Review Article DOI: 10.18231/2455-6785.2018.

0003

Vertical control in fixed orthodontics- A review

Yumna Qamar1,*, Mohd. Tariq2, Sanjeev Kumar Verma3, Jiju Mohan4, Ali Amir5
1,4,5
Junior Resident, 2,3Professor, Dept. Orthodontics and Dentofacial Orthopedics, 1-4Z.A. Dental College, Aligarh Muslim
University, Aligarh, Uttar Pradesh, 5Institute of Dental Sciences, Bareilly, Uttar Pradesh, India

*Corresponding Author:
Email: [email protected]

Abstract
Control of vertical dimension is recognised as an important as well as often difficult part of orthodontic treatment. Ineffective
vertical control cause downward and backward rotation of mandible, prolonged treatment times, and compromised treatment
results. Vertical control is often difficult, as most methods used to exert vertical control are highly patient-dependent. Controlling
vertical dentoalveolar development is often difficult, because most orthodontic mechanotherapy tends to produce vertical
movement of teeth. Vertical movement of teeth are least resisted therefore immediate effect is seen. Vertical control is difficult
also because most methods depends on patient compliance.

Keywords: Vertical control, Hyperdivergent.

Many terms have been used to describe the morphological descriptors suggested by Bjork4 in his
excessive vertical facial height, including study by impants include inclination of the mandibular
hyperdivergency, dolichofacial pattern, and symphysis, the shape of the lower border of the
leptoprosopic pattern.1 The adequate control of the mandible, the curvature of the mandibular canal, the
vertical dimension is crucial for a successful inclination of condylar head, and the thickness of the
anteroposterior correction. Extreme clockwise rotation, cortical bone below the symphysis.
high angle type, hyperdivergency, dolichofacial pattern,
adenoid faces, idiopathic long face, total maxillary Why it is Necessary
alveolar hyperplasia, and vertical maxillary excess all Controlling vertical dentoalveolar development is
have excessive vertical growth of the maxilla as their often difficult, because most orthodontic
common denominator. Thus it is difficult to classify mechanotherapy tends to produce vertical movement of
this vertical maxillary dysplasia in traditional teeth. Vertical movement of teeth are least resisted
anteroposterior classification. Maxillary molars are therefore immediate effect is seen. Musculature also
considered to be the primary ‘bite openers’ and have a large effect on vertical control as the weaker
mandibular incisors, the primary ‘bite closers’ musculature allow less resistance to increase in lower
(Schudy,1964)2 Increase in the vertical facial dimension facial height during the treatment. Proffit5 stated that
cause more vertical displacement and rotation of there are three indicators that can be used to predict the
maxilla and mandible, resulting often in prolonged tendency toward openbite. These are:
treatment times, compromised treatment objectives, 1. The cranial base flexure angle (saddle angle): an
and, often, poor esthetic results. The treatment objective increased saddle angle predisposes to dental and
in a patient having sufficient potential for growth skeletal openbite.
should be to restrain and control maxillary descent and 2. The orientation of the maxilla: being up anteriorly
prevent eruption of anterior teeth. When the severity of and down posteriorly.
vertical deformity is so great that reasonable correction 3. A short ramus height and obtuse gonial angle.
cannot be obtained by growth modification or Various treatment mechanics that extrude posterior
camouflage, the combination of orthodontics and teeth will hinge the mandible back, open the bite, and
orthognathic surgery may provide the only viable lengthen the anterior vertical dimension. In the adult
treatment. The following article provides a review on patient, extrusion of teeth in the posterior segment will
the control of vertical growth during the active fixed lead to an opening of the bite through backward
orthodontic treatment. rotation of the mandible, i.e., an increase in facial
height and in overjet. Space closure can involve
Predictors of Vertical Growth protraction of the posterior teeth, which can have the
The various morphological features associated with effect of extrusion, especially when significant tipping
hyperdivergent growth includes the increased lower of molars is involved. One frequently used method of
anterior facial height, increased gonial angle, short space closure and interocclusal correction is the use of
mandibular ramaus, decreased posterior facial height1. Class II elastics. The side effects of the elastics are
Skieller3 et al found that mandibular morphology may lower molar and upper anterior extrusion, with a
be used to anticipate the direction of residual growth steepening of the occlusal plane.
based on the type of previous development. The
Indian Journal of Orthodontics and Dentofacial Research, January-March,2018;4(1)9-12 9
Yumna Qamar et al. Vertical control in fixed orthodontics- A review

Vertical Control During Fixed Orthodontic Therapy distal or mesial to the lateral incisor. The forces were
Vertical Pull Chin Cup: The vertical chincup has been applied with the help of power cord which is attached to
used as a supplementary device with intraoral fixed rings of molar implants to the arch wire between the
applainces. It consists of a chin cup and a head bonnet first and second molars. It produces an initial force of
connected either by elastics or an elastic strap to 300-450gms in the posterior region and 175-250g of
generate forces in the vertical direction. Haass6 force in the premolar and anterior region.11 It was
described the use of a vertical pull chin cup alone (in observed that maxillary anterior teeth intruded at the
Class I patients with severe vertical dysplasia) or in rate of 1mm permonth and molars at the rate of 0.6mm
conjunction with cervical gear (when accompanied with per month. It was observed that vertical adjustable
an anteroposterior problem).The vertical chincup corrector can be used for intrusion of posterior as well
displays an anterior rotation of the mandible, with the as anterior along with retraction of anterior.
resultant force vector passing through the anterior part Active Vertical Corrector: It is an appliance
of the mandibular corpus and 3cm from the outer consisting of repelling magnets placed in bite blocks
canthus of the eye. Eren7 studied the effects of vertical which cover the posterior teeth. Dellinger12 indicated
chincap alone and found a decrease in the mandibular that vertical can be controlled by constant intrusive
plane angle, posterior rotation of the maxilla, decrease forces by active vertical corrector which under the
in the lower posterior dentoalveolar height and an magnetic field causes increased cellular activity with
increase in overbite in openbite cases. The vertical possibility of microcurrent flow acting as an positive
control pat is requested to wear the chincup 12hrs a day tissue stimulator with saliva acting as an electrolyte.
the forces used is a minimum of 16 ounces on each side KAlra13 reported an increase in mandibular length,
and the direction of pull is as forward as possible. intrusion of teeth and an upward and forward
High Pull Headgear: High pull headgear is highly autorotation of the mandible with the use of fixed
recommended to control extrusive effects of treatment magnetic applainces. Babre and Sinclair14 reported
and to bring a positive change in the growth pattern. maxillary and mandibular, molar intrusion and
High pull headgear usually attaches to the maxillary autorotation of the mandible with active vertical
first molar, and has a strap that crosses the top of the corrector. B Melson15 on studying the effect of bite
head. The direction of the force applied to the molar block with and without repelling magnets in rhesus
varies with the design of the facebow, but is usually monkey studied the histomorphological effects and
designed to apply an upward (intrusive) and backward mentioned remodeling in both the pterygomaxillary
(distalizing) force. The force level is generally between suture and in the zygomaticootemporal suture. Kuster
250 to 300 g per side. Some clinicians have advocated and ingervall16 compared the use of spring loaded bite
much higher force levels in the range of 1,200 to 9,000 blocks with bite blocks with repelling magnets. Their
g.8,9 Unfortunately, all treatment with a headgear or results showed an average improvement in openbite of
chin-cup, whether for dental movement, growth 1.3mm in the spring loaded group and 3mm in magnet
modification, or control of the vertical dimension, is group.
compliance. Firouz et al10 stated that high pull headgear Mandibular Bite Block: Fixed composite bite blocks
can cause relative restriction of downward and forward on mandibular molars acts for effectively controlling
maxillary growth as well as distalization and intrusion the vertical height. Mc namara17 reported no intrusion
of the maxillary molars. of the maxillary or mandibular teeth, although the
eruption of teeth was inhibited by the appliance. Altuna
and woodside18 reported depression of maxillary molars
with mandibular bite blocks. This treatment approach is
claimed to be effective by inhibiting the increase in
height of the buccal dentoalveolar processes, thus
preventing down and back rotation of the mandible. It is
most effective before cessation of growth of the jaws.
The improvement was believed to be caused by
mandibular anterior rotation attributed to molar
intrusion and increased anterior eruption.
Vertical Holding Applaince: The vertical holding
Fig. 1: (A) Diagrammatic representation of vertical appliance was introduced by deberardinis et al19 who
pull chin cup. (B) High pull headgear modified the transpalatal arch in an attempt to control
the vertical dimension of high angle patients. The
Vertical Adjustable Corrector: John P devincenzo acrylic button of the modified vertical holding
deisgned the VAC with one buccal bar, a trans arch appliance was of a uniform diameter of 17mm and
stabilizing wire, and three skeletal implants in which thickness which was positioned midway between the
two were placed in the zygomatic processes superior to maxillary first molars and premolars 6mm away from
the maxillary sinuses while one anterior was placed the palate to allow pressure from the tongue to act as an
Indian Journal of Orthodontics and Dentofacial Research, January-March,2018;4(1)9-12 10
Yumna Qamar et al. Vertical control in fixed orthodontics- A review

intrusive force as described by chiba et al.20 Umemori increased lower anterior facial height. Yamaguchi and
et al21 recommended initial force of 500gms while kalra Nanda25 concluded that the changes in horizontal and
et al suggested about 90gms/tooth for molar intrusion in vertical position of the molars were dependent on the
growing children. type of force application, and not on the extraction or
Low Mandibular Lip Bumper and Lingual Arch: nonextraction strategy. When extractions are part of the
Cetlin and Ten Hoeve22 advocated the use of a lip treatment plan, it is important to control the vertical
bumper for the development of the lower dental arch. position of maxillary and mandibular molar teeth to
They suggested that if the lip bumper were adjusted avoid their vertical occlusal movement, which could
low, the cheek and lip mucosa would rest above the nullify the desirable closing rotation of the mandible,
appliance, and this will inhibit vertical mandibular particularly in adults.
molar dentoalveolar development. Multiloop Edgewise Arch Wire: Kim26 popularized
Use Class II or Class III Elastics in High Angle the multiloop edgewise arch wire (MEAW) for
Cases: It has been reported that attachment of Class II correction of openbite malocclusion. The MEAW
elastics to the lower second molars created a more contains horizontal and vertical loops fabricated from a
horizontal vector of force (Thorow, 1970). Pearson 16 x 22 ss wire in an L - shape fashion the vertical
(1997) recommended avoidance of elastic application to loops act as a break between the teeth, lowers the load
the lower second molars.He stated that if elastic deflection rate and provides horizontal control. The
engagement is absolutely necessary, short Class II horizontal loops further reduces the load deflection rate
elastics could be attached from upper first molar to a and provides vertical control. Typical tip back bends of
class II hook and then to the distal of the lower 3-5degrees are given on each tooth. Elastics are placed
premolar. Roth (1985) reported that one, two, three between the loops that lie mesial to opposing cuspids.
short Class II elastics on each side may be applied from Mini-implant Anchorage System: Recently, the use of
the mesial aspect of the lower first molar to the mesial implants as a source of absolute skeletal anchorage has
of the upper second premolar, from the distal of the been reported.
lower second premolar to the mesial of the upper first Umemori et al21 used the titanium miniplate to intrude
premolar, and from the distal of the lower first premolar posterior teeth, thereby reducing the vertical dimension
to the upper canine. in adults with openbites. The titanium miniplates were
Extraction of teeth for vertical control: According to fixed to the buccal cortical bone around the apical
pearson23 extraction of premolar leads to mesial drift of regions of the lower first and second molar teeth and
posterior teeth which causes closure of mandibular were used to intrude the posterior teeth. The lower
plane angle. Garlington and Logan24 found that molars were intruded 3 to 5 ram, and the openbite was
enucleation of mandibular second premolars is significantly reduced with almost no vertical movement
beneficial, in selected cases, to control the vertical of anterior teeth. A lower lingual arch is required to
dimension. The criteria for selection included minimal counteract the buccal moment generated by molar
lower arch discrepancy, a mandibular plane angle intrusion when forces are applied from the buccal.
greater than 38°, a hyperdivergent skeletal pattern, and

Fig. 2: (a) Maxillary Vertical Adjustable Corrector (a= skeletal anchors; b = buccal bar; c = ligature wires; d
= power cords) (Devincenzo JP. A new non-surgical approach for treatment of extreme dolichocephalic
malocclusions. Journal of Clinical Orthodontics. 2006;15:161-70)
[b]. Sealed active vertical corrector (Dellinger EL. A clinical assessment of the active vertical corrector—a
nonsurgical alternative for skeletal open bite treatment. American Journal of Orthodontics. 1986 May
1;89(5):428-36.)
[c] Posterior bite blocks.
[d] Vertical holding appliance.
[e] MEAW Applaince.
Indian Journal of Orthodontics and Dentofacial Research, January-March,2018;4(1)9-12 11
Yumna Qamar et al. Vertical control in fixed orthodontics- A review

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