Apresentado no A.A.O. - Scientific Posterboards Exhibit Nº 41 - 7 de maio de 2006

Use of a Bite Ramp in Orthodontic Treatment

Leonardo Tavares Camardella; Elvira Gomes Camardella; Guilherme Janson

Abstract

The bite ramp is a very useful orthodontic device to correct deep overbite and curve of Spee which prevent bonding of the mandibular incisors in the beginning of orthodontic treatment. The aim of this presentation is to describe a case report of a Class II with deep overbite and curve of Spee where the bite ramp was used to allow the bonding of mandibular incisors in the beginning of orthodontic treatment. This procedure helps in decreasing treatment time.

Introduction

Biteplanes can be used in Class I and Class II, division 1 and 2 cases for the correction of deep bite with moderate overjet1 and their shape was inspired by the lingual orthodontic brackets2. Biteplanes are often used when bracket interference makes it difficult to bond the mandibular anterior or even the mandibular posterior teeth at the start of treatment3.
Biteplanes can be fixed1, 4, 5 or removable6. Removable biteplanes depend on patient cooperation what unfortunately makes treatment less effective because the appliances are often worn only part-time, lost or broken. Besides, removable appliances can also produce mucosal trauma and, if oral hygiene is poor, chronic candidal infection of the entire palatal mucosa can result5. Many of these problems can be overcome by using a fixed biteplane, which is worn full-time and is more hygienic.
Fixed biteplanes can be included in lingual arch appliances fixed to orthodontic bands on the upper first molars7 or can be constructed with glass ionomer cement5, composite resins1 or self-curing acrylic resins4. In this second case, they are generally bonded on lingual surface of maxillary incisors. After biteplanes are bonded, speech can be slightly affected for a day and mastication for a week1, however patients adjust to speaking more quickly than with removable biteplanes5. Accidental debonding of a bonded biteplane is rare because occlusal forces are moderated by the propioceptive reflex, and most pressure is directed against the tooth surfaces1.
The bite ramp in a kind of bite plane developed by GAC and its advantages are: it is not necessary to be built, it is easy to bond and it is hygienic. The only disadvantage is that this orthodontic device is more expensive than the other ways of opening the bite1, 4, 5.
This presentation shows the use of bite ramp in orthodontic treatment and its advantages in decreasing treatment time during overbite correction and leveling curve of Spee.

Case Report

This case report concern an 12-year-old male, presenting with a Class II division 2 malocclusion, with an accentuated curve of Spee and deep overbite. The patient still presented two deciduos teeth, the maxillary right canine and the second molar (figure 1). The periapical and panoramic radiographs showed sound periodontal conditions and the presence of all permanent teeth (figures 2 and 5).

Fig 1: Photographs before treatment: A, B and C, facial photographs; D, E and F, intraoral photographs.
Figures A, B and C
Figures D, E and F

The cephalometric analyses shows that, according to ANB, patient presented a regular basal bone relationship because the mandible retrusion. The maxillary and mandibular incisors were tipped lingualy, according to 1.NA and 1.NB and his growth was predominantly vertical. Patient presented a good profile with competent lips (figure 2 and table).

Fig 2: Radiographs before treatment: A, cephalometric; B, panoramic.
Figures A and B

Table: Pretreatment and posttreatment components
 Measurements  Pretreatment  Posttreatment 
Maxillary component
SNA (o)80.274.8
Co-A (mm)94.393.5
A-Nperp (mm)-0.8-4.6
Mandibular component
SNB (o)76.672.7
P-Nperp (mm)-9,0-11.2
Mand Length (mm)122.6130.2
Maxilomandibular relationship
ANB (o)3.72.1
Wits (mm)2.0-0.9
Facial pattern
(FMA) (o)32.332.5
NS.GoGn (o)38.540.6
Lower face height72,882,6
Maxillary dentoalveolar component
1.NA (o)18.123.3
1-NA (mm)3.85.0
Mandibular dentoalveolar component
1.NB (o)16.226.9
1-NB (mm)3.46.1
IMPA (o)78.290.3
Soft tissue
Nasolabial angle (o)121,7128,3
Line S Upper/Lower (mm)-2,4/ 0,3-6,9/ -3,1

To decrease treatment time during leveling curve of Spee and overbite correction, it was used the bite ramp, which is an orthodontic device that is bonded on lingual face of the maxillary central incisors. This procedure allows the bonding of mandibular incisors and facilitates the overcorrection of overbite because the brackets can be bonded on a more incisal position (figures 3 and 4). After three months, the deep bite was corrected and the posterior teeth occluded, what shows the effectiveness of the bite ramp, mainly because the full-time use. Radiografically no significant alterations were noted on maxillary and mandibular incisors roots during the use of the bite ramp (figure 5).

Fig 3: A, overjet after bite ramp bonding; B, bonding of mandibular teeth; C, bite ramp bonding.
Figures A, B and C

Fig 4: Overjet after 1 month of use of bite ramp.

Fig 5: Periapical radiographs: A and B, before bite ramp bonding; C and D, after bite ramp removal.
Figures A, B, C and D

The malocclusion was treated with 0.022-inch slot pre-adjusted appliances. Patient used IHG for 12 hours a day during leveling and alignment, which sequentially progressed from 0.016-inch NiTi wires, through 0.016, 0.018, 0.020 and finally 0.018 X 0.025-inch rectangular stainless steel archwires. In the end of treatment, patient used Class II elastics bilateral to improve the anteroposterior relationship. Treatment time lasted 2 years and 3 months. At the end of treatment a Hawley plate and a bonded canine-to-canine retainer were installed in the maxillary and mandibular arches respectively.
The facial photographs show a good posttreatment facial profile with competent lips. The patient was satisfied with his teeth and profile. The final occlusion showed a Class I molar relationship on both sides and the inicial deep overbite was overcorrected (figures 6 and 7). The superimpositions show that patient had a predominant vertical growth and the mandible experienced a downward and posterior displacement. The maxillary incisors were retruded and the mandibular incisors were labially tipped and retruded (figure 8).

Fig 6: Photographs after treatment: A, B and C; facial photographs; D, E, and F, intraoral photographs.
Figures A, B and C
Figures D, E and F

There are basically four ways to treat a deep bite: (1) leveling of the arch through eruption of premolars, associated with a clockwise rotation of the mandible, which serves to increase lower facial height; (2) intrusion of lower and/or upper incisors; (3) labial inclination of the incisors; and (4) molar extrusion8. In this case, overbite was corrected by extrusion of mandibular molars and restriction of vertical development of mandibular incisors (figure 8).

Fig 7: Posttreatment radiographs: A, cephalometric; B, panoramic.
Figures A and B

Fig 8: Superimpositions of inicial and final tracings.

The bite ramp was very useful in this case because made possible the overbite correction in the beginning of treatment and in a little time (3 months), consequently decreasing treatment time. According to some authors9-12, the higher inicial overbite, the higher relapse and the necessity of overcorrection during treatment. The bite ramp allows the brackets bonding of mandibular incisor in a more incisal position, what helps in attain an overcorrection of deep bite in the end of treatment. In this case report it is not observed any alteration of maxillary and mandibular incisors root during the use of the bite ramp.

Conclusions

Bite ramp is a very effective device in orthodontic treatment to correct rapidly deep overbite in the beginning of treatment. Its advantages are: it doesn’t need patient cooperation, it is used full-time, it is not necessary to be built, it is easy to bond and it is hygienic.

References

1. Philippe J. Treatment of deep bite with bonded biteplanes. J Clin Orthod 1996;30:396-400.
2. Alexander CM et al. Lingual orthodontics. A status report. J Clin Orthod 1982;16:255-62.
3. Heinrich CK. A practical biteplane for use with fixed appliances. J Clin Orthod 1993;27:508-10.
4. Madsen R. Bonded acrylic lingual biteplanes. J Clin Orthod 1998;32:311-7.
5. Jackson S, Sandler PJ. Fixed biteplanes for treatment of deep bite. J Clin Orthod 1996;30:283-7.
6. Banks PA, Carmichael G. Modified arrowhead clasps for removable biteplanes. J Clin Orthod 1998;32:377-8.
7. Forsberg CM, Hellsing E. The effect of a lingual arch appliance with anterior bite plane in deep overbite correction. Eur J Orthod 1984;6:107-15.
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10. KIM TW, LITTLE RM. Postretention assessment of deep overbite correction in Class II Division 2 malocclusion. Angle Orthod. 1999;69:176-86.
11. Uhde M, Sadowsky C, Begole E. Long-term stability of dental relationships after orthodontic treatment. Angle Orthod 1983;53:240-52.
12. Wood C. The effect of retention on the relapse of Class II division 1 cases. Br J Orthod 1983;10:198-202.