Closing Anterior Open Bites:

The Extrusion Arch

Robert J. Isaacson and Steven J. Lindauer
The principles of mechanics can be adapted to the treatment of clinical
problems in many ways. Anterior open bites, long a troublesome problem in
clinical practice, can be addressed with arch wire mechanics using asym-
metrical V bends in the wire. The activation of the wire is the reverse of the
intrusion arch and will effectively work as an extrusion arch to close anterior
open bites w i t h o u t the use of anterior vertical elastics. The open bite closure
can involve both jaws or be limited to extruding the teeth in 1 jaw only. All
of the mechanics are opposite to those associated with a 1-couple intrusion
arch. The system can be designed so that the reciprocal forces and mo-
ments, acting at the molar, can be controlled. Strategies for control of
unwanted tooth movements require attention to all of the components of
the force system and not just the desired bite closing forces. (Semin Orthod
2001;7:34-41.) Copyright © 2001 by W.B. Saunders Company

he t r e a t m e n t o f malocclusion c o m m o n l y ated long-face skeletal problem and try to reduce

T requires control of the d e e p bite. As a re-
sult, the intrusion arch and intrusion mechanics
vertical facial height with surgery (LeFort surgery)
or intrusion of molars (vertical pull headgears,
have long b e e n present in some f o r m in most splints, or repelling magnets). Other approaches
appliance systems. accept the existing skeletal morphology and focus
The remarkable fact is that the reverse version on local factors addressing treatment toward the
of this problem, the open bite, has received far less tongue (cribs or tongue reduction surgery) or the
attention. This may be because o p e n bites occur facial musculature (functional appliance shields).
less frequently. However, open bites are present in Often, however, the cause c a n n o t be posi-
all orthodontic practices and are problems in tively identified, and the o p e n bite is treated
which practitioners do not always enjoy predict- with dental compensations. Undoubtedly, the
able success. The need for a reliable biomechani- most c o m m o n a p p r o a c h has b e e n the use of
cal technique for open bite closure that does not vertical elastics to close the anterior o p e n bite.
require patient compliance has been obvious. Almost all orthodontists have used this ap-
Anterior open bites may look very similar to proach, and almost all orthodontists have expe-
each other, but it is likely that they have various rienced some degree of dissatisfaction with their
factors contributing different amounts to their eti- inability to close anterior o p e n bites reliably,
ology. As a result, it is not surprising that open bite mostly based on the r e q u i r e m e n t of patient com-
treatments involve a wide variety of treatment ap- pliance to make the t r e a t m e n t succeed.
proaches. Some approaches focus on the associ- This article is devoted to the use of an auxil-
iary wire, placed over complete or segmented
arch wires, to p r o d u c e tooth m o v e m e n t and
From the Department of Orthodontics, School of Dentistry, Vir- dental compensations for anterior dental o p e n
ginia Commonwealth University, Richmond, VA. bites with no patient compliance required.
Supported in part by the Medical CoUegeof Virginia Orthodontic
Education and Research Foundation.
Address correspondence to Robert~ Isaacson, DDS, MSD, PhD,
Department of Orthodontics, School of Dentist'u, Virginia Common- The Extrusion Arch
wealth University, Richmond, VA 23298-0566.
Copyright © 2001 by W.B. Saunders Company The extrusion arch is a term that was coined to
1073-8746/01/0701-0005535.00/0 describe the reverse action of the already exist-
doi:l O.1053/sodo. 2001.21064 ing and well-established intrusion arch. T h e

34 Seminars" in Orthodontics, Vol 7, No 1 (March), 2001: pp 34-41

 Closing Anterior Open Bites 35

term, extrusion arch, is probably somewhat mis- won by the patient. The extrusion arch, how-
leading because the action of the wire is not to ever, gives the orthodontist the ability to close
extrude the tooth from its attachment appara- anterior o p e n bites without patient compliance,
tus. and in addition, to decide whether the open bite
What does h a p p e n when a tooth is moved closure should come fi~om just the maxillary
vertically within the alveolar process? w h e n the teeth moving down, just the mandibular teeth
o p e n bite closes, does the tooth move with re- moving up, or both.
spect to the alveolar process and leave the alve- The biomechanics of an extrusion arch are
olar process b e h i n d with a longer clinical crown fairly straightforward. As with most clinical prob-
resulting? All available evidence shows that, lems, the first question is, Which teeth do I want
whether the tooth is intruded or extruded, ver- to move in what direction? With an anterior
tical m o v e m e n t brings the entire attachment ap- open bite the answer is clear. I want the front
paratus, including the alveolar process and the teeth to move vertically together. Now, however,
gingival tissues, with the tooth. In fact, some the question is more sophisticated: Do I want the
work has even been reported describing treat- u p p e r teeth, the lower teeth, or both to move
m e n t procedures to try to prevent the attach- vertically?
ment from the normal process of following the Sometimes the anterior open bite is primarily
vertical m o v e m e n t of a tooth in those cases a skeletal growth problem. 4 The disproportion-
where a treatment requires a longer clinical ate bony facial growth results from relatively
crown. 1 more vertical growth at the alveolar process as
The extrusion arch is a new adaptation of the c o m p a r e d with the vertical growth occurring at
biomechanical principle of an off-center bend, the ramus (Fig 1). This is a long-face problem
or asymmetrical V, in an arch wire to develop a evolving and, in the most troublesome situa-
specific set of biomechanical responses. 9 Despite tions, a backward rotating facial growth pattern.
the fact that many systems have used the princi- in these individuals, the anterior alveolar pro-
ples of an intrusion arch to treat deep bites for cess must grow vertically rapidly or the open bite
many decades, the concept of using the reverse will get worse. If the clinical open bite extends
configuration of the wire to treat anterior o p e n from molar to molar, the problem is likely to be
bites was only recently reported, a a skeletal problem with insufficient dental com-
The principle of an extrusion arch has been pensations and is even more difficult to treat.
applied as a segmental wire for some time, pre- If the o p e n bite is a local problem, and just
dominantly to bring in impacted canines. ~ The involves an anterior segment of teeth, the prog-
application of this principle with a continuous nosis is m u c h better. This is especially true if a
auxiliary arch wire to multitooth anterior o p e n cephalometric analysis shows a skeletal pattern
bites emerged when teaching new residents the with relatively normal vertical development.
principles involved in the use of intrusion Sometimes the local causative factor, eg, a digit,
arches. W h e n a new resident described the in- is no longer present, but the tongue, lips, and
trusion arch backward, the obvious application t r a c t i o n are maintaining the dental o p e n bite.
to an o p e n bite became apparent. When the This kind of open bite will be relatively indepen-
authors applied this theory clinically and used dent of vertical facial growth. O f course, the
an upside down intrusion arch in an open-bite possibility of a skeletal open bite existing in com-
patient who was not willing to wear vertical elas- bination with local factors adapted to the open
tics, the open bite closed in a matter of several bite is quite possible.
weeks. This was indeed a very impressive new When an open bite problem is addressed by
application of an old principle. inserting a continuous arch wire into the brack-
The extrusion arch is a very efficient and ets on all the teeth, the results are rarely satis-
effective way to close anterior open bites, and factory. Wiping reverse occlusal curve in the
open bites are the nemesis of most mechanics. maxillary wire a n d / o r a large accentuated curve
The vertical elastic has been the most c o m m o n l y in the lower wire simply is not effective. The
used tool in the past and, too often, vertical mechanics are slow to work, and the side effects
elastics became a contest of wills between the are often undesirable. W h e n the wire is left in
orthodontist and the p a t i e n t - - a contest often place long enough, the result is often essentially
36 Aaacson and Lindauer

a t r a n s f e r o f the o p e n bite f r o m the a n t e r i o r

A t e e t h to the p r e m o l a r s .

Action at the Molar

Figure 2 shows the s i m p l e 2 - d i m e n s i o n a l sche-
matic view of the actions of a n e x t r u s i o n arch.
Notice t h a t it is the exact reverse of a n i n t r u s i o n
arch. W h e n the a n t e r i o r e n d o f the e x t r u s i o n
arch wire is b r o u g h t u p to attach to the incisors,
a s e c o n d - o r d e r c o u p l e o r t e n d e n c y for r o t a t i o n
is p r o d u c e d at the m o l a r . This c o u p l e will always
rotate the m o l a r c r o w n m e s i a l / r o o t distal with a
c e n t e r o f r o t a t i o n l o c a t e d exactly at the c e n t e r of
resistance. No o t h e r k i n d of r o t a t i o n is possible
with a c o u p l e regardless o f w h e r e the b r a c k e t is
p l a c e d o n the tooth.
A l t h o u g h this f u n d a m e n t a l force system will
B always act as shown, several a d d i t i o n a l actions
o c c u r as a p a r t o f the force system i n the same
wire. I n b i o m e c h a n i c a l terms, the s e c o n d - o r d e r
c o u p l e at the m o l a r c a n n o t exist w i t h o u t equi-
l i b r i u m , ie, the n e e d for the system to be i n

Figure 1. Average facial growth pattern, in which the

vector of vertical growth component at the condyle
and fossa equals the sum of the vertical growth at the
I alveolar processes and maxillary sutures (A). This re-
sults in no mandibular rotation. The direction of
mandibular displacement will be a translation in the
direction of the condylar growth. However, when the
mandible rotates, the rotation is a result of the ratio of
the vertical component of condylar growth to the
vertical component of alveolar and sutural growth.
f The same amount of condylar growth as shown in
Figure 1A, but a lesser amount of vertical growth
occurring at the sutures and alveolar processes (B).
c This results in a forward rotating mandibular growth
pattern with a concurrently shorter lower facial height
and characteristically deep labiomental fold. The den-
tition will most conunonly show deep anterior over-
bite despite the occurrence of lesser amounts of ver-
tical alveolar growth. The lip-to-tooth distance is
usually reduced. The same amount of condylar
growth as shown in Figures 1A and 1B, but a greater
amount of vertical growth occurring at the sutures
and alveolar processes (C). This results in a backward
rotating mandibular growth pattern with a concur-
rently longer lower facial height and an associated
characteristic mentalis strain and dimpled chin. Be-
cause the alveolar process must grow more in the
anterior region, any inability to dentally compensate
for the skeletal growth results in an anterior open
bite. The choice of dental compensation and an ex-
trusion arch as a treatment is based on the esthetics of
the lip-to-tooth distance, which is already commonly
increased in these patients.
 Closing Anterior Open Bites 37

!
..... z , J

) ', :?}
,::~ •
I
egJoOOQ° J

Figure 2. Schematic view of the biomechanics of an Figure 3. Same as Figure 2, but showing the equilib-
extrusion arch. Elevation of the anterior portion of rium forces (arrows in bold) and the second-order
the wire creates a second-order couple at the molar couple at the molar (shaded arrows). The compo-
bracket, resulting in crown mesial/root distal rotation nents of the equilibrium shown and the second-order
around the center of resistance (arrows in bold). The couple in Figure 2 are inseparably related, and chang-
equilibrium of this couple is another couple com- ing the magnitude or location of either one of them
posed of the extrusive force at the incisor and an will affect the other.
intrusive force at the molar (shaded arrows).

c e n t e r of resistance o f the m o l a r intrusively a n d

b a l a n c e . This b a l a n c e r e q u i r e s that, b e c a u s e the
to rotate the m o l a r a r o u n d the c e n t e r o f resis-
m o l a r will w a n t to rotate i n a c o u n t e r c l o c k w i s e
t a n c e i n a crown f a c i a l / r o o t l i n g u a l d i r e c t i o n .
d i r e c t i o n , a n e q u a l t e n d e n c y for the system to
This is a relatively m i n o r c o m p o n e n t o f the ex-
rotate i n a clockwise d i r e c t i o n m u s t also be
t r u s i o n arch force system.
p r e s e n t . Physics r e q u i r e s that the s u m o f the
m o m e n t s i n all p l a n e s m u s t e q u a l zero.
T h e e q u i l i b r i u m , or b a l a n c e , is a c h i e v e d be-
r/m/ g
cause the a n t e r i o r e n d o f the wire wants to ex- N o n e of the m u l t i p l e u n d e s i r a b l e actions at the
t r u d e the i n c i s o r a n d the wire i n the m o l a r t u b e m o l a r will b e s i g n i f i c a n t if the e x t r u s i o n arch is
will w a n t to i n t r u d e the m o l a r (Fig 3). T h e s e 2 allowed to act for o n l y a l i m i t e d l e n g t h o f time.
forces are e q u a l a n d o p p o s i t e a n d d e f i n e an- This is n o t a n issue o f differential forces, it is o n e
o t h e r c o u p l e t e n d i n g to rotate the whole system of t i m i n g . W h e n a n e x t r u s i o n arch is u s e d to
clockwise i n a n a m o u n t e q u a l a n d o p p o s i t e to
the t e n d e n c y of the c o u p l e at the m o l a r b r a c k e t
to rotate the system counterclockwise. This equi-
l i b r i u m is a b a l a n c e , a n d c h a n g i n g any p a r t of
the system will u n a v o i d a b l y c h a n g e the o t h e r
parts also. If it is d e s i r e d to c o u n t e r a c t s o m e
u n w a n t e d c o m p o n e n t o f a system i n equilib-
r i u m , it is r e a s o n a b l e to a d d a d d i t i o n a l force
systems o n top o f this s y s t e m - - t h i s will n o t affect
the e q u i l i b r i u m . It is n o t r e a s o n a b l e to alter the
arch wire itself w i t h o u t e x p e c t i n g the o t h e r com-
F F
p o n e n t s o f the e q u i l i b r i u m to c h a n g e also.
W h e n viewing the e x t r u s i o n arch wire f r o m Figure 4. Frontal view of the intrusive force present at
the f r o n t a l p l a n e as i n Figure 4, it is a p p a r e n t the molar when an extrusion arch is activated. Be-
cause the force is acting lateral to the center of resis-
that the intrusive force at the m o l a r t u b e is
tance, a m o m e n t is created for crown facial and root
a c t i n g lateral to the c e n t e r of resistance. A n lingual rotation around the center of resistance. This
intrusive force a c t i n g lateral to the c e n t e r o f moment acts to rotate the tooth simultaneously with
resistance will result in a t e n d e n c y to move the the intrusive force present.
38 lsaacson and Lindauer

e x t r u d e a n t e r i o r t e e t h , it is m o v i n g t h e c o n i c a l cally. N i c k e l t i t a n i u m overlay a r c h wires effi-

r o o t s o f t h e a n t e r i o r t e e t h in a d i r e c t i o n t h a t ciently m o v e t e e t h t o w a r d t h e a r c h in a vertical
r e q u i r e s little o r n o b o n e r e s o r p t i o n . T h e s e d i r e c t i o n only. S e g m e n t a l e x t r u s i o n arches, how-
t e e t h c a n a n d d o m o v e very rapidly. I n m o s t ever, a r e m o r e effective w h e n s i m u l t a n e o u s
cases, a n t e r i o r t e e t h c a n easily m o v e in a n e x t r u - m o v e m e n t s o f t e e t h a r e r e q u i r e d in a vertical as
sive d i r e c t i o n 1 to 2 m m p e r m o n t h . I f t h e well as a b u c c a l o r l i n g u a l d i r e c t i o n .
e x t r u s i o n a r c h is left in p l a c e l o n g e r t h a n a Obviously, t h e b e s t s o l u t i o n for o v e r t r e a t m e n t
c o u p l e o f m o n t h s , t h e f o r c e systems a c t i n g o n is p r e v e n t i o n , a n d it is advisable to see these
t h e m o l a r will b e g i n to m a n i f e s t . T h e s e m o l a r patients more frequently than might be the nor-
a c t i o n s r e q u i r e s u b s t a n t i a l a m o u n t s o f b o n e re- m a l p r a c t i c e , u n t i l t h e c l i n i c i a n has g a i n e d con-
s o r p t i o n , b u t t h e y c a n b e c o m e e v i d e n t if t h e f i d e n c e in w h a t to e x p e c t . T h e a u t h o r s com-
e x t r u s i o n is left in p l a c e f o r a p r o t r a c t e d p e r i o d . m o n l y use a n t e r i o r o p e n b i t e e x t r u s i o n a r c h
The most common reason an orthodontist wires c o n c u r r e n t l y with l i g h t n i c k e l t i t a n i u m
leaves a n e x t r u s i o n a r c h in p l a c e t o o l o n g is a r c h wire in p l a c e in t h e b r a c k e t s o f t h e e n t i r e
f a i l u r e o f t h e o p e n b i t e to close clinically. T h e arch. T h i s t e n d s to k e e p t h e b r a c k e t h e i g h t s
e x t r u s i o n a r c h is a n overlay a r c h a n d it m a t t e r s n e a r e a c h o t h e r a n d to k e e p t h e e x t r u s i o n a r c h
w h a t r e s i s t a n c e is p r e s e n t as a r e s u l t o f t h e a r c h wire system f r o m g e t t i n g o u t o f c o n t r o l .
wire in t h e b r a c k e t s u n d e r t h e e x t r u s i o n a r c h . T o allow t h e a r c h wire f r e e d o m to w o r k a n d
F o r t h e e x t r u s i o n a r c h to b e effective, it is n e c - still m a i n t a i n t h e b r a c k e t r e l a t i o n s h i p s to e a c h
essary for t h e t e e t h to m o v e vertically in d i f f e r e n t o t h e r , it is advisable to use e i t h e r a l i g h t wire in
a m o u n t s with r e s p e c t to e a c h o t h e r . If a n a r c h the brackets under the extrusion arch or some
wire is in place, t h e wire m u s t y i e l d b e t w e e n t h e o t h e r f o r m o f c o n t r o l m e c h a n i s m to p r e v e n t
b r a c k e t s . If this a r c h wire in t h e b r a c k e t s is t o o o v e r t r e a t m e n t . W h e n this c o n t r o l is flexible
stiff, t h e forces o f t h e e x t r u s i o n a r c h wire c a n n o t e n o u g h to allow t e e t h to m o v e vertically, it will
manifest and are negated. also b e g i n to m o v e a d j a c e n t t e e t h as t h e i n c i s o r
O n t h e o t h e r h a n d , t h e e x t r u s i o n a r c h wire is t e e t h m o v e vertically. It s h o u l d b e n o t e d t h a t j u s t
capable of such rapid tooth movement that as t h e l i g h t wire allows t h e a n t e r i o r t e e t h free-
t h e r e is a j u s t i f i a b l e c o n c e r n f o r k e e p i n g t h e d o m to m o v e , it will also allow t h e p o s t e r i o r
a p p l i a n c e u n d e r c o n t r o l . It is n o t advisable to t e e t h f r e e d o m to m o v e . T h e r e f o r e , w h e n treat-
use this a r c h wire with a p a t i e n t w h o has a h i g h m e n t is p r o t r a c t e d , t h e effects at t h e m o l a r will
risk o f m i s s i n g s u b s e q u e n t a p p o i n t m e n t s . Be- b e c o m e i n c r e a s i n g l y a p p a r e n t . This is especially
cause o f c o n t r o l s , t h e a u t h o r s have n o t h a d over- t r u e if t h e m o l a r is b a n d e d a l o n e with n o sup-
t r e a t m e n t r e s u l t in o v e r e x t r u s i o n o f a n t e r i o r p o r t f r o m t h e a d j a c e n t teeth.
teeth. H o w e v e r , t h e a u t h o r s have h a d o v e r t r e a t - A n a l t e r n a t i v e to t h e use o f n i c k e l t i t a n i u m
m e n t r e s u l t in o v e r e x p r e s s i o n o f o t h e r c o m p o - wires in all t h e b r a c k e t s is t h e use o f stiff wire in
n e n t s o f t h e system; s u c h as e x a g g e r a t e d m o l a r t h e b r a c k e t s o f t h e t e e t h y o u d o n o t wish to
r e s p o n s e s a s s o c i a t e d with a p a t i e n t w h o d i d n o t i n t r u d e o r r o t a t e in t h e b u c c a l s e g m e n t (Fig 5).
r e t u r n to t h e clinic f o r a p r o t r a c t e d p e r i o d . This stiff s e g m e n t u n d e r t h e e x t r u s i o n a r c h will
O v e r e x t r u s i o n has o c c u r r e d w h e n t h e e x t r u - stabilize t h e b u c c a l s e g m e n t , m i n i m i z i n g t h e
s i o n a r c h has b e e n u s e d as a s i n g l e - t o o t h seg- m o l a r r e s p o n s e s . S h o u l d any r e s p o n s e s to t h e
m e n t , eg, to b r i n g d o w n a h i g h facially l o c a t e d f o r c e at t h e m o l a r a p p e a r , t h e y w o u l d have to
c a n i n e . W h e n u s e d as a s i n g l e - t o o t h a p p l i a n c e , have t h e i r a c t i o n o n t h e e n t i r e s e g m e n t o f t e e t h
t h e e x t r u s i o n a r c h is at g r e a t e s t risk o f o v e r t r e a t - as if it w e r e o n e b i g t o o t h . T h e t e n d e n c y for t h e
i n g t h e p r o b l e m . S t o p p i n g t h e extrusive m o v e - w h o l e s e g m e n t o f t e e t h to r o t a t e c a n b e f u r t h e r
m e n t a n d a l l o w i n g t h e t o o t h to r e l a p s e , o r re- c o u n t e r e d by h a v i n g t h e p a t i e n t w e a r vertical
v e r s i n g t h e a c t i o n o f t h e a r c h wire, b e s t c o r r e c t s elastics in j u s t t h e b u c c a l s e g m e n t . G e n e r a l l y ,
this. A t t h e p r e s e n t time, t h e a u t h o r s b r i n g d o w n b e t t e r success has b e e n a c h i e v e d in g e t t i n g pa-
single, vertically u n e r u p t e d t e e t h m o s t o f t e n us- tients to w e a r l a t e r a l v e r t i c a l elastics as o p p o s e d
i n g n i c k e l t i t a n i u m overlay wires. Use is m a d e o f to g e t t i n g t h e m to w e a r a n t e r i o r vertical elastics.
segmental extrusion arches, primarily for palatal This g r e a t e r r e s i s t a n c e u n i t will r e d u c e t h e
c a n i n e s , b e c a u s e t h e y c a n b e a c t i v a t e d laterally a m o u n t o f r e s p o n s e seen, b u t it will n o t c h a n g e
at t h e s a m e t i m e t h a t t h e y a r e a c t i v a t e d verti- t h e f o r c e system a c t i n g o n t h e m o l a r . Because
 Closing Anterior Open Bites 39

Figure 5. A segment of steel wire in the brackets of Figure 6. A segment of steel wire placed in the inci-
the posterior teeth to stabilize the molar and resist the sors to extrude the incisors as one big tooth. They will
mesial crown rotation resulting from the second-or- maintain their relationship to each other, but will
der couple. For the rotational forces to manifest, they change bracket heights relative to the remainder of
would have to rotate the entire segment of teeth, the arch as the extrusion arch works.
which would tend toward a lateral open bite. An
advantage of the segmented approach is that the an-
terior teeth are free to move while the posterior teeth
are stabilized. The disadvantage is that the bracket
heights between the anterior and posterior segments
tend to get malaligned as the open bite is closed. For
this reason it is preferable to use extrusion arches just
before appliance removal. Insertion of a straight arch
wire after bracket heights are malaligned with an
extrusion arch will likely result in recreating the an-
terior open bite just closed.

t h e heavy s e g m e n t o f wire d o e s n o t i n c l u d e the

a n t e r i o r t e e t h to b e e x t r u d e d , t h e a n t e r i o r t e e t h
are f r e e to m o v e vertically,

Action at the Incisors

T h e e x t r u s i o n a r c h is n o r m a l l y u s e d to e x t r u d e
a n t e r i o r teeth. E x t r u s i o n can involve single t e e t h
o r g r o u p s o f teeth. W h e n a g r o u p o f t e e t h is to
be e x t r u d e d , a s e g m e n t o f heavy a r c h wire may Figure 7. Action of the extrusion arch at the incisors.
The biomechanics shown in Figures 2 and 3 are all
be u s e d in the b r a c k e t s o f t h e a n t e r i o r t e e t h , a n d still present, but not shown in this figure. This Figure
t h e t e e t h are e x t r u d e d as if t h e y w e r e o n e big shows the m o m e n t created as a result of where force
t o o t h (Fig 6). of the extrusion arch wire is applied at the incisors.
T h e q u e s t i o n arises as to w h e t h e r the extrusion Because the wire is tied more anteriorly, the line of
extrusive force is further away from the center of
arch wire s h o u l d be fled to a s e g m e n t o f wire in the
resistance. This results in a m o m e n t created by the
incisor brackets, fled to a c o n t i n u o u s arch wire in force equal to the force times the distance the force is
all o f the brackets, or p l a c e d directly into the away from the center of resistance. This m o m e n t will
brackets o f the incisors. Any o f these a p p r o a c h e s tend to tip the incisors lingually. Minimizing the dis-
will probably be effective. T h e decision o f which to tance the force acts in front of the center of resistance
reduces the m o m e n t and this tendency for lingual
use is a m a t t e r o f c o n v e n i e n c e a n d control. I f the
rotation. This happens when the extrusion arch is tied
extrusion arch is fled to a s e g m e n t o f wire in the at the lateral incisors. The tendency for lingual tip-
a n t e r i o r brackets, the s e g m e n t o f wire moves the ping can also be overcome with a stop on the extru-
teeth attached as o n e big tooth. This will m o v e sion arch in front of the molar tubes.
40 Aaacson and Lindauer

Figure 8. Adult male patient with a chief complaint of a midline diastema (A). When told of the potential for
open bite closure without surgery, he consented to treatment (B). Anterior and posterior teeth treated as
segments, and extrusion aches begun in both upper and lower arches. Note the mesial molar crown tip because
of the second-order couple. Note also the intrusion and buccal tip of the molar resulting from the force acting
at the bracket lateral to the molar center of resistance (B). Open bite closure after 2 months of extrusion arch
mechanics (C). Vertical elastics have been worn in the buccal segments to resist and correct the molar tendency
to tip to the mesial. The incisors were rebracketed at a more gingival position to allow insertion of a straight arch
wire (C). Result 17 mouths after appliance removal (D). Retention used employed routine removable appli-
ances. Patient has had prosthetic restoration of anterior teeth for esthetic purposes, and the result continues to
be stable. Note molar position is the same as it was prior to treatment.

readily, b u t will move the incisor brackets to dif- force is tied at the c e n t r a l incisors, it is p r o b a b l y
ferent heights t h a n the rest of the teeth i n the a c t i n g a n t e r i o r to the c e n t e r o f resistance (Fig
arch. If the exwusion arch is tied to a c o n t i n u o u s 7). Such a force, i n a d d i t i o n to t r a n s l a t i n g the
nickel t i t a n i u m wire, the bracket heights are better incisors vertically, will act a n t e r i o r to the inci-
m a i n t a i n e d with respect to each other. T h e speed sors' c e n t e r of resistance. Clinically, the incisors
of extrusion may be somewhat slowed down, b u t will t e n d to tip l i n g u a l l y a n d u p r i g h t , t h e r e b y
the extrusion is kept u n d e r better control in terms r e d u c i n g arch p e r i m e t e r . T h e best m e t h o d to
of overtreatment. If the extrusion arch wire is avoid the latter is to try to apply the force m o r e
placed into the incisor brackets, it m u s t be able to posteriorly by tying the e x t r u s i o n arch at the
be seated, a n d t h e n it will move the incisors as o n e lateral incisors.
big tooth. This latter configuration is really a 2-cou-
ple system, a n d the third-order torque at the inci-
The Wire
sors i n f l u e n c e s the forces of extrusion. This makes
it a m o r e c o m p l e x system without any special ad- T h e m a g n i t u d e of the extrusive force u s e d is
vantages. It is analogous to the relationship be- a r o u n d 100 g for 4 incisors. This is easily
tween a 1-couple i n t r u s i o n arch (the reverse of the a c h i e v e d with a 90 ° b e n d i n a 0.016 X O.022-inch
extrusion arch) a n d the c o m m o n l y used utility stainless steel a r c h wire with a helix at the molar.
arch. More c o m m o n l y use is m a d e o f the same size of
A p p l i c a t i o n of a n y e x t r u s i o n force to a n t e r i o r t i t a n i u m m o l y b d e n m n alloy (TMA) wire w i t h o u t
t e e t h is effective j u s t as the a p p l i c a t i o n of a a helix. This is m o r e c o m f o r t a b l e for the p a t i e n t
single force is effective a n y w h e r e else. If the a n d is easy to insert. T h e u s u a l care m u s t be
 (;losing Anterior Open Bites 41

Figure 9. Adult female patient showing the occlusal pattern of dental compensation for a skeletal open bite
(date 2/93) (A). Following appliance placement, the dental open bite became more manifest (date 6/93) (B).
Extusion arches were placed at this time in the upper and lower arches (date 6/93) (B). After 1 month of
extrusion arch mechanics, also having placed a continuous light arch wire beneath the extrusion arches (date
7/93) (C). Following 2 months of extrusion arch mechanics the open bite was closed (date 8/93) (D). Because
a continuous light wire had been placed in the brackets beneath the extrusion arches; the vertical alignment of
the teeth relative to one another was not excessively altered.

t a k e n to o v e r b e n d this alloy to get the activation a c h i e v e d by the a u t h o r s with e x t r u s i o n arches

desired. have b e e n g e n e r a l l y positive, as illustrated i n
Figures 8 a n d 9.
Retention
T h e p r o b l e m of r e t a i n i n g o p e n bite c o r r e c t i o n s Acknowledgment
is the same irrespective o f the t r e a t m e n t that The authors thank Ms. Carol Wilkins for her help in prepar-
closed the o p e n bite. It is e x p e c t e d t h a t L e F o r t ing the illustrations for this article.
surgical o p e n bite closure p r o c e d u r e s will b e
relatively stable, a n d these t r e a t m e n t s actually
r e d u c e the space for the t o n g u e . E x t r u s i o n
References
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ation in vertical facial growth and associated variation in
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