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A Voice in the Arena: Bite Ramps, Part 1: Class 2 Bite Ramps by Dr. Chad Foster

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A Voice in the Arena: Bite Ramps, Part 1: Class 2 Bite Ramps   

by Chad Foster, DDS, MS, editorial director

Over the past two years in my practice, I don’t think there has been a bigger game-changer in our clinical process in regard to treatment efficiency than strategically positioning and shaping our bite turbos.

Shaped bite turbos, sometimes called “bite ramps,” are not new in orthodontics; they’ve been around in different forms and applications ever since orthodontists started using bonded disarticulation techniques. Through my participation in online forums, I have been inspired by the techniques of others, and in this month’s column, I’ll share a case progress example and my thoughts on how I approach Class 2 bite ramps.

To begin with, Class 2 bite ramps are not a universal fi x for any and every Class 2 malocclusion. They do not produce orthopedic mandibular advancement, and they likely don’t restrain maxillary growth or significantly distalize maxillary dentition. Their principal A-P effect is similar to that of Class 2 elastics or Class 2 corrector springs—they advance/mesialize the mandibular dentition. In this manner, in regard to patient selection, if a patient is not an ideal candidate for advancing the mandibular dentition because of excessive lower anterior proclination or other patient-specific factors, they are not likely an ideal candidate for Class 2 bite ramps. On the other hand, if they’re deemed a good candidate for Class 2 elastics or Class 2 corrector springs, they are most likely also a good case to start with Class 2 ramps. And to go further: When Class 2 ramps are used properly in these types of cases, I fi nd the occlusal correction occurs much faster and with less reliance on patient cooperation.

For Class 2 patients who are ¼–½-step Class 2 and diagnostically are favorable for AP orthodontic correction with Class 2 elastics or Class 2 corrector springs, I place my bonded Class 2 ramps on the upper first bicuspids (U4s). I use blue Band-Lok for the adhesive that is to be bonded and shaped. The bite ramp needs to extend to the distal far enough that the disto-occlusal aspect of the ramp contacts the distal surface of the lower first bicuspids (L4s). This angle and position of where the ramp contacts is critical. In this position under normal occlusal and masticatory functioning, the ramp will facilitate (in addition to reciprocal vertical forces) a distal force on the U4s and a mesial force on the L4s. In this way, vertical occlusal forces can partly be redirected in an A-P direction to aid in Class 2 correction.

For me, Class 2 ramps are always used in combination with light, short Class 2 elastics (2-ounce, 3/16-inch) worn from the U4s to the L6s. These elastics are worn full time immediately after braces are placed.

When bonding the ramps on the U4s, the adhesive will often need to extend a bit over the occlusal surface of the upper second bicuspids (U5s), and attention should be paid to not bond the U4s and U5s together if adhesive touches the U5s. Also, as treatment progresses, it’s important to check the contact position of the ramps at every visit. As the Class 2 correction occurs, it is necessary to progressively reduce the distal aspect of the ramp so it does not contact the mesial aspect of the L5s. If the mesial aspect of the L5s touches the ramp, it will effectively inhibit any further favorable A-P forces facilitated by the ramp.

It’s not uncommon to see space develop distal to the L4s as the L4–4 segment mesializes. This is a good sign that the ramp is working and the space will eventually close, with the mandibular posterior teeth being pulled forward under indirect anchorage of the ramps. Don’t be concerned if this spacing does not occur, however; often, the mandibular posterior segments track forward simultaneously as the L4–4 segment mesializes so the space does not open, particularly in patients who are doing a good job with their Class 2 elastics.


Progress case example

The progress case demonstrates a Class 2 ramp in action. It’s not a dramatic Class 2 correction; it is submitted as a routine example of the early progress I consistently observe using these ramps even in noncompliant patients. This 13-year-old patient presented with a ¼-step to ½-step Class 2 occlusion and diagnostically I graded him as suitable for Class 2 correction via elastics or corrector springs. In the consult, his mother informed me he was not likely to be compliant with elastics (his older brother was very poorly compliant as well). I banded the U6s in anticipation of likely needing to use Class 2 corrector springs in the later stages of treatment. Fig. 1 is pretreatment, Figs. 2a and 2b were taken the day of bonding, and Fig. 3 was taken after seven months (our third appointment after bonding). At every appointment, the patient has told me he hasn’t been wearing his elastics, even when sleeping.

A Voice in the Arena: Bite Ramps, Part 1: Class 2 Bite Ramps
Fig. 1
A Voice in the Arena: Bite Ramps, Part 1: Class 2 Bite Ramps
Fig. 2a
A Voice in the Arena: Bite Ramps, Part 1: Class 2 Bite Ramps
Fig. 2b

A Voice in the Arena: Bite Ramps, Part 1: Class 2 Bite Ramps
Fig. 3


The buccal photographs are not exactly apples to apples in regard to their angulation, but the cusp tip of the L4 is now in complete Class 1 position. Space has opened distal to this tooth, which we will close with power chains as we now advance into stainless steel wires. The distals of the L4s now continue to be abutted against the mesial aspect of the ramps, so as space closure occurs, there will be a much greater degree of lower posterior mesial movement rather than reciprocal space closure, because of indirect anchorage of the ramps. The distal aspect of the ramp has been progressively reduced at each visit to make sure the L5s are not contacting the ramps.

Even in the absence of compliance with elastics—I think the only time the patient has had them on is when we place them for the purposes of our photographs—early Class 2 correction is well under way in this case, and it’s unlikely that Class 2 corrector springs will be needed. Poor compliance will not likely be the rate-limiting factor in this case in regard to when we complete treatment, and that benefits in no small way the patient, his mom, my rapport and quality of relationship with both of them, and our office efficiency. For the clinician and clinical team, there is definitely a learning curve when it comes to placement, shaping and modifying these ramps, but the juice is worth the squeeze!

As orthodontists, we are quite often at odds with “the bite.” How often do we find ourselves fighting the bite to achieve the correction we desire? I have found that shaping bite turbos can be an opportunity to inexpensively, efficiently and creatively redirect the force of the bite to my advantage in many cases, and I hope you will find the same!
 

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