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A Voice in the Arena: Bite Ramps, Part 2: Class 3 Bite Ramps by Dr. Chad Foster

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

by Chad Foster, DDS, MS, editorial director

As I mentioned in my December column, I don’t think there has been a bigger game-changer in my office’s clinical process in regard to treatment efficiency than strategically positioning and shaping our bite turbos. [Editor’s note: If you missed Dr. Foster’s December column, which focused on Class 2 bite ramps, click here.]

Here, I’ll share a few case examples and my thoughts on how I approach Class 3 bite ramps. (I will be presenting this material with much more in-depth discussion during a scientific lecture at the general session of the 2023 AAO Annual Session in Chicago, so if you’re attending that meeting, I hope to see you at my presentation!)

To begin with, Class 3 bite ramps are not a universal fix for any and every Class 3 malocclusion. They do not produce orthopedic maxillary advancement and they likely don’t restrain mandibular growth. Their principal anteroposterior (AP) effect acts to advance/mesialize the maxillary dentition and retract/distalize the mandibular dentition, to “jump” a tooth or teeth out of anterior crossbite. In this manner, in regard to patient selection, if a patient is not an ideal candidate for these tooth movements or if the crossbite is secondary to a more significant skeletal Class 3 jaw position, they might not be an ideal candidate for Class 3 bite ramps. If, however, the patient in anterior crossbite is a good candidate for these tooth movements, I find the occlusal correction occurs much faster and with less reliance on patient cooperation.

The key to case selection with Class 3 ramps is simple. Have the patient fully seat themselves in centric occlusion. Then have them slightly open to the point where the anterior tooth/teeth crossbite is unlocked and see if there is a retrusive AP slide into centric relation that brings the anterior teeth closer into a more edge-to- edge position. If this is the case, and if the upper incisor angulation aesthetically/functionally allows a mild increase in labiolingual torque and the lower incisor angulation also aesthetically/functionally allows a mild decrease in labiolingual torque, then you likely have a great case to employ this technique.
A few additional tips:
  • When bonding the ramp to lower anterior teeth, make sure you bond it to multiple teeth for a splinting effect. When it is individually bonded to a single or multiple separate teeth, the stress from the occlusion can be too traumatic for a single tooth to handle.
  • Make sure the ramp is steep enough to have a good AP effect; if the ramp is too flat, the AP effect diminishes.
  • Pay attention to where the ramp contacts: It should be contacting the upper tooth/teeth in crossbite at the ideal position on their lingual surface.

Case 1
         
Class 3 Bite Ramps
 
Case 2
Class 3 Bite Ramps
Class 3 Bite Ramps

Class 3 Bite Ramps
Class 3 Bite Ramps


Case 1 and Case 2 show the application of Class 3 bite ramps in mixed dentition in the absence of any other fixed appliances. This technique is inexpensive and very efficient. Both cases had correction occur in less than four months, which is typical in a mixed-dentition case with one or multiple incisors in crossbite where the patient can drop to a more edgeto- edge bite in CR. In my opinion, every orthodontist should consider using this technique instead of limited Phase 1 braces treatment in most of their mixed-dentition, single- or multiple-tooth crossbite cases. It is absolutely a win/win, and especially for the patient and parents, it is conservative and cost-effective.

Case 3
Class 3 Bite Ramps
Class 3 Bite Ramps
Class 3 Bite Ramps
 

Case 3 shows a Class 3 ramp placed on the lower anteriors of an adolescent patient who was in complete anterior crossbite. She could drop to an almost edge-to-edge position in CR. The progress photo shows full correction at only nine weeks after upper braces and the bite ramp were applied.

Case 4
Class 3 Bite Ramps
Class 3 Bite Ramps
Class 3 Bite Ramps
 

Case 4 shows a more significant Class 3 adult camouflage case where a bite ramp played an integral role early on in “jumping” the anterior occlusion.

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 in many cases that shaping bite turbos can be an opportunity to inexpensively, efficiently and creatively redirect the force of the bite to my advantage, and I hope you will find the same!

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November 2023
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