Developmental Alteration of the Form of Denture Frame in Skeletal Class HI Malocclusion and Its Significance in Orthodontic Diagnosis and Treatment Sordao Salo, Hiroko Sakai Tamer Sugistita, Aushi Malsumeto, Milsuyoshi Kubota and Yeshi Sucubi Department of Orthodontics, Kanagawa Dental College Abstract The purpose of this study was to investigale the cevelpmental characteristics of the dento-facial complex the ckelsial clazz Ill malocclusion. Twerty2oven Japanese longitudinal samples aged 6 years through 14 ysars with normal ccclusicn and 400 patients with skeletal Class Ill malocclusion aged 3 yeas through 1G years were selected for cephalometric evaluation, The wettical postion of the posterior teeth in Class Ill rualocdusion was nol stable during the growth, The over eruption of molars induced unfavorable skeletal changes that the mandible rotated downward cresting an antenor openbie and the mandible grew forward causing a skelelal Class Ill malocclusion. The mclar ower eruption due to pesiericr discrepancy fellowed by a functional anteior displcament of the mandbls and subsequent growth of the condyl: may be the majar problem in developing a high angle Class Ill malocclusion. The elimination of the posterior discrepancy and the reconstruction of the occlusal plane, therefors, shoukl be ths fundamental objective in treatment of Class UL maleeclusion. Thus, trealment of high ande skeletal Class Ill malocclusion was achieved by the control of the occlusal plane subsequent to the extraction of second or third molars. Key words; Glass Il maloodusion Posterior discrepancy ‘Occlusal plans Developrreant Molar over eruption Treatment INTRODUCTION Skeletal Class Hi malocclusion is usually characterized as having a steep mardibulor plane angle, obtuse gonial angle, an overdavelcped rmandible, an under develeped meaxills, and a small cranial hase angle which may displice the glenoid fossa anteriorly to cause a forward positioning of the mandible. It has been gsneraly accepizd thal these fxclors conbribuis to the development of skeletal malocclusions as well as facial deformities, and are believed to be criginated from the a5genetic andior environmental factors. However, recent studies regarding the relationship between the funcional occlusal change and the mandibular growth indicated that changes in the occkisal function induce both pronounced and subtle alterction throughout the cranial complex. Past two decades of research concerning dantofacial complex led us to the conclusion that the denioaleolar and the centalacial complex are obviously adaptable to the functional demeand in occlusal configurations Morsover, ihe sludies pertinent to a genelic influence of skeletal malocelusicns such as Class in and cpendite did net show that thase skeletal changes: are under the genelic regulation, Through the year of clinical experience il i= recogrized thal the nfrelsiicrship between the development of the lower Bice and the cant of occlusal plane in the facial prefile is en important Fxcler contibuling to the vertical compenert of malocclusicn. The incinalion of the occlusal plane in the lower face infusnces the functicral positicn of the marditle, The purpese of this stuchy is ta dernonstrate the possibilty of posterior discrepancy as an etiologic facia the Stvedoprmert of shel Clare Ml rialoccuston Lecause i ales Ihe cecesl plafe and the treatment concept. Such concept, therslyre, must he amenced for an appropriate clinical approach to the treatment of Class Ill malocclusions. MATERIALS AND METHOD From the file of Kanagawa Dental College Onhodentic Department, 27 chidren with normal occhision and 400 pationts with skeletal Class ll mabccksion aged 3 ysars through 1B yecrs were selected. Longitudinal samples with normal oodusion were selected based on the following criteria 1. The nomial anteroposterior relatianship of the meaeifaand the mareible 2. Ho malocclusions. 3. Arebatively normal proportion ofthe denlotscial structure, Lateral cephalegrame were traced and the following measurements were obtained. Angular measurements: (Fig. 4) 1. Frankfort Horizontal plane (FH) to the mandibular plane (MP). 2, Palatal plans (PP) to the mandibutar plane. 4. AB plane (AB) tothe mandibular plane 4. AB plane to the palatal plane. 5, Occlusal plans (OP}1o the mandibular plane. 6, Overbite Depth indicator (O01) 7. Anteroposterior Dysplasia Indicator (APDI or AB-PP}. Linear measurements: (Fig. 1) 610 The Isngih of manilary base; measured in milimeters between two points projected ont the paldtal plane hom the peint &(4"}and from the posterior pein of the mescila (F). 2, The length of anterior masillary bass; measured in millimsters between A’ and 6". The point 6" is obtained on the PP by drawing a perpendicular line from the mesial surface of the menilary first molar. In adlion, in order to exarnine the developmental changes of mauillary and mandibular occlusal planes, the angle of remillary occlusal plane to the patsial plane perpendicular (IOP) and the angls of mandibular occlusal plane to the symphysis axis (Merton to the midpcint of infracental widih) (LOP) were utiized (Fig.2}, RESULTS The mandibular plane angk in the bngtudinal normal occlusion samples, in general, showed a radual decrease from six years through 14 years old (Table |, Fig.3) . Upon further examination, ¢ Sias evident tha the Trond ochedon eampleeeretted cof hws Seyi, one showing a gradual decreage in the PLFA ange and the other indicaing a relatively lable FEAMP angle at any stage during the growth and development. fin interesting finding was the fact thet there was no indivcisal ‘with on increment of the mandibdar plane angle observed in the normal occlusion sample, suggesting thal there was no jecparous patlern to cause a hyperdivergency of the kawer face to devebpa maloockision The develpmertal changes in skebtal Class Hi malocdusion cam be chserved in tre groups: one showing a slightly decressing Frankbortmendbulsr plane angle which is refered as the low angk Glaes Ill, and the other with increasing mandibular plane angle which is refered ta as the high angle Ghaes HI (Fig. 3). Thus, in this study. Glass in sarples were calegcrized inlo ths high angle Class in group and the low angle Glass Ill group based on the average mandibular plane angle of 25.0 degrees. The PP-MP ande in nomal occlusion sample ako decreased trom 29.6 deqres to 24.6 dogree alrg with changes ih the mandibular plne ange. The angles of the occhsal plane to the mandibular plane and the AB plane to the mandibular pline were relatively stable in any stages of the development while the AB to the palatal plane angle was edghily increased with the age (Fig 4). Anteroposterior maxillary base kent in the nonnal occlusion sarnple increased with the age while the distance behween A and & decreased (Fig). In both high and low angle Clase Il groups, cement of antemposterior madlary base length (AP) was smaller and the decreasing of At fencth was grealer than thal of normal occlusion qroup, respectively (Fig 5) . The changes of the palatal plane to the mandibular plans angle in the Class Il group were simdar to those of the chenges found in the mandbular plane angle which indiceted parallel downward growth of the maxilla, (Date nck shown) Theange of the AB plane ta the mandibular plane (AB-MP) in the Class Il sampk showed different features compared ip the normal occlusion group (Fig). In the low angle Glass Ill group, an average of 67.3 degress al the ags of 3 years was found to decrease gradualy with the age, Al 14 years of age, this wake decreased fo 58.0 degrees which indicated that there was a forward displacement of the mandible. In the high angle Class Ill group ako showed decreasing values of this angle from 7 through 16 years ofage. In contrast io the angle of AB tn the mandibular plene, AD to the palstal plane angis (&42-PP}in beth high and low angle Class Ill groups increased with the age, indicating a mandibular forward dispbcemert folowed by the mancibular geesth. (Fig. 7) The ang of occlusal plane to the mandibular plane showed diferent growth changes between the high and the low angle Class Il groups (Fig.8} The increment of the occlusal plane in relation to the mandibular plane wee distinctly observed in the high angls Class Ill group whiks this angle in ths low uvangle Class Ill group showed characteristic changes with two peaks at the age ofS ancl 10. tn the high angk: Cless Wl group, the increment of the occlusal plane in relation tb the meandbular plane angle was correlated fo the decreasing angle of the AB lo the: patslal plane (Fig a) . Ho such condation was observed in the parameters of OP-MP, AB-MP and AB-PP in the low angle Glaxs i group (Fig.9 b}. The COI values were found to decrease gradually with the age in both high ard low angle Clase I groupe while the APDI values increazed (Fig. 1 0). Thess vahes were relatively stalle in the longitudinal normal occlusion sample. As shown in figure 14, the changes that tock place in the OO! and the APDI values were funclicralty related to each olhar in Class IM grouse. In ther words, the decreasing ODI values woul increase the values of AAPM, indicaaling thal there isa chess relationship between the ‘vertical dimension of the dentkion and ths anteroposterior component af the mandible The upper oochsal plane angle (OP) in the normal oockision sample increased slightly with the age whie the lower cccusal plane angle (LOP) decreazed fon the age 6 through 10, and increased slightly, thereafier Both the upper and bwer occlusal plane anges reached approximately 78 degrees atage of 14 (Fig. 12 a). The LIOP end the LOP angles in Chess Ill groups showed a tendency to increase, incicating a possibilty of over eruption of molars (Fig. 2b). Figure {3 demonstrates a case with the change of the UCP and the LOP that created a skeletal Class Ill Case presentation Avfemale (] 7 yeers 3 months} with anterior cross bite and lower anterior crowding Cephobometically, the mandibe demonstrated a fervard growth tendency with an ODL of 68. 6 and an APLA of 952. Dentally, the patient occluded with a Glass llrelationehip (Fig. 14a). Upper and lower molars were aver-erupted with an UIOP of 81.6 and an LOP of 680. Thus the oockusal plane ‘wars horizonialized followed bya forward desplacement of the mandible Treatment cbjeclives fer this patient were to eliminate the posterior discrepancy end cortrel the ‘occlusal planes. After removing the rmaxillary third molars, an edgewise appiance was placed (Fig. 18) . Maxillary end mancibular modified offset archwires (MOAI's) which were incorporating a certain degree of tip back bend were inserted, and vertical elastics were used to control the oochisal plane. Jfler 3 months, upperand hwer MOAWs were exchanged to mulioop ecgeewise archers (MEAVs), Elastics were attached to the upper sscond loop (distal to canine) and lower firsl loop (mesial to canine; the so called short dass Ill elastics). vokling the conventional long class Ml slastics was planned to prevent the estrusicn of manillary molars. Aller 16 months of edaswise therapy, the appliance was removed and retained with removable retention plates (Fig. 15, 16) Superposition of the tracings from before and afier edgenise treatment showed the changes of mandibular position (Fig.14b,c). malocclusion. This particular case showed severe molar eruption from the age 6 to 17 years. DISCUSSION Many diagnostic procedures have bean proposed, and the anteroposterior component as one dimension has been amply analyeed and discussed, but the inbrmatian conceming the vettical corpenent is insufficient. The occlusal plane is the mot important component tha alfects the: kawer face vertically. As described, the vertical postion of posterior testh in Clase in malocclusion is not stable during the growth and develbpment. Continuous molar eruption in Clases Ill maloodusion ‘occurs not only during the qrowth pericd of the facial structure, bul aleo cccum during the posl- pubertal growth period. Iw this sense, the genetic Fxclor may nol be the sole reason to create this type of Gass Il malocclusion; rather, the conlinued erupticn of second and third motars in at liruited a8space may be the major conbibuting factor for Class lll malocclusion. Thus, this may be considered as en elfect of the posteriordiscrepancy or posterior crowding, ‘When aversruption of the molars eccure, several unfaverable changes may take place (FigiT). F the patient's growth potential is low, the mandible rotates backward depending upon the amount of increment of the vertical height of the molars. Consequenlly, an antericr opendie may be created, Homever, ifthe palient has snough growth petential, the verlical growth ofthe condyle stimulated. Then, the mandible rotates Karward creating skeletal Glass Ill malocclusion, Cophabrretricaly, this phencmenan is expressed as a horizontalication of the ooclusal plane: i. inctsaing obtussness of ths occlusal plans 1o the mandibular plans angle and decreasing angks of the AB plane to the mandibular plane. ais shown in Figure"! 7, the balance of AB-hIP, PP-MP, and AB-PP angles was closely related to the changes of OP-MP angle in the high angle Class Il group although the bwrangl: Glass Ill giaup did not relate to the increasing vertical dimension. lnpication of Treatment Approach to the Skeletal Class Ill Malocchusion Horiccrtalization of the cant of oockical plans induced by the postarior discrepancy has been described as ane of the important etishgic factors in the bevelopment of skeletal Class Il maloceusion 1011 , especialy those with high angle skeletal malocclusicns. Melar overeruption followed by a functional anterice desplacement of the mareible mary be the mapr problem in devebping a high angle Gass lll malocclusion. Thus, the jon of posterior discrepancy and reconstruction of ecclusal plane chould be the fundamental trealment objeciives: in the trealment of Class Il makchisian In our practice, basically he Mulleap Edgewize Arch Wire (MEAN) technic developed by Kir used fo reconstruct the occlusal plane in order to correct Cass Il malocclusion. The basic force system used and a ealed case using this approach are shown in Figuret® and 15, ‘With the use ofthis system, the Iellewing chenges are expected 1. The posterior testh are inlurdsd and uprighted so thal ths occlusal plane can be reconsiructed, and the mandible can be repositioned presteriady. 2, Reposilioning of the mandible prevents the coucklaravergrewth, 3. The masilla can be protracted fo a downward forward direction, In ender to prevent a horizontaization of the occlusal plane, comentional leng Class Il elastics should not be used in the comecticn of Gass Ill malocclusion because such elastics tend to extruds the upper second mols. Raher, shart Claes tl elastics on the MIEAW ack up would preduce 2 desired resuh. To diminald the posterior discrepancy. the upper and krwer third riclars should be excracted prior to the oned of treatment, IFthe patient i too young fer extraction, the upper second molars ehoukl be removed instead of thid molars with the condiicn that the develpment of the third molars is gocd nice, morphology and direction, Along with the remaval of upper second melars, the lower third molars should be extracted. Occasionally, a gerrnectomy can be perlormed simply if the develbpmertal stage is young enough. References co]1) Carlson, S.D: Craniofacial bisbgy as “normal scienos" . In Johnston, LE. ed. Vistas in Orthedontics, ppl2-37, 1985, Lea & Feviger, Philadelphia, PA 2) McNamara, JA: Neuromuscular and skeletal adaplations to allered function in the orakacial region. dun. J. Chihod, G4; S7EHi06, 1973, 3) McNamara, Ji.Jr. and Bryan, FA: Long-term mandibular araptations to pretruasize function: fn experimental study in Macaca mulila. un, J. Orthod, Dentise. Crthap. 2 : 98-108 1987 4.) Petrovic, #4: Experimental and cybemetic approachs ta ths mechanism of action of tinctional appliances on mandibular growth. In: McMamara, J.Adr, Rikbens, Kuk, Eds. Malocckision and the periodontium. Monograph 16, Craniofacial growth series, Jann ftbor : 1564, Gener for humen greawth and development. University of Mschigan, 6) Litton, S.F.: Agenetic study of dase Ill malocclusion. Am, J. Orihadonl. 68 : 865-577, 1970 6) Salo, 8. Alleration of occlusal plane dus ta postzrior discrepancy raked to development of malocclusion - Introduction ta denture frame analysis. Bull. Kanagawa Dent Coll 15 > 116- 123, 1987 7) Salo, S., Takamneta, K. and Suzuki, Y.: Posterior discrepancy and development of skeletal class Il malocclusion: # importance in orlhedontis conection of skeletal class III malocclusien. Crib. Review, Now/Dec: 16-25, 1868 8) Kim, YH: Gverdite depth indicator with particular reference to anterior open-betes sim. J. Orthod 65 :8U6-610, 1974 9) Kim, Y.H. and Vilas, J.J.: Anteroposterior dysplasia indicator: an adjunct to cephalomentric deferential diagnosis. Am, J, Obed. 73: 618-835, 1978 10) Sato, &. and Suzuki, Y. Relstionship between the development of skeletal mesio-oodusion anc posterior toolrto-denture base discrepancy lis significance in the orthedonlic reconstruction of skeletal dass Ill malocclusion, J. Jpn. Orthod. Sos. 47: 768-8410, 1988 11) Sato, 5: A new orthodontic approach to mandibular lateral displacernent maloodusion Iimperiance of occlusal plane reconstruction. Dentistry in Japan. 26: 81-85, 1989 12) Kim, YH. Anterior openbite and its iresiment with ruultiloop edgewise arciwire. Angle Crihod BF 200-321, 1987 40LL oF ig.2 Moncusemares | uapor anc kaa BOONES ome Fig} Panes ond ienoatia on dw caprwezrr usec oma 4 an-FP 5 sind POPOVOROPT (tb aa idgnts i" at re cee a High anal 7 reese PORE T EMH RTH 0 ‘Age ( years) Fig.d. Changes of the mandibular plane te the Franklert hargontal plane CF H-MIP) with age in fhe setetsl cle ‘gruns and norrnal osclusion araup. or-nirges ¥ wr * ‘oP-wets} Fikret ect a ey arden (CA and he A cara tt rane Be Se oe AB pe foe pend ‘AG BE! tm ue ar ef ape eb ne Allongitudinal esrrpie) and wiih eneootal Clave jal maasurements at subjects weh nowmal aceuaian Tate 7 fs [SbSHNeSnanas seeeqneencaay| | g) teheesant—ons Seeders r anes faeneennmeene mnernenceansy BRARAR Ra SRReS sadananasase qeerenses reise s ee cereng LL a — it x rms la| woeneesomencn Sag rita ae Renaranagedee Faahatahelne se ia ereneeore | | @sazeaggazacs sa thecessnas anne SaRaaeese faeedeaad pP nveerwoscenaneWiiiecwwes age Canes} Ane rebar Fig Changes of foe pmermponiericr asblary Hnmth Fig.6 Changes oi the AB ple ta the mancibuwe TA-Po: ord mansitmry Sout molar paciton (A'-E) eth flan (ARLE) mith age ttm classi groups end age 11th oneal greups an rarmal eadwion 4p rersia pecinson grec. oP-me ¥ io = “AGE EA AGE (TEARS) Fig.7 Changes af the AB plana tz the ealata) pire Fig. Grangos of ro occkvsa! plow to het mart CHIMP! eth age tn the sineett grouse wet nonel plane COP-MP) with age in the slaeelE geeupe aad scchunins rip ‘wera occasion group. 43“Trier it tare se Aas (ears) nm Fig.A8 Changes ofthe over blio dacth indicator Fiat Carlin bt the COL ar tha APO ‘Dai ana a aemaopectace csp ecko! ae EN NS nue gro ae he re TOUpE uns harman grup Bota wurber Yee ctv a =. Teron waw i Tiewateusene Aga [Rese pe C¥rsra) figt2 changes cf ew upper oectueal pura (USO) and ee ew cextuea! plane CLOP! Mtn age ot Pe ncorat eeunion grasp [a and te clase lt matinchustan groupe: (B) 4“CT AUTRE Bee Age (Yours) fm uvoer une tomer tual are CR, fi 7 naa oftcb dried he wile! asa IQ.IE Basie Haren system using maltitong eckeewine archwien (MEAW) and vertical olzztics FigA@ Facal phalograghe inpre (al aed post (bh) erfhodontic Iragtenart sition ye fo pstenos chscropare oe ese op ly, the tales ca at ABP, PB PAP aral AGL PP arg 45rmanr oe we ko mo Fig15 Representation! the aterabon of occlusion during orthodontic ewenern micas 8 malocchision (Crevinued) 46The Role of Posterior Diserepancy in the Development of Skeletal Class ll Malocelusion-Its Clinieal Importance- Cynthia Protacio and Sadao Sato Manira. Philgpin, *Departmert of Cirthadon Kanagooa Dental College. Yoknsubii, Kanagaea, Japan Surenary An affort has boon made bo characterize tha skeletal chssll malocdusion and tp elucidate and piu light ta fur sflects of posterior discrepancy on skeletal configurations. Not only is the conection of anterospastarior daviatian af the dentolacial complex necessary bul even more important is the contral of the vertical dimension ta arrive al a stable occlusion. In this respect fis impcetart to recogrize the effects of the horizontalizafion of the occlusal plane (OP! as induced by poster discrepancy, R.aliscts the vericel eelationshio of the dentiéon providing interkerences in jsoclusal funchan a5 wall as © contributes to the maleafion of the mandible, associnted with an unstable derture scheme and a resulard relapse of the bected deriton, It should be emphasized that the predominant orthodonte roatment objects in the comecton of skalatal classill malcediusion is te grmaniy eliminate posterior discrepancy and recenstuct ne OP. As Inees congiderabons are recognized and applied rovlinely m1 diagnaeis and Wealment planning Wa-can expect 2 ctably codueion and the rasiment of cketotal clase bh malsociucion wil nat bo cuch a great burden as well 2s even possibie reduce ihe perceniape of surgical cases, ocelusion lic vib pues of Ineeceuonton, aia skeicvon which is in fet the rationale bebinel Muclt researet fs boon directa waved mechanics the use.of functional appliances and techniques in orthodontic trearment that To what factor cun we ascribe the excessive wtanately, litte cattersticn has been given xs the mandibular growth we see in skeletal class ll study of how malocclusions develop particularly malecelusions ? fs it really genetic or ackpeive in skeletal makocelusions. Thus, many orthocoetiss nature? According to Moss et. al”) and Petrovic hive been drown to be “technique-oriented” nther "the morphology and growth of the lower face than “etiolegy-onented” doctors are influcnce mu ql Bis ture that orthodontists dest with the most fe mn. In a growing facial skeleton, the complicated aratomnical complex in all cresition that adaptability i primarily. locates it tbe tunction.of.. medical science ix meting slow progress in gaining the dhriition, while it an understanding of the growth of the. jaws. But sunuris and a the amich credit must bs given to the werks dene by o The particular problem underlying skeletal number of excellent researchers such as Pemovic ’ mulocdusions is related to the discrepancy im size, mfr adruappaeed those from, position of the structures composing the dentofacial complex. Flow then can the ehologic chassificatiog of dentofacial disturhanoe be defined " In ender to do this, there is anced tt identify the characteristic syrnpioms that ane manifested in that Mess *), and. MeNarnara™ 48‘particular maloccliwen and snalyec:its developer process, Skeletal Class I] malocelusions are usually charcierined ax having a large mandibular plane angle, obuise gonial angle, an over developed mandible, ani undendeveloped maxilla, ancl a small ‘cranial base angle which may disalace the glenaid fossa anteriorly, pramobon the foward growth of the mandible. It has been generally nocepted that These factors cOnUibWte t the development of Skeletal malocclusion ax well as fucked efunmities and are believed to originate from genctic or environmental factors. Studies done change in occlu. propeance inh the: we cranial complex*, The dentoalveola functional demand in i. and slenjofacial comples 4s primanty a result of oeclnsal funtion, ThroJB¥ years of Ine eyele proceeds and aggravates the process of the developmant of a doeletal class [E malacchusicn, A New Perspective it the Development af Skeletal Chass. Maaeasione I has been thought and accepted that skeletal class [ll malocclusion is due 10 the abnormal overgrowth of the mandible. However, this concept needs 10 be amends send instead reoognize tat the abnormal skeletal or dentealveolar configurations are a result of abnocmal occlasal function involving masticatory and perioral crascle function, Extensive stuaties '°*' have indicated thar the adapiation of skeletal and dentoalveotar elements of the fice, following functional balance of the orofacial region. These studies thal thy mandibular ysoyth is regulated prieuarily by the smacillary occlusal surface. ‘Skeletal configuralions as shown by the present halometics only reveal the “Sympiems” and not the etiologic factor for the paricular malocclusion, A lack of such pertinent orthodontists to ipnore important factors: such as posterior discrepancy, acclusal interfemee, eo, whic are the “culprits” to the: serie cof thks inn causes most anna was never considsoss/ io sald in determining, the, 35 etiologic factor of the skeletal malocclusinn. [arcover, if was concentrated! rm vof the dentition, A Orthodontic Approsch io the Treatment af Skeletal Clow i! Mabcciusion ince posterior discrepancy is considered 0 be. an etiologic factor for the devdlopment af skeletal velaselll malocclusion ther isa crucéal need then to change our Geampent objectives in the coreetion of skelctal classlll makecclusion which is as follows 4) Btiminwe posterior discrepancy (2) Depression of molars () Reconstruct the ooclusal plane {making it more indined orsteep! ‘in the elimination of posicraw discrepancy the Sind rokars should be cxtractiod. Usually however, it is prcfeeable te extract the upper 2nd enotars instcad in the extraction of the Latter, studies reveal that upper 3rd malars have a Preclictuble and fiwerable path off eruption afer 2nd molar extractions, which is eet tro in lower 3nd molars. Howeser, if (he development of the Sef molar tooth germs de not appear to be of the sare: sine of morphology ty sabstitute the 2nd molars, then this is the time when the 3nd molars shoukd be The lower 3rd molars showld be extracted even if they are impacted. Occasionally, ‘germectomy is reccenmnended. Aso, event extracted. Treatment |Heefanios Fundamentally, the Modified Offset Archwire (MOAW) and the Muliloup Edgewise Arctimire UMEAW) *© are used to depress the mokirs and reconstruct the occlusal plane. But prior i this, rotations or poorly positioned beackels areFig. 9 Orthodontic apmroach to the correction of shelotal Class li malooslusian, (a) Moditind cHent archwires (MOAW) and ston Classillelastics are used in early staps af treatment. (b) Mulilcop edgawiss anchwvine [MEAW) and vertical elastics are incorporated inte the racansiracton of aHlectod ceclusat plane. cluinated, ‘The 116% .022 Eleiloy blue wire (MO, Co.] is utilized for the MOAW and MEAW, Heart treatment is necessary after the ‘wines have hea ent te strengthen the archwire, ‘The MOAW is constructed! with 2 horizontal loups (Fig.82), The first loop is positioned between the laleral incisor and canine and the 2nd Joop has a ventical \oop contains a 30-tegree tip hack bend at 5mm. cfistal tothe: vertical loop, The horizontal loop serves to reduce the load / deflection rase and provides vertical comtral and hook far the ehesthes, The vertical loop also placed deal uo tte tube af the: bast mokar which acts as a stop, After the Last molars are uprighted, a space will be created between the barct molars and the weil anterior do therm. lupeghting prevnalars. Th onder oy yprizht the pemoders, the MIELANY is This space then ix used for 36 removed and the MEAW (Fig. 80) isinerts, The MEANW us peopased by Dr. YH. Kim should have a deep curve of Spee in the upper archvane and a reverse on the lower archwire. Anterior vertical clashes oe shost class Uelastics (3/16 in, & 92) ve a must in order to counterbalance the inmucting force: created by the archwire an the meisors and also 1 simultaneously provide manditulsr reinusion, The comventionally used long class Ll elastics would further elongme the upper molars, horizomalize the OP and provide occlusal interference and deflection making the skeletal malocclusion worse". Thus, i is nent usesl The use of MOAW and MEAW with vertical or short class elastics would give way to the following events [Fig 8b) ; (1) the posterior reeth souk be intrudect ancl uprighicd sothat the upper GP isreconstructed ; (2) condylaradapiation which wecelerates the cemection of class [1 maiecctusion would be expected, (Case Repert Amale (15 years and 4 montis! with an antegior apenbite whase cephalometi¢ craving shows a mandibular Forward goth vendency with an SNA of #4 degree ark an SNB of 74 degree, Denture frome analysis indicaied a Rorizontalized occlusal plane (OP-MP=26 degree) and forward displacement of the mandible (AB-MP=35 theyre) (Table 2). Denmally, the pation! oxchuckec swith 8 Chess Llrelationship, Lower incisors were relroclined relative to he mandibular plane. ‘Treatment objectives fer this patient were to eliminate the posietior discrepancy and control the occlusal plane, After removing the maxillary and mandibular 3rd cocks, an edgewise applance was placed and the teeth were aligned. As his dentition were aligned, aeierior oponbite and mickline discrepancy were accentuated (Fig), Maxillary and mundibular MEAWs were inserted andl anterior vertical elastics were: used tn control the ecclusal plane inclination, This force system of the applicaion of MEAW ark) clastic aimed ti tip the occlusal plane antertorly, repositioning the mandible backward and pulling the maxilla downward an forward somuitancoussly, After 15 months of edgewise treatment, the appliance was removed ane retained With a remowable neuiners ‘Superimposition of the wacing from the initial examination i the end of active ueatmcnt reveals maxilary forward growth while the mandibular 37 Table. 2 Denture frame analysis of pretreatment ard pouttreatmant. FH MP reMr op-Me | onsury rr. growth was indhibised {Fig. 00? . Cehalometerically, an increased SNA (71) and decreased SB (715) were observed [impeovement of ODI (56.00) and -APDI (86.5) figures were obtained (Tabile 2}. Discussion Very few studies have been directly devoted to the developeneneal process involved in skeletal clase T] malecetusion im relation to the taoth.tc. sGormure base discrepancy problern that may explai the primary etiology for many malocclusion. 1 dugnostic we heen desi the aniero-posterior component ax dimension has been amply analyzed an, t uniorianatly, fir exterely insufficient ane pertps veulesiee As.we have described, catlicr the ORais, se component uf the lower face shighl influenced sterior discrepangy. — Manya9orhodontists have beng agreed that discrepancy pmblems are inkimalely rebited Ws various Iypes at snalocelusion, Inaue. etal." suggested that a space deficiency in the posterior region has an effect on she mesial drif of the Ist molar, which seems tobe peiogic cether then physiologic. Thus, posterior discrepancy exerts" squevzing-out” forces and at 10) Cophalogram drasinge from dhe iri ination (a) and the nd of orthodontic Wroarment (0) , tracings, ‘And cupanimpasition (ch of ine ‘produces not only the rnasial inctination but also the vertical growth or overeruption of the molars which ‘results (othe tne of the OP, Mervover, ts was that the Mux OP (Max OP-SN} was smaller inthe openbite cuses af adult class Il and. class [1 malnochusions. Horizontalization of the maxillary OF induces bod the functional displacement of Tue srounclible and the active tmnsformution of the TMJ. Extensive studies hawe indicanad that the aukgvatioe of skeletal and dentoalvedtar elements of the face following. functional dispSaceerent of the mundi beast a ‘re establishimer of structural ang functional blancs of the orofacial mgion * ‘Continuous ibukar forward displacement with forward rowsion due to molar see will result in the development of class ID malooeiusiwo The cecurence af the cvereruption after puberty may cause a manclibubar buckwant Tolation to sesuh acal it figure. As described, be a olyective in conecting negative may be 8 PUInay owerjet and lass Urelatiogstuip of the mandible, Feta nce ean be chunged during weaiment. ‘Thus, the posterior discrepancy must he eliminated, und the curventional long, clase Il elnerics, which produces: the vertical clomgation of posterior weeth ehould mit bbe used Raterence: L Petrovic, AG., Stutzman, J, : The biology of peclusal development. MManagraph, University of Michigan, Ann Arbor, Michigan, 1977. 2. Mow, MLL. The primary role of functional matrices in taclal growth. Am. 1 Orthod 55: 556-577, 1069, 3. McNamara 1A. It. Bryan, FLA: Long-terrt mandiblar adaptations ta protorupive function ~ an experimental study in Macaca mulaita, Am, J Orthod, Demutyelal Orthop 42: 94-1011 LRT, él 4. Elgoyhen, J.C, Mayers, RE, MeNamarat.A,. Jr, Rioln, MLL. : Craniofacial agaptation 12 protarusive function in young thesus monkey. km. J, Onbul, 62: 4694811, 1972, 5, Sato, 8., Motoyanagi, K., Suzuki, 1, Imasaka. 8. Sucuki. Y. : Longitudinal study of the ciavlopiment ‘of ckelatal malocclusion’. J. Japan Oth See 47 1186-196, 1988, 6 Sato, 5. = Alteration of ooglusal plane due to posierlor discregancy related to development af malecclusion-introduction to denture frame analysis. Bull, Rangawa Dont, Cotl, 15 = 115-123, 19R7, 7. Samo, $, Sumuki, N.. Suewki, ¥. + Longitudinal study of the cant of occlusal plane and denture: frama in cages wen conpanitally missing think molars. Further evidence for the occlusal plane change falsted to posterior discrepancy. J Fegan Orthod. Soe. 47; 517-525, 1988, 8. Sam, §., Soka, H.. Sugishita, T., Matsumoto, A., Kubota, M. and Suzuki, ¥.: Davelopmental altetalian of the form of denture frame in gkolatal calselll malocclusion and its. significance in orthodontic diagnosis and treatment. lot. J. MEAW. 1: 33-86, 14 9. Sama 5 : Cee mpon : Developmental characierizabers of skolotal Classi malocclusion. Angle Obert. 64 WS-112. 1a 10, Kim, YH. Anterior apenbite and its jroatmant with multiloop edigewisa archwire, Angle Onheul 57 : 290-321, 1987 L Inoue, N.. Hui-Kut, Co, Ite, G., Shiena, K., Kuragann, $., Kamegai, T. Selina, ¥_, Yuyartiay Yor Takagi, O., Tura, K. + Influence of tenth-to- donture base discrepancy on space closure jollowing premature loss of dacicuaus taath Am. J Cethod, 83 : 22-434, 183. 12. McNamara, J. A. Jr. : The role af functional appliance in contemporary orthadantcs, New Vistas in orthodontics. Lea & Febiger. Philadelphia, 38075, 1995