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
have long b e e n present in some f o r m in most
appliance systems.
The remarkable fact is that the reverse version
of this problem, the open bite, has received far less
attention. This may be because o p e n bites occur
less frequently. However, open bites are present in
all orthodontic practices and are problems in
which practitioners do not always enjoy predict-
able success. The need for a reliable biomechani-
cal technique for open bite closure that does not
require patient compliance has been obvious.
Anterior open bites may look very similar to
each other, but it is likely that they have various
factors contributing different amounts to their eti-
ology. As a result, it is not surprising that open bite
treatments involve a wide variety of treatment ap-
proaches. Some approaches focus on the associ-
From the Department of Orthodontics, School of Dentistry, Vir-
ginia Commonwealth University, Richmond, VA.
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-
wealth University, Richmond, VA 23298-0566.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0701-0005535.00/0
doi:l O.1053/sodo. 2001.21064
vertical facial height with surgery (LeFort surgery)
or intrusion of molars (vertical pull headgears,
splints, or repelling magnets). Other approaches
accept the existing skeletal morphology and focus
on local factors addressing treatment toward the
tongue (cribs or tongue reduction surgery) or the
facial musculature (functional appliance shields).
Often, however, the cause c a n n o t be posi-
tively identified, and the o p e n bite is treated
with dental compensations. Undoubtedly, the
most c o m m o n a p p r o a c h has b e e n the use of
vertical elastics to close the anterior o p e n bite.
Almost all orthodontists have used this ap-
proach, and almost all orthodontists have expe-
rienced some degree of dissatisfaction with their
inability to close anterior o p e n bites reliably,
mostly based on the r e q u i r e m e n t of patient com-
pliance to make the t r e a t m e n t succeed.
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
dental compensations for anterior dental o p e n
bites with no patient compliance required.
The Extrusion Arch
The extrusion arch is a term that was coined to
describe the reverse action of the already exist-
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
term, extrusion arch, is probably somewhat mis-
leading because the action of the wire is not to
extrude the tooth from its attachment appara-
tus.
What does h a p p e n when a tooth is moved
vertically within the alveolar process? w h e n the
o p e n bite closes, does the tooth move with re-
spect to the alveolar process and leave the alve-
olar process b e h i n d with a longer clinical crown
resulting? All available evidence shows that,
whether the tooth is intruded or extruded, ver-
tical m o v e m e n t brings the entire attachment ap-
paratus, including the alveolar process and the
gingival tissues, with the tooth. In fact, some
work has even been reported describing treat-
m e n t procedures to try to prevent the attach-
ment from the normal process of following the
vertical m o v e m e n t of a tooth in those cases
where a treatment requires a longer clinical
crown. 1
The extrusion arch is a new adaptation of the
biomechanical principle of an off-center bend,
or asymmetrical V, in an arch wire to develop a
specific set of biomechanical responses. 9 Despite
the fact that many systems have used the princi-
ples of an intrusion arch to treat deep bites for
many decades, the concept of using the reverse
configuration of the wire to treat anterior o p e n
bites was only recently reported, a
The principle of an extrusion arch has been
applied as a segmental wire for some time, pre-
dominantly to bring in impacted canines. ~ The
application of this principle with a continuous
auxiliary arch wire to multitooth anterior o p e n
bites emerged when teaching new residents the
principles involved in the use of intrusion
arches. W h e n a new resident described the in-
trusion arch backward, the obvious application
to an o p e n bite became apparent. When the
authors applied this theory clinically and used
an upside down intrusion arch in an open-bite
patient who was not willing to wear vertical elas-
tics, the open bite closed in a matter of several
weeks. This was indeed a very impressive new
application of an old principle.
The extrusion arch is a very efficient and
effective way to close anterior open bites, and
open bites are the nemesis of most mechanics.
The vertical elastic has been the most c o m m o n l y
used tool in the past and, too often, vertical
elastics became a contest of wills between the
orthodontist and the p a t i e n t - - a contest often
35
won by the patient. The extrusion arch, how-
ever, gives the orthodontist the ability to close
anterior o p e n bites without patient compliance,
and in addition, to decide whether the open bite
closure should come fi~om just the maxillary
teeth moving down, just the mandibular teeth
moving up, or both.
The biomechanics of an extrusion arch are
fairly straightforward. As with most clinical prob-
lems, the first question is, Which teeth do I want
to move in what direction? With an anterior
open bite the answer is clear. I want the front
teeth to move vertically together. Now, however,
the question is more sophisticated: Do I want the
u p p e r teeth, the lower teeth, or both to move
vertically?
Sometimes the anterior open bite is primarily
a skeletal growth problem. 4 The disproportion-
ate bony facial growth results from relatively
more vertical growth at the alveolar process as
c o m p a r e d with the vertical growth occurring at
the ramus (Fig 1). This is a long-face problem
evolving and, in the most troublesome situa-
tions, a backward rotating facial growth pattern.
in these individuals, the anterior alveolar pro-
cess must grow vertically rapidly or the open bite
will get worse. If the clinical open bite extends
from molar to molar, the problem is likely to be
a skeletal problem with insufficient dental com-
pensations and is even more difficult to treat.
If the o p e n bite is a local problem, and just
involves an anterior segment of teeth, the prog-
nosis is m u c h better. This is especially true if a
cephalometric analysis shows a skeletal pattern
with relatively normal vertical development.
Sometimes the local causative factor, eg, a digit,
is no longer present, but the tongue, lips, and
t r a c t i o n are maintaining the dental o p e n bite.
This kind of open bite will be relatively indepen-
dent of vertical facial growth. O f course, the
possibility of a skeletal open bite existing in com-
bination with local factors adapted to the open
bite is quite possible.
When an open bite problem is addressed by
inserting a continuous arch wire into the brack-
ets on all the teeth, the results are rarely satis-
factory. Wiping reverse occlusal curve in the
maxillary wire a n d / o r a large accentuated curve
in the lower wire simply is not effective. The
mechanics are slow to work, and the side effects
are often undesirable. W h e n the wire is left in
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

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egJoOOQ° J

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

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
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
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
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
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 -
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
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
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
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
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-
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
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 .
The most common reason an orthodontist
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
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
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
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 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 .
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 -
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
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
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
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
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
manifest and are negated.
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
capable of such rapid tooth movement that
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
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
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
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-
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 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
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 -
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 -
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
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
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 .
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 -
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 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
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 ,
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 -
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 -
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-
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
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
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-
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
segmental extrusion arches, primarily for palatal
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
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-
cally. N i c k e l t i t a n i u m overlay a r c h wires effi-
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
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-
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
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
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 .
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
is p r e v e n t i o n , a n d it is advisable to see these
patients more frequently than might be the nor-
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-
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-
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
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
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
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
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
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 .
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
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
o t h e r , it is advisable to use e i t h e r a l i g h t wire in
the brackets under the extrusion arch or some
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
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
e n o u g h to allow t e e t h to m o v e vertically, it will
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
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
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-
d o m to m o v e , it will also allow t h e p o s t e r i o r
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-
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
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
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-
p o r t f r o m t h e a d j a c e n t teeth.
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
wires in all t h e b r a c k e t s is t h e use o f stiff wire in
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
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).
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
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
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
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
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
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
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
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
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 ,
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-
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
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.
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
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
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
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
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
t o o t h (Fig 6).
T h e q u e s t i o n arises as to w h e t h e r the extrusion
arch wire s h o u l d be fled to a s e g m e n t o f wire in the
incisor brackets, fled to a c o n t i n u o u s arch wire in
all o f the brackets, or p l a c e d directly into the
brackets o f the incisors. Any o f these a p p r o a c h e s
will probably be effective. T h e decision o f which to
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
extrusion arch is fled to a s e g m e n t o f wire in the
a n t e r i o r brackets, the s e g m e n t o f wire moves the
teeth attached as o n e big tooth. This will m o v e
Figure 7. Action of the extrusion arch at the incisors.
The biomechanics shown in Figures 2 and 3 are all
still present, but not shown in this figure. This Figure
shows the m o m e n t created as a result of where force
of the extrusion arch wire is applied at the incisors.
Because the wire is tied more anteriorly, the line of
extrusive force is further away from the center of
resistance. This results in a m o m e n t created by the
force equal to the force times the distance the force is
away from the center of resistance. This m o m e n t will
tend to tip the incisors lingually. Minimizing the dis-
tance the force acts in front of the center of resistance
reduces the m o m e n t and this tendency for lingual
rotation. This happens when the extrusion arch is tied
at the lateral incisors. The tendency for lingual tip-
ping can also be overcome with a stop on the extru-
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-
ferent heights t h a n the rest of the teeth i n the
arch. If the exwusion arch is tied to a c o n t i n u o u s
nickel t i t a n i u m wire, the bracket heights are better
m a i n t a i n e d with respect to each other. T h e speed
of extrusion may be somewhat slowed down, b u t
the extrusion is kept u n d e r better control in terms
of overtreatment. If the extrusion arch wire is
placed into the incisor brackets, it m u s t be able to
be seated, a n d t h e n it will move the incisors as o n e
big tooth. This latter configuration is really a 2-cou-
ple system, a n d the third-order torque at the inci-
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-
vantages. It is analogous to the relationship be-
tween a 1-couple i n t r u s i o n arch (the reverse of the
extrusion arch) a n d the c o m m o n l y used utility
arch.
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 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
single force is effective a n y w h e r e else. If the
force is tied at the c e n t r a l incisors, it is p r o b a b l y
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
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
incisors vertically, will act a n t e r i o r to the inci-
sors' c e n t e r of resistance. Clinically, the incisors
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
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
avoid the latter is to try to apply the force m o r e
posteriorly by tying the e x t r u s i o n arch at the
lateral incisors.
The Wire
T h e m a g n i t u d e of the extrusive force u s e d is
a r o u n d 100 g for 4 incisors. This is easily
a c h i e v e d with a 90 ° b e n d i n a 0.016 X O.022-inch
stainless steel a r c h wire with a helix at the molar.
More c o m m o n l y use is m a d e o f the same size of
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
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
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.
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
is the same irrespective o f the t r e a t m e n t that
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
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
arches p r o b a b l y have n o m o r e n o r less ability to
be stable t h a n a n y o t h e r t r e a t m e n t p r o c e d u r e .
T h e q u e s t i o n of r e t a i n e r s is difficult b e c a u s e
the typical Hawley type r e t a i n e r has little i m p a c t
o n o p e n bites. A r e m o v a b l e r e t a i n e r c a n k e e p
teeth f r o m t i p p i n g to the facial, which, if occur-
ring, will r e d u c e overbite. R e m o v a b l e r e t a i n e r s
c a n n o t p r e v e n t actual t r a n s l a t i o n o f the c e n t e r
of resistance i n a n intrusive d i r e c t i o n . Results
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.
Acknowledgment
The authors thank Ms. Carol Wilkins for her help in prepar-
ing the illustrations for this article.
References
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rules for arch wire design. Semin Orthod 1995;1:3-11.
3. Lindauer SJ, Isaacson RJ. One-couple orthodontic appli-
ance systems. Semin Orthod 1995;1:12-24.
4. Isaacson JR, Isaacson RJ, Speidel TM, et al. Extreme vari-
ation in vertical facial growth and associated variation in
skeletal and dental relations. Angle Orthod 1971;41:219-
229.