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2020-01-21
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Contemporary Multiloop Edgewise Archwire (MEAW) Technique
: Old-fashioned but useful
Tae-Woo Kim (金泰佑) DDS MSD PhD
Professor
Department of Orthodontics
School of Dentistry, Seoul National University
AAO 2020 WINTER CONFERENCEJW Marriott Austin • Austin, Texas, USA • February 7-9, 2020
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1) 2013 A Combination of Mini-Implant and MEAW to Correct a Skeletal Class II Open Bite https://www.aaoinfo.org/node/625
2) 2014 Open bite treated by intruding posterior teeth; Methods, outcomes, stability and guidelines https://www.aaoinfo.org/node/2382
3) 2015 Orthodontic Treatment of Skeletal Class II Open Bite; 1) Closing the open bite and 2) Solving the A-P discrepancy
https://www.aaoinfo.org/node/4792
4) 2016 Ankylosis of Anterior Teethhttps://www.aaoinfo.org/meeting-archive/2016-annual-session#topbar
1) 2017 Second molar extraction for open bite treatmenthttps://annual-session.aaoinfo.org/meetings/2018-annual-session/
6) 2018 Molar intrusion with skeletal anchorage, from single tooth intrusion to canting correction and skeletal open bite
https://annual-session.aaoinfo.org/meetings/2018-annual-session/
E-handouts of Open bite lectures are available at
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Introduction
•Young Ho Kim & MEAW (Open bite, Class II, Class III, Finishing)
•Mechanics & Wire bending
Diagnosis and indications
•Differential diagnosis
•MEAW or Mini-implant
Successful Cases
•Extraction 77/77, 77/88, 88/88
Unsuccessful Cases
•DJD
Report on the literature
Retention and stability
•Four major etiologic factors – Mouth breathing, Tongue trusting, TMD, Weak muscle
77/88
Class II Class III
77/77 88/88
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MEAW technique
MEAW technique
Chicago, 2000, 5 6
http://meaw.com/
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Multiloop Edgewise Arch Wire (MEAW)
• 018x022 stainless steel
MEAWs are made of 018x022 ss wire.
Upper Lower
7
.022 X .028
8
018x022 stainless steel
•Class II correction
U: MEAW
L: Ideal arch wire
•Class III correction
U:Ideal arch wire
L: MEAW
Closing anterior open bite
U: MEAW
L: MEAWMEAWs can be used to correct Class II relation, Class III relation and open bite. To close the anterior open bite, MEAWs are used both in upper and lower arches.
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•Class II correction
U: MEAW, L: Ideal arch wire
5/16” Class II elastics
To correct Class II relationship, MEAW is applied in the maxillary arch and Ideal arch(019x025ss) is used in the mandibular arch. Class II 5/16” 6oz elastics are applied.
①
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•Class III correction
U: Ideal arch wire, L: MEAW
5/16” Class III elastics
To correct Class III relationship, MEAW is applied in the mandibular arch and ideal arch(019x025ss) is used in the maxillary arch. Class III 5/16” 6oz elastics are applied.
② ③
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•Openbite correction
U: MEAW, L: MEAW
3/16” up/down elastics
To close the anterior open bite, MEAWs are used both in maxillary and mandibular arches. 3/16” 6oz elastics are applied from the first upper loop to the first lower loop.
④
⑤
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•018x022 stainless steel
To make MEAWs, 4 to 5 L-shaped loops are made between teeth. 13 14
An 043-CK plier is used to make a MEAW.
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• Front cylinder: .045”• Middle cylinder: .060” • Rear cylinder: .075”
Tips have three cylindrical sections; front cylinder being of .045“ diameter, middle cylinder being of .060" diameter and the rear cylinder being of .075" diameter.
• Lower flat beak
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Cutter can be used for both round and rectangular wire up to .025" saving time and motion.
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Arch turret without torque
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19 20
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Check the symmetry and flatness.
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Between #2 and #3, the first L loop is made. 23 24
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13
6mm
2.5mm
4.5mm2
25 26
27 28
7 134567mm
8mm 6mm 7mm 6mm
2.5mm
4.5mm2
7mm
Sequentially, upper L loops are made. 29
7 134567mm
8mm 6mm 7mm 6mm
2.5mm
4.5mm2
7mm
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Upper MEAW shows L loops in perpendicular to the arch. The arch doesn’t have torques.
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20~25°
5~10°
To avoid gingival impingement or cheek mucosa irritation, L loops have a buccal tipping. The angle increases progressively distally.
31The arch is made flat.
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• Upper
The upper MEAW33
• Lower
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The lower MEAW
7 134567mm
8mm 6mm 7mm 6mm
2.5mm
4.5mm
7mm
8mm 6mm 6mm 7mm 6mm
2.5mm4.5mm
2
7mm
7 13456 2
Average size of L loops
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The final upper and lower MEAWs were made.
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Upper and lower MEAWs shows a good coordination.
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Tip back bends• Provides reverse curve of Spee
Tip back bends are applied to each loops, 3° to 5° .
Finally, the upper arch has a compensating curve and the lower arch has a reverse curve of Spee.
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Tip-back bends are applied to each loops.How many degrees do you bend?
1. Extrusion of anterior teeth is the main effect.2. Very slight intrusion of posterior teeth is also secondary effect, “Rocking
chair effect”.
“Rocking Chair”
v
Up & Down
elastics
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1. Extrusion of anterior teeth is the main effect.
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1. Extrusion of anterior teeth is the main effect.2. Very slight intrusion of posterior teeth is also secondary effect, “Rocking
chair effect”.
“Rocking Chair”
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1. Extrusion of anterior teeth is the main effect.2. Very slight intrusion of posterior teeth is also secondary effect, “Rocking
chair effect”.3. Distal tipping contributes to the correction of molar relationship.
“Rocking Chair”
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“Handle of a car”
1. Extrusion of anterior teeth is the main effect.2. Very slight intrusion of posterior teeth is also secondary effect, “Rocking
chair effect”.3. Distal tipping contributes to the correction of molar relationship. This
effect is increased by Class II elastics (In Class III, by Class III elastics). 4. .
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“Molar movement in open-bite”
Very slight intrusion + Distal tipping
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Reasons why I use MEAWs instead of curved TMA or NiTi wires?
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“Handle of a car”
Distal tipping or intrusion of a molar can be controlled very
accurately and effectively with a stiff stainless wire. And also the
load-deflection rate is decreased well with the L loops. 46
“Handle of a car”
1. If the handle is made of a flexible material, it would not be easy
to control well (tip-back and intrusion) and
2. it would be hard to adjust the wires (vertical or in-&-out steps)
for compensating the minute errors of bracket positioning. 47
Yang WS, Kim BH, Kim YH Angle Orthod 2001;71:103–109.
Regional Load Deflection Rate (LDR) of MEAW
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x2 x3 x8 x2 x3 x8
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Yang WS, Kim BH, Kim YH Angle Orthod 2001;71:103–109.
Regional Load Deflection Rate of MEAWHigher LDR
Lower LDR
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Yang WS, Kim BH, Kim YH Angle Orthod 2001;71:103–109.
Regional Load Deflection Rate of MEAW
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Indications
Mini-implant caseMolar intrusion (536480 )
MEAW caseIncisor extrusion (377589)
The left case was treated with the MEAW technique, extrusive mechanics. However, the right case was treated with the mini-implant mechanics, intrusive mechanics.What factors were considered to select the mechanics? 52
The first factor was ‘The initial amount of Incisal Display ’. Compare the height of incisal edge with the level of stomion.
Mini-implant caseMolar intrusion (536480 )
MEAW caseIncisor extrusion (377589)
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In the left case, the extrusion of the upper incisor is desirable. However, the right case allows a minimal extrusion of the upper incisor.
Mini-implant caseMolar intrusion (536480 )
MEAW caseIncisor extrusion (377589)
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Initial
The second factor was the ‘Lip Incompetency’. The right case presented of lip incompetency. However, the left case did not feel hard to close his lip (No ‘strains’ around lips).
Mini-implant caseMolar intrusion (536480 )
MEAW caseIncisor extrusion (377589)
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Debonding
After the orthodontic treatment with the mini-implant intrusion mechanics, the right case did not feel hard to close his lips.
Mini-implant caseMolar intrusion (536480 )
MEAW caseIncisor extrusion (377589)
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The third factor was the ‘Skeletal Class II pattern’. Both casesshowed a very similar skeletodentoalvelar pattern. However, the right case showed a little severer Class II pattern.
Mini-implant caseMolar intrusion (536480 )
MEAW caseIncisor extrusion (377589)
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Mean SDMEAW377589
Mini-implant536480
SNA 81.8 6.0 78.8 80.0
SNB 80.2 5.3 73.5 74.0
ANB 1.8 2.0 5.3 6.1
U1to FH 116.5 6.0 115.1 115.2
IMPA 90.2 5.4 98.4 96.2
IIA 126.2 8.0 113.3 115.6
FMA 26.8 1.8 33.3 33.1
SN-GoMe 32.8 4.3 43.8 40.8
AFH 136.4 6.8 144.5 143.0
ODI 73.3 5.9 78.2 76.8
APDI 86.0 4.0 84.5 78.1
ANBs were 5.3 and 6.1. APDIs were 84.5 and 78.1.
Mini-implant caseMolar intrusion (536480 )
MEAW caseIncisor extrusion (377589)
58Kim YH, Vietas JJ. Anteroposterior dysplasia indicator (APDI):
an adjunct to cephalometric differential diagnosis. Am J Orthod 1978;73:619-33.
Considering three factors, in the left case, the extrusion of incisors was proper. However, the right case needed the intrusion of upper posterior teeth and the autorotation of mandible.
Mini-implant caseMolar intrusion (536480 )
MEAW caseIncisor extrusion (377589)
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Please, compare real treatment results. We can select the adequate techniques differentially, considering three factors.
Mini-implant caseMolar intrusion (536480 )
MEAW caseIncisor extrusion (377589)
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Incisor extrusion (377589)
Graphically, the treatment procedures will be demonstrated. First, the left case treated with the extrusive mechanics, MEAW, will be shown. 61
Incisor extrusion (377589)
First, after leveling and decrowding, upper second and lower third molars were extracted. Second, MEAWs were applied to close the open bite by extruding the incisors. 62
Graphically, the right case treated with the mini-implant mechanics will be shown. He was treated with ‘intrusion’.
Molar intrusion (536480 )
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Leveling
During leveling, upper incisors were extruded a little, and some portion of the open bite was resolved.
Molar intrusion (536480 )
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Molar intrusion (536480 )
Leveling
After leveling, a mini-implant was placed in the mid-palatal area. 65
Molarintrusion
Next, upper molars were intruded in ‘en masse’ mode,and the open bite was closed by autorotation of mandible.
Molar intrusion (536480 )
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1. Incisal display 2. Lip incompetency 3. Skeletal pattern
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In summary,
Successful Case
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2003.3.11 2003.3.11
Female Mean(sd) 2003.11.25
18y 10m
SNA 81.6(3.2) 80.7
SNB 79.2(3.0) 74.2
ANB 2.5(1.8) 6.5
FMA 24.3(4.6) 42.6
ODI 72.2(5.5) 73.3
U1 to FH 116.0(5.8) 102.2
IMPA 95.9(6.4) 92.1
Interincisal angle
123.8(8.3) 123.1
Upper lip E-line
-0.9(2.2) 4.1
Lower lip E-line
0.6(2.3) 5.1
2003.11.25 Before orthodontic treatment2004.3.27
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2004.2.32004.9.11
2005.2.242005.5.8
2005.8.31Debonding
2005.8.31Debonding
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2005.8.31Debonding
Female Mean(sd) 2003.11.25 2005.8.31
18y 10m 20y 7m
SNA 81.6(3.2) 80.7 82.0
SNB 79.2(3.0) 74.2 75.3
ANB 2.5(1.8) 6.5 6.8
FMA 24.3(4.6) 42.6 39.2
ODI 72.2(5.5) 73.3 72.4
U1 to FH 116.0(5.8) 102.2 99.4
IMPA 95.9(6.4) 92.1 90.5
Interincisal angle
123.8(8.3) 123.1 131.0
Upper lip E-line
-0.9(2.2) 4.1 1.6
Lower lip E-line
0.6(2.3) 5.1 3.7
2005.8.31 Debonding
2003.11.25 Before
2005.8.31
2016.6.8Post-treatment 11Y 5M
Unsuccessful Case
DJD with CO-CR discrepancy
Unstable condylar position
DJD and Class II elastic bands
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TMD patients’ TMJs are like a broken hinge.
As the door isn’t closed well, it is hard to make a good occlusion in TMD patients, esp. with CO-CR discrepancy.
Normal DJD
Some patients show the forward mandibular shift by Class II elastic bands,
Normal DJD
instead of movements of teeth.
Normal DJD
When it is useless to use Class II elastic bands, total retraction of maxillary teeth by using skeletal anchorage may be considered.
Report on the literature
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MEAW technique
• Kim Y, Anterior openbite and its treatment with multiloopedgewise archwire. Angle Orthod. 1987:57(4):290–321. https://www.angle.org/doi/pdf/10.1043/0003-3219%281987%29057%3C0290%3AAOAITW%3E2.0.CO%3B2
Diagnosis – ODI, APDI, Combination factor, Extraction index
• Young H Kim, Overbite depth indicator with particular reference to anterior open-bite, Am J Orthod 65:586-611. https://doi.org/10.1016/0002-9416(74)90255-3
• Kim YH, Vietas JJ. Anteroposterior dysplasia indicator: an adjunct to cephalometric differential diagnosis. Am J Orthod. 1978 Jun;73(6):619-33. https://doi.org/10.1016/0002-9416(78)90223-3
• R. Silva Meza, Young H. Kim Cephalometric Analytic Procedure. http://orthofree.com/cms/assets/pdf/99.pdf
• Tanaka E, Sato S. Longitudinal alteration of the occlusal plane and development of different dentoskeletal frames during growth. Am J Orthod Dentofacial Orthop 2008;134:602-3, https://doi.org/10.1016/j.ajodo.2008.02.017. Am J Orthod DentofacialOrthop. 2008:134 (5):602.e1–602.e11. https://www.ajodo.org/article/S0889-5406(08)00776-2/pdf
Skeletodental changes with MEAW
• Toshiya Endo, Koji Kojima, Yoshiki Kobayashi, ShohachiShimooka, Cephalometric evaluation of anterior open-bite nonextraction treatment, using multiloop edgewise archwiretherapy, Odontology (2006) 94:51–58. https://link.springer.com/article/10.1007%2Fs10266-006-0061-5
• Seong-Cheol Moon, Young-II Chang, Cephalometric evaluation of anterior openbite malocclusions treated by multiloop edgewise archwire technique, Korean J Orthod, 1993:23(4): 565-606. (English abstract)
Stability
• Young H Him, Unae Kim Han, Diana D Lim, Ma Laarni P Serranon, Stability of anterior openbite correction with multiloop edgewise archwire therapy: A cephalometric follow-up study, Am J Orthod Dentofacial Orthop 2000;118:43-54
Case reports
• Marañón-Vásquez GA, Soldevilla Galarza LC, Tolentino Solis FA, Wilson C, Romano FL, Aesthetic and functional outcomes using a multiloopedgewise archwire for camouflage orthodontic treatment of a severe Class III open bite malocclusion, J Orthod. 2017 Sep;44(3):199-208. https://doi.org/10.1080/14653125.2017.1353789
• Marco Antonio Cruz-Escalantea, Aron Aliaga-Del Castillob, Luciano Soldevillac, Guilherme Jansond, Marilia Yatabee, Ricardo Voss ZuazolafExtreme. Extreme skeletal open bite correction with vertical elastics, Angle Orthod. 2017;87:911–923. https://doi.org/10.2319/042817-287.1
• Benedito Freitasa, Heloiza Freitasb, Pedro César F dos Santosc, Guilherme Jansond, Correction of Angle Class II division 1 malocclusion with a mandibular protraction appliances and multiloop edgewise archwire technique, Korean J Orthod 2014;44(5):268-277. http://dx.doi.org/10.4041/kjod.2014.44.5.268
Case reports
• Gerson Luiz Ulema Ribeiro, Saulo Regis, Jr, Tais de Morais Alves da Cunha, Marcos Adriano Sabatoski, Odilon Guariza-Filho, Orlando Motohiro Tanaka, Multiloop edgewise archwirein the treatment of a patient with an anterior open bite and a long face, Am J Orthod Dentofacial Orthop 2010;138:89-95. https://doi.org/10.1016/j.ajodo.2008.03.036
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Research
• Yang WS, Kim BH, Kim YH, A Study of the Regional Load Deflection Rate of Multiloop Edgewise Arch Wire, Angle Orthod 2001;71:103–109. https://www.angle.org/doi/full/10.1043/0003-3219%282001%29071%3C0103%3AASOTRL%3E2.0.CO%3B2
• Seung-Hak Baek , Soo-Jung Shin , Sug-Joon Ahn and Young-Il Chang, Initial effect of multiloop edgewise archwire on the mandibular dentition in Class III malocclusion subjects. A three-dimensional finite element study, European Journal of Orthodontics 30 (2008) 10–15. https://doi.org/10.1093/ejo/cjm098
Retention and stability
Atrophy of Masticatory muscles
Open biteWeak bite force
TMD symptoms
Anterior disc displacement
Condylar resorption
Vicious cycle
Pain in Movement
Tongue thrust
Mouth breathing
MEAW
Detailing
Strategies for retention
in open bite cases
1. After correction of open bite,
at the detailing stage, distally
tipped molars were corrected.
Detailing Retention
Strategies for retention
in open bite cases
2. During the detailing stage,
018x 022”ss with shoe hooks
were used with up & down
elastics. Elastic-wearing time
was decreased gradually from
24 hours to 0 hour, monitoring
the overbite & any bad habits.
Conceptually, the detailing
stage was regarded as a
retention period and it was
extended as long as possible.
Start of detailing
Debonding
Initial
3-year post-treatment
Strategies for retention
in open bite cases
3. Patients were educated
during active treatment and/or
post-treatment period to
masticate more than thirty
times for each spoon of food,
if TMJs had no discomfort.
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Strategies for retention
in open bite cases
4. At the stage of debonding, it
is recommended that the
occlusal contact areas be as
wide as possible.
Debonding
Initial
This may provide more
stable mandibular position
and maximum bite force.
Strategies for retention
in open bite cases
5. Mouth breathing, tongue
posture & habits are monitored
every year after debonding.
Frequent rhinitis and
mouth breathing may make
the tongue posture lower
and protruded. It may be a
relapse factor.
2000.12.18
(Initial)
Strategies for retention
in open bite cases
5. Mouth breathing, tongue
posture & habits are monitored
every year after debonding.
Frequent rhinitis and
mouth breathing may make
the tongue posture lower
and protruded. It may be a
relapse factor.
2018.12.21
post-treatment
13 years 9 months Fixed retainer + Labial buttons + U/D elastics
How to retain the result after debonding?1. Monitor the causes: TMJ pains, tongue thrust &
mouth breathing. 2. Use Fixed retainers(4-4). 3. When a relapse tendency found, apply labial
buttons (22/33) with u/d elastics 3/16” 6 oz.4. Instruct patients to chew many times during
eating meals (to increase muscle tonicity).5. Train swallowing without thrusting tongue.
How to make labial button?
1) Etching 2) Wash and dry 3) Primer application 4) Curing
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5) Place a Separator ring on cervical area
6) Inject Flowableresin in the ring. 7) Curing 8) Remove a
Separator
9) Polish and check the undercut.
Fixed retainer(4-to-4
3M Unitek 0.8mm Twist wire, REF 260-0321
2014.1.151 year after debonding
3M Unitek Twisted wire 0.8mm REF 260-032
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Strategies for retention in open bite treatment with MEAW are as follows;
1) After correction of an open bite, at the detailing stage, upright the distally tipped molars.
2) Check the etiologic factors.
- mouth breathing
- tongue thrusting
- weak masticatory muscle force
- tongue thrusting, and
- TMD.
In Summary
• MEAW technique can be used after leveling to correct Class II, Class III, and open bite malocclusion efficiently. The occlusal plane also can be changed. Third molars (or second molars) are extracted to remove the wedge or the posterior crowding.
• MEAW’s indication, successful cases, unsuccessful cases, pieces of literature, retention, and stability were presented.
• If wire bending ability is equipped, it will be one of the powerful and useful tools for open bite treatment.
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