on top right side of screen under related posts. regards Dr. Salama


Reply

Joanne. IMO that approach would be a last resort. Personally I find it difficult to replace nature with foreign body materials for the sake of convenience. I viewed the attached link and I would be curious as to the comments of the "NYU faculty specialists" on this case. Chuck


Reply

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