ABSTRACT ÖZET

An optimal treatment of deepbite requires a careful diagnosis, a proper treatment plan and efficient app-liance design. Excessive overbite may restrict growth of the mandible and mandibular dentoalveolar regi-on. It may cause temporomandibular joint disorders and increased masticatory muscle activities. Hence, treatment of deepbite in growing patients is critical. Deepbite can be corrected with intrusion of incisors , extrusion of posterior teeth, flaring of anterior teeth, and/or surgery. In patients with short anterior facial height, extrusion of posterior teeth may be the proper treatment choice to reduce overbite. Fixed anterior biteplane appliance has been used in correction of deepbite in several studies. But these investigations only focused on clinical and cephalometric changes. Therefore, the aim of this case report is to present effects of fixed anterior biteplane appliance on sto-matognathic system of a patient with deepbite. A 9.7 year old male patient had decreased lower facial height, uprighted maxillary central incisors and inc-reased overbite. Lateral cephalometric radiographs, electrovibratographic, electromyographic and ele-ctrognatographic recordings were obtained from the subject before (T0) and after fixed anterior biteplane treatment (T1). After 6 months of treatment, overbite was reduced, lower anterior facial height was increa-

Derin örtülü kapanışın optimal tedavisi; dikkatli tanı, uygun tedavi planı ve etkili aparey dizaynını gerektir-mektedir. Aşırı örtülü kapanış mandibulanın ve man-dibular dentoalveolar bölgenin gelişimini sınırlayabil-mektedir. Temporomandibular eklem rahatsızlıklarına ve artmış çiğneme kası aktivitesine de yol açabilmek-tedir. Bu nedenle büyüyen hastalarda derin örtülü kapanışın tedavisi önemlidir. Derin örtülü kapanış keserlerin intrüzyonu, posterior dişlerin ekstrüzyonu, anterior dişlerin labiyale hareketi ve/veya cerrahi ile tedavi edilmektedir. Kısa anterior yüz yüksekliği olan bireylerde posterior dişlerin ekstrüze edilmesi örtülü kapanışın azaltılması için uygun tedavi seçeneğidir. Sabit anterior biteplane apareyi çeşitli çalışmalar-da derin örtülü kapanışın tedavisinde kullanılmıştır. Fakat bu araştırmalar sadece klinik ve sefalometrik değişiklikler üzerine odaklanmıştır. Bundan dolayı, bu olgu raporunun amacı sabit anterior biteplane tedavi-sinin derin örtülü kapanışlı bir hastanın stomatognatik sistemi üzerine etkilerini sunmaktır. 9,7 yaşında erkek hastada azalmış alt yüz yüksekliği, dikleşmiş üst san-tral kesici dişler ve artmış örtülü kapanış mevcuttu. Bireyden sabit anterior biteplane tedavisi öncesi (T0) ve sonrası (T1) lateral sefalometrik radyografi, elektrovibratografik, elektromiyografik ve elektrogna-tografik kayıtlar alındı. 6 aylık tedaviden sonra örtülü

Hacettepe Diş Hekimliği Fakültesi DergisiCilt: 32, Sayı: 4, Sayfa: 65-73, 2008

Effects of Fixed Anterior Biteplane Treatment on Stomatognathic System of a

Patient with Deepbite

Sabit Anterior Biteplane Tedavisinin Derin Örtülü Kapanışlı Bir Hastanın Stomatognatik Sistemine

Etkileri

*Bengisu AkArSu DDS, PhD, *Semra Cİğer DDS, PhD

*Hacettepe University Faculty of Dentistry Department of Orthodontics

OLGU RAPORU (Case Report)

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INTRODUCTION

Deepbite is defined as the vertical overlap of the mandibular incisors by the maxillary inci-sors more than 3mm when the posterior teeth are in occlusion1. The factors that contribute to deepbite may be classified as dental, skeletal and soft tissue. Over-eruption of the mandibular or maxillary incisors, retroclination of the inci-sor teeth, infra-occlusion of the mandibular or maxillary posterior teeth may classified as dental factors1,2. The skeletal factor, on the other hand, is described as the counter clockwise rotation of the mandible and it occurs due to increased pos-terior vertical growth compared to anterior verti-cal growth3. Soft tissue factors are high lower lip line that guide the maxillary and mandibular incisors to erupt in a more retroclined position4 and lateral tongue thrust5.

An optimal treatment of deepbite requires a careful diagnosis, a proper treatment plan and efficient appliance design. Deepbite can be cor-rected with intrusion of incisors6-8, extrusion of posterior teeth9,10, flaring of anterior teeth10-11, and/or surgery12,13.

In patients with short vertical facial dimen-sion, extrusion of posterior teeth using anterior biteplane, functional appliances, cervical head-gear may be the treatment choice to reduce over-

bite3. To eliminate the patient compliance, fixed anterior biteplane has been used in deepbite patients14-16. In these clinical and cephalometric investigations, fixed anterior biteplane therapy was found to be effective in reduction of deep-bite14-16.

Yet in literature, no study was found about the effects of fixed anterior biteplane on tem-poromandibular joint sounds, masticatory mus-cles and masticatory movements in patients with deepbite. Therefore, the aim of this case report is to present the effects of fixed anterior biteplane treatment on stomatognathic system of a patient with deepbite.

CASE REPORT

A 9.7-year-old male patient was referred to orthodontic treatment. He had labially inclined upper laterals and uprighted centrals, increased overbite, reduced lower anterior facial height, and mixed dentition (Figure 1-6). Cephalometric anal-ysis of the patient showed brachyfacial growth pattern. Overbite was 6 mm and lower incisors to A-Pog plane was -3 mm. (Table I, Figure 7).

Ethic committee report was taken from the Medical, Surgical and Medicine Research Ethic Committee of “ Hacettepe University” in ad-vance of the start of the research. The patient

KEYWORDSBiteplane, deepbite, electromyograhy,

electrognatography, electrovibratography

ANAHTAR KELİMELERBiteplane, derin örtülü kapanış, elektromiyografi,

elektrognatografi, elektrovibratografi

sed and the inclination of upper incisors was impro-ved successfully. Fixed anterior biteplane appliance did not cause any temporomandibular disorders and had no detrimental effect on chewing and speech.

kapanış azaldı, alt yüz yüksekliği arttı ve üst kesici diş inklinasyonları başarıyla düzeltildi. Sabit anterior biteplane apareyi herhangi bir temporomandibular rahatsızlığa neden olmadı ve çiğneme ve konuşma üzerine zararlı bir etki göstermedi.

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FIGURE 1-6

Pre-treatment extraoral and intraoral photograhs

1 2

34

5 6

68

was informed about the treatment which would be carried out; and he was voluntary for the re-search.

Treatment objectives were to reduce the overbite, increase the lower anterior facial height, correct the inclination of the upper incisors and improve mandibular position. A fixed anterior biteplane appliance was used to reduce the need for the patient’ s cooperation (Figure 8,9).

Fabrication of the fixed anterior biteplane appliance: In the patient, maxillary first molars were fitted with orthodontic bands and alginate impressions were than taken. On the maxillary dental cast, a lingual arch extended between the first maxillary molars was made and welded to the bands. The arch was also equipped with oc-clusal stops resting on the first premolars. La-biolingual springs were placed behind the upper central incisors. Bite registration was taken caus-ing a separation of the upper and lower molars of approximately 4 mm. The dental models were transferred to the articulator, thereafter the fixed anterior biteplane was prepared and was placed to first molars (Figure 8,9). No other orthodontic appliances were used during the period of treat-ment.

In addition to lateral cephalometric radio-graphs, electromyographic (EMG), electrognato-graphic (EGN) and electrovibratographic (EVG) records were taken by using a computer program (BioPAC Version 2,03 System,BioResearch INC.,Milwaukee, Wisconsin) at the beginning (T0) and at the end of the fixed anterior biteplane treatment (T1).

After 6 months of treatment, fixed anterior biteplane appliance was removed (Figure 10-15).

TABLE I

Cephalometric measurements

SNAo SNBo ANBo Facial deptho

Maxillary heighto FMAo GoGnSNo

Lower lip to esthetic plane mm

T0 77.5 74 3.5 81.5 53 10 23 -5

T1 78 75.5 2.5 83.5 53.5 15 27 -2.5

Lower facial heighto

Na-Me mm

ANS-Me mm

Na-ANS mm

Overbite mm U1-SNo U1-FHo Saddle o

T0 33.5 106.5 58 51 6 93 106 126

T1 36.9 111.5 61.7 52 2 99 112 124

FMIAo IMPAo L1-MP mm

L6-MP mm

L1 extrusion mm

U1-PP mm

U6-PPmm

L1-Apog mm

T0 73 93 37 29 5 26 17.5 -3

T1 65 96 37 31.5 3 25.5 17 -1.5

FIGURE 7

Lateral cephalometric analysis (1:SNAo, 2:SNBo, 3:ANBo, 4:Facial deptho, 5: Maxillary heighto, 6: FMAo, 7: GoGnSNo, 8:

Lower facial heighto, 9: Overbite mm, 10: U1-SNo, 11: U1-FHo, 12: FMIAo, 13: IMPAo, 14: L1-MP mm, 15: L6-MP mm, 16: L1

extrusion mm, 17: U1-PP mm, 18: U6-PP mm)

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FIGURE 8-9

Fixed anterior biteplane cemented to the maxillary first molars

8 9

FIGURE 10-15

Post-treatment extraoral and intraoral photograhs

10 11

1213

14 15

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Deepbite decreased, lower anterior facial height increased and inclination of upper incisors in-creased. An increase of 1.5o of SNB angle and an increase of 2o of facial depth angle was found at T1 (Table I). Labial inclination of the upper and lower incisors, extrusion of the mandibular first molar, anterior and inferior position of the mandible were found in local superimpositions. Upper and lower lips were positioned more ante-riorly after the fixed anterior biteplane treatment (Figure 16).

Electromyographic, electrognatographic and electrovibratographic measurements at T0 and T1 are presented in Table II-IV.

DISCUSSION

The measurements which are used to assess the facial growth pattern (FMA, GoGnSN, lower anterior facial height, Na-Me, ANS-Me) increased

at T1. These results are in conformity with the previous studies14,15. The upper face height (N-ANS) and maxillary height angle did not show any significant change. Fixed anterior biteplane had an inhibiting effect on the vertical develop-ment of the maxilla14.

Growth of mandible and the mandibular den-toalveolar region were restricted by excessive overbite in growing patients17,18. The increase of SNB angle and facial depth angle, the decrease of ANB angle at T1 could show anterior position of the mandible after reduction of the deepbite.

With regard to dental findings, the height of lower incisors (L1-MP) did not change sig-nificantly with treatment. This is consistent with the previous studies14,15. On the other hand, the distance between the lower incisor and occlusal plane (lower incisor extrusion) decreased and the amount of eruption of the lower molars (L6-MP)

FIGURE 16

Pre-treatment and post-treatment cephalometric superimpositions

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TABLE II

Electromyographic measurements at rest position

EMG (µV) TA right TA left MM right MM left SCLM right SCLM left DA right DA right

Rest positionT0 2.3 5.7 1 1.2 0.4 5.2 5.3 1.3

T1 0.3 3.1 0.5 0.9 0.6 4.4 2.9 1

TABLE III

Electrognatographic measurements at chewing and speech

EGN Opening time ms Closing time ms Occlusal timing ms Total timing ms

T0 T1 T0 T1 T0 T1 T0 T1

Chewing timing (right)

330.4 279.1 281.9 235.1 456.4 339.4 1068 853.6

Chewing timing (left)

247.4 223.7 318.1 192.8 482.4 337.9 1048.0 754.50

Sagittal mm Frontal mm Horizontal right mm Horizontal left mm

T0 T1 T0 T1 T0 T1 T0 T1

Speech 8.0 8.8 7.7 7.8 0.8 1.9 2.2 2.8

T0 T1

Freeway space

3.1 3.3

TABLE IV

Electrovibratographic measurements during mouth opening and closing

EVG (Hz) Mouth opening Mouth closing

Total integral

RightT0 27.4 34.2

T1 17.5 14.4

LeftT0 33.4 18.3

T1 15.9 14.8

Integral<300

RightT0 21.1 26.4

T1 12.9 10.9

LeftT0 26.4 13.7

T1 11.6 11

Integral>300

RightT0 6.3 7.8

T1 4.6 3.5

LeftT0 7 4.6

T1 4.3 3.8

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increased at T1. It can be said that relative in-trusion of the lower incisors was obtained due to the mandibular posterior teeth extrusion that changed the occlusal plane.

With the placement of labiolingual spring in the biteplane, the palatally inclined upper inci-sors improved to ideal values. The proper incli-nation of the upper incisors was shown to facili-tate the stability of the deepbite reduction19.

Surface EMG is a commonly used diagnosing method in evaluation of facial muscle activities. In literature, EMG values in healthy patient were given between 0,5-1,4 µV for masseter muscle (MM), and 1,0-1,9 µV for anterior temporal mus-cle (TA) at rest position20. The appointed normal values for anterior digastricus (DA) and sterno-cleidomastoideus (SCLM) varried between 1,0-1,5 µV20. In the present case, the EMG activities at rest position was found higher than normal. Recent studies showed that the patients with deepbite had greater masticatory muscle activi-ties compared to normal subjects21,22. After re-duction of deepbite, masticatory muscle activities at rest got closer to normal values (Table II).

EGN is the process that records the speed, direction and displacement of the mandibular movements as 3D data by the means of a mag-net placed on mandible and BioResearch JT-3 Tracker. Chewing timing was in normal range at T0 and T123. The findings about speech was found lower when compared with the findings of Nielsen et al24. The patient was told to count from 80 to 90 loudly during speech recordings. Nielsen et al.24 might have used different words during the speech recordings and this might be responsible for the difference. Posterior teeth extrusion obtained after fixed anterior biteplane treatment did not change freeway space (Table III). This was stated as a factor that increase the stability of deepbite treatment by Nanda25.

Measurements were done separately for opening and closing mouth movements during the EVG recordings. High reliability and repeat-ability of the EVG method used in this case re-port to evaluate joint sounds were reported26.

The electrovibrotographic values were in normal range at the beginning of the treatment and did not change after the treatment in the present case (Table IV).

CONCLUSION

Fixed anterior biteplane appliance reduced the overbite, increased the lower anterior facial height and improved the inclination of the upper incisors successfully. It did not cause any tem-poromandibular disorders and had no detrimen-tal effect on chewing and speech in the present case.

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CORRESPONDING ADRESS

Bengisu AKARSU DDS, PhDHacettepe University Faculty of Dentistry Department of Orthodontics 06100 Sıhhiye-ANKARA

Tel. (312) 311 64 61 Fax: (312) 309 11 38 E-posta: bengisuakarsu@yahoo.com

Geliş Tarihi : 09.07.2008 Received Date : 09 July 2008 Kabul Tarihi : 17.11.2008 Accepted Date : 17 November 2008

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