New Concepts and Treatment Approach to

the Different Types of Malocclusions

Preface
Sadao Sato 4#

Development and Orthodontic Treatment of Skeletal Class III Malocclusion

without Surgical Intervention
Sadao Sato, Susutmt Akinioto, Hisaaki Shinji, Eiiana Midori Tanaka and Ales Celar 51

Different Mechanics for Orthodontic Correction of Class II Openbite

and Class III Openbite Malocclusions
Sadao Sato, Masaaki Kaneko, Kenichi Sasaguri, Eiiana Midori Tanaka and Ales Celar 65

Orthodontic Reconstruction of Occlusion in Class III Malocclusion

with Low Mandibular Plane Angle
Akiyoshi Shimsu, Eiiana Midori Tanaka and Sadao Sato yg

Application of MEAW Mechanics to the Treatment of Class III Malocclusion

with Dental Mid-Line Discrepancy
Kenichi Sasaguri, Susiunu Akinioto, Hisaaki Shinji, Eiiana Midori Tanaka and Sadao Sato 87

Orthodontic Treatment of Class III Malocclusions Associated

with Mandibular Lateral Deviation
Susinmt Akinioto, Mitsmjoshi Kubota, Atsushi Matsnmoto, Sadao Sato,
Eiiana Midori Tanaka and Ales Celar 95

Interception of Decompensated Class III Malocclusions in Early Mixed Dentition

Hisaaki Shinji, Takehiko Hiyama, Mina Yamaguchi, Kanji Onodera and Sadao Sato W5

Interdisciplinary Treatment Approach to a Patient with Severe Mandibular

Displacement and Dysfunction of Craniomandibular System
Katsushi Tantaki, Ales G. Celar, Rudolf Slavicek and Sadao Sato U3
 Preface

New Concepts and Treatment Approach to the Different Types of Malocclusions

Dental medicine revolves around the study of occlusion. The basis of occlusion is not simply the

interdigitation of the aligned teeth in both the upper and lower jaws, but a combination of their positional
relationship and the functional movement of the mandible. This is controlled by a complex system of
functional elements, i.e. the masticatory muscles, neuromuscular system, TMJ function etc., which serve
as the basis of dental treatment. Orthodontics, a branch of dental medicine, constructs an occlusion by
correcting misaligned teeth. In Prosthodontics, the recontouring of tooth crowns, as the primary measure
in bite construction, is an important approach in improving malocclusion. Therefore, in clinical practice,
especially in orthodontics, it is essential to fully understand the physiology of occlusal function and the
biology of tooth movement.

However, so far, these important topics have not been satisfactorily dealt with in orthodontics. Looking

at the history of the subject, the development of orthodontics has tended to focus more on orthodontic
appliances and their improvement. With continuous technology as the focal point of therapeutic
advancement, the treatment effects on malocclusion have certainly improved and clinical application

has expanded. Nevertheless, numerous contradictions have come about as a result of mere technological

advancement. The orthodontic approach seems have become isolated from dental medicine and to have
enclosed itself in a specialized field.

Orthodontic advances in the past failed to give pertinent attention to the etiology of malocclusion and

mechanism of its development. The introduction of cephalometric radiography in orthodontic diagnosis

has definitely played a significant role in understanding malocclusion. However, this does not clearly
show the cause of malocclusion. It only localizes the site of skeletal malocclusion and shows the degree
of deviation. Elimination of the cause is an indispensable factor in a radical treatment method and enables
stable results to be obtained. This only means that current orthodontics simply identifies and treats
symptoms rather than targeting the cause.

Moreover, current orthodontic therapy has insufficient therapeutic objectives. To improve the facial
profile as a treatment objective, orthodontics can obtain results as if it were a section of cosmetic orthopedic
surgery. Of course, in managing the maxillofacial area, the relevance in the improvement of facial profile
must not be neglected, but this should not be the ultimate treatment objective in orthodontics. As
previously mentioned, orthodontic therapy is one of the effective approaches in occlusal construction.
However, as a treatment objective, there are still no basic guidelines or established therapeutic techniques

for each particular type of occlusion to be managed. Now the time has come to re-evaluate orthodontic
therapy.

Since the arrival of the Angle expansion arch appliance, several improvements have been introduced
in the evolution of the current full bracket system. From a mechanical standpoint that constitutes,
apparently, a satisfactory accomplishment. However, there is the question of why there are still a number
of patients who are difficult to treat. Why does malocclusion recur after treatment? Does this mean that
serious errors were committed in the planning and development of occlusal treatment? As numerous
improvements are being made, the current treatment approach has become too complicated. This is
perhaps, due to the unpredictable results obtained by palliative treatment based on a less accurate diagnosis
only through the identification of symptoms.

Orthodontic occlusal construction should be widely applied in dental medicine. However, this does
not reconcile the concerns of present orthodontics, as the contradiction is evident from its new standpoint.
Hence, there is a need for the introduction of a new treatment philosophy based on the functional rather
than esthetic necessary requirements according to the health and well being of the patient.

In this BKDC topic, the dynamic mechanism of the development of malocclusion will be clearly
discussed. On this basis, the diagnosis, treatment objectives, and treatment techniques for orthodontic
occlusal construction will also be explained.

Finally, it must be mentioned that the articles appearing here were previously published in the Journal
of Informationen aus Orthodontie und Kieferorthopadie, Volume 37 July 2005 issue, in the German
language. Members of our Department of Craniofacial Growth and Development Dentistry were kindly
invited to publish our approach to the various malocclusions by Professor H.P. Bantleon, Orthodontic
Department, University of Vienna, Austria. Therefore these English translation issues are presented here
in their secondary publication with copyright permission from Thieme, Stuttgart, Germany.

Sadao Sato D.D.S.,D.D.Sc.

Department of Craniofacial Growth and Development Dentistry,
Division of Orthodontics,
Kanagawa Dental College, Yokosuka, Japan

March 2007
Bulletin of Kanagavva Dental College
Vol. 35, No. 1, March, PP. 51-63, 2007

Development and Orthodontic Treatment of

Skeletal Class III Malocclusion without
Surgical Intervention

Sadao Sato, Susumu Akimoto, Hisaaki Shinji,

Eliana Midori Tanaka, and Ales Celar*

Department of Craniofacial Growth and Development Dentistry,

Kanagawa Dental College

Department of Orthodontics, Medical University of Vienna, Bemhard Gottlieb

Dental Clinic, Vienna, Austria

Abstract

In this article, the development of Class III open bite malocclusion is explained from a
human evolutional perspective. The authors focus on vertical development of the craniofa-
cial complex with its hyperdivergent tendency. The position and inclination of the occlusal
plane are affected primarily by the posterior occlusal vertical dimension. On the basis of this
principle, steepening of the occlusal plane (inclined postero-superiorly) causes the develop
ment of a Class II malocclusion and concomitantly the mandible adopts a retruded position.
Particularly, the cant of the upper posterior occlusal plane - upper second premolar to upper
second molar at the occlusal surface - is considered one of the most important determinants
for the antero-posterior position of the mandible. On the other hand, when the occlusal plane
is oriented almost horizontally or becomes abruptly flatter, a Class III malocclusion will de
velop as a result of the inducing anterior rotational adaptation of the mandible. Depending on
the skeletal and neuromuscular adaptation capacity, an open bite malocclusion may also
appear if there is an imbalance in the functional adaptation of the mandible to maxillary
occlusal surfaces that continuously descend during vertical growth in order to achieve proper
functional occlusion, which also induces excess or less hyperdivergency of the lower face.

Key words: Human crattiofacial skeleton I Basicranial flexion I Occlusal

vertical dimension I Class III malocclusion I Open bite

Evolutional background of Viscerocranium to 180, however, in man, this decreases to approximately

and Class III malocclusion
Observations made on human skeletal evolution re
veal that the most significant morphologic change of the
facial skeleton has occurred over the last four to five
million years. Bipedalism and erect posture of the en
tire human body have caused an uprighting of the skull
(Fig. 1). The human craniofacial skeleton underwent an
almost rectangular flexion. Also the cranial base assumed
a larger bend and the foramen occipitalc magnum was
displaced anterior-inferiorly. Therefore, in contrast to
humans, primates have a large cranial base angle close
Accepted for publication on October 5,2006.
Address for correspondence: Sadao Sato, Department of
Craniofacial Growth and Development, Kanagawa Dental College,
82 Inaoka-cho, Yokosuka, Kanagawa, 238-8580, Japan.
Tel: +81-46-822-8880 (ex. 2381) Fax: +81-46-822-8844
125 (Fig. 2).
This postural change of the skeleton also affects the
facial morphology in terms of hyperdivergence of the
lower face. Subsequently, the dentition has been ren
dered susceptible to an anterior openbite, which is a
malocclusion exclusive to the human specie. The adop
tion of an upright posture of the body has caused the
growth pattern to be vertical rather than horizontal. This
vertical facial development has given us some difficulty
in properly fitting the upper and lower dentition, be
cause a descending spatial positioning of the maxillary
occlusal plane may easily create an anterior opening of
the upper and lower jaws if there is no continuous man-
dibular rotational adaptation. Also, the neuromuscular
system must work against this hyperdivergent tendency
in order to maintain full occlusal contacts. Thus, the
S. Sato etui.
adaptation of occlusion against the vertical growth of
the facial skeleton is possible through a serial functional
adaptation of the mandible.
During human ontogenesis, the viscerocranium, es
pecially the maxillary complex, mainly grows in a down
ward direction as the posterior vertical dimension
increases, due to the vertical growth of alveolar bone,
which is a consequence of tooth eruption.
Table 1: Alteration of Occlusal Plane and Mandibular Plane during Growth
Bull. Kanagawa Dent. Col. 35 (2007)
Therefore, during this growing process, a gradual
flattening of the occlusal plane occurs (Table 1) (1-3) and
consequently the mandible can adapt by way of rota
tion by anterior repositioning to achieve a proper func
tional occlusion - full intercuspation -. This type of
adaptation may induce secondary condylar growth
which provides a decrease in the mandibular plane angle
(Fig. 3).
Fig. 1: Evolution and morphology of the human craniofa-
cial skeleton. Morphologic changes during evolution ac
company the upright posture of body and skull. The flex
ion of the cranial base greatly influences the facial profile
and the growth direction of the maxillary complex.
 Development and Orthodontic Treatment of Class III Malocclusion

Fig. 2: Comparison of craniofacial skeleton in human and primates. The human cranial base assumes a larger
bend, thereby reducing the degree of flexion (N-S-Ba) in contrast to primates. Flexion of the cranial base
causes maxillary vertical elongation while extension causes anterior rotation of the maxillary complex.

Mandibular rotational adaptation is a primary and

important process of the natural growth of the face, and
failure of this process creates a skeletal type of maloc
clusion. The functions of the anterior mimic and bucci
nator muscles include closing and helping the mandible
to adapt by rotational movement, so that the upper and
lower surfaces fit. Patients with weak mimic muscle ac
tivity develop an anterior openbite malocclusion, as the
mandible cannot adapt through rotation. It can be said
that the openbite in modern humans originates from the
inability to balance vertical dimensions of occlusion.
The degree of basicranial flexion differs in the vari
ous types of malocclusions (Table 2) (4). The cranial base
angle (N-S-Ar) comes to approximately 124,25,2 in class
I patterns. Prom this average value, a more obtuse (ex
tension) angle indicates skeletal class II and a more acute
(flexion) angle means skeletal class III. The more pro
nounced the class [II pattern, the higher the flexion of
the cranial base and the greater the tendency of the cran
iofacial complex to hyperdivergence (Fig, 4). The devel
opmental process of skeletal class TIT malocclusions Fig. 3: Concept regarding occlusal plane changes and man

includes vertical elongation of the maxilla and an in
crease in the occlusal vertical dimension of the poste
rior molar segment. Subsequently, the mandible rotates
forward in order to maintain anterior occlusal contacts
(Fig, 5). Because of its appearance, class III malocclu-
dibular adaptation. Eruption of the maxillary molars creates
a flat occlusal plane, which induces anterior mandibular ro
tational adaptation and consequently allows forward man
dibular growth followed by secondary condylar growth and
the mandible can reach a skeletal class I.
S. Sato et a\. Bull. Kanagawa Dent. Col. 35 (2007)

Table 2: Cranial Base Angle Associated with sion has been considered an anterior-posterior or trans
verse deviation. However, from a developmental view
the Various Types of Malocclusion
point, class III malocclusion certainly deals with a
Malocclusions N-S-Ar vertical component. In the past, this aspect was ne

Class III 122.2 4.7

glected and orthodontists struggled to correct the an-
teroposterior dentoalveolar relationship in class III
Class 1 124.2 + 5.2

ClassII, Div.2 125.5 + 4.8

pa tients. Trea tmen t options such as chin cups, long class

Class II, Div. 1 128.9 4.5

III elastics, premolar extraction, orthognathic surgery,
etc. are all based upon the idea of correcting the class III
Hopkin GB sl.nl, 1968, Angle Orthod 38; 250
malocclusion in the anterior-posterior direction. Further
more, understanding this malocclusion as a vertical

Class III Class II

Fig. 4: Comparison of typical skeletal class
III and class II malocclusions. Differences in
basicranial length and angle, position and in
clination of the occlusal plane, maxillary and
mandibular position and posture, and den
toalveolar vertical height are seen.

Fig. 5: Developmental process of skeletal class III malocclusion. The posterior occlusal vertical dimension is considerably enlarged.
The mandible adapts through forward rotation resulting in mandibular prognathism. Also in class I, an increment in molar and
premolar occlusal vertical dimension occurs (a), but in class III the posterior discrepancy causes an excessive increase in posterior
occlusal vertical dimension and more pronounced flattening of the occlusal plane. Functional mandibular adaptation is necessary for
occliisat compensation (intercuspation) with subsequent mandibular prognathism (b. c).
 Development and Orthodontic Treatment of Class UI Malocclusion

problem and targeting and treating its real cause will
prevent post-treatment relapse.
Adaptation of the viscerocranium and class
III malocclusion
The flexure of the cranial base angle is related to
changes in. the craniofacial skeleton. In other words, the
more developed the class III, the more accentuated the
flexion of the cranial base and the greater the tendency
of the orofacial complex to grow vertically. In skeletal
class II, the length and angle of the cranial base are large
and the facial morphology is oriented horizontally. The
extent of the basicranial flexion greatly influences the
facial profile and the growth direction of the maxillary
complex (5,6). Longitudinal observations on growth and
orientation of the cranial base in skeletal Class III mal-
occlusions clearly show why the mandible is becoming
prognathic or retrognathic. This verticalized orofacial
growth induces serious problems in the development
of malocclusions such as mandibular hyperdivergency
and posterior discrepancy, which will be discussed be
low.
The main reason for the vertical development of the
orofacial complex is the flexion of the cranial base. The
dynamic connection, of the sphenoid, vomer and maxil
lary bones transfers the basicranial motion causing the
maxillary complex to grow in a mainly downward di
rection. In primates, the maxilla moves anteriorly or ro
tates forward during growth and consequently, the
maxillary dentition may attain a sufficiently large an
teroposterior dimension. Dynamic motion of the primate
sphenoid vomer maxilla complex enlarges the anterior-
posterior distance of the dentition (Fig. 2). In man, this
anteroposterior distance is reduced due to the flexed
cranial base and the orofacial skeleton displaces verti
cally downward. In particular, the maxilla moves infe-
riorly and therefore the maxillary occlusal plane tends
to displace downward in space. Insufficient mandibular
adaptation to maxillary vertical elongation constitutes a
key factor in mandibular hyperdivergency (5, 6).
Another aspect to take into consideration is the max
illary growth, and eruption of the posterior teeth. Most
of the growth in the anteroposterior dimensions origi
nates through bone apposition from the posterior aspect
to the maxillary tuberosity. The initial appositional
growth at the tuberosity arises with the forward transla
tion of the maxillary complex. Lack of maxillary transla
tion makes it difficult to provide an eruption space for
the posterior molars. In primates, the maxillary forward
growth supports the tuberosity growth and increases the
anteroposterior orofacial dimension. This horizontal
maxillary growth creates a space for the eruption of the
second and third molars. In modern man, the primary
vertical maxillary growth does not allow sufficient hori
zontal space to develop in the molar segment. Lack of
eruption space In the posterior molar region has been
termed posterior discrepancy (Fig. 6) (7-14).
Posterior discrepancy and occlusal plane
Posterior discrepancy denotes the difference between
molar tooth size and denture base size in the posterior
segment distal to the first permanent molar. Basically, a
negative discrepancy is assumed to refer to the lack of
space in the dentition. Posterior discrepancy is associ
ated with molar crowd ing in extreme spatial deficiency
(Fig. 6).
Posterior discrepancy significantly increases the prob
ability of third molar impaction. Wisdom teeth repre
sent a serious dental problem that is frequently
encountered. Once third molar impaction occurs, poste
rior discrepancy may cause an over-eruption of the ad
jacent teeth due to the "squeezing-out" effect. The

c bfi

Fig. 6: Relation among maxillary growth, eruption space, posterior discrepancy and occlusal vertical dimension. Most of the
growth in the maxillary anteroposterior dimension originates through bone apposition from the posterior aspect to the max
illary tuberosity. Lack of maxillary translation makes it difficult to provide eruption space for the posterior molars; this creates
posterior discrepancy that causes an over-eruption of the adjacent teeth and changes the inclination of the occlusal plane.
S. Sato et si.
over-erupted molars produce occlusal interferences that
act as a fulcrum causing functional mandibular transla
tion with subluxation of the mandibular condyles and
consequently, the active transformation of the condylar
cartilage. This then results in mandibular forward dis
placement that either adapts through and/or develops
an anterior openbite. [f the interference emerges con
tinuously during growth, the mandible will be forced
to permanently adapt to this new occlusal configuration.
Such morphologic alterations resulting from functional
mandibular adaptation influence the development of
skeletal malocclusion.
As mentioned previously, the orofacial skeleton in
Homo sapiens is susceptible to hyperdivergence because
of the postural change during evolution. The over-erup
tion of molars increases the posterior vertical dimension
of the dentition and facilitates the tendency toward skel
etal hyperdivergency (Fig. 6).
However, the process of mandibular hyperdiver
gency is a very complex one. An increase in the poste
rior occlusal vertical dimension is followed by an
anterior mandibular rotational adaptation where the
anterior mimic muscles and perioral soft tissues play an
important role in closing and helping to adapt the man
dible by rotational movement resulting in a balanced
occlusion, with proper occlusal contacts. Patients with
inherent mouth breathing or weak muscle tone show a
higher prevalence for anterior openbites.
On the other hand, the rotational forward movement
of the mandible indicates the mechanism for develop
ing mandibular pro- gnathism. In normal growth sub
jects, the occlusal plane gradually flattens slightly due
to the increment in the posterior vertical dimension of
occlusion. During the development of a class HI maloc
clusion, the mandibular adaptation that occurs is char
acterized by a marked forward rotation in response to
the excessive increase in the posterior occlusal vertical
dimension (caused by the "squeezing out effect" of pos
terior discrepancy) that leads to mandibular pro-
gnathisrn. Under these considerations, orthodontic treat
ment of skeletal class 1TI maiocclusions must be accom
plished by the elimination of posterior d iscrepancy and
reconstruction of the posterior occlusal plane to re-es
tablish the proper vertical dimension.
Treatment mechanics for correction of class
III malocclusion
The treatment mechanics used in the orthodontic cor
rection of Class IIL maiocclusions are not difficult to ap
ply. The treatment objectives for a Class III high angle
should be clearly established for the correction of reverse
overbite - openbite that has resulted from a poor for
ward mandibular adaptation, i.e. the sequelae of basic-
ranial flexion; posterior discrepancy with molar
over-eruption, and therefore, increased posterior verti-
Bull. Kanagawa Dent. Col. 35 (2007)
Fig. 7: Treatment mechanics in class III malocclusion:
uprighting and intrusion of upper and lower molars by tip
back bends in both multiloop edgewise arch wires and use
of vertical elastics or short class III elastics at the anterior
loops. Treatment objectives are decreasing the posterior oc
clusal vertical dimension and steeper orientation of the oc
clusal plane.
cal dimension. When treating such patients, the orth
odontist should not only aim to improve the dentoal-
veolar relationship but should also consider the dynamic
system of skeletal balance with its cycle reactions that
take place during the malocclusion development pro
cess. The substantial changes occurring in the develop
ment of a Class HI high angle are forward mandibular
rotation and the subsequent orofacial compensation. In
this sense, posterior occlusal vertical dimension consti
tutes an. important parameter that influences the entire
orofacial balance.
The active phase of orthodontic treatment has been
to focus on correcting the inclination of the posterior
occlusal plane associated with the control of the occlusal
vertical dimension, i.e. an increase in the existing verti
cal dimension must be corrected at the occlusion by the
intrusion of the upper and lower molars as a method of
steepening the occlusal plane (tipping the occlusal plane
posterosuperiorly and decreasing the vertical dimension
in the molar area). In order to reconstruct the occlusal
plane, a multiloop edgewise arch wire (MEAW) is placed
in both dental arches (Fig. 7) (15,16). The MEAWs con
tain progressive tip-back bend from the premolar to the
molar area. Anterior loops are used to support vertical
or short class III elastics (3/16" in., 6 oz.). Conventional
use of long Class III elastics must be avoided because
further upper molar extrusion may aggravate the mal
occlusion. By this approach, the mandible is able to adapt
posteriorly with a subsequent change in the entire
orofacial complex. It has become possible to bring about
an improvement in the occlusion (6,17).
 Development and Orthodontic Treatment of Class III Malocclusion

Patient 1
This patient consulted the dental clinic at the age of
eight years in the period of mixed dentition. He pre
sented a reverse overjet. Orthodontic treatment was con
tinuously carried out until age 13 with no good result.
At that time, the patient was recommended for
orthognathic surgery, but he refused it. The treatment
was discontinued. At age 19, the patient complained of
his facial appearance with a reverse overbite as well as
impaired mastication (Fig. 8, 9).
The patient records show the skeletal changes from
age 8 to 19 years: the occlusal plane became very flat, an
anterior openbite developed and the mandibular plane
angle decreased (Fig. 10). Superimposition of lateral
cephalometric radiographs indicates an extremely in-
Fig. 8: Patient 1: Pre-treatment frontal and profile views.

Fig. 9: Pre-treatment Intraoral views.

Fig. 10: Cephalometric superimposition to visualize growth changes. Cephaiograms at age 8 years (a), 19 years (b), and superimpo
sition of the tracings showing the increase in occlusal vertical dimension at the molars and the flattening of the occlusal plane, i.e. a
forward mandibular rotational adaptation during the development of skeletal class III maiocclusion with mandibular prognathism.
S. Sato et al.
Fig. 11: Pre-treatrnent Panoramic radiograph showing in
creased molar vertical dimension caused by posterior crowd
ing (posterior discrepancy) due to form, growth, and erup
tion of second and third molars.
Bull. Kanagawa Dent. Col. 35 (2007)
creased vertical occlusal dimension in the molar area
and the flattened occlusal plane. Panoramic radiograph
reveal impacted third molars with a low potential of
eruption (Fig. 11). This case was diagnosed as having a
skeletal prognathism with a reverse overbite caused by
mandibular forward rotation, which resulted from an
increased vertical occlusal diinension due to posterior
discrepancy.
The treatment objectives were to provide a steep oc
clusal plane for the posterior adaptive repositioning of
the mandible, to correct the crowding and improve the
occlusion by uprighting and alignment the dentition.
First, the impacted upper and lower third molars were
removed in order to eliminate the posterior discrepancy.
Then standard edgewise appliances were bonded to all
teeth and the levelling and alignment stage was started
using 0.014-inch Australian wire. Three months later,
maxillary and mandibular MEAWs were engaged for
occlusal plane control with vertical short class III elas
tics in the anterior area (Fig. 12). Eight months after the
Fig. 12: Follow-up intraoral views (a)
after three months, (b) after 10
months, (c) after 20 months, and (d)
two years post-treatment,
 Development and Orthodontic Treatment of Class III Malocclusion

onset of treatment an overlay expansion wire made of 0.7

mm stainless steel was additionally used on the maxil
lary dental arch for its expansion. Class III elastics were
continuously worn until the achievement of optimal and
stable occlusion. After 17 months the active treatment
was completed. The occlusion accomplished tended to
ward class ITT but the cephalometric super imposition
substantiated a mandibular posterior shift and a steep
ened occiusal plane (Fig. 13).

Patient 2
This patient was also brought to the clinic at 8 years
old and orthodontic treatment was performed to elimi
nate crowding. At age 13 treatment finished but the pa
tient returned at age 23 years. His chief complaint was
Fig. 13: Pre and post-treatment cephalometric superimposi-
inverse overjet (Pig. 14, 15). Between the ages of eight
tion: steeper occiusal plane and mandibular posterior posi
and 22 years, the occiusal plane had become flatter and
tion with less hyperdivergence are obvious.
the mandibular plane angle had decreased (.Fig. 16).
Cephalometric tracing super imposition of ages 13 and
22 revealed the descent of the posterior occiusal plane
(Fig. 17). The panoramic radiograph showed impacted
upper and lower third molars with an unfavorable in
clination and low eruption potential (Fig. 18). At age 23,
a skeletal reverse occlusion and a high angle character
were diagnosed in spite of a low value for the mandibu
lar plane angle (FH-MP 23). Other characteristics were
found, such as retroclination of lower incisors, exces
sive functional anterior rotation of the mandible that
resulted from the increased vertical height of the denti
tion, dysfunctional mandibular position and imbalance
of the whole orofacial. complex.
The treatment objectives consisted in achieving a
posterior adaptive repositioning of the mandible and

Fig. 14: Patient 2: Pre-treatment frontal and profile views.

Fig. 15: Pre-treatment intraoral views.

S. Sato et a]. Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 16: Follow-up facial profile views dur

ing growth course. Class III facial appear
ance worsened affer age 12.

Fig. 17: Cephalometric superirnpositions of

growth course at age 12 years (a) and 23
years (b) indicating the flattening of the oc-
clusal plane after increasing the posterior
occlusal vertical dimension and the signifi
cant forward mandibular rotation.

establishing a proper functional occlusion. At tine begin

ning of treatment, all third molars were extracted to
eliminate the posterior discrepancy. Standard edgewise
brackets and. tubes were bonded to all teeth. Levelling
was performed using 0.014-inch Australian wire arches.
One month later, MEAWs were incorporated in both
dental arches and the occlusal plane was corrected with
short class III elastics {Fig. 19). After four months of treat
ment, the upper dental arch was expanded with an over
lay wire (0.7 mm stainless steel). Nine months later a
0.016"x0.022" ideal arch wire was placed in the maxil
lary arch and the class III elastics remained in use. After
12 months the active treatment was finished (Fig. 19,20).
The therapeutic occlusion showed a tendency to class
III. However, cephalometric superimposition demon
strated a mandibular backward position with a slight
hyperdivergence resulting from the steeper occlusal
plane (Fig, 21).

Fig. 18: Panoramic radiograph: (a) Pre-treatment and (b)
Post-treatment.
Discussion
It has been generally accepted that mandibular de
velopment depends on the direction of condylar growth
and the difference in growth between anterior and pos
terior facial height. If vertical condylar growth exceeds
the vertical growth at the sutural-alveolar process area,
a forward or closing mandibular rotation occurs and vice
 Development and Orthodontic Treatment of Class III Malocclusion

a Fig. 19: Foliow-up intraora! views dur

ing and post-treatment: fa) beginning of

treatment, (b) after two months, fc) end

of treatment after 12 months, and fd)

two years post-treatment.

Fig. 21: Pre-treatment and post-treatment cephalometric superim-

position shows backward repositioning of the mandible,
Fig. 20: Post-treatment frontal and profile views. hyperdivergence, and a slightly steeper occlusal plane.
S. Sato ct al.
versa (18-21). Molar over-eruption occurs in individu
als with reduced functional biting force caused by mus
cular weakness. Mouth breathing constitutes an
additional problem displacing the mandible downward
while the dentition gains in height secondarily. These
statements rest upon the genetic determination of
growth potential and direction which are both influ
enced by dentition and alveolar growth. The develop
ment of an openbite malocclusion has been attributed
mainly to these factors but mandibular growth is also
influenced by environmental factors (22-26). Many re
searchers report an increment in mandibular condylar
growth and mandibular angle alteration caused by man
dibular anterior shift. McNamara and Bryan (26) ob
served a considerable increase in mandibular growth
following artificial protrusion in rhesus monkeys over
a period of 144 weeks. Also Petrovic (27) found adap
tive changes in mandibular morphology as well as in
the temporomandibular joint. It was concluded that
adaptive changes in mandibular corpus represent the
type and character of a malocclusion.
On the other hand Sato ct al. (7-14) demonstrated that
a space deficiency in the posterior region (posterior dis
crepancy) has a pathological effect that exerts squeez-
ing-out forces and produces not only mesial drifting but
also over-eruption of molars, causing an increment in
posterior occlusal vertical dimension with a subsequent
flattening of the occlusal plane and forward mandibu
lar rotational displacement. If there is no continuous
functional mandibular adaptation, this will result in the
development of a class III openbite malocclusion.
The previous hypothesis that an openbite results from
mandibular hyperdivergence was abandoned as evi
dence emerged that an increase in occlusal vertical di
mension influences the continuous process of forward
mandibular rotational adaptation, which is essential for
human orofacial development. Longitudinal studies of
craniofacial growth in different populations confirm that
an increment in occlusal vertical height and flattening
of the occlusal plane induces forward mandibular rota
tional adaptation (Table 1). During growth, the occlusal
plane gradually becomes flatter (FH-OP) and the man
dibular plane angle (FH-MP) decreases if no
hyperdivergence prevails.
Orthodontic treatment should therefore focus on con
trolling the occlusal vertical dimension and occlusal
plane inclination. Indeed, the application of these con
cepts and MEAW mechanics after elimination of poste
rior discrepancy provides a simple treatment strategy
for correcting Class III malocclusions in a very short time.
During the retention phase, removable retainers are
worn in both dental arches from six to eight months.
The basic problem of skeletal Class III malocclusion is
the posterior vertical dimension. Post-treatment stabil
ity depends on the maintenance of this vertical height.
Bull. Kanagawa Dent. Col. 35 (2007)
From this point of view, no retainer provides the effect
of keeping vertical distances. Vertical stability is attained
by the final adjusted occlusion and occlusal function.
For this reason, the careful establishment of a proper
dental occlusion is the key point in post-orthodontic sta
bility. It is incorrect to attempt to maintain an occlusion
without perfect finishing according to each individual
case. However, retention for a limited period of time is
indispensable in preventing horizontal problems as
crowding.
The patients cited in this article wore Hawley retain
ers day and night for approximately five months after
removal of the fixed appliances. Later on the same re
tainers were used for another three to four months only
at night and then the retention was ceased. The post-
retention occlusion remained stable. Both patients re
port exemplified occlusal stability once posterior
discrepancy had been removed with the inclination of
the occlusal plane. Thus, posterior discrepancy is con
sidered an important pathogenic factor. Even in severe
skeletal Class III cases, a correction of the malocclusion
can now be achieved solely by orthodontic treatment
without the need for orthognathic surgery in a relatively
short amount of time.
Acknowledgements
This work was performed in Kanagawa Dental College,
Research Institute of Occlusion Medicine and supported by a
grant-in-aid for open research from the Japanese Ministry of
Education, Culture, Sports, Science and Technology. The content
of this article was originally published in the journal Information
Orthodontic und Kieferorthopadie (IOK) in German. This issue
in BKDC topics is a secondary publication after translation into
English with copyright permission from IOK (Thieme).
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 Bulletin of Kanagawa Dental College
Vol. 35, No. 1, March, PP. 65-77,2007

Different Mechanics for Orthodontic Correction

of Class II Openbite and Class III
Openbite Malocclusions

Sadao Sato, Masaaki Kaneko, Kenichi Sasaguri,

Eliana Midori Tanaka and Ales Cefar*

Department of Cmniofacial Growth and Development Dentistry,

Kanagawa Dental College
Department of Orthodontics, Medical University of Vienna, Bernhard Gottlieb
Dental Clinic, Vienna, Austria

Abstract

In most cases, diagnosis and treatment planning tor skeletal openbite malocclusions can
I be complex and constitutes a real challenge particularly in those accompanied by antero-
postenor maxillo-mandibular discrepancies.
The present paper deals with high angle and low angle Class III malocclusions as well as
with Class II openbites. Utilization of MEAWs (multiloop edgewise arch wires) with different
tip back mechanics and short vertical elastics can be effective in reconstructing the occlusal
plane inclination, and so allow the repositioning of the mandible. Tooth alignment with cor
rected occlusal plane inclination can lead to a physiological mandibular position which is the
key to stability of the properly adjusted occlusion.

Keywords: Class II malocclusion I Class III malocclusion I Openbite

Introduction
The reason why openbites and mandibular
hyperdivergence are quite often seen in human beings
is not just a dental problem but also one of the topics in
human evolution. Through the years, orthodontic his
tory has faced this question but actually has still no clear
answer. Therefore, an accurate treatment plan cannot
be established and palliative therapies are still carried
out including unnecessary extractions or combined treat
ment with orthognathic surgery.
The condition high angle indicates mandibular
hyperdivergence and involves functional problems re
lated to the maxillary position, temporomandibular joint
function, balance of the maxillo-mandibular complex
and the facial skeleton as well as the skull, and muscle
Accepted for publication on October 5,2006.
Address for correspondence: Masato Matsuo, Tissue Engineering
Division, Institute for Frontier Oral Science, Kanagawa Dental
College, 82 Inaoka-cho, Yokosuka, Kanagawa, 238-8580, Japan
Tel: +81-46-822-8880 (ex. 2381) Fax: +81-46-822-8844
activity. In this regard, restoration of function achieved
only by extraction or surgical correction of patient's
morphology is questionable. In addition, surgical cor
rection is a treatment option with associated risks. Most
patients prefer not to have surgical intervention and in
deed, many patients refuse it. High angle openbites de
note the malocclusion with the highest frequency of
surgical intervention. Until now, there are no definite
guidelines on how to treat openbites according to the
state of the art.
Twenty years ago, Ellis et nl. (1, 2) studied the char
acteristics of maxillary and mandibular occlusal planes
as well as the anterior-posterior mandibular position in
class II and class III openbite subjects. They concluded
that the problem was caused by anteroposterior devia
tions of the maxilla and the mandible and that this should
be treated by surgical correction. On the other hand, Kim
Y.H. (3-5) has treated numerous patients with openbite
malocclusion with no surgical intervention. Kim's or
thopedic correction was successfully carried out by
S.Sato etal. Bull. Kanagawa Dent. Col. 35 (2007)

changing the occlusal plane using a product of his own Pi'

development, the multiloop edgewise arch wire
(MEAW). According to our experience, MEAW treat
FH'OPtQ
ment for occlusal plane correction is not Limited to VOP(A)
FH-OP(A)
openbite malocclusions but is very effective in correct FU-OP(P)
*UOP(C)
ing the occlusal plane in any malocclusion with no sur UOP(C)
VOP(A)
gical intervention (6-1.3). In our practice, we sometimes ~* UOP(P)
UOP(P)
have to deal with openbite malocclusions that are very MP'OP(C)
difficult to treat. Most of them consist of a class U high MP-OP(A)
MP-OP(P)
angle with an openbite. Still, there are no contemporary
LOP(B)
clinical guidelines for effectively treating openbite mal LOP(Pog)
OP(A-P)
occlusion with class II or class III that use an exclusively
orthodontic approach. Pog

Our duty as doctors of dental medicine is to find the

cause of this malocclusion and to define accurate treat
ment methods. The aim of this article is to present an
orthodontic approach to the treatment of different types
of high angle openbite malocclusions. This contribution
should be considered helpful for further research in this
field.
Fig. 1: Cephalometric measurements regarding occlusal
planes. OP(C) conventional occlusal plane, OP(A) anterior
occlusal plane, OP(P) posterior occlusal plane, UOP upper
(maxillary) occlusal plane, LOP lower (mandibular) occlusal
plane, OP (A-P) the difference between anterior and poste
rior occlusal planes.

Developmental characterization of openbite 11=0.5860

malocclusion P<0.0001

Many skeletal malocclusions are considered as

openbite even those including mandibular prognatbism
as well as retrognathism. Treatment guidelines and clini
cal procedures depend on skeletal conditions. A precise
description of the character of the openbite is indispens
able for correct diagnosis.
High angle morphology indicates the posterior man
60 70 80 90 100
dibular rotation in hyperdivcrgent skeletal patterns. A
APDI (Anfero posterior DispJasiu [mik'utur, l'l'-AH)
close evaluation of the development of openbites reveals
that what has occurred is not just a simple rotation. De Fig. 2: Correlation between upper (maxillary) posterior oc
clusal plane, UOP(P) and anterior-posterior maxillomandibu-
pending on the occlusal plane, the mandible rotates for
lar relationship (PP-AB). A flat maxillary posterior occlusal
ward or backward. According to our findings (14-20),
plane UOP(P) creates a skeletal class III, a steep maxillary
the most determinant factor in mandibular
posterior occlusal plane UOP(P) a skeletal class II.
hyperdivergence has been the inclination of the maxil
lary posterior occlusal plane (upper occlusal plane - pos
terior, LJOP-P; Fig. 1, 2, 3). The steeper the posterior
segment of the occlusion, the greater the posterior rota
tion of the mandible will be, creating a class 11 openbite
malocclusion. The flatter the occlusal plane, the more so-
the mandible will rotate forward and a class III openbite
may develop (Pig. 2). Furthermore, it should be kept in
mind that a steeper cant of the occlusal plane induces 70-
greater mandibular hyperdivergence and that a flatter
inclination of the occlusal plane decreases the mandibu
lar plane angle (Fig. 3). (.(I
2(1 3(1 411 5(1
Longitudinal growth studies in subjects with a class 10
PP-MP
11 high angle openbite only show a slight increment in
Fig. 3: Correlation between upper posterior occlusal plane
posterior occlusal vertical height and a steeper orienta
UOP(P) and lower facial hyperdivergency (PP-MP). Leveling
tion of the occlusal plane. Subsequently, an anterior the cant of the posterior occlusal plane UOP(P) to an almost
openbite develops because of mandibular posterior ro horizontal orientation is related to the closure of the lower
tation (Fig. 4). Class II and class III openbites differ in face. A steeply inclined cant of the posterior occlusal plane
the vertical height of the molar occlusion, inclination of UOP(P) is associated with hyperdivergence of the lower face.
 Different Mechanics for Treatment of Class II and Class III Openbite
the occlusal plane, and adaptive movement of the man
dible (Fig. 5). For the correction of a class III openbite,
the mandible should be repositioned posteriorly, by
steepening of the occlusal plane (i.e. a posterior-supe
rior orientation). In order to close a class TI openbite mal-
occlusion the flattening of the steep occlusal plane will
provide a forward adaptation of the mandible. So dif
ferent dynamic systems are needed in the therapy of class
I] openbite and class III openbite malocclusions.
Diagnostic approach to the high angle -
"long face syndrome"
In the treatment of patients with a high angle
dysgnathia, the characterization of the inherent maloc-
clusion is the most important issue. Skeletal patterns are
generally evaluated by cephalometric analysis. We will
limit this analysis to a method that is easy to handle.
Such an analysis is necessaiy to understand the relation
ship between occlusal vertical dimension and mandibu
lar adaptation.
Fig. 4: Development of a class II openbite
in longitudinal growth observation. During
normal growth the mandible rotates for
ward in response to the increasing molar
vertical dimension and the mandibular
plane angle remains stable (a). If the cant
of the occlusal plane becomes so steep that
the mandible cannot rotate forward (insuf
ficient eruption of maxillary molars, over-
eruption of mandibular molars), then a
retrognathic openbite appears (b).
Fig. 5: Concept regarding occlusal plane
changes and mandibular adaptation. A flat
occlusal plane due to the eruption ot upper
molars induces the mandibular forward
rotation. This forward mandibular growth
is accompanied by secondary condylar
growth. Molar over-eruption causes the oc
clusal plane to be too flat and subsequently
gives an excessive mandibular forward
thrust, i.e. a tendency toward class III
openbite (a). Insufficient eruption of the
posterior molars creates a steep occlusal
plane; posterior rotational mandibular dis
placement produces a tendency toward
class II openbite (b).
Denture Frame Analysis (Fig. 6)
The relationship between the occlusal plane and the
shape of the orofacial skeleton can be evaluated using
the simple cephalometric method introduced by Sato (21,
22), i.e. the Denture Frame Analysis. The four horizontal
planes used in the construction of a denture frame are:
the Frankfort horizontal (FH), the palatal plane (PP), the
mandibular plane (MP), the AB-line (AB), and the oc
clusal plane (OP). The adaptive movements of the max
illa and the mandible are evaluated against the functional
planes, particularly the occlusal plane. The cant of the
occlusal plane related to the intersection with PP and
MP indicates the relative incline of an occlusal plane
orientation that is either too steep or too flat.
In the diagnosis and treatment plan of high angle
malocclusions, the dynamic mechanism that occurs due
to an altered occlusal vertical dimension and the subse
quent skeletal adaptation must be taken into consider
ation. Very often in class IT openbite malocclusion, the
posterior occlusal plane (UOP-P) is steeply oriented at
the molars and the mandible rotates backward, i.e. the
mandible cannot functionally adapt forward against the
S. Sato et at.
FH-lllF
PP-KP
OP-HP
Fig. 6: Denture Frame Analysis. The relationship between
occlusal plane and orofacial structures is analyzed by appli
cation of Frankfort horizontal (FH), palatal plane (PP), man-
dibular plane (MP), AB-line (AB), and the occlusal plane (OP).
The type of maxillary and mandibular adaptation is analysed
facing functional cephalometric planes, particularly the oc
clusal plane.
steepening of the occlusal plane. This causes an anterior
openbite. During growth, this event Inhibits condylar
growth (compression of the condyle) and the high angle
condition is aggravated.
In the case of posterior discrepancy, an overeruption
of the upper molars occurs and the posterior occlusal
plane inclination flattens. The mandible is displaced for
ward with anterior rotation in response to the increase
in posterior vertical dimension and consequently, the
orofacial skeleton becomes a class III.
The orthodontic treatment approach must realize this
developmental background and the outcome of the high
angle morphology, either class II or class III. This view
discloses the morphologic structures, the functional ad
aptation of the orofacial skeleton, and the character of
the malocclusion.
Analysis of malocclusion by Kim's ODI and
APDI (Fig. 7) (23, 24)
Kim described compound cephalometric measure
ments for the analysis of vertical and anterior-posterior
components of malocclusion, He named them overbite
depth indicator ODI and anterior-posterior dysphsin indica
tor APDI. Their mathematical sum represents the combi
nation factor CF.
The ODI consists of two angles, i.e. (1) the angle be
tween FH and PP and (2) the angle between AB and MP.
Among various cephalometric measurements the ODI
shows the highest statistical correlations with dental
overbite. An anterior openbite results from an increased
posterior occlusal vertical dimension and the angle AB-
Bull. Kanagawa Dent. Col. 35 (2007)
ODI: 3+4
APDI: 1+2+3
CF: ODI+APO)
Fig. 7: Kim's analysis evaluates vertical and anterior-poste
rior components of malocclusion: ODI, APDI, and CF. The
ODI is associated with the overbite and the normal ODI value
averages 72 in Asians (approximately 75 in Caucasians).
Lower values indicate an openbite, higher values a skeletal
deep bite. The APDI describes skeletal anterior-posterior re
lationships (mean 81; higher values indicate class 111, smaller
values class II). The smaller the CF value, the more the high
angle tendency prevails, and extractions become more likely.
MP is small relative to the anterior mandibular adapta
tion. In this case the ODI value is small.
The APDI consists of three angular measurements
(FH-PP, AB-NPg, FH-NPg) but corresponds to the angle
PP-AB. The APDI evaluates the skeletal classes I, IT, and
111 of the lower face. The average APDI-value for class J
is 81; higher values indicate class 111, lower values class
II.
Small CF-values represent a high angle tendency.
This is why the CF is used in determining the necessity
for tooth extraction in orthodontic therapy: the lower
the CF, the higher the necessity for extraction. Extrac
tion of teeth does not refer to the exclusive extraction of
premolars. An evaluation of which teeth need to be ex
tracted will be performed depending on each individual
case.
Treatment objectives for class III openbite
In the development of a class III openbite, the key
point is the increment in the occlusal vertical dimension
of the posterior teeth. In the case of molar over-erup
tion, the occlusal plane will become flatter and the man
dible will adapt by forward rotation in order to attain
occlusal contacts. In other words, the mandible rotates
forward and reaches a class III relationship. Whenever
the forward mandibular rotational adaptation is insuf
ficient m the vertical direction, a class III openbite will
arise. The basic problem behind this development origi
nates from a posterior discrepancy and the subsequent
alteration of the cant of the occlusal plane as well as
mandibular adaptation.
 Different Meciianics for Treatment of Class II and Class III Openbite

Fig. 8: Orthodontic mechanics for correction of class 111 and class II openbite malocclusions. Class 111 openbite malocclusion requires
a steeper occlusal plane for backward adaptation of the mandible. Tip back bends of the MEAW correct the post-canine teeth to an
upright position and intrude the molars. Short class III elastics are used on the front teeth. In class II with an openbite the mandible
rotates and is displaced posteriorly. These patients will benefit from a flatter occlusal plane by elimination of the molar interferences,
which will then allow a physiologic mandibular forward rotation. This goal is reached by using moderate tip back bends in the
maxillary MEAW, strong tip back bends in the mandibular MEAW, and short anterior class II elastics.

With reference to its development, class 111 openbite
malocclusion will benefit from steepening of the occlusal
plane, which induces mandibular backward adaptation.
The orthodontic correction must aim at uprighting the
posterior teeth and any additional intrusion of the mo
lars. This approach will steepen the occlusal plane with
a concomitant release of the squeezing-out effect at the
molars. The convenient treatment mechanics used are
tip back bend activations of the multiloop edgewise arch
wires and vertical or short class III elastics on the ante
rior teeth (Fig. 8).
During the reconstruction of the occlusal plane, one
limitation can be the occurrence of molar crowding,
which is followed by an increase in the vertical height
of the molar dentition during uprighting, and a subse
quent forward rotation of the mandible. Therefore, in
most cases, priority is given to a solving the posterior
discrepancy problem, usually by extraction of the third
molars. In some cases, the extraction of the upper third
molar may be very difficult and the surgery carries with
it a high risk. Following this, the second molar may be
extracted if the inclination of the third molar has been
assessed as being favourably positioned for eruption into
occlusion later on.
Figures 9-14 show a class Til openbite malocclusion
in an 18-year-old patient. The diagnosis includes molar
over-eruption in posterior discrepancy and class III
openbite due to a flat occlusal plane. Orthodontic treat
ment was started after extraction of the upper and lower
third molars. After seven months of active treatment,
the anterior openbite was corrected and the treatment
ended. The patient wore a retainer for six months. The
occlusion remained stably visible during the two years
and five month follow up period.
Treatment objectives for class II openbite
According to morphologic studies on class II openbite
malocclusion, the maxillary occlusal plane is inclined
too steeply at the posterior segment. As a consequence,
the physiologic forward adaptation and the mandibu
lar growth are often restricted. Furthermore in class II,
the mandibular posterior discrepancy promotes man
dibular molar over-eruption. This elevation of the oc
clusal surfaces is followed by a posterior rotation of the
mandible. In other words, the mandible in class II
openbite malocclusion is displaced by a backward rota
tion because of less-erupted maxillary molars with over-
erupted mandibular molars. In addition, the steep
occlusal plane interferes with mandibular movement
and forward rotation does not take place. Therefore, the
occlusal plane must be flattened in order to eliminate
the molar interference and initiation of the physiologic
forward adaptation. The orthodontic treatment of class
II openbite malocclusion focuses on the extrusion of the
maxillary molars and the intrusion of the mandibular
molars in order to flatten the occlusal plane. The me
chanics for this correction consist of moderate tip back
bends in the maxillary MEAW and strong tip back bends
in the mand ibular MEAW. Vertical or short class II elas
tics are used at the anterior loops (Fig. 8).
Figures 15-20 show an 18-year-old female patient
with class TI openbite and cranio- mandibular dysfunc
tion. She complained of a shooting pain in the temporo-
mandibular joints. The class II openbite malocclusion
was associated with mandibular backward rotation and
a very steep posterior occlusal plane. In prior orthodon
tic treatment, all third molars were removed and the
occlusal plane was flattened by MEAW mechanics. The
oiLtcome of active treatment over a period of 19 months
S. Sato etal Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 9: Class 111 with openbite.

Pre-treatment frontal and profile views.

Fig. 10: Pre-treatment intraoral views.

Fig. 11: Pre-treatment cephalogram and panoramic radiograph.

,-
 Different Mechanics for Treatment of Class II and Class III Openbite

Fig. 12: Intraoral views during treatment; (a) at onset of treatment, (Id) after two months,

(c) after four months, (d) after seven months, and (e) two years after finishing treat
ment.
S. Sato etal Bull. Kanagawa Dent. Col. 35 (2007}

Fig. 13: Post-treatment frontal and profile views.

a Fig. 14: Cephaiometric tracing before

treatment (a) and superimposition of trac

ings before and after treatment (b).

Table 1. Denture Frame Analysys

Different Mechanics for Treatment of Class TI and Class III Openbite

Fig. 15: Class II with openbite. Pre-treatment frontal and profile views.

Fig. 16: Pre-treatment Intraoral views.

Fig. 17: Panoramic radiograph before and after treatment.

S. Sato et nl. Bull. Kanagawa Dent Col. 35 (2007)

Fig. 13: Intraoral views during treatment: (a) at

onset of treatment, (b) after one month, (c) after
seven months, (d) after 19 months, (e) one year
later, and two years five months after the end of
treatment.
 Different Mechanics for Treatment of Class II and Class III Openbite
Fig. 19: Post-treatment frontal and profile views.
was the correction of the anterior openbite and the elimi
nation of temporomandibular joint pain and dysfunc
tion. Two years and five months after finishing
orthodontics., the dentition remained stable without
major alterations.
The cephaiometric changes of both patients presented
in this article are described in Table 1.
Discussion
Generally, openbite malocclusion has been consid
ered a vertical anomaly in the relationship between
maxillary and mandibular arches or between the max
illa and mandible as in deep bite. The development of
openbite has been interpreted from various aspects such
as developmental disharmony of the jaws, abnormal
habits related to lip and tongue function, excessive erup
tion, etc. The direction of mandibular growth and con
comitant functional factors have been considered, to be
an important factor in aggravating the openbifce (25-28).
Sato et al. emphasized the increment in the vertical
Fig. 20: Cephaiometric tracing before
treatment (a) and superimposition of
tracings before and after treatment, (b)
Orthodontic treatment flattened the
steep posterior occlusal plane and a
slight forward mandibular displace
ment is visible.
occlusal dimension in the posterior part of the dentition
because of the squeezing out effects of molar crowding
(posterior discrepancy). The subsequent flat occlusal
plane conditioned the mandibular adaptation in terms
of a forward rotation, which again created a class III
openbite malocclusion (6, 7, 10-13,16-19, 21). Previous
hypotheses stated that the increase in the molar vertical
height of the occlusion had affected the hyperdivergence
of the inandible and the openbite. Later on, it was con
cluded that the increased posterior occlusal vertical di
mension had been actually followed by a mandibular
adaptation with forward rotation. This mechanism has
an important influence on orofacial growth and agrees
with descriptive studies of normal individual orofacial
growth in different populations. These studies also sub
stantiate the forward rotation of the mandible, an in
crease of the posterior height of the occlusion, and
flattening of the occlusal plane's orientation (29,30). Dur
ing growth, the angle between the Frankfort horizontal
and occlusal plane (FH-OP) has become continuously
S. Sato el al.
smaller and more horizontal, and the mandibular plane
angle (FH-MP) has shown a decrease without hyperdi-
vergence.
Clinical observations of openbite malocclusion do not
show molar over-eruption and flattening of the occlusal
plane. Subjects with a steep occlusal plane and decreased
occlusal vertical dimension may bring etiologic insight
and diagnosis into confusion. This is why orthodontists
consider a surgical correction the only achievable treat
ment option. Openbite has been viewed as a difficult
malocclusion for orthodontic treatment and corrections
have been carried out with concomitant orthognathic
surgery.
Difficulties in treating openbites probably arise from
palliative treatment options without etiological consid
eration of the malocclusion. The body's adaptive re
sponse will only fulfil the requirements if correct
treatment has been applied. In suitable compensatory
function, the occlusion will remain stable. Orthodontic
treatment has the potential to use inherent adaptive
properties and promote proper individual function. The
most important treatment objectives are the control of
the vertical dimension and the reconstruction of the oc
clusal plane.
In high angle class II openbite malocclusion there is
insufficient occlusal contact because of the low occlusal
vertical dimension at the molars and the steep posterior
occlusal plane. In the case of adaptive mandibular pos
terior rotation, a class II openbite will develop. Along
with this background, there is still another problem,
namely the dynamic skeletal balance in the openbite.
The treatment should not only correct the den to- alveo
lar situation but also make use of the dynamic system
with its supporting skeletal balance. In the development
of skeletal class III openbite, an inverse adaptation takes
place, i.e. the background of the skeletal class III con
sists of a flexion of the skeleton, a hyperdivergent face
due to maxillary downward growth, and an increased
occlusal vertical dimension. In addition, the occlusal
plane levels posteriorly (Fig. 5). That is why an inverse
curve of Spec is generated in class III. Under these cir
cumstances, the mandible responds in terms of a for
ward rotation.
The most important functional determinants for the
orofacial balance are the occlusal vertical dimension and
the posterior occlusal plane inclination (31). Thus, in the
orthodontic treatment of skeletal Class II or III openbite
malocclusions, successful results are obtained when con
trolling the posterior vertical dimension and posterior
occlusal plane inclination.
Acknowledgements
This work was performed in Kanagawa Dental College,
Research Institute of Occlusion Medicine and supported by a
Bull. Kanagawa Dent. Col. 35 (2007)
grant-in-aid for open research from the Japanese Ministry of
Education, Culture, Sports, Science and Technology. The content
of this article was originally published in the journal Information
Orthodontie und Kieferorthopadie (IOK) in German. This issue
in BKDC topics is a secondary publication after translation into
English with copyright permission from IOK (Thieme).
References
1. Ellis, E. III. and McNamara, J. A. Jr. (1984). Components of adult
Class III openbite malocclusion. American journal of
Orthodontics. 86: 277-290.
2. Ellis, E. III., McNamara, J.A. Jr. and Lawrence, T.M. (1985).
Components of adult Class II open-bite malocclusion. journal
of Oral and Maxillofacial Surgery. 43:92-105.
3. Kim,Y.H. (1987). Anterior openbite and its treatment with
multiloop edgewise arch wire. Angle Orthod. 57: 290-321.
4. Kim, Y.I 1. (1999). Treatment of severe openbite malocclusions
without surgical intervention. In: McNamara, J.A. Jr. (Ed).
Growth modification: what works, what doesn't, and why.
Craniofacial Growth Series, vol. 35, Ann Arbor: Center for
Human Growth and Development. The University of
Michigan, pp. 193-212.
5. Kim, Y.H. (2000). Treatment of anterior openbite and deep
overbite malocclusions with the multiloop edgewise archwire
(MEAW) therapy. In: The Enigma of the Vertical Dimension.
Craniofacial Growth Series, vol. 36, Ann Arbor: Center for
Human Growth and Development, McNamara J.A. Jr, (Ed.),
The University of Michigan, pp. 175-202.
6. Sato, S.A. (2001). Treatment approach to malocclusions under
the consideration of craniofacial dynamics. Grace Printing
Press Inc. (Philippines).
7. Sato, S., Akimoto, S., Matsumoto, A., Shirasu, A. Yoshida, J.
and Sato, S. (2002). MEAW - Manual for the clinical application
of MEAVV technique. Printing Press Inc. (Philippines).
8. Fujita, A., Ono, K., Maruta,Y. and Sato, S. (1995). New approach
to the treatment of Class II malocclusion with high mandibular
plane angle based on occlusal plane control. Bull Kanagauui
Dent Col. 23: 63-68.
9. Sagara, N., Takahashi, S., Lin, J-M. and Sato, S. (1995).
Orthodontic treatment of Class II malocclusion with
temporomandibular joint dysfunction. Bull Kanagaxi'ii Dent Col.
23: 55-62.
10. Sato, S. (1994). Case report: Developmental characterization
of skeletal Class III malocclusion. Angle Orthod. 64:105-112.
11. Protacio, C. and Sato, S. (1995). The role of posterior
discrepancy on the development of skeletal Class III
malocclusion - Its clinical importance, hit J. MEAW Tech Res
Found. 2: 5-18.
12. Sato, S., Dennis, C.L., Miyakawa, Y. and Kim, R.I I. (1998). The
development of openbite as a result of posterior discrepancy
and its treatment approach using mutiloop edgewise arch wire.
//// /. MEAW Tech Res Found. 5: 5-15.
13. Sato, S., Takamoto, K. and Suzuki, Y. (1988). Posterior
discrepancy and development of skeletal Class HI
malocclusion. Orthodontic Revieio. Nov/Dec: 16-29.
14. Hwang, D.H., Akimoto, S. and Sato, S. Relationship Between
the Occlusal Plane Inclination and Mandibular Posture in the
Hyperdivergent Type of Skeletal Frame.
15. Hwang, D.H., Akimoto, S. and Sato, S. Occlusal Plane and
Mandibular Posture in the Hyperdivergent Type of
Malocclusion in Mixed Dentition Subjects.
16. Sato, S., Motoyanagi, K., Suzuki, T., Imasaka, S. and Suzuki,
Y. (1988). Longitudinal study of the development of skeletal
malocclusions. J.jpn Orthod Soc. 47: 186-196.
17. Sato, S., Suzuki, N. and Suzuki, Y. (1988). Longitudinal study
of the cant of occlusal plane and denture frame in cases with
congenitally missing third molars. Further evidence for the
 Different Mechanics for Treatment of Class II and Class III Openbite
occlusal plane change related to posterior discrepancy. /. //;//
Orlhod Soc. 47: 517-525.
18. Sato, S., Sakai, H., Sugishita, T., Matsumoto, A., Kubota, M.
and Suzuki, Y. (1994). Developmental alteration of the form
of denture frame in skeletal Class III malocclusion and its
significance in orthodontic diagnosis and treatment, bit }.
MEAW Tech Res Found. 1: 33-46.
19. Sato, S. and Suzuki, Y. (1988). Relationship between the
development of skeletal mesio-occlusion and posterior tooth-
to- denture base discrepancy - Its significance in the
orthodontic reconstruction of skeletal class III malocclusion.
journal of Japanese Orthodontic Society. 47: 796-810.
20. Fushima, K., Kitamura, Y., Mita, H., Sato, S., Suzuki, Y. and
Kim, Y.H. (1996). Significance of the cant of occlusal plane in
Class 11 division 1 malocclusion. Eur J. Orthodonl. 18: 27-40.
21. Sato, S. (1987). Alteration of occlusal plane due to posterior
discrepancy related to development of malocclusion -
Introduction to denture frame analysis. Bull Kanngawa Dent
Coll. 15: 115-123.
22. Freudenthaler, J.W., Celar, A.G. and Celar, R.M. (1994).
Denture Frame Analysis- I'osteriore Diskrepanz Funktionelles
Konzept nach S. Sato. Informational. 3: 359-370.
23. Kim, Y.I I. (1974). Overbite depth indicator with particular
reference to anterior open-bite. Am / Orlhod. 65: 586-610.
24. Kim, Y.I I. and Vietas, J.J. (1978). Anteroposterior dysplasia
indicator. An adjunct to cephalometric differential diagnosis.
Am J. Orlhod. 73: 719-733.
25. Lowe, A.A. (1980). Correlations between orofacial muscle
activity and craniofacial morphology in a sample of control
and anterior openbite subjects. Am J. Orthod. 78: 89-9.
26. Prof fit, VV.R. (1978). Equilibrium theory revisited: factors
influencing position of the teeth. Angle Orthod. 48: 175-18.
27. Subtelny, J.I:, and Sakuta, M. (1964). Open-bite: diagnosis and
treatment. Am J. Orthod. 50: 337-358.
28. Mizrahi, E. (1978). A review of anterior open-bite. Brit J. Orthod.
5: 21-27.
29. Richardson, E.R. (1991). Atlas of craniofacial growth in
Americans of African Descent, Center for Human Growth and
Development, Craniofacial Growth Monograph Series.
30. Bhatia, S.N. and Leighton, B.C. (1993). A manual of facial
growth, A computer analysis of longitudinal cephalometric
growth data. Oxford Univ. Press.
31. Slavicek, R. and Sato, S. (2001). The dynamic functional
anatomy of craniofacial complex and its relation to the
articulation of the dentitions (pp. 482-514). Das Kauorgan
Funktione und Dysfunktionen. Gamma Dental Edition,
(Austria).
Bulletin of Kanagawa Dental College
Vol. 35, No. 1, March, PP. 79-86, 2007

Orthodontic Reconstruction of Occlusion

in Class III Malocclusion with Low
Mandibular Plane Angle

Akiyoshi Shirasu, Eliana Midori Tanaka and Sadao Sato

Department of Craniofaeial Growth and Development Dentistry, Kanagawa Dental College

Abstract

In orthodontics, occlusal reconstruction should be one of the ultimate goals in the achieve
ment of both aesthetically satisfactory and functionally effective treatment. The establish
ment of a proper vertical dimension of occlusion through occlusal plane control will provide a
balance for the maxillofacial complex. A skeletal Class III low angle malocclusion case in
early permanent dentition accompanied by an anterior cross bite, decreased vertical dimen
sion and mandibular midline deviation to the right is presented and a report given on a treat
ment plan accomplished by extracting the upper second molars to facilitate the reconstruc
tion of the occlusal plane by uprighting the mandibular posterior teeth with the concomitant
use of MEAWs (Multiloop Edgewise Arch Wire).

Key words: Class III Low angle I Occlusal plane I Vertical dimension I
MEAW technique

Introduction mony with vertical condylar growth. Although antero

The basic objective of orthodontic treatment is to re
store the harmony of the maxillofacial skeleton through
the control of occlusion with appropriate vertical dimen
sion. In other words, the restoration of the harmony of
the maxillofacial complex through occlusal treatment is
the responsibility of every orthodontist in daily prac
tice. In the treatment of malocclusion associated with
skeletal symptoms, occlusal reconstruction is difficult,
especially in patients with a Class III malocclusion. There
are different types of Class III malocclusion, high angle
and low angle (1-6). In these types of cases, the vertical
and anteroposterior problems of the jaw are complicated,
and difficulty in the diagnosis and occlusal reconstruc
tion is due to the absence of a standardized procedure
on which force system to apply.
A Class III malocclusion with an anterior openbite
and a low mandibular plane angle is often termed a func
tionally shifted crossbite, and is skeletally characterized
by poor vertical growth of the upper face resulting in a
lack of posterior occlusal vertical dimension and dishar-
Accepted for publication on October 5, 2006.
Address for correspondence: Akiyoshi Shirasu, Department of
Craniofaeial Growth and Development Dentistry, Kanagawa Dental
College, 82 Inaoka-cho, Yokosuka, Kanagawa, 238-8580, Japan.
Tel: +81-46-822-8880 (ex. 2381) Fax: +81-46-822-8844
posterior growth of the maxilla does not present much
of a problem, the anterior crossbite is associated with a
deep overbite due to the excessive forward rotation of
the mandible.
Orthodontic reconstruction of occlusion in this type
of malocclusion requires an increase in occlusal vertical
dimension. Even though ME AW mechanics (6-9) is gen
erally considered to be an effective treatment modality
for an openbite condition, this technique can also be uti
lized to correct the occlusal vertical dimension in a Class
III case with a low mandibular plane angle. A case is
presented to show how the MEAW technique was uti
lized to correct such a malocclusion.
Case Description
The patient, a girl, 12 years and nine months old,
complained mainly of mandibular prognathism. Her
face appeared almost symmetrical and oval in shape
frontally with a prognathic profile of the lower face (Fig.
1-A). The molar relationship was in Class III with a stron
ger tendency toward the left, causing the mandibular
midline to shift to the right by half a tooth. The overjet
and overbite were -3.3 and 2.7mm, respectively. No
crowding was observed (Fig. 1-B).
Cephalometric analysis indicated a mandibular prog-
A. Shirasuef al. Bull. Kanagawa Dent. Col. 35 (2007)

A: Pretreatment facial views and cephalometric tracing.

B: Pre-treatment intraoral views.

Fig. 1: Facial views, cephalometric tracing and intraoral views in pre-treatment.

nathism with SNA = 82.9, SNB = 83.7, and ANB differ
ence of -0.8. The mandibular plane showed a low angle
with FH-MP of 22.0 and PP-MP of 22.4s. The A'-P' dis
tance was 48.8mm and showed no anteroposterior dis
crepancy of the maxilla. The occlusal plane was slightly
inclined with an OP-MP of 11.3 and OP-MP/PP-MP of
50.6%. Kim' s analysis (10-11) showed OD1 = 62.2% APDI
- 95. J and CF = 157.2, indicating a Class III malocclu-
sion with a low angle tendency (Table 1). Panoramic
radiography revealed mesially inclined molars and miss
ing mandibular third molars that had been extracted
previously. The maxillary third molars were present (Fig.
10).
Diagnosis
The case was diagnosed as having an anterior
crossbite with a low angle tendency, lack of occlusal
vertical dimension in the molar area, and excessive for
ward rotation of the mandible.
Treatment Objective
The objectives of treatment were to upright the me
sially inclined mandibular molars, to reconstruct the
occlusal plane by increasing the occlusal vertical di
mension and to readapt the mandible to a more distal
position.
 Orthodontic Treatment of Low Angle Class III Malocclusion

Table 1: Cephalometric analysis ot pre-treatment to two years post-treatment

Treatment 16inch, 6 oz.) in the anterior area (Fig. 3).

The treatment plan was to extract both maxillary sec
ond molars to facilitate the reconstruction of the occlusal
plane and to upright the mandibular posterior teeth.
Standard edgewise appliances were placed on the max
illary and mandibular teeth to initiate leveling with
0.014-inch super-elastic wires (Fig. 2). The initial wires
were replaced with iMEAWs (0.016 x 0.022 inch Elgiloy
wire) that were kept in place until the end of treatment.
Approximately twenty-five degrees of continuous tip-
back bends were placed in the MEAWs initially to start
uprighting the posterior teeth to correct the occlusal
plane by utilizing vertical and short Class III elastics (3/
Because the anterior overbite and overjet improved
two months later, the tip-back activation was reduced
to zero degrees. Instead, step-up bends were incorpo
rated into the posterior sections of the MEAWs to in
crease the vertical dimension (Fig. 4).
Five months later, a short Class II elastic on the right
and a short Class III elastic on the left were placed to
improve the midline (Fig. 5).
With the achievement of the desired position of the
mandible seven months after the onset of treatment, the
step-up bends in the posterior sections were gradually
reduced (Fig. 6).
A. Shirasu ct til. Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 2: Intraoral views at onset of treatment.

Fig. 3: Ten days after beginning treatment. The MEAW therapy began with short Class III elastics.

Fig. 4: Four months after beginning treatment. Step-up bends were added on the posterior dentition.

Fig. 5: Five months after beginning treatment. To correct the midline, Class II elastic was used on the right and Class III elastics
on the left.
 Orthodontic Treatment of Low Angle Class III Malocclusion

Fig. 6: Seven months after beginning treatment. Step-up bends were gradually reduced in the posterior dentition.

Fig. 7: Ten months after beginning treatment. The malocclusion showed improvement.

Fig. 8; Ten months after beginning treatment. Tooth positioner is used for retention.

Since a normal occlusion was obtained ten months
later, all the brackets and the bands were removed to
start the retention with a tooth positioner (Fig. 7, Fig. 8).
Treatment Results
The post-treatment profile showed an improvement
in the patient's prognathic lower face with the molar
relationship in Class I and no midline deviation. The
overjet and overbite were improved to 4.2 and 1.1 mm,
respectively (Fig. 9-A, B); however, a slight midline de
viation to the right was noted two years after treatment
(Fig. 11).
Superimposition of pre- and post-treatment
cephalograms showed a clockwise rotation of the man
dible as a result of an occlusal plane change and an in
creased vertical dimension caused by the up righting of
the posterior teeth (Fig. 12). The mandible was readapted
to a more downward and backward position due to the
increment of 2.8C of FH-MP, 2.6 of PP-MP and a flatten
ing of OP-MP by approximately 5 (Table 1). The har
mony of the skeletal jaw relationship was restored with
the achievement of the treatment goals.
Discussion
In a reversed malocclusion with a low mandibular
plane angle, there is insufficient vertical growth of the
dento.fad.al complex, and because of this, the vertical
dimension in the posterior dentition is insufficient, cre
ating a discrepancy in its relationship to the vertical
growth of the mandibular condyle. Normally, though
there is less of a problem in the antero- posterior growth
of the maxilla, this usually manifests a symptom of over-
bite of deep reversed occlusion due to the
hyperprotrusion of the mandible. The treatment objec
tive in this type of patient is to improve the functional
A. Shirasu ct al.
Bull. Kanagawa Dent. Col. 35 (2007)

A: Post-treatment facial views and cephalometric tracing.

B: Post-treatment intraoral views.

Fig. 9: Facial views, cephalometric tracing and intraoral views in post-treatment.

Fig. 10: Panoramic radiographs. A, pre-treatment (13 yrs nine months) and B, post-treatment (14 yrs eight months).
 Orthodontic Treatment of Low Angle Class III Malocclusion

Fig. 11: Two year post-treatment intraoral views.

Fig. 12: Evaluation of treatment results.

A, post-treatment cephalometric superimposition and B, pre-, post-, and two years post-treatment

excessive rotation of the mandible by increasing the ver
tical dimension.
Conventional orthodontic treatment for a functional
cross bite has been based, on growth control and devel
opment with a functional appliance and/or a chin cap
therapy. Subsequent reconstruction of the occlusion by
moving the teeth within the alveolus bones imposes a
great burden on the patient by causing a treatment of
long duration and results that are less than satisfactory.
The treatment method described here made it possible
to achieve the goals of orthodontic occlusal reconstruc
tion in a relatively short term by restoring the closed
vertical dimension that forms the skeletal characteris
tics of a functional anterior crossbite. MEAW (7-11) is
an arch wire developed by Kim Y.H. in which horizon
tal loops are bent from the contact point of the distal
part of the lateral incisors to the posterior part of the
entire teeth. Tooth alignment from the premolars to
A. Shirasu et al.
molars is possible with the continuous tip back bend of
MEAW. Moreover, reconstruction of the occlusal plane
can be performed with the force system coming from
the tip back bend and the vertical elastics. Therefore,
MEAW mechanics provides a very effective means for
accomplishing the treatment goals.
Acknowledgements
This work was performed in Kanagawa Dental College,
Research Institute of Occlusion Medicine and supported by a
grant-in-aid for open research from the Japanese Ministry of
Education, Culture, Sports, Science and Technology. The content
of this article was originally published in the journal Information
Orthodontie und Kieferorthopadie (IOK) in German. This issue
in BKDC topics is a secondary publication after translation into
English with copyright permission from IOK (Thieme).
References
1. Protacio, C. and Sato, S. (1995). The role of posterior
discrepancy on the development of skeletal Class III
malocclusion - Its clinical importance. International journal of
MEAW Technic and Research Foundation. 2: 5-18.
2. Sato, S., Takamoto, K. and Suzuki, Y. (1988). Posterior
discrepancy and development of skeletal Class III
malocclusion. Orthodontic Review. Nov/Dec: 16-29.
3. Sato, S. (1994). Case report: Developmental characterization
of skeletal Class III malocclusion. Angle Orthodontist. 64:105-
112.
Bull. Kanagawa Dent. Col. 35 (2007)
4. Sato, S. and Suzuki, Y. (1988). Relationship between the
development of skeletal mesio-occlusion and posterior tooth-
to-denture base discrepancy - Its significance in the
orthodontic reconstruction of skeletal class III malocclusion.
journal of Japanese Orthodontic Society. 47: 796-810.
5. Sato, S., Sakai, H., Sugishita, T., Matsumoto, A., Kubota, M.
and Suzuki, Y. (1994). Developmental alteration of the form
of denture frame in skeletal Class III malocclusion and its
significance in orthodontic diagnosis and treatment.
International journal of MEAW Technic and Research Foundation.
1: 33-46.
6. Sato, S.A. (2001). Treatment approach to malocclusions under
the consideration of craniofacial dynamics. Grace Printing
Press Inc. (Philippines).
7. Kim, Y.H., (1987). Anterior openbite and its treatment with
multiloop edgewise arch wire. Angle Orthodontist. 57: 290-321.
8. Kim, Y.II. (1999). Treatment of severe openbite malocclusions
without surgical intervention. In: Growth modification: what
works, what doesn't, and why, Craniofacial Growth Series,
vol. 35, Ann Arbor: Center for Human Growth and
Development, McNamara, J.A. Jr., (Ed.), The University of
Michigan, pp. 193-212.
9. Kim, Y.H. (2000). Treatment of anterior openbite and deep
overbite malocclusions with the multiloop edgewise archwire
(MEAW) therapy. In: The Enigma of the Vertical Dimension.
Craniofacial Growth Series, vol. 36, Ann Arbor: Center for
Human Growth and Development, McNamara, J.A. Jr., (Ed.),
The University of Michigan, pp. 175-202.
10. Kim, Y.H. (1974). Overbite Depth Indicator with particular
reference to anterior openbite. American journal of Orthodontics.
65: 586-611.
11. Kim, Y. H. and Vietas, J. J. (1978). Anteroposterior Dysplasia
Indicator: an adjunct to cephalometric differential diagnosis.
American journal of Orthodontics. 73: 619-635.
Bulletin of Kanagawa Dental College
Vol. 35, No. 1, March, PP. 87-94, 2007

Application of MEAW Mechanics to the

Treatment of Class III Malocclusion with
Dental Mid-Line Discrepancy

Kenichi Sasaguri, Susumu Akimoto, Hisaaki Shinji,

Eliana Midori Tanaka and Sadao Sato

Department ofCraniofacial Growth and Development Dentistry, Kanagawa Dental College

Abstract

Midline discrepancy is considered to be one of the complex issues surrounding the plan
ning of orthodontic treatment. Unusual tooth extraction, such as the unilateral removal
of premolars is sometimes applied in an attempt to correct this problem. A clinical case with
a 4 mm midline discrepancy and an anterior cross bite was treated orthodontically with the
application of a multi-loop edgewise arch wire (MEAW) system and no tooth extraction was
performed. The result of the treatment was quite stable and indicated the necessity of repo
sitioning the mandible in asymmetric patients. Based on the results of the treatment, it can
be concluded that a conservative approach that avoids extraction and that consists of fitting
MEAWs with the appropriate use of elastics is an effective mechanotherapy that allows dif
ferential tooth movement and corrects midline discrepancy.

Key words: MEAW I Midline discrepancy I Class III

Introduction anterior cross bite by counter clockwise rotation of the

In orthodontic practice, the correction of midline dis
crepancies constitutes one of the major concerns and un
usual solutions, such as unilateral premolar extractions
are sometimes performed in an attempt to correct this
problem. However, orthodontic treatment with such
dental mutilation involves not only the necessity of the
long-term utilization of asymmetric mechanics, but also
results in an unstable occlusion with unilateral compen
sating molar class II or class III interdigitation. The case
presented here showed a mandibular midline deviation
of 4 mm to the left from the upper dentition with an
anterior cross bite. This case was treated orthodontically
with no tooth extraction and a multi-loop edgewise arch
wire (MHAYV) system was applied to correct both the
Accepted for publication on October 5,2006.
Address for correspondence: Kenichi Sasaguri, Department of
Craniofacial Growth and Development Dentistry, Kanagawa Dental
College, 82 Inaoka-cho, Yokosuka, Kanagawa, 238-8580, Japan.
Tel: +81 -16-822-8880 Fax: +81-46-822-8844
mandible and the midline discrepancy by uprighting the
buccal segment of the displaced side of the mandible.
The treatment result was quite stable and indicated that
the functional reposition of the mandible is indispens
able in asymmetric patients.
Case Presentation
A female patient, 17 year 11 months old consulted
us, complaining mainly of anterior cross bite and mid
line discrepancy. Her facial appearance was rather sym
metrical in a frontal view with a straight facial profile.
The occlusion findings showed that the mandibular
midline was deviated 4 mm to the left from the upper
dentition with an anterior cross bite, an overjet of 2 mm
and an overbite of 2 mm. The molar relation was Class
III on both sides. The right upper first molar was inter-
digitated with the antagonistic lower second molar. The
calculated arch length discrepancy of the upper and
lower dentitions was 2 mm positive and 1 mm positive,
K. Sasaguri et al.
respectively (Fig. 1). Intra-oral examination indicated the
impossibility of attaining anterior teeth contact, even
though the mandible was manipulated backward.
The cephalometric measurements of the craniofacial
complex revealed a skeletal Class III with ANB of -2
degrees, ODI 70, and APD1100 (Fig. 2, Table 1). Frontal
cephalogram analysis did not show an obvious man
dibular lateral displacement and the upper dental mid-
line was coincident with the facial midline, while the
lower dental midline had shifted 4 mm to the left. A
panoramic radiograph displayed the presence of right
upper and lower third molars.
Mandibular position analysis using the mandibular
position indicator (MPL SAM articulator) did not indi
cate a major deviation of the mandible between the man
dibular reference position (RP) and intercuspal position
(ICP).
Fig. 1: Pre-treatment intraoral and extraoral views.
Mandibular position indicator (MPI) did not show significant difference between reference position (RP) and intercuspal position
(ICP).
Bull. Kanagawa Dent. Col. 35 (2007)
Diagnosis and Treatment Planning
This case was diagnosed as a skeletal Class III mal-
occlusion with anterior cross bite and midline discrep
ancy. The orthodontic treatment plan called for the
installation of 0.01.8 standard edgewise appliances with
MEAWs following third molar extraction, in order to
produce an improvement of the anterior cross bite by
raising the bite and uprighting the right buccal teeth to
correct the midline shifting.
Treatment Sequence
Upper and lower edgewise brackets were bonded
after third molar extraction. Leveling was started with a
0.014 round NiTi plane arch wire. An upper MEAW with
a contraction combination loop and a lower MEAW were
inserted and their tip back bends and crown lingual
torque were accentuated during the progression of treat-
 Application of MEAW to Treatment of Class III with Mid-line Discrepancy

ment. intermaxillary elastics of 3/16 inches 6 oz between

the upper second loop and the lower first loop (short
Class 111 elastics) were used continuously on both sides.
Since the molar overjet decreased with the uprighting
of the lower buccal teeth, enlargement of the upper den
tition was achieved by applying an overlay expansion
wire (Mulligan). Moreover, for the purposes of closing
the gaps, which had appeared due to the flaring of the
upper front teeth; short Class HI elastics with posterior
cinch back activation were used (Fig. 4, a-f). The total
active treatment was 24 months and the retention pe
riod was 12 months.
Comparing the conditions immediately following
orthodontic treatment and those prevailing 16 months
later, there was no difference between the panoramic
radiograph and the MPI findings (Fig. 3, b, c and Fig. 5-
7).

Fig. 2: Pre-treatment cephalometric analysis Treatment Results and Discussion

, Left| Right The case presented here was diagnosed as skeletal
Class III malocclusion without functional mandibular
shift based on an analysis of the following data; an ar
ticular diagnostic mounted cast, axiographic records of

Table 1: Comparison of cephalometric measurements

K. Sasaguri et al.
Fig. 3: Panoramic radiographs: (a) pre-treaiment, (b) post-
treatment, (c) sixteen months after treatment
mandibular movement, and frontal and lateral
cephalograms. This case was considered a midline shift
due to the influence of the lower right third molar, be
cause there was no significant difference between the
anteroposterior position of the right and left upper first
molars, while the right lower first molar was positioned
anteriorly compared to the left first molar (Fig. 4a).
After three months of leveling, MEAWs with pas
sive crown lingual torque was applied using short Class
III elastics full time. A moderate tip back bend was built
into the upper ME AW. Since the lower right buccal teeth
needed more uprighting than in the left; the tip back
bend of the lower right buccal segment was more ac
centuated than that on the left (Fig. 4 b and c). Due to
the right-left difference of the molar relationship, greater
active elastic forces were exerted on the right side than
in the left, although the same short Class III elastics were
used on both sides. This was effective to bring about
differential tooth movement in the case of the midline
shift.
During progression of molar uprighting, the overjet
of the buccal segments gradually decreased due to the
buccal uprighting of the lower premolars and molars.
Thus, enlargement (expansion) of the upper dentition
by overlay wire (Mulligan) was carried out with strong
Bull. Kanagawa Dent. Col. 35 (2007)
crown lingual torque in the MEAW to prevent any un
favorable inclination of the buccal teeth (Fig. 4d). Even
though axis control of the buccal teeth was performed,
the scissor-bite tendency affecting the upper and lower
second molars was not avoided (Fig. 4e). Therefore, great
care should be taken when using this mechanics espe
cially in the combination of MEAW and overlay expan
sion devices.
In order to obtain the Class I molar relationship, an
upper MEAW was fitted that had a contraction loop built
into it, while at the same time, the lower buccal teeth
were in the process of uprighting. When Class III elas
tics were used, the upper anterior teeth began to flare
out, and the advantage of the contraction loop was not
only to prevent anterior spacing, but also to provide a
molar Class I relation due to the molar mesial move
ment arising from the cinch back activation at the termi
nal loops (Fig. 4e). The superimposition of cephalometric
tracings revealed a molar mesial movement with no
unfavorable mesial inclination. The labial inclination of
the upper incisors, the lingual inclination of the lower
incisors and a mandibular clockwise rotation due to the
extrusion of the upper molars contributed to correcting
this malocclusion.
The superimposition of cephalograms taken before
and after orthodontic treatment indicates that the labial
inclination of the upper front teeth, the lingual inclina
tion of the lower front teeth and mandibular clockwise
rotation due to upper molar extrusion contributed to the
correction of the anterior cross bite. There was no sig
nificant difference in the lower left first molar position
between before and after orthodontic treatment, while
the position of the lower right first molar was corrected
4 mm distally and the position of the right upper first
molar was corrected 2 mm mesially. These changes in
the position of the upper and lower first molars greatly
contributed to an improved molar relation (Fig. 8). Based
on these observations, it can be concluded that MEAW
with appropriate elastic use was effective on the differ
ential tooth movement on the right and the left. How
ever, because at 14 months after orthodontic treatment
there was a relapse and the right molar relation had re
turned 2 mm (Fig. 9), it is necessary to consider how to
bring about a stabilized occlusion.
Acknowledgements
This work was performed in Kanagawa Dental College,
Research Institute of Occlusion Medicine and supported by grant-
in-aid for open research from the Japanese Ministry of Education,
Culture, Sports, Science and Technology. The content of this article
was originally published in the journal Information Orthodontie
und Kieferoi thopadie (IOK) in German. This issue in BKDC topics
is a secondary publication after translation into English with
copyright permission from IOK (Thieme).
 Application of ME AW to Treatment of Class III with Mid-line Discrepancy

Fig. 4: Intraoral views (a to f) showing the progression of the orthodontic treatment within a total period of 24 months.
K. Sasaguri et al. Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 5: Intraoral and extraoral views and mandibular position record by MPI after orthodontic treatment.
 Application of MEAW to Treatment of Class III with Mid-line Discrepancy

vs. X-

Z _o. R n

z
Fig. 6: Intraoral views and mandibular position record (MPI) sixteen months after treatment.

Fig. 7: Cephalometric analysis: (a) post-treatment, (b) sixteen months after orthodontic treatment
K. Sasaguri et al.
Fig. 8: Superimposition of tracings pre and post treatment.
Fig. 9: Superimposition of tracings pre-treatment and sixteen months later.
References
1. Kim, Y.H. (1987). Anterior open bite and its treatment with
multiloop edgewise arch wire. Angle Orlhod. 57: 290-321.
2. Kim, Y.H. (1974). Overbite depth indicator with particular
reference to anterior open-bite. Am.}. Orthod. 65: 586-610.
3. Kim, Y.I I. and Vietas, J.J. (1978). Anteroposterior dysplasia
indicator. An adjunct to cephalometric differential diagnosis.
Am. j. Orthod. 73: 719-733.
Bull. Kanagawa Dent. Col. 35 (2007)
4. I'iehslinger, E., Celar, A., Celar, R., Jager, VV. and Slavicek, R.
(1993). Reproducibility of the condylar reference position. /.
Orofac. Pain. 7: 68-75.
5. Slavicek, R. (1988). Clinical and instrumental functional
analysis and treatment planning. Part 4. Instrumental analysis
of mandibular casts using the mandibular position indicator.
/. Clin. Orthod. 22: 566-575.
Bulletin of Kanagawa Dental College

Vol. 35, No. 1, March, PI3. 95-104, 2007

Orthodontic Treatment of Class III

Malocclusions Associated with
Mandibular Lateral Deviation

Susumu Akimoto, Mitsuyoshi Kubota, Atsushi Matsumoto, Sadao Sato,

Eliana Midori Tanaka and Ales Celar*

Department of Craniofacial Growth and Development Dentistry,

Kanagawa Dental College
* Department of Orthodontics, Medical University of Vienna, Bernhard Gottlieb
Dental Clinic, Vienna, Austria

Abstract

A Skeletal Class III reversed occlusion morphologically defined by mandibular prognathism,

maxillary retrognatism or a combination of the two is often accompanied by mandibular
lateral deviation (MLD) and in most cases is considered an indication for orthognatic sur
gery. Posterior discrepancy, i.e. tooth-to-denture base discrepancy in the posterior area
resulting in crowding distal to the first molars, has not been regarded as an etiological factor
causing lateral mandibular displacement. In this respect, it is important to recognize the
effects of the flattening of the occlusal plane (OP) as well as variations in the vertical dimen
sion on both sides due to the unilateral over-eruption of the molars caused by the squeez-
ing-out effect of posterior discrepancy. This affects the vertical relationship of the dentition
providing interferences in occlusal function and contributes to the malposition of the man
dible, associated with a decreased vertical dimension and higher positioning of the man
dibular condyle on the displaced side. Therefore, it should be emphasized that elimination of
the posterior discrepancy prior to the differential vertical dimension control of the occlusal
planes is of paramount importance in the planning of any treatment of Class III malocclu
sions with MLD. Two clinical case examples will illustrate how premature occlusal contacts
have resulted in lateral mandibular deviation in dentitions showing posterior discrepancy.
Orthodontic treatment was achieved with the reconstruction of the deviant occlusal planes
using multiloop edgewise arch wires subsequent to the extraction of the third molars to
eliminate the posterior discrepancy in order to reestablish the appropriate mandibular posi
tion and to improve the lateral mandibular displacement and associated symptoms relating
to temporomandibular joint dysfunction with no surgical intervention.

Key words: Class HI malocclusioti I Lateral mandibular deviation I Posterior

discrepancy I Occlusal Plane I Multiloop edgewise arch wire

Introduction purely orthodontic approach (1-9). The current situation

A skeletal configuration characterized by a reverse
overjet-overbite and mandibular lateral deviation in
volves a combination of different three-dimensional
dental and skeletal components (anterior-posterior,
transverse and vertical) causing the development of the
malocclusion. This MLD malocclusion is a complex clini
cal entity assessed as unlikely for correction with a
Accepted for publication on October 5, 2006.
Address for correspondence: Susunui Akimoto, Department of
Craniofacial Growth and Development, Kanagawa Dental College,
82 Inaoka-cho, Yokosuka, Kanagawa, 238-8580, Japan.
Tel: +81-46-822-8880 (ex. 2381) l:ax: +81-46-822-8844
is predominantly suggestive of surgical correction as the
only treatment option for the management of many MLD
adult cases.
Treatment of malocclusion can be roughly divided
into two groups based on the treatment prognosis: pal
liative or curative therapy. Where the cause is unknown,
palliative therapy is carried out. If the cause can be sus
pected or identified, an etiology-oriented treatment is
preferable because a relapse will be more likely to occur
after palliative treatment that does not correct or eradi
cate the cause of the problem.
S. Akimoto et al.
The etiological factors in the development of MLD
malocclusions have been claimed to originate from ge
netic backgrounds, mal- formations, abnormal habits,
growth anomalies, external injuries, etc. Most of the MLD
conditions are treated in a palliative way. If the devia
tion exceeds a certain limit as judged by the individual
orthodontist, the correction of the malocclusion is often
considered to be too difficult to treat without surgical
intervention.
However, irregularities in tooth position are fre
quently encountered in different types of malocclusion
and it is not particularly unusual to be confronted with
MLD in orthodontic patients. No claim for the above-
mentioned etiology can be made for the majority of pa
tients but rather a small minority. A discussion of dental
positional irregularities follows.
Deviation from the ideal dental position, so called,
dental malposition or misalignment of the teeth impairs
the dental arch form, generates occlusal premature con
tacts, and the position of the mandible is highly affected
(2, 3). Minor or major MLD malocclusions result from
transversely different degrees of deviation from the den
tal position (10) (see patient 1). MLD malocclusion shows
a transverse inclination of the occlusal plane as well as
different muscle activity on both sides because of dis
parities between the left and right occlusal vertical di
mensions (11). From this point of view, many MLD cases
can be treated using orthodontics by eliminating the etio
logical factor, i.e. the discrepancy in tooth position. In
fact, surgical correction is not a consideration. The fol
lowing clinical cases document non-surgical orthodon
tic therapy with elimination of the MLD associated cause,
particularly the posterior discrepancy (1,4, 5,12-14).
Patient 1
An 18-year-old female patient consulted the dental
clinic again with a jaw deviation as her chief complaint
(Fig. 1). At age 11, the previous orthodontist had diag
nosed a slight tendency toward an inverse overbite and
had applied a multi-bracket treatment for approximately
six months (Figs. 2, 3). Following this, a chin cup was
used and the lower third molars were extracted to pre
vent the anterior cross bite. In Fig. 4, a mandibular posi
tion with a coincidence of dental maxillary and
mandibular midlines can be seen accompanied by a uni
lateral occlusal contact at the right molars, whereas an
openbite and inverse over jet prevail anteriorly.
The displacement of the mandible to the left resulted
from the occlusal interference on the right side where
the second molar had been squeezed out and had over-
erupted due to the abnormal high position of the right
upper third molar (see panoramic radiograph in Fig. 1).
Considering a therapeutic position with coincident mid-
lines (Fig. 4), the treatment mechanics was focused on
designing a force system to correct the anterior crossbite
Bull. Kanagawa Dent. Col. 35 (2007)
and reestablish the differences in the occlusal vertical
dimensions on both sides.
In the pathogenesis of MLD, posterior discrepancy
has been considered to be an underlying factor. For this
reason, extraction of the upper third molars had been
performed before the placement of the multi-bracket
appliance in both arches. The engaged multiloop edge
wise arch wires (15) were activated and heat-treated to
produce the subsequent movements; 1) uprighting and
intrusion of mandibular molars, 2) intrusion of the max
illary molars, 3) a marked intrusion on the right com
pared to the left side. At the same time, short class III
elastics (3/16 inch, 6 oz.) were used in the anterior loops.
Three months after starting orthodontic treatment, a
significant improvement in the occlusion had occurred
(Fig. 5). The above-mentioned mechanics enabled the
transverse correction of the occlusal plane inclination
by controlling the differences of vertical dimension on
both left and right sides - a key feature in the treatment
of MLD (15). The duration of active treatment was ap
proximately one year. Intraoral photographs taken af
ter bracket removal (Fig. 6) show that the stability of the
occlusion after one month is the same as after five months
and 20 months of the retention phase (Fig. 7). A slight
class III tendency persisted in the first molar.
In spite of the short treatment length, the stability of
the occlusion was accomplished by eliminating the di
agnosed cause even in MLD combined with anterior
openbite and reversed occlusion. In this sense, the cor
rection of the posterior discrepancy represents a signifi
cant treatment objective although the lack of posterior
space for the eruption of third molars has often been
neglected. In this exemplary patient we may assume that
the MLD would not have been able to develop if the
third molars had been extracted earlier in the initial treat
ment approach. A current extraction option is the re
moval of the maxillary second molars instead of the third
molars to relieve posterior discrepancy, namely before
age 15. This prompt intervention helps avoid the prob
lem of time until the third molars can be removed.
Patient 2
A woman aged 24 years who was attending a dental
clinic requested surgical correction for her facial asym
metry (MLD). Her main concerns were occlusal dishar
mony, a prominent chin, and a crooked facial
appearance. Her mandible had shifted to the left and
her right cheek was straight while the left cheek was
rather round (Fig. 8). The intraoral photographs showed
that all third molars had erupted, furthermore there was
an anterior openbite, a crossbite of the left canines, a ten
dency toward inverse overjet, and the lower midline had
shifted 5.5 mm to the left (Fig. 9).
According to the patient's history, all previous con
sultations in Yokohama and Tokyo at age 13 had con-
 Orthodontic Treatment of Class 111 Malocclusion with Mandibular Lateral Deviation

Fig. 1: Patient 1. Facial (frontal and profile views) and intraoral (anterior, occlusal and lateral views) photographs and panoramic
radiograph at age 18. Head posture tends to turn toward to the left, differences in vertical position between the left and right eyes and
shoulders, lower midline discrepancy to the left 3 mm, overbite and overjet 1 mm each (almost edge-to-edge), mandibular third
molars extracted, different direction of left and right maxillary third molars: the mesial inclination of the right third molar caused the
squeeze-out of the right second molar creating occlusal interference on the right side which produced the mandibular shifting to the
left and the class III tendency increased.
S. Akimoto et ah Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 2: Frontal and profile views at initial consultation at age 11 yrs, four months.

Fig. 3: Facial (frontal and profile) and intraoral views during six months treatment and after bracket removal. A chin cup was
used for a further six months, whereupon both mandibular third molars were extracted.
 Orthodontic Treatment of Class Ul Malocdusion with Mandibular Lateral Deviation

Fig. 4: Intraoral views of second consultation at the dental clinic show coincident midlines whereas coincidence of the midlines from
the actual position show a negative overbite and overjet, occiusal contact at the right premolars but no occlusal contact on the left
side. Therefore the right vertical occlusal dimension is longer than that on the left.

Fig. 5: Intraoral views three months after the beginning of treatment: canine relationship almost reaches class I. Improvement of the
midlines, overjet and overbite is observed.

Fig. 6: Intraoral views one month after orthodontic appliance removal.

S. Akimoto et ah
Fig. 7: Post-treatment frontal and profile views after five months and post-treatment intraoral views after 20 months.
eluded that an improvement of her occlusion could only
be achieved through surgical intervention. So she waited
to reach the age possible for operation and as a conse
quence, came to our institute. In addition, from age 17
onward, the facial asymmetry had become more pro
nounced in concordance with the eruption of the third
molars. Moreover the patient preference was for non-
surgical treatment, if possible.
The removal of all third molars was considered cru
cial owing to their association with MLD. Then orth
odontic therapy was carried out without surgery (Fig.
10). The inherent trend toward skeletal inverse overbite
made it necessary to upright and intrude the mandibu-
lar posterior teeth. This is why a plain arch wire (.016
inch round) was used on the maxillary dentition while
an MEAW with a reverse curve of Spee (.016 x .022 inch)
was engaged in the mandibular arch. Vertical short class
III elastics (3/16 inch, 6 oz.) were used at the anterior L-
loops. As shown in the figures, class III elastics were
used at the same corresponding spots on the left and
right. As a result, the elastics generated a higher force
on the right side due to the MLD (Fig. 11). Improvement
in the midline had already become visible after six weeks
Bull. Kanagawa Dent. Col. 35 (2007)
(Fig. 12). Seven months after the beginning of treatment,
the overjet and overbite had turned into positive values
(Fig. 13).
The active orthodontic treatment lasted approxi
mately 16 months (Fig. 14). The correction of the maloc-
clusion was achieved only by orthodontic therapy
although the patient had been advised to undergo
orthognathic surgery at other medical institutions. Pos
terior discrepancy was regarded as the cause of the MLD
and its elimination, was accompanied by the correction
of the openbite and the skeletal reverse occlusion.
Discussion
Orthodontic diagnosis and treatment of skeletal re
versed occlusion with MLD should find and correct the
etiology of the present symptoms. Many of these are
slight deviations from a normal tooth position. The dif
ferences iii the extent of symptoms depend on the per
sistence of the causative factor. Some symptoms remain
minor while the pathogenic impact lasts longer in other
patients. Then the necessity for surgical correction may
erroneously appear unavoidable. However, dental po
sitional deviations have not been taken into sufficient
 Orthodontic Treatment of Class III Malocclusion with Mandibular Lateral Deviation

Fig. 8: Patient 2. Facial (frontal and profile) views. The

patient was worried about her occlusion, a prominent
chin, an oblique face with the mandible shifted to the
left, the right cheek being straight and the left cheek
round.

Fig. 9: Pre-treatment intraoral views. All third molars had erupted. Viewed from the frontal aspect, a correct intercuspation
disclosed the mandibular midline deviation of about one lower incisor width and an anterior openbite. From a lateral view,
the overjet was 0 mm.

consideration as the cause of developing MLD. It still
could happen that MLD patients, who might be success
fully corrected by a pure orthodontic approach, are still
eligible and need to undergo orthognathic surgery.
MLD does not occur exclusively in skeletal reversed
occlusion but also in mandibular retrognathia. In MLD
malocclusion there is a higher probability of temporo-
mandibular dysfunction than in other malocclusions (8,
9). Both patients in this article suffered from temporo-
mandibular dysfunction symptoms, which were relieved
by orthodontic therapy. From this point of view, maloc
clusion has been strongly associated with temporoman-
dibular dysfunction and many patients have also shown
an association with posterior discrepancy.
S. Akimoto et si. Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 10: Intraoral views after third molar extractions, just before bracketing.

Fig. 11: intraoral views at the beginning of treatment.

Fig. 12: Above: Lateral view with coin

cident midlines at the time of bracket

fixation showed a skeletal openbite.
Below: Lateral view with coincident mid-
lines six weeks after starting treatment.
The direction and orientation of the oc-
clusal plane movement was visible.
 Orthodontic Treatment of Class 111 Ma I occlusion with Mandibular Lateral Deviation

Fig. 13: After seven months, overjet and overbite have become positive - initially overjet and
overbite were negative when the midlines coincided.

Fig. 14: Intraoral views at the end of treatment. After 16 months, the appliances were removed. The midlines

coincided and the openbite was corrected.

and Suzuki, Y. (1994). Developmental alteration of the form

Acknowledgements
This work was perforated in Kanagawa Dental College,
Research Institute of Occlusion Medicine and supported by a
grant-in-aid for open research from the Japanese Ministry of
Education, Culture, Sports, Science and Technology. The content
of this article was originally published in the journal Information
Orthodontie und Kieferorthopadie (IOK) in German. This issue
in BKDC topics is a secondary publication after translation into
English with copyright permission from IOK (Thieme).
References
1. Sato, S. (1987). Alteration of occlusal plane due to posterior
discrepancy related to development of malocclusion -
Introduction to denture frame analysis. Bull Kanagawa Dent
Coil. 15: 115-123.
2. Sato, S. (1994). Case report: Developmental characterization
of skeletal Class III malocclusion. Angle Orthod. 64:105-112.
3. Sato, S., Sakai, H., Sugishita, T., Matsumolo, A., Kubota, M.
of denture frame in skeletal Class TTI malocclusion and its
significance in orthodontic diagnosis and treatment hit j.
MEAW Tech Res Found. 1: 33-46.
4. Sato, S., Takamoto, K. and Suzuki, ,1988), Posterior
discrepancy and development of skeletal Class III
malocclusion. Orthodontic Review. Nov/Dec: 16-29.
5. Sato, S. and Suzuki, Y. (1988). Relationship between the
development of skeletal mesio-occlusion and posterior tooth-
to-denture base discrepancy - Its significance in the
orthodontic reconstruction of skeletal class III malocclusion.
journal of Japanese Orthodontic Society. 47: 796-810.
6. Sato, S., Takamoto, K., Fushima, K.., Akimoto, S. and Suzuki,
Y. (1989). A new orthodontic approach to mandibular lateral
displacement malocclusion - Importance of occlusal plane
reconstruction -. Dentistry in japan. 26: 81-85,
7. Pushima, K., Odaira, Y., Saito, N., Tsurumi, F. and Sato, S.
(1998). Dental asymmetry in facial asymmetry. Bulletin of
Kanagawa Dental Colleg. 26:15-21.
8. Inui, M., Fushima, K. and Sato, S. (1999). Facial asymmetry in
S. Akimoto et al.
temporomandibulnr joint disorders. Journal of Oral
Rehabilitation. 26:402-406.
9. Fushima, K., Inui, M. and Sato, S. (1999). Dental asymmetry in
temporomandibular disorders, journal of Oral Rehabilitation. 26:
752-756.
10. Sato, S.A. (2001). Treatment approach to malocclusions under
the consideration of craniofacial dynamics. Grace Printing
Press Inc. (Philippines).
11. Akimoto, S., Fushima, K., Sato, S. and Suzuki, Y. (1995).
Masticatory muscle activity of the facial asymmetry cases -
Effects of the different combination of bite blocks -. The journal
of Orthodontic Society. 54(6): 436-440.
12. Protacio, C. and Sato, S. (1995). The role of posterior
discrepancy on the development of skeletal Class III
Bull. Kanagawa Dent. Col. 35 (2007)
malocclusion - Its clinical importance, hit J. MEA\N Tech Res
Found. 2: 5-18.
13. Sato, S., Suzuki, N. and Suzuki, Y. (1988). Longitudinal study
of the cant of occlusal plane and denture frame in cases with
congenitally missing third molars. Further evidence for the
occlusal plane change related to posterior discrepancy. /. jpn
Orthod Soc. 47:517-525.
14. Sato, S., Dennis, C.L., Miyakawa, Y. and Kim, R.H. (1998). The
development of openbite as a result of posterior discrepancy
and its treatment approach using mutiloop edgewise arch wire.
hit /. MEAW Tech Res Found. 5: 5-15.
15. Sato, S., Akimoto, S., Matsumoto, A., Shirasu, A., Yoshida, J.
and Sato, S. (2002). MEAW - Manual for the clinical application
of MEAW technique. Printing Press Inc. (Philippines).
Bulletin of Kanagawa Dental College
Vol. 35, No. 1, March, PP. 105-111, 2007

Interception of Decompensated Class III

Malocclusions in Early Mixed Dentition

Hisaaki Shinji, Takehiko Hiyama, Mina Yamaguchi,

Kanji Onodera and Sadao Sato

Department of Craniofacial Growth and Development Dentistry, Kanagawa Dental College

Abstract

In the early period of mixed dentition, various malocclusions may potentially occur that can
manifest themselves clinically. Preventive and interceptive treatment must be given prior
ity in order to avoid the risk of developing a skeletal malocclusion in the future. During the
development of the dentition, a deficiency in the vertical dimension of occlusion may result in
a Class III malocclusion with a closed mandibular rotation as a sign of the vertical decom
pensation. The correction of the occlusal vertical dimension with the use of simple treatment
procedures such as supra-occlusal surfaces normalizes the occlusion during the later devel
opment as well as possible. This article describes an early treatment of the Class III maloc
clusion caused by decompensation, where the vertical dimension was raised by using supra-
occlusal surfaces. Due to bite raising, the mandible adapts to a posterior position and the
dentition continues to erupt into a Class I relationship. The correction of the occlusal vertical
dimension can reorient the developmental direction abnormal tendency from the early mixed
dentition period.

Key words: Class III I Interceptive treatment I Early treatment I

Vertical dimension

Introduction malocclusion in the permanent dentition. If malocclu

In the early period of mixed dentition, various mal
occlusions such as crowding, deep bite, cross bite and
openbite may occur that can manifest themselves clini
cally. For this reason, priority must be given to preven
tive and interceptive treatment in order to avoid the risk
of a skeletal malocclusion developing in the future. Con
sidering malocclusions, there is a tendency to focus only
on the dentition and to overlook the developmental
changes in the facial complex, the mandible, as well as
the maxilla. A treatment approach for the correction of
malocclusions without regard to growth and develop
mental changes can lead to a lack of stability and an in
crement in relapse risk. Under certain circumstances,
surgical correction is likely to be needed when treating
Accepted for publication on October 5,2006.
Address for correspondence: Hisaaki Shinji,Department of
Craniofacial Growth and Development Dentistry, Kanagawa Dental
College, 82 Inaoka-cho, Yokosuka, Kanagawa, 238-8580, Japan.
Tel: +81-46-822-8880 (ex. 2381) Fax: +81-46-822-8844
sion is detected in the early developmental stage and
when the mandibular and facial growth patterns are
properly controlled, the number of cases needing surgi
cal intervention for the treatment of skeletal dysgnathias
will be reduced. The relevant steps to prevent maloc
clusion are considered to be: to more clearly understand
the growth and developmental changes in the craniofa
cial complex, as well as the occlusion, and to correct the
developing malocclusion at the earliest possible stage.
Relationship between cranio-facial complex
and the mandible
Since the origin of bipedalism with an upright body
posture, the cranial base angle has slowly become
smaller. Concomitantly, the growth direction of the
maxillary complex bordering the cranial base has
changed to predominantly downward instead of for
ward, and the head has adopted an erect and upright
posture. Additionally, the antero-posterior dimension
 1. Shinji et ah
of the maxilla has reduced and the space available for
the molars has correspondingly decreased. This explains
the high frequency of third molar impaction in modern
man. Such a discrepancy in the molar area (posterior
discrepancy) can cause an over-eruption of the poste
rior teeth and several unfavorable changes in occlusion
take place (1-6). This explains how a hyper divergent
(high angle) Class III nialocclusion with anterior
openbite develops. The flattening of the occlusal plane
as a result of the increment of the posterior vertical di
mension is due to posterior discrepancy. The mandible
adapts functionally to this by rotating forward to main
tain the occlusion, using the over-erupted molar area as
a fulcrum of rotational axis. Simultaneously, the man
dible also moves forward. A hyper divergent Class III
nialocclusion is therefore understood to be the result of
a forward positioning of the mandible opposed to the
enlarging of the posterior occlusal vertical dimension.
On the other hand, a hypo-divergent (low angle) Class
III nialocclusion can also occur during the development
of dentition, in addition to a hyper divergent nialocclu
sion. This develops through decompensation caused by
a reduced posterior occlusal vertical dimension, in other
words insufficient posterior vertical support.
Class III malocclusion caused by
decompensation
Homo sapiens, with its varying types of skeletal
frame has a tendency to reach Class I occlusion despite
the existing skeletal deviations. This means that the func
tional development and the consequent structural ad
aptation show a somatic response to constantly attain a
normal function, to stabilize, and to maintain it. But
reaching the ortho-function is only possible through the
compensation of skeletal shifting. When the adaptation
reaches its limit, the body uses a compensatory mecha
nism to achieve a more efficient function. Compensa
tory mechanisms appear in all varieties of skeletal
alterations especially during the period of dentition de
velopmental in order to accomplish the ortho-function.
Where there is insufficient compensation, a skeletal
alteration caused by decompensation develops. In such
a case, early occlusion treatment is important because
decompensation is the factor that has the greatest influ
ence on functional malocclusion during dentition devel
opment later on. A Class III malocclusion develops due
to the simple forward rotation of the mandible as a re
sult of an insufficient occlusal vertical dimension (dec
ompensation) or due to a forward rotation of the
mandible as a result of an excessive occlusal vertical di
mension (adaptation). Most hypo-divergent Class III
malocclusions are accompanied by a vertical decompen
sation as a result of a lack of occlusal vertical dimen
sion. Therefore, any increase in occlusal vertical
dimension is appreciated as compensation for reaching
Bull. Kanagawa Dent. Col. 35 (2007)
the later regular occlusion development. If the develop
ing malocclusion is influenced therapeutically, it is nec
essary to keep in mind that the nialocclusion seems to
be dependent on the occlusal plane and the occlusal ver
tical dimension.
This article proposes early treatment of the Class III
malocclusion caused by decompensation, where verti
cal dimension is raised by using supra-occlusal surfaces.
Two patient treatment plans arc presented as an ex
ample.
Treatment
At the initial examination, there is an evaluation of
the patient's chief complaint, the anamnesis, and the
initial findings. Articulator-mounted models (Fig. la),
MPI (Mandible Position Indicator), panoramic radio
graph (Fig. 2a) and cephalograms (Figs. 2b and c), ex
tra-oral/ intra-oral pictures, and a functional analysis
in the articulator (vertical dimension, occlusal plane,
mandibular position, and TMJ) are used for the diagno
sis and treatment plan. After a thorough explanation to
the patient, treatment begins with his/her consent.
Adjusting the occlusion position of the model at the
MPI, waxing of the new supra-occlusal surfaces of the
lower deciduous molars is performed in order to estab
lish the new corrected mandibular position. The waxed
occlusive surfaces are formed from the Kerr impression
compound. The hardened Kerr silicone impression is
used as a mold (matrix) for the later added acrylic resin
(fill in and repositioning onto the non-waxed up/off
model). The manufactured supra-occlusal surfaces will
be cemented to the occlusal surfaces of the deciduous
molars and are to be regularly checked. Fig. lb shows
the supra-occlusal surfaces formed by acrylic resin.
Patient 1
A seven-year-old boy visited the pediatric depart
ment of the Kanagawa Dental College Hospital com
plaining chiefly of a nialocclusion. He exhibited early
mixed dentition with an anterior cross bite. The normal
number of teeth was presented and no abnormal find
ings appeared on panoramic radiograph examination,
as shown in Fig. 2a. The results of the cephalometric
analysis of the lateral cephalogram are shown in Tables
1 and 2. The overjet and overbite were 1.0 mm and 0.0
mm respectively. The terminal plane was a mesial step
type on both the right and the left side. A pointed den
tal arch form in the maxilla and squared in the man
dible were observed at the dental cast analysis. Also,
the upper right and left first molars were erupting. In-
traoral photographs (Figs. 3a ~ g) show the progress of
this case. The upper central incisors were observed to
be erupting with a reversed occlusion (anterior cross bite)
at the time of the initial examination. The intraoral pho
tographs taken at the initial examination and after ap-
 Interceptive Treatment of Class III Malocclusion

Fig. 1: The establishment of the caps as supra-occlusal surfaces (acrylic resin).

(a) Articulating mounted casts, fb) Supra-occlusal surfaces on the deciduous molars.

Fig. 2: Radiographs at the point of the initial examination (case 1):

(a) Orthopantomograrn, (b) frontal cephalogram, (c) lateral cephalogram.
H. Shinji et al. Bull. Kanagawa Dent. Col. 35 (2007)

Table 1: Analysis of the cephalogram at the time of the initial examination - Cephalometrical analysis

Cephalomelric Analysis

Data Average/mean Standard

deviation

Facial angle 85 83.7 3.3

Convexity 175 163.5 5.3
A-B Plane -4 -6.7 2.4
Mandibular plane 33 31.5 5.1
Y-axis 64 63.8 3.6
Occlusal plane 20 14.4 4
Interincisal angle 134 12.1
L-l to mandibular plane 88 89.5 6.5
FH-SN 8 8 3
SNP 75 76 5.5
SN-GN 74 71.6 1.9
SNA 79 81.4 3.3
SNB 76 76.2 2.9
U-l to I'M 104.8 9
U-l to SN 96.8 8.2
Gonial angle 135 130.1 1.3
GZN 87 89.4 5.3
Kamus inclination 78 81.6 4.4

Table 2: Analysis of the cephalogram at the time of initial examination - Denture frame analysis

Denture Frame Analysis

Standard
deviation

FH-MP 4.3
PP-MP 3.9
OP-MP 3.7
OP-M P/PP-MP
AB-MP 4.4
A'-P' 2.5
A'-6' 2.5
A'6'M'P'
I-AB(o) 4
I-AB (mm) 1.5
l-AB(o) 4.4
1-AB (mm) 1.4
Intermolar angle 3.7
ODI 5.3
APDI 4.4

plying the supra-occlusal surfaces are shown in Figs. 3a
and b. At the point of applying the supra-occlusal sur
faces, an anterior openbite was visible. One month after
the supra-occlusal surfaces had been applied, the over-
bite had become approximately 1.0 mm (Fig. 3c). An
edge-to-edge bite is seen to remain after two months (Fig.
3d). Fig. 3e shows an occlusal condition after three
months. Fig. 3f shows an occlusal condition after seven
months. The normal position of the anterior teeth was
gradually reached after nine months (Fig. 3g).
 Tnterceptive Treatment of Class III Malocclusion

Fig. 3: Changes in the occlusion (case 1).

(a) Intra-oral pictures at the time of the initial examination (b) At the time of applying the supra-occlusal surfaces
(B) one month later (d) two months later (e) three months later (f) seven months later (g) nine months later.
H. Shinji et a\. Bull. Kanagawa Dent. Col. 35 (2007)

Patient 2 at the time when the supra-occlusal surfaces were ap

An eight-year-old child with reversed occlusion (an
terior cross bite) received the same treatment as patient
1. Figure 4 shows the occlusion changes from the begin
ning of the initial examination. At the time of the initial
examination an anterior cross bite was present (Fig. 4a),
plied, there was a slight anterior openbite (Fig. 4b), 11
months later the bite was corrected (Fig. 4c). The condi
tion after one year and five months is shown in Fig. 4d,
and two years and five months later, an appropriate
anterior tooth position was reached (Fig. 4e).

Fig. 4: Changes in the occlusion (case 2).

(a) Intra-oral pictures at the time of the initial examination (b) At the time of applying the supra-occlusal surfaces (c) 11
months later (d) one year and five months later (e) two years and five months later.

Discussion
The dento-alveolar growth is tightly correlated with
the maxillo-facial development and should therefore not
be considered separately. The same applies for the oc
clusion development. From a functional standpoint, the
dento-alveolar growth and the maxillo-facial develop
ment influence each other. Consequently, it is impor
tant to completely grasp the effects on the occlusion
whenever iatrogenic occlusal changes are present dur
ing the developmental period, and furthermore, to cor
rect them accordingly. The occlusal plane and occlusal
vertical dimension play an extremely important role in
the development of malocclusions and are therefore es
sential factors to be considered in the planning and treat
ment phase (7, 8).
The effectiveness of an early treatment of the ante
rior cross bite in Class III malocclusions during the de
velopmental phase has already been shown. The
advantages of the active control of the occlusal vertical
dimension have been only reported by Al-Sehaibany et
al. (9, 10) and Alexander et a\. (11). As proven in this
paper, during the development of the dentition, a defi
cient vertical dimension in the occlusion may result in a
Class III malocclusion with a closed mandibular rota
tion as a sign of the vertical decompensation. Due to bite
raising, the mandible adapts to a posterior position and
the dentition continues to erupt into a Class I relation
ship.
The correction of the occlusal vertical dimension with
simple treatment procedures such as supra-occlusal sur
faces normalizes the occlusion during the later devel
opment as far as possible.
The discrepancy in the vertical dimension that origi
nated in the developmental period of the occlusion can
exceed the adaptation capacity and lead to functional
anomalies later on. The correction of the occlusal verti
cal dimension can reorient the developmental direction
abnormal tendency from the early mixed dentition pe
riod on.
Interceptive Treatment of Class III Malocclusion
Acknowledgements
This work was performed in Kanagawa Dental College,
Research Institute of Occlusion Medicine and supported by a
grant-in-aid for open research from the Japanese Ministry of
Education, Culture, Sports, Science and Technology. The content
of this article was originally published in the journal Information
Orthodontie und Kieferorthopadie (1OK) in German. This issue
in BKDC topics is a secondary publication after translation into
English with copyright permission from IOK (Thieme).
References
1. Sato, S. (1994). Case report: Developmental characterization
of skeletal Class III malocclusion. Angle Orthod. 64:105-112.
2. Sato, S., Sakai, II., Sugishita, T., Matsumoto, A., Kubota, M.
and Suzuki, Y. (1994). Developmental alteration of the form
of denture frame in skeletal Class III malocclusion and its
significance in orthodontic diagnosis and treatment, Int f.
MEAW Tech Res Found. 1: 33-46.
3. Sato, S., Dennis, C.L., Miyakawa, Y. and Kim, R.H. (1998). The
development of openbite as a result of posterior discrepancy
and its treatment approach using mutiloop edgewise arch wire.
hit}. MEAW Tech Res Found. 5: 5-15.
4. Sato, S., Takamoto, K. and Suzuki, Y. (1988). Posterior
discrepancy and development of skeletal Class III
malocclusion. Orthodontic Review. Nov/Dec: 16-29.
5. Sato, S. and Suzuki, Y. (1988). Relationship between the
development of skeletal mesio-occlusion and posterior tooth-
to-denture base discrepancy - Its significance in the
orthodontic reconstruction of skeletal Class III malocclusion.
journal of Japanese Orthodontic Society. 47: 796-810.
6. Sato, S., Motoyanagi, K., Suzuki, T., Imasaka, S. and Suzuki,
Y. (1988). Longitudinal study of the development of skeletal
malocclusions. /. Jpn Orthod Soc. 47:186-196.
7. Sato, S.A. (2001). Treatment approach to malocclusions under
the consideration of craniofacial dynamics. Grace Printing
Press Inc. (Philippines).
8. Sato, S., Akimoto, S., Matsumoto, A., Shirasu, A., Yoshida, J.
and Sato, S. (2002). MEAW - Manual for the clinical application
of MEAW technique. Printing Press Inc. (Philippines).
9. Al-Sehaibany, F., and White, G.E. (1996). Posterior bite raising
effect on the length of the ramus of the mandible in primary
anterior crossbite: Case report. /. Clin. Pediatric Dent. 21:21-26.
10. Al-Sehaibany, P., and White, G.E. (1998). A three dimensional
clinical approach for anterior crossbite treatment in early mixed
dentition using an ultrablock appliance: case report. /. Clin.
Pediatric Dent. 23:1-8.
11. Alexander, S., Jumlongras, D. and White G.E. (1999).
Perspective in posterior vertical dimension: three case reports.
/. Clin. Pediatric Dent. 23: 301-314.
Bulletin of Kanagawa Dental College

Vol. 35, No. 1, March, PP. 113-125, 2007

Interdisciplinary Treatment Approach to a

Patient with Severe Mandibular Displacement
and Dysfunction of Craniomandibular System

Katsushi Tamaki1, Ales G. Celar2, Rudolf Slavicek3 and Sadao Sato4

1 Department of Oral ami Maxilbfacial Rehabilitation,

Kanagawa Dental College

2 Department of Orthodontics, University of Vienna, Vienna, Austria

3 Department of Environmental and Medical Sciences,
Center for Interdisciplinary Dentistry, Donau Umversitat Krctns
4 Department of Craniofacial Growth and Development Dentistry,
Kanagawa Dental College

Abstract

Mandibular lateral displacement (MLD) malocclusion demands one of the most difficult
treatment modalities, because it can be associated with complex symptoms such as
TMJ pain, head and neck pain, cervical pain, and functional disturbances of the
craniomandibular system (CMS). This report describes an interdisciplinary approach includ
ing endodontic, orthodontic, and prosthodontic treatment of MLD malocclusion with severe
problems in the CMS, head and neck and including other somatic symptoms. Clinical exami
nation and instrumental analysis of the functional condylar paths using computerized
axiographic recordings of hinge axis movement indicated a displaced mandible due to incor
rect articulation of the teeth and lack of posterior occlusal support. Orthodontic correction of
the dentition provided mandibular repositioning and relief from muscle pain and dysfunction.
Prosthodontic occlusal reconstruction provided a stabilization of the corrected mandibular
position, and ensured proper occlusal guidance and occlusal support. Post-treatment exami
nations indicated that most of the pain dysfunction symptoms had disappeared and smooth
condylar movements were observed with no limitation during normal functions. A
multidisciplinary approach combining orthodontics and prosthodontics enhanced the treat
ment of a complex malocclusion and its functional disturbances without need for surgical
intervention.

Key words: CMS I Mandibular displacement I Orthodontics I Prosthodontics

Introduction synovial apparatus, ligaments, retroarticular connective

All phases of restorative dentistry and orthodontics
are dependent on the position of the mandible relative
to the cranium and the functional movements of the
mandible. Over the years, emphasis has been placed on
technical procedures but very often the inability to
achieve success in treatment was not due to the incor
rect application of any given technique but rather fail
ure to comply with certain unalterable biological
principles in the living individual (1).
The craniomandibular system (CMS) consists of bony
structures of temporomandibular joints, articular disks,
Accepted for publication on October 5,2006.
Address for correspondence: Katsushi Tamaki, Department of
Prosthodontics, Kanagawa Dental College, 82 Inaoka-cho,
Yokosuka, Kanagawa, 238-8580, Japan.
Tel: +81-46-822-8880 (ex. 2381) Fax: +81-46-822-8844
tissues and muscles with neural control networks (1, 2).
The system is involved in several physiological func
tions such as mastication, swallowing, respiration,
speech, head posture, facial expression, and stress man
agement (4).
Tt is important for the progress of the profession that
dentists have a sound knowledge of the physiologic
importance of the CMS and that they undertake clinical
practice in accordance with a broad physiologic ap
proach. The orthodontic and prosthodontic approach
must consider treating functional disturbances of the
CMS, and the mechanical therapy must confirm to the
fundamental physiology of all the parts as they func
tion collectively and interdependently as a biological
unit. Tf any dental procedure violates any of the ana
tomical and physiological principles concerned, it will
K. Tamakia etal. Bull. Kanagawa Dent. Col. 35 (2007)

fail to attain the objective of restoring normal function

and may even further enhance the abnormal function.
Often dental treatment does not consider the CMS
but only the teeth and their occlusion relation. The gen
eral aim, therefore, should be referred to as functionally
optimal occlusion with a physiological mandibular po
sition. This term signifies an occlusion that is in func
tional harmony with the whole masticatory system,
comprising the supporting tissues, the facial skeleton,
the CMS and an occlusion that ensures efficient func
tionality without placing any undue strain on the inte
gral structures (5-7).
In order to properly evaluate abnormal function, it
is necessary to understand the physiology of the CMS.
In this paper, we describe an interdisciplinary approach
involving the functional assessment of condylar move
ment in a patient with severe displacement of the man
Fig. 1: Facial photographs before occlusion treatment. Symp
dible and functional disturbance of the system.
toms regarding CMS dysfunction associated with facial asym
metry.
Clinical Report

Case Preseittation
The patient was a 29-year-old male Japanese male
complaining of severe TMJ pain, joint clicking of the right
TMJ, headaches, cervical tension, pain in the right eye
ball and further unidentified symptoms such as red heat
of the eyelid, shoulder stiffness and lower back pain
(lumbago) with facial asymmetry (Fig. 1). In addition,
he complained that his mandible and masticatory
muscles soon became fatigued and that he suffered pain
after speaking. For this reason, being a teacher in high
school, he had given up Ms job.
Intraoral and ocdusal findings
The dental occlusion was compromised with mul
tiple previous prosthodontic treatments showing a com
plete scissor bite in the left buccal segment. The mandible
had shifted severely 5 mm to the right and the facial
appearance was asymmetrical (Fig. 2).
Clinical examination of the CMS
Palpation of the TMJ indicated that the retroarticular
region of the right TMJ was painful. The muscles relat
ing to the head and neck posture and mastication, espe
cially the temporalis, masseter, and digastric muscles
on the right side indicated stiffness accompanying the
pain.
Panoramic and dental radiogrciphic findings
Panoramic and dental radiographs photography re
vealed that most of the posterior teeth had been given
root canal treatment and several teeth showed apical
lesions. These root canals were treated before any oc
dusal treatment was started (Fig. 3). The lateral TMJ ra
diographs showed a posteriorly displaced right condyle,
while the left condyle showed a normal position in the
fossa (Fig. 4).
Cephalometric analysis of craniofacial structures
The morphological measurements of the craniofacial
complex taken with a lateral cephalogram revealed a
decreased vertical jaw relationship with a lower facial
height (LFH) of 40 degrees and retrognathic mandible
(Fig. 5). Frontal cephalogram analysis showed asymme
try of the dentofacial complex caused by the displace
ment of the mandible.
Functional analysis of condylar movements
The functional condylar movement was recorded at
the hinge axis using a computerized system (CADIAX,
Gamma corp. Klosterneuburg, Austria) (8-11). The
condylar path of the right TMJ showed a typical tracing
of reciprocal clicking with excessive translation move
ment, indicating a displacement of the articular disc and
loose ligaments (12-17). When the right condyle trans-
la ted forward d uring protrusion and retrusion and open
ing/closing movements (Fig. 6), the hinge axis paths
showed that the condyle had shifted laterally with the
clicking, then had moved forward smoothly. This sug
gested that once the disc entered a normal position, the
condyle would be able to move regularly. During speak
ing, both condyles were working in an approximately 4
to 5 mm forward position from the reference position
(RP) (18-21). The rest position of the condyle was located
4 mm and 1.6 mm anterior to the RP on the right and the
left, respectively.
 Interdisciplinary Treatment of Craniomandibular Dysfunction

Fig. 2: Intraoral photographs before occlusal

treatment. Severe mid-line discrepancy with large
overjet and overbite and scissor bite on the left

side were observed. A severely compromised

occlusion with different prosthodontic restora

tions was clearly evident.

Fig. 3: Panoramic radiograph. Almost all the

teeth had been treated previously in some way.

Fig. 4: TMJ radiographs {Schuller method). The right side of the condyle indicates pos
terior displacement.
K. Tamakia et al. Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 5: Cephalometric tracings before occlusion treatment. The lateral tracing shows a
low vertical dimension with an LFH of 45 degrees. Frontal tracing indicates lateral dis
placement of the mandible to the right.

a Open/Close b Pro/Ret
JT-4L.JJ.J. .!-

i <

c Mediotrusion right Mediotrusion left

.'

d Phonation

Fig. 6: Axiographic tracings of condylar movements us

ing Cadiax program:

a; opening/closing, b; protrusion/retrusion:
c; mediotrusion/medioretrusion right-left, cf; phonation.
 Interdisciplinary Treatment of Craniomandibular Dysfunction
Diagnosis and treatment planning
The diagnosis was malocclusion with cranioman
dibular dysfunction associated with mandibular lateral
displacement. Muscular dysfunction due to mandibu
lar lateral displacement seemed to be the cause of the
head and neck pain, the dysfunction and other somatic
symptoms. Primarily, the objectives of the treatment
were to correct the mandibular position. The estimated
therapeutic position (ETP) of the mandible was calcu
lated as 4 mm forward in the right condyle and 2 mm
forward in the left condyle from the RP. A splint therapy
was initiated with the endodontic treatment simulta
neously. In the ETP, there was no vertical occlusal sup
port on both sides of the dentitions. In order to correct
the mandibular position, orthodontic treatment with an
edgewise appliance was planned to improve the tooth
position and axial inclination, to correct the occlusal
plane, and to provide vertical occlusal support.
Prosthodontic treatment was also planned to rehabili
tate the function with a provisional restoration with an
terior occlusal guidance as the first step, leading to the
achievement of full mouth reconstruction of the occlu
sion as a result of a sequential guidance scheme.
Progress of occlusion treatment
The occlusal splint was constructed in the ETP on a
SAM2 articulator and was worn throughout the day
except during meals. The splint provided a non-click
ing smooth movement of the mandible and a significant
reduction of pain (Fig. 7). Root canal treatment was car
ried out during splint therapy.
After the endodontic treatment, orthodontic treat
ment was initiated with the standard edgewise appli
ance. After two months, multiloop edgewise arch wires
(22) (Kim Y.H., 1987) were inserted to upright the pos
terior teeth (Fig. 8). After ten months of orthodontic treat
ment, all the metal crowns were replaced with temporary
acrylic crowns to stabilize the mandibular position, af
ter which, orthodontic treatment continued. The edge
wise appliance was removed after 14 months of
orthodontic treatment (Fig. 9).
Immediately following orthodontic treatment, the
hinge axis paths were recorded (Fig. 10). Based on the
new recordings, the right condylar position was reposi-
tioned one more millimeter forward, because the open
ing/closing movement indicated occasionally clicking.
Individual inclinations for the occlusal guidance were
calculated from the tracings (mediotrusion movement)
to create a so-called "sequential guidance occlusion" (23,
24). The new temporary crowns were made of hard resin
(Estenia), Kurare Corp. Japan) to retain the occlusion
and provide more functional occlusal surfaces (Fig. 11).
No conventional retention was planned. After cementa
tion of the temporary crowns and wearing for ten
months, the final restorations were made using fiber-
reinforced composite material (Targis-Vectris, Ivoclar
Corp, Liechtenstein) (25) for the premolar and molar
teeth. Ceramic crowns (IPS Empess, Ivoclar Corp.
Liechtenstein) (26,27) were placed on the anterior teeth
according to the individual inclinations calculated from
the hinge axis tracing (protrusion movement) (Fig. 12).
Results of Occlusion Treatment
All the symptoms regarding the CMS including right
TMJ clicking disappeared after rehabilitation with the
temporary crowns. It was possible to reconstruct occlu
sion in the corrected position of the mandible with the
sequentially guided occlusion. The facial asymmetry was
reduced. The lower facial height (LFH) increased from
40 to 45 degrees and the mandibular occlusal plane lev
eled off with an inclination of 15 degrees to the axis-
orbital plane. The antero- posterior mandibular position
moved slightly forward as revealed by the superimpo-
sition of pre- and post-treatment cephalogram tracings
(Fig. 13). After treatment, the movement along the
condylar paths remained smooth with no clicking or
limitation. It is noteworthy that the deviation of the
condyle in the horizontal projection disappeared (Fig.
14). The hinge axis position during speech was 1 to 2
mm forward from RP (Fig. 15). The distance from RP to
the new ICP was 1.5 mm on the right side and 0.3 mm
on the left side. The TMJ lateral X-ray examination of
both condyles also showed a normal condylar position.
Clinical examinations after the treatment indicated that
most of the symptoms had disappeared. Facial asym
metry had significantly improved during the sequence
of combined treatment (Fig. 16).
Discussion
There are two concepts to be considered in the mat
ter of occlusion of the teeth. The first is the anatomical
or morphological concept. A matched set of natural teeth
could be arranged so as to have proper contact relations
and axial inclinations with the maximum intercuspation
of the masticating surfaces, and then, an ideal occlusion
would exist. The second, and by far the most important,
is the physiological or functional concept of occlusion
as it participates in its role as one of the important com
ponents of the stomatognathic system. Normal function
of the postural muscles and both TM joints are highly
dependent on the articulation of the teeth. Thus, an ana
tomically ideal occlusion must coincide with the func
tional concept of occlusion. The muscular function of
the cranio-mandibular hyoid-cervical connection can be
influenced by the articulation of the teeth.
Lack of proper contact between the upper and lower
teeth in a physiological position of the mandible induces
the mandible to displace into an abnormal position with
an accompanying dysfunction of muscular connection.
Faulty intercuspation can produce abnormal muscle
K. Tamakia et a!.
Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 7: Occlusal splint fabricated in the esti

mated therapeutic position (ETP)

Fig. 8: Orthodontic treatment with standard

edgewise appliance. Multi-loop edgewise
archwire (MEAW) applied to upright poste
rior segment After ten months of orthodon
tic treatment, temporary acrylic crowns were
placed on the posterior teeth to establish
posterior occlusal support.
 Interdisciplinary Treatment of Craniomandibular Dysfunction

Fig. 9: Intra-oral photographs after

orthodontic treatment.

Oben/Close

Phonation
g B !'J in 9

Fig. 10: Axiographic tracing of condylar movement immediately af

ter orthodontic treatment. The clicking movement of the right condyie

.
V-T has disappeared.
K. Tamakia et al. Bull. Kanagawa Dent. Col, 35 (2007)

Fig 11: Diagnostic waxing with sequential guidance occlusion concept.

Fig. 12: Provisional restoration after orthodontic treatment. The guidance inclination of
each tooth was calculated from axiographic tracings. Acrylic provisional crowns with
functional guiding planes were placed instead of conventional retention procedures.
 Interdisciplinary Treatment of Craniomandibular Dysfunction

Fig. 13: Final reconstruction achieved after ten months provisional restoration. The grinding movement of the mandible offers poste
rior clisocclusion.

Fig. 14: Cephalometric superimposition of pre~ and post occlusion treatment. The mandibu-
lar posture had improved not only as for vertical height, but also transverse dimension.
K. Tamakia et al. Bull. Kanagawa Dent. Col. 35 (2007)

Fig. 15: TMJ radiographs (Schiiller method). Position of right side of the condyle im
proved and central part ot glenoid fossae positioned.

a Open/Close b Pro/Ret

Fig. 16: Axiographic tracings of condylar movements.

a; opening/closing, b; protrusion/retrusion, c; phonatlon, d; bruxism (grinding movement).
 Interdisciplinary Treatment of Craniomandibular DystLinction
Fig. 17: Facial frontal views comparing pre- and post-treatment.
functions expressed as facial pain, headaches, cervical
pain and emotional stress. And likewise, faulty
intercuspation can produce an abnorma] TMJ function
expressed as clicking, crepitus and restricted and pain
ful condylar movement. The patient presented here was
a typical case who had severe problems due to man-
dibular lateral displacement caused by failure of the
proper articulation of the teeth. Clinical and instrumen
tal examination revealed that the cranial-mandibular-
hyoid-cervical muscular connection was affected by the
dysfunctional movement of the mandible not only in
movements such as protrusion/retrusion and opening/
closing, but also during speech.
MLD ma [occlusion is one of the most difficult condi
tions to treat, because it is accompanied by problems
such as condylar displacement to abnormal positions,
asymmetrical muscular function/ dysfunction, occlusal
plane deviation, and head-neck pain syndromes. The
independent therapeutic approaches of orthodontics and
prosthodontics tend to result in a compromised correc
tion of the MLD malocclusion because the orthodontic
vertical] zation of occlusal height is limited without sur
gery and the prosthodontic correction of axial tooth in
clinations is also limited. Therefore, many cases with
MLD have been treated by orthognathic surgery (28).
Surgical procedures, however, may be limited in the
correct repositioning of a displaced condyle. A surgical
separation between the mandibular body and the ramus-
condyle part followed by repositioning the mandibular
body can retain the condyle in. its abnormal position.
Owen reported that it is not uncommon for either
anterior and posterior condylar displacement or both
on patients with a posterior crossbite (6, 7). Many re
ports show functional disturbances of masticatory
muscle activity (29,30) and condylar paths (12,17), and
a high incidence of TMJ disorder (14,15) in subjects with
facial asymmetry. The patient presented in this article
had obvious TMJ disturbance with clicking.
A combination of orthodontic and prosthodontic cor
rection of an MLD malocclusion associated with com
plex symptoms of the CMS is one of the significant
procedures to improve states of dysfunction. Orthodon
tic treatment provides gradual alteration of the func
tional surfaces of the occlusion, enabling the mandible
to adapt to a new position, while prosthodontic treat
ment provides proper support and occlusal guidance
for each tooth.
Condylar position, vertical dimension and occlusal
plane are compensation factors of the occlusion for each
skeletal pattern. "Compensation" refers to the capacity
of the teeth, the dentoalveolar process and the facial skel
eton to cope with structural variations in the mastica
tory organs (31).
Condylar positions must be respected in occlusal re
constructions, especially in subjects with a displaced
mandibular position. Therefore the treatment mandibu
lar position has to be recognized at the stage of plan
ning occlusal treatment by means of an estimated
therapeutic position. An estimated therapeutic position
is successful when it obtains the physiological mandibu
lar position. Anterior positioning of the mandible was
intended not only to correct the mandibular position but
also to compensate for the skeletal pattern in this Class
U case. In the treatment of case presented here, although
the right and left condyles were repositioned 5 mm and
2 mm forward, the distance between the RP and the ICP
after treatment was only 1.5 mm and 0.3 mm, respec
tively. Therefore, it can be concluded that condylar re
positioning therapy in dysfunction cases with
mandibu lar displacement provides healing and remod
eling processes in the joint structure, and consequently
reduces the RP-ICP distance. The combination of orth
odontic and prosthodontic procedures provides a favor
able approach to a complex case with CMS dysfunction.
The vertical jaw relationship and the inclination of
the occlusal plane were corrected taking into consider-
K. Tamakia el a\.
ation compensation for the skeletal pattern. Therefore,
the lower facial height increased to 45 degrees and the
inclination of the mandibular occlusal plane to axis-or
bital plane increased to 15 degrees according to the den-
toalveolar compensation of the Class II skeletal pattern,
and as a result, the posterior disocclusion was achieved
with little effort.
Anterior guidance has to be performed in coordina
tion with posterior guidance. Sequential guidance oc
clusion with canine dominance (24, 27) was applied in
order to accomplish stress management with low muscle
activity, which showed disocclusion in the premolar and
molar parts during excentric mandibular movement.
Summary
This article presents an interdisciplinary approach
to an MLD malocclusion with severe dysfunction of the
CMS. In the first stage, the large lateral displacement of
the mandible was corrected by orthodontic treatment
to the estimated therapeutic position. The diagnosis of
the displaced mandibular position was the key to suc
cessful treatment of the MLD malocclusion. Correct
molar occlusal support and occlusal guidance in the
anterior teeth were established in the final stage of oc
clusal therapy. After this correction, the clinical exami
nation and functional analysis of the CMS indicated that
the management of the pain dysfunction symptoms had
resulted in a subjective state with no pain symptoms and
no TMJ clicking. The condylar movements were smooth
without limitation. A combined approach of orthodon
tics and prosthodontics made it possible to treat a com
plex malocclusion with no surgical intervention in a
period of 27 months.
Acknowledgements
This work was performed in Kanagawa Dental College,
Research Institute of Occlusion Medicine and supported by grant-
in-aid for open research from the Japanese Ministry of Education,
Culture, Sports, Science and Technology. The content of this article
was originally published in the journal Information Orthodontic
und Kieferorthopadie (IOK) in German. This issue in BKDC topics
is a secondary publication after translation into English with
copyright permission from IOK (Thieme).
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