1 opening the bite with bite turbo

the subject deals with types of turbo and application of turbos in orthodontics

1. Use of a Bite Ramp or bite turbo in Orthodontic Treatment by Dr. Maher Fouda Professor Of Orthodontics

2. CLASS II DEEP OVERBITE; BONDING BRACKETS ON THE LOWER ANTERIORS IS IMPOSSIBLE

3. The Bite Ramps are easy to make and use. Etch and prime the palatal of the maxillary centrals. Fill the Bite Ramp mold with MiniMold cure light material. With light pressure, place and hold the filled mold against the tooth with the flat edge of the mold parallel to the incisal edge of the central then cure. To ensure that the ramps are equal on both teeth use a bracket gauge to mark the lingual incisal edge where the flat edge of the mold will be placed. Note: If your ramp does not extend far enough lingually to engage the lower anterior teeth, refill the ramp mold halfway, place the mold over the original ramp and cure . Curing time depends on the light and curing material used but should not exceed 15 seconds.

4. 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.

5. 1. Upper 2X6 and posterior bite openers, 2.6 months Xbow followed by compensatory maxillary expansion, now hold expansion and test Cl II correction for 5 months. Higgins XBOW ®  Class II Corrector

6. The Higgins XBOW ®  Class II Corrector is an alternative to the Herbst ® * appliance for  treatment of Class II malocclusions in children and adolescents. The Phase I  appliance allows simultaneous anteroposterior and transverse correction. The XBOW pits the entire mandibular arch against the maxillary bicuspids and molars,  which opens space for the erupting canines. Used in conjunction with the Forsus ™ Fatigue  Resistant Device from 3M Unitek , the XBOW appliance allows overcorrection of the molars  into a Class III relationship. The Higgins XBOW Appliance consists of: •   Maxillary expansion appliance •   Triple "L" Arch ®  (lower labial lingual arch) •   Forsus Fatigue Resistant Device (25mm Direct Push Rod) and Gurin Locks ( allow for easy activation). Forsus Device & Gurin Locks available from your 3M Unitek representative. Higgins XBOW ®  Class II Corrector

7. Maxillary Expansion Appliance with Headgear Tubes on the First Molars and Bonded Occlusal Rests on the Second Molars Triple “L” Arch™ with Bonded Rests on the First Bicuspids Xbow ™ with Forsus ™ Fatigue Resistant Device EZ Module and end caps from Comfort Solutions, Inc. ( Gurin locks rotated 90 degrees for comfort ) Higgins XBOW ®  Class II Corrector

8. In the past, Class II correction meant the use of headgear for several hours a day or wearing rubber bands consistently for many months. Other appliances also worked completely inside the mouth, but were bulky and had to be fabricated by an outside dental laboratory after impressions of your teeth were taken .

9. 3M Unitek has developed the Forsus ™ Fatigue Resistant Device to address this specific treatment need. The appliance consists of a metal spring and rod that connect to parts of your braces, hidden away by your cheeks and lips. Because the spring actively applies a light, continuous force, treatment goals can be achieved quickly and without the need for patient compliance with rubber bands or other external appliances. It only takes one appointment to install the 3M Forsus appliance and requires no special adjustments by the patient. The length of time the appliance is worn depends on the severity of the problem and varies on a case-by-case basis Higgins XBOW® Class II Corrector

10. Day of bite opener switch from posterior to anterior (bite-turbo) 5 months into full braces

11. We begin most cases with posterior bite openers. They remove occlusal interferences to prevent debonds as well as allowing lower alignment with the lightest forces

12. _____________________ bite turbo placed_____________________Class II elastics to erupt lower molars and correct overjet from bite opening This is where patient cooperation is needed. Class II springs cannot open the bite. Over-correct to incisal edge to edge

13. 9 months progress with full brace

14. 12 months braces

15. One of the most important things we do in our practice is the treatment of TMJ (Temporomandibular joint disorders, TMD)  These problems can cause the mandible to lock closed and the joint to click and pop.  This can cause extreme pain and suffering.  The TMJ is the most complicated joint in the entire body.  When you open about half way the joint acts like a ball and socket joint, just like your knee or elbow.  Then when you open past halfway your lower jaw has to actually slide forward.  The lower jaw moves "out of the socket".  This is the only joint in the body that does that.   It also  has three areas of articulation:  1.  the right joint 2.  the left joint 3.  the bite and the teeth.  If any of these three are out of balance then the whole system is out of balance and then the problems begin.  When we start orthodontic treatment in our office we place mounds of blue glue on the biting surfaces of the lower first molar teeth to separate the teeth.  This removes this third part of the chewing system so that the TMJs can move into their ideal positions without the interference of the bad bite.  As the bite comes together we remove these splints so that we can make the bite as perfect as possible.  These are a very annoying part of the treatment, but is probably one of the most important things we can do for the health of the jaws and bite   Bryan P . S Nelson DDS M

16. OCCLUSAL BUILD UP TO RAISE THE BITE IN CASESS OF ANTERIOR CROSSBITE

17. Bite Turbos Bite turbos (BTs) have come to mean any occlusal stops on teeth that unlock the malocclusion for greater freedom of tooth movement Bite-turbos made of type II glass ionomer cement were attached to the occlusal surfaces of the lower first molars to prevent bracket interference during the initial alignment phase Anterior BTs provided an incisal stop that allowed the posterior segments to extrude and level to correct the lower curve of Spee . In addition, the mandible was free to move anteriorly for a more comfortable occlusion with the maxilla. Anterior BTs can be quite versatile. In addition to the present application on the lingual surfaces of maxillary incisors , they can be bonded on the lingual surface of lower incisors to assist in anterior cross bite correction According to where they are positioned, BTs are classified as anterior and/or posterior .

18. Anterior BTs for deep bite cases are bonded more gingivally for big overjet cases Weak teeth, such as endodontically treated maxillary incisors, are a contraindication for BTs because they are prone to fracture glass ionomer bite turbos are bonded on the lingual surface of upper central incisors to provide an intrusive force on the upper and lower incisors, in addition to opening the posterior bite to facilitate crossbite correction

19. After the initial alignment of the maxillary arch, anterior bite turbos are bonded on both upper central incisors to correct the deep bite Anterior bite turbos are excellent tools for the correction of deep bite if opening the bite and posterior mandibular rotation are acceptable mechanics. They are easy to use and decrease the treatment time for many patients .

20. Anterior bite turbos on maxillary incisors tend to intrude lower incisors, and furthermore serve as effective vertical stops for the overbite .

21. The axial inclination of the maxillary incisors must be considered. If they are upright or retroclined , it may be necessary to correct the inclination prior to installing BTs It is important to check the axial inclination of the maxillary incisors before bonding BTs. Occlusal force from lower incisors can produce an undesirable moment, so partial correction of maxillary incisor inclination is necessary before bonding lingual BTs on maxillary incisors.

22. However, for lingually tipped upper central incisors, the line of occlusal force may be lingual to the center of resistance (CR) which can result in more lingual tipping . Thavarungkul suggests bonding the anterior bite turbos after both central incisors have been proclined slightly. This allows the force vector to pass in anterior of CR in order to correct the deep bite

23. If anterior bite turbos are applied before the initial alignment of the incisors, the line of occlusal force may be distal to the center of resistance (CR) resulting in more lingual tipping .

24. After some labial movement of the maxillary central incisor crowns, the line of force (green) is labial to CR which is a preferable force system

25. For open bites, posterior BTs can be combined with squeeze exercises to intrude molars

26. Inverting brackets changes torque from positive to negative or vice versa (in this case, on the upper right lateral incisor from +10º to -10º), which expands torque options and generates early root torque movement in the desired direction upon insertion of the rectangular wire. Case photos courtesy of Dr. Bill Thomas, Poway, CA

27. This case is an example of the most commonly employed use for reverse torque. As the light round wire aligns in such a case, the crown of the upper right lateral incisor will come forward, leaving the root in its palatal position. To combat this “ pseudotorque ,” place an inverted +10º upper right lateral incisor bracket (now with reverse torque) to create a -10º torque bracket. Upon engaging the first rectangular wire, the root will begin to detorque and move labially toward its ideal position. With this protocol, you no longer need to await the major mechanics phase of treatment to correct the palatally positioned root. Once the root is in ideal position in relation to the crown, flip the bracket to its normal position and rebond (now with +10º) to ensure that the root does not continue to move labially .

28. When inverting brackets for reverse torque, keep the brackets on the same side of the arch so the root tip remains the same mesiodistal . For example, when inverting an upper lateral bracket with 9º of distal root tip in the same arch (A), the distal root tip remains the same ( B).

29. Note: When inverting brackets for reverse torque, be sure to keep the brackets on the same side of the arch so the root tip remains the same mesiodistal . See illustrations A and B. Placing them on the opposite side of the arch will change the intended root tip (mesial to distal and vice versa). By the way, we use the term "reverse torque" when discussing inverting brackets to minimize a patient's fear that we're placing a bracket upside down.

30. – Unlock the Malocclusion: Disarticulate the Arches with Bite Turbos Clinicians who use bite turbos normally place them on the lingual surfaces of upper anterior teeth in deep-bite cases to bond both arches at once (Figure 3). As we’re all aware, bite turbos benefit treatment in numerous ways: 1. Protect the enamel from bracket wear / debonding . 2. Improve the effect of light wires on arch development . 3. Improve the effect of early light elastics for A/P, vertical and transverse corrections. See Essential #3. 4. May have an impact on correction of excessively low or high mandibular plane angles ( brachyfacial or dolichofacial patients).

31. In my practice, a bite turbo has come to mean any resin bump that unlocks the malocclusion for greater freedom of movement. Using bite turbos more creatively, however, can have far-reaching treatment implications Bite turbos can also assist directionally in Class III cases. For such cases, I often form bite turbos (Mini-Mold starter kit, Ortho Arch, Schaumberg, IL) on the lingual surfaces of the lower incisors in such a way that they have an incline designed to allow the upper incisors to slide down it toward a Class I position. For all anterior bite turbos, I use Blugloo ™ two-way color change adhesive, which turns from clear to blue during bonding and debonding , making it easy to see during placement and removal. If the turbo debonds during treatment, the adhesive will turn blue, easing the patient’s mind that it is not a tooth fragment.

32. I try to select bite turbo locations to enhance the direction of the treatment goals. While this is an admittedly simplistic approach, I generally choose posterior bite turbos for high-angle cases and anterior bite turbos for low-angle cases. For example, in high-angle cases, using bite turbos in the posterior can cause intrusion of the posterior teeth that helps close down the high-angle. In low-angle cases, anterior bite turbos in conjunction with early light posterior vertical elastics will extrude posterior teeth and correct a low-angle deep bite by posterior eruption . Flowing resin into the occlusal grooves of lower first molars to make a flat plane fosters directional crossbite correction

33. Dr. Stuart Frost shared his idea of using flowable resin to correct posterior crossbites when placing bite turbos in the anteriors is difficult (Figure 4). He flows a transparent pink resin (Triad® Gel Flowable , Dentsply , York, PA) into the occlusal grooves of lower first molars to make a flat plane, which fosters crossbite correction in conjunction with early light crossbite elastics by allowing freedom of interarch movement. The pink color of the resin makes the bite turbo easy to see during placement and removal and its transparency shows the occlusal surface through the turbo. Note: It may be necessary to air cool the Triad Gel because it warms up during the curing process. Early light elastics in this Class III case were worn from bonding day to improve the efficiency of treatment Light Elastics for Early Dental Base Movement

34. For cross bites, unlocking the inter-digitation with contralateral BTs is effective for facilitating transalveolar correction Glass ionomer bite turbos a re placed in the palatal cusps of the first molars in order to open the bite and allow the second molars to move . Scissors bite of upper second molars

35. Glass ionomer bite turbos were placed in the palatal cusps of the first molars in order to open the bite and allow the second molars to move . Scissors bite of upper second molars .

36. Scissors bite of upper second molars

37. TREATING AN ASYMMETRIC CLASS II CASE WITH suresmile

38. Biteplanes  can be used in Class I and Class II, division 1 and 2 cases for the correction of deep bite with moderate overjet and their shape was inspired by the lingual orthodontic brackets.  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 treatment.

39. Biteplanes  can be fixed or removable. 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 result. Many of these problems can be overcome by using a fixed  biteplane , which is worn full­time and is more hygienic

40. Bite opening in the anterior was due to switching turbos to lower 6s . At 8 weeks, the crossbite had sufficiently resolved so crossbite elastics begun at bonding were discontinued as .018” Copper Ni- Ti archwires were engaged. Note: A calculus bridge scaled at this appointment has been preventing lower anterior alignment.

41. At 7 months, the .018” x .025” Copper Ni- Ti wires had just been engaged after 2.5 months in .014” x .025” Copper Ni- Ti wires At 13 months, the .018” x .025” Copper Ni- Ti wires had been engaged for 6 month At 18 months, the upper .018” x .025” Copper Ni- Ti wires had been engaged for 11 months. The case would now transition to a TMA finishing wire in the upper arch and Reverse Curve wires in the lower arch before finishing in .018 ”

42. Fixed  biteplanes  can be fixed to orthodontic bands on the upper first molars

43. Fixed bite plane  can be constructed with glass ionomer cement, composite resins or  self­curing  acrylic resins. In this second case, they are generally bonded on lingual surface of maxillary incisors

44. Palatal composite bite block The bite blocks are used when bracket interference makes it difficult to bond the mandibular anterior and posterior teeth's at the start of the treatment. Earlier bite planes were used in class II division I and division II cases for the correction of deep bite with moderate overjet. Bite planes can be fixed or removable . Removable bite planes depend on patient cooperation and can also cause mucosal trauma whereas the fixed bite blocks do not contact the lower incisors uniformly .   Dr. Akhter Husain Professor and Head,Department of Orthodontics and Dentofacial Orthopaedics , Yenepoya Dental College, Yenepoya University Dr. Vivek Amin Professor,Department of Orthodontics and Dentofacial Orthopaedics , Yenepoya Dental College, Yenepoya University Revista Latinoamericana de Ortodoncia y Odontopediatría Depósito Legal Nº: pp200102CS997 - ISSN: 1317-5823 - RIF: J-31033493-5 Calle El Recreo Edif. Farallón, piso 9 Ofic . 191, Sabana Grande, Caracas, Venezuela Teléfonos: (+58-212) 762.3892 - 76

45. The Palatal composite bite blocks (PCB) can be used to the following reasons.   1- They are absolutely customized for each patient. 2-It is done by using routine materials in Dentistry.  3-It gives an anterior bite plane effect

46. Procedure Step  I: The patient is clinically evaluated with an extent of deep bite and the amount of bite to be raised. This can be done arbitrarily by bonding a bead of composite material on the occlusal surface of the lower first molar which can be fine-tuned by grinding of the composite till a satisfactory vertical relation is established

47. Step II : Impressions of both the arches are made using alginate. A wax bite registration is made clinically which is transferred to the simple hinge articulator. Thereby recoding the desired amount of bite opening required

48. Step II I: Small inlay or pattern wax blocks are placed on the palatal surfaces of the upper anteriors and each one carved out as individualized platform in such a way that all anterior contact simultaneously.

49. Step IV : A specialized tray is loaded with silicon putty and the impression is made only of the palatal side

50. Take out the impression, wash and dry using a 3 way syringe. Load the depression caused by the wax platform using restoration composite material.

51. Step V : The palatal aspects of teeth are prepared by etching and priming and the tray is transferred back into the mouth positioned properly.

52. A UV light is applied on the labial sides of the anterior till an initial set of the composite is assured. The tray is removed again to confirm polymerization

53. Clinically, articulating paper is used to ensure uniform contacts of the lower anteriors on all the platforms. Once this is done the patient is ready for the regular orthodontic strap up .

54. Advantages: Simple to use. Customized individual anterior bite blocks. Does not require patient compliance. Uniform contact of the lower anterior on the platform.  Does not interfere with the mechanotherapy . Helps to open bite (anterior bite plane effect).

55. Several appliances both fixed and removable have been utilized for this purpose, including anterior or posterior bite splints, bonded lingual bite planes and bonded occlusal composite resin build-ups . These appliances have some limitations. Bite splints require impressions, laboratory procedures, and extra appointments for insertion and monitoring. Removable plates require patient compliance

56. 8-step fixed bite block procedure without cementation offers multiple advantages November 16, 2016 By Amit Sidana , BDS, MDS; Pooja Tiwari, BDS; and Ragni Tandon , BDS, MDS Bite planes can be used in Class I and Class II, Division 1 and Division 2 cases for the correction of a deep bite with moderate overjet. A deep bite must be opened before brackets can be bonded in the mandibular arch. The most common devices used to open the bite are removable anterior or posterior bite planes and glass ionomer cement (GIC).

57. Fixed bite block procedure 1. Place the band on teeth Nos. 19 and 30, and take an alginate impression. Keep in mind that in the impression, the band is placed in the proper position. 2. Pour the impression in plaster of paris , and then remove the cast after the plaster of paris sets. 3. Bend the lingual arch (0.9 mm) wire and adapt it lingually in the mandible (figure 1)

58. 4. For the occlusal component, adapt the wire (0.7 mm) to the occlusal surface. Start from the middle of the second molar and move up mesially to the interdental space between the first and second premolar. Then, give a vertical bend downward to adapt between the embrasure area and the end resting on the lingual arch (figure 1) 5. Solder the lingual arch onto the band and the occlusal component onto the lingual arch (figures 2a and 2b).

59. 6. Apply separating media on the occlusal surface of the posterior teeth, and form an acrylic bite block on the occlusal component (figures 3a and 3b)

60. 7. Remove it from the cast and cement the band onto the respective teeth (figures 4a and 4b 8. After the desired correction is achieved, cut the occlusal component near the solder point with the help of a cutter, and remove the block. Advantages This fixed bite plan technique offers several advantages: It does not need patient cooperation. It can be used full time. It does not require any bonding material, so there is no damage to enamel. It is hygienic. It can be easily removed .

61. A removable posterior bite plane is temporary, can be lost or broken, and sometimes may even be swallowed by patients. GIC bite blocks can cause discomfort during chewing due to the single points of contact on each side. Many of these problems can be overcome, however, by using a fixed bite plane without cementation, which is then easy to remove after correction.

62. The Bite Plane is a removable or fixed device to prop open the bite. It is usually used when the front teeth overlap too much (deep overbite) which can cause impingement on the gum tissue or the teeth to wear down. It also props open the upper teeth to keep lower braces from being bitten off and the wires to work more freely

63. The removable Bite Plane fits in the roof of the mouth and has a flat plane just behind the upper front teeth. The lower front teeth contact this plane which keeps the front teeth apart. This also keeps the back teeth apart which makes chewing a little difficult until the back teeth grow down into contact (6 months to one year). It is worn all the time even for eating unless the doctor gives different instructions .

64. Bonded lingual bite planes can’t be adjusted and are difficult to remove. Composite resin bite-blocks require additional clinical time and may cause occlusal enamel wear of opposite teeth if filled composite resins are used .

65. Güray (1999) introduced a new type of bite-opening appliance, the temporary bite raiser . Its main disadvantage is that it does not allow headgear or auxiliary wires to be placed simultaneously . Picture 1: Insert the proximal wings of the Bite Raiser into the headgear tube and tie the proximal wings to the headgear tube with a stainless steel ligature followed with an elastomeric separator. Picture 2: Overlay the Bite Raiser onto the molar occlusal surface and tie the “T” spur to the palatal button or lingual cleat with an elastomeric separator Application of the Güray Bite Raiser ™

66. Also in cases of bruxism, composite may wear down making it ineffective, requiring extra clinical time to restore it to the appropriate height. As proposed by Fine, bonding lingual brackets to the maxillary central incisors causes opening of bite but its use should be limited to Class I or Class II division 2 cases with minimal overjet .

67. Further, these lingual brackets can be fragile similar to the mandibular labial brackets they are supposed to protect .

68. Correction of palatally blocked out canines in adults can pose a problem in aspects of patient tolerance to various appliances like bite plates and /or bite blocks, given to provide occlusal clearance for the tooth to be moved buccally . INNOVATIVE TEMPORARY BITE RAISING APPLIANCES USED IN ORTHODONTICS EUROPEAN JOURNAL OF PHARMACEUTICAL AND MEDICAL RESEARCH ejpmr , 2016,3(9), 156-157

69. In this case, the patient compliance for bite plate and bite block was minimal as the patient was a stage artist and didn’t want any palatal coverage which would hamper speech. Thus, bilateral temporary acrylic bridges were used to provide anterior bite clearance, so that the palatally blocked out canine could be moved buccally into proper alignment

70. PROCEDURE Upper and lower alginate impressions were made. The casts were then sent to the laboratory for fabrication of bilateral lower temporary acrylic bridges extending from the 1st premolar to the second molars on either side without altering the natural contours of the teeth. Bite was taken for uniform occlusal contact .

71. Space was created for blocked out canine after initial alignment and levelling before cementation of the bridges. The bridges were cemented using zinc oxide eugenol cement and could be easily removed after the desired tooth movement. The bridges provided enough occlusal clearance for the upper left canine to be moved buccally into alignment .

72. Correction of a maxillary canine-first premolar transposition using mini-implant anchorage

73. Bite raising was achieved by bonding composite on the occlusal surfaces of both mandibular first molars.

74.  After  biteplanes  are bonded, speech can be slightly affected for a day and mastication for a week, however patients adjust to speaking more quickly than with removable  biteplanes . 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 surfaces

75. 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 bite Anterior BTs provided an incisal stop that allowed the posterior segments to extrude and level to correct the lower curve of Spee . In addition, the mandible was free to move anteriorly for a more comfortable occlusion with the maxilla

76. Case Report This case report concern an 12­year­old 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 ).

77. 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).

78. 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. After three months, the deep bite was corrected and the posterior teeth occluded, what shows the effectiveness of the bite ramp, mainly because the full­time use.  Radiografically  no significant alterations were noted on maxillary and mandibular incisors roots during the use of the bite ramp   A, overjet after bite ramp bonding; B, bonding of mandibular teeth; C, bite ramp bonding

79. Overjet after 1 month of use of bite ramp Periapical radiographs: A and B, before bite ramp bonding; C and D, after bite ramp removal

80. The malocclusion was treated with 0.022­inch slot  pre­adjusted  appliances. Patient used IHG for 12 hours a day during leveling and alignment, which sequentially progressed from 0.016­inch  NiTi  wires, through 0.016, 0.018, 0.020 and finally 0.018 X 0.025­inch 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  canine­to­canine  retainer were installed in the maxillary and mandibular arches respectively

81. 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 . The superimpositions show that patient had a  predominanant 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  .

82. 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).

83. 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 authors912, 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 . 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 full­time, it is not necessary to be built, it is easy to bond and it is hygienic

84. Tongue Trainers Tongue Trainers may be used in severe  tongue­thrusts  to aid in closing an open bite