The 20 Principles of the Alexander Discipline, Volume 3. R.G. "Wick" Alexander

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СКАЧАТЬ place, it is very important to follow through to make sure the patient does not reverse this thinking. In our practice, the patient is instructed to place a Band-Aid on the offending thumb as a “burglar alarm” reminder. A new Band-Aid should be placed every day, and the used Band-Aids should be kept in a ziplock bag. This bag is then brought to the office in 3 weeks. Also, the patient is asked to make and bring a 3-week calendar noting the successful days.

      I always make it a point to tell the parents to be supportive and encouraging during these first 3 weeks. I tell them to praise the patient each night for completion of another successful day. The parents might choose to give a special reward or gift at the end of the 3 weeks.

      An honest conversation can do wonders to stop a child from continuing a bad habit. And the parents are always grateful.

       Mouth breathing

      Mouth breathing is the result of a nasal or airway blockage and/or protruding anterior teeth. Volume 2 of this series outlines a test to administer to check for nasal or airway blockage (see page 171). Our goal as orthodontists is to allow the patient’s lips to touch when relaxed and while breathing through the nose.

       Tongue thrust

      Tongue thrust is a great example of muscular imbalance affecting tooth position. If the tongue functions properly during swallowing, the maxillary intermolar width as well as the anterior incisor overbite and overjet should be normal. If the tongue thrusts through the anterior teeth during swallowing, however, there may be incisor flaring, which could lead to an open bite. A simple tongue thrust diagnosis can be determined during the initial examination. This can be done by palpating the temporomandibular joints (TMJs) for any clicks and gently pulling the lower lip down and asking the patient to swallow. By observing the movement of the tongue, we can easily see if a tongue thrust is present.

      Historically, tongue thrusts have been attacked with tongue cribs. These appliances are barbaric in my estimation, and I have always preferred “tongue therapy” to retrain the tongue, as taught to me by a speech therapist. Volume 2 of this series outlines this five-step procedure (push, click, slurp, squeeze, and swallow; see page 172).

       Weak occlusal forces

      Although excessive occlusal forces can cause attrition and/ or TMJ problems, inadequate occlusal forces can allow the teeth to drift into undesirable positions, usually into an anterior open bite and a vertical skeletal pattern. In order to overcome this problem, patients should be taught how to train their muscles of mastication. Squeezing exercises can increase maximum bite force and increase resistance to fatigue (Thompson D, unpublished study, 1995).

      Dr Laurie Parks studied the records of 50 patients with medium- to high-angle open bite malocclusions.¹ She discovered that the performance of masticatory muscle exercises during treatment of skeletal open bite produced greater increases in overbite than treatment alone. She concluded that squeezing exercises in conjunction with tongue swallowing exercises significantly improve overbite and provide a much better chance for long-term stability.

      Therefore, although open bites will not close by tongue control and squeezing exercises alone, these changes to the environment will ensure long-term stability once the open bite is closed orthodontically.

       Traditional Orthopedic Approaches to Open Bite Treatment

       High-pull facebow

      If worn with extreme compliance, the high-pull facebow can intrude the maxillary molars (Fig 1-1). However, it is unrealistic to expect the patient to wear it full-time, so a better goal is to keep SN-MP at its initial position by wearing it 12 hours per day.

Fig 1-1 High-pull facebow.

       Transpalatal arch

      Clinical experience has taught me that this appliance can help to maintain the vertical skeletal angle but cannot reduce it.

       Chin cup

      Again, this appliance can help to maintain the vertical skeletal angle but certainly cannot reduce it. Clinically, wearing the chin cup will keep the teeth in occlusion, which prevents overeruption of the posterior teeth.

       Temporary anchorage devices

      The most exciting possibility for controlling and reducing the vertical skeletal angle involves intrusion of the maxillary and mandibular molars with temporary anchorage devices (TADs). If these devices are stable in the long term, this technique will change the approach to high-angle treatment in the future.

       Alexander Discipline on Open Bite Mechanics

      I can remember early in my career observing an open bite mandibular arch study model and how the arch was nicely leveled (Fig 1-2). It looked like a finished arch in a pretreatment deep bite occlusion. It made sense that I should treat this arch with mechanics opposite to those for a deep bite malocclusion.

Fig 1-2 (a and b) Open bite study models.

       Diagnosis

      • Observe the resting position of the upper lip. It should be 4 to 5 mm from the incisal edge of the central incisors.

      • Observe the smiling position of the upper lip. It should be within 1 to 2 mm of the gingival line. See volume 2 of this series (page 112) for the “Gucci Gucci” technique on getting the patient to smile naturally.

      In open bite cases, it is common for the upper lip to cover much of the maxillary anterior teeth during a smile. Part of the treatment includes extrusion of the incisors to create more incisor exposure. This is accomplished by placing a reverse curve in the 0.016 SS and 17 × 25 SS maxillary archwires (Fig 1-3) and later, if needed, up-and-down anterior box elastics (Fig 1-4).

Fig 1-3 (a and b) Reverse curve of Spee.

Fig 1-4 Anterior box elastics.

       Dental open bite versus skeletal open bite

      When the skeletal pattern is normal (low vertical skeletal angle) but the bite is open, this can be treated as a dental open bite. With proper biomechanics and exercises, this patient should have excellent results. When the open bite is skeletal, the problems are magnified. Surgery may be the only solution.

       Open bite mechanics

      • Bracket placement: The goal is to intrude the posterior teeth and extrude the anterior teeth. This is accomplished by changing the bracket height placement. For all of the teeth out of occlusion, the brackets are placed 0.5 mm more gingivally. For those teeth in occlusion, the brackets are placed 0.5 СКАЧАТЬ