Is this case better suited to be treated by posterior intrusion or anterior extrusion. The dental open bite of 5 mm has both a skeletal component and a dental component. How would you treat this case??
Is there any evidence from the literature than any of the above ttts is more stable than the other?
Edit : Thanks for all the info and the kind feed back . I added more records to obtain the right advice. Actually I have already treated this case, but the case was refused on grounds of stability. The claim was extrusion is less stable that intrusion, and that may not have been the best treatment option for this patient.
The etiologic cause of this case to me was unknown. I couldn't really pinpoint any tongue thrusting. He definitely had increased FMPA , but I still thought may be the open bite was due to low calcium levels during early stages of development !
The patient's medical history was : hypoparathyrodism , and he is on Calcium replacement now. I know that requires milder forces for the fear of root resorption. He had TMD symptoms and clicking. Stabilizing splint was fabricated before starting treatment.
First. a lot more information would be required to adequately diagnose and recommend a treatment plan. Molar intrusion via orthodontic tooth movement would be a very difficult feat to accomplish of a magnitude sufficient to produce mandibular auto-rotation and close a 5mm anterior open bite. Second, it is impossible to assess the impact of anterior dental extrusion on the lip-incisor relationship and whether there would be an unesthetic gingival display should you select this course of treatment. So with incomplete patient records, (no cephalpometric measurements, no description of the soft tissue esthetic concerns, health history, etc.) it is impossible to provide meaningful advice.
I hope that this answer provides a bit insight into the issues to consider.
From esthetic point of view, you need the face photo of smile and rest to evaluate the incisal display and gum display. If the lip is situated at low position when smiling, the intrusion of the anterior teeth is O.K. But if the lip posiiton is too high , you'd better choose the intrusion of posterior teeth.
As I see , eventhough i cannot exactly say because of no cephalometric data,
it appears the case of high mandibular angle. so some degree of intrusion of posterior teeth will be needed.
The photo shows the occlusal plane is opened anteriorly. So the only the leveling by the anterior elastic and curved wire will result in the closure of bite.
And the intrusion by TPA will be additive help.
When smiling, incisal display relatively has some room for extrusion about for 2~3 mm.
So occlusal liveling with anterior elastic and intrusion of posterior teeth by TPA will be helpful.
Gd evng mam,
The case is a vertical grower. Please evaluate ceph for vertical relation of maxilla, maxillary dentition, mandible, mandibular dentititon. He may be a case of class I rotated to class III.
He has constricted upper arch, which may have restricted forward mandibular movement. It is quite possible that as you will do arch wire expansion, mandible will slide forward.
For complete info plz fwd the ceph values along with upper and lower occlusal photograph.
TMD is a broad term. It encompass plethora of disorders. U need a thorough investigation. If symptoms have resolved with splint this shows that there is no intra capsular disorder. U need to check for musculo - occlusal problem and disorders mimicking TMD.
Good evening Dr Gagan, Thanks for your answer :)
For some reason the question seems not to show the ceph values, and the photos, which are already attached to the question., no idea why.
It is worth mentioning that TMD symptoms disappeared completely uptill now after the anterior bite closure .It has been nearly a year since the debonding.
This is a class I hyperdivergent bimax protrusion. I would recommend extraction of 4 premolars, likely the 5s, and intrude posterior maxillary and mandibular teeth. You will need a TPA and a LA. You need to change the vertical dimension of this patient to improve facial esthetics. Look at my AAO's 2017 lecture to see the technic I use to obtain normal vertical proportion of the face
https://www.aaoinfo.org/system/files/media/documents/Chamberland_Sylvain_Vertical%20Dimension%20and%20Facial%20Aesthetics.pdf
Thanks Dr Sylvian for the interesting answer, and the lecture . Very kind of you.
As the question pertains to stability, long term data on posterior intrusion is still deficient. However, for high angle cases, extraction approach does seem to provide higher stability for anterior open bite correction. Furthermore, if the patient has a poor tongue posture, or any other habits, it should be corrected for a stable result.
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