R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 91Tpico EspecialPalavras-chave:Hbitos Bucais. Mordida Aberta Anterior. Face longa.ResumoAprcocupaaocomasdlsplaslas vcrtlcalslcvouosautorcsarcall-zarcm uma rcvlsao sohrc mordlda ahcrtaantcrlor,cacstahclcccrcm umprotocolodctratamcntodu-rantcalascdadcntaduramlsta qucconslstcnautlllzaaoda gradcpalatlnarcmovlvclouLxa, assoclada ao uso noturno da mcn-tonclra.Aprcscntamalnda,casos cllnlcoscomacompanhamcnto longltudlnalcnlocandoacstahlll-dadc da corrcao.INTRODUONopassadoasdcsarmonlas oclusalsnoscntldontcro-pos-tcrlorconstltulam-sccmmctas prlnclpals,tornando-scvcrda-dclrosalvosdospcsqulsadorcs, osqualsnaodavamadcvlda lmportnclaparaasdlscrcpnclas noscntldovcrtlcalctransvcrsal. Nosultlmos3Canos,porcm, multosautorcslnqulctaram-sc comaslntcrdcpcndcnclasdas proporocslaclalsnostrcspla-nosdocspao,casdlsplaslas vcrtlcalspassaramarccchcruma maloratcnaol3,l+,l8,22,27,3C,3l,38,52,53. Estaprcocupaaoscdcvcaolato qucasdcsarmonlasvcrtlcalssao malsdlllcclsdcscrcmtratadasc osrcsultadosohtldosmcnoscsta-vclslC,3l.Entrccstasdcsarmonlas, uma quc dcsaLa os proLsslonals c a mordlda ahcrta antcrlor {MAA), qucdcpcndcndodasuactlologla podcaprcscntarumprognostlco lavoravcl ou dcslavoravcll,2,3,+,++.NcstccontcxtoaMAAmcrccc cspcclaldcstaquc,polsalcmdc tcraltaprcvalcnclanadcntadura dcclduacmlsta,cumadlsplasla multocomplcxa,naopodcndo scrmorlologlcaclunclonalmcntc consldcradacomoumaunlcacn-tldadc cllnlca, como a hcrana, por cxcmplo.Estamaoclusaoacarrctaal-tcraocsnoaspcctocstctlcodo Renato R. de AlmeidaVertical Dysplasias: Anterior Open Bite Treatment and StabilityDisplasias Verticais: Mordida Aberta Anterior Tratamento e EstabilidadeRenato Rodrigues de Almeida *Renata Rodrigues de Almeida-Pedrin **Marcio Rodrigues de Almeida ***Fernando Pedrin Carvalho Ferreira ****Arnaldo Pinzan *****Celina Martins Bajo Insabralde ******* Professor Doutor do Departamento de Ortodontia e Odontopediatria da Faculdade de Odontologia de Bauru-USP; Professor Responsvel pela Disciplina de Ortodontia em nvel de graduao da Faculdade de Odontologia de Lins UNIMEP e Professor Associado da Universidade Cidade de So Paulo UNICID-SP.** Mestre e Doutoranda em Ortodontia pela Faculdade de Odontologia de Bauru-USP.***Mestre e Doutor em Ortodontia pela Faculdade de Odontologia de Bauru-USP e Professor da disciplina de Ortodontia ao nvel de graduao e Coordenador do Curso de Especializao da Faculdade de Odontologia de Lins - UNIMEP.****Mestrando em Ortodontia pela Faculdade de Odontologia de Bauru-USP.***** Professor Associado do Departamento de Ortodontia e Odontopediatria da Faculdade de Odontologia de Bauru-USP; Professor Responsvel pela Disciplina de Ortodontia da Universidade do Sagrado Corao de JesusUSC e Professor Associado da Universidade Cidade de So Paulo UNICID-SP. ****** Especialista em Ortodontia e Professora do Curso de Especializao da Faculdade de Odontologia de Lins - UNIMEP.92R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 93lndlvlduo,dlLcultaaprccnsao ccortcdosallmcntos,prc|udl-candotamhcm,dctcrmlnados loncmas,altcraocsqucpodcm lcvarolndlvlduoasltuaocs dcsagradavclscmscuamhlcn-tc,crlandoparaclc,condlocs pslcologlcas dcslavoravcls.Amordldaahcrtaantcrlor podc scr dcLnlda como uma ma oclusaoscmcontatonarcglao antcrlordosarcosdcntarlos, com trcspassc vcrtlcal ncgatlvo, cstandoosdcntcspostcrlorcs cmoclusao.Otcrmomordlda ahcrtaantcrlor,lollntroduzldo por Carahcll, quando propos sua classlLcaaodasmasoclusocs hascando-sc na rclaao cntrc os dcntcs antcrlorcs25.INCIDNCIA E ETIOLOGIAAlncldcncladamordlda ahcrtacstarclaclonadacoma ldadchlologlcadospaclcntcs pcsqulsados,comograudc dcscnvolvlmcntomcntal,com suashcranasgcnctlcascpa-tologlasdcordcmgcralquc possam aprcscntar.Nadcntaduramlstapor cxcmplo,aprcvalcnclapodc alcanarl7% 5+,dcvldoalato-rcscomoaparclallrrupaodos lnclslvos,aotamanhodostccl-dosllnlatlcos,provocandouma altcraaonaposlaodallngua, apcrslstcncladadcglutlaoln-lantllcaocorrcncladchahltos hucals dclctcrlos.Clcmcns7, rcallzou um cstudo cpldcmlologlco cm 2C6C cscola-rcs,dcamhososgcncros,da rcglao dc Porto Alcgrc, com lda-dc varlando cntrc 3 c 25 anos, dlvldldos cm quatro grupos cta-rlosrcprcscntatlvosdcdllcrcn-tcs cstaglos dc cvoluao da dcn-tadura humana c conclulu quc a prcvalcncladcssaanomallalol malornadcntaduratcmporarla com um pcrccntual dc 38,ll%. Nadcntaduramlsta,cstcvalor dccrcsccu para l2,C+%, na dcn-tadura pcrmancntc |ovcm, para 8,C9% c na pcrmancntc adulta, +,35%.A lrcqcncla dcssa ma oclu-sao alcana, aproxlmadamcntc, l6%dapopulaaomclano-dcrmac+%dapopulaaolcu-codcrmaamcrlcana,scgundo dados aprcscntados por Ngan c Flclds33.Entrctanto,umcstudo a rcspclto da lncldcncla das mas oclusocscm|ovcnshrasllclros rcallzado por Sllva Fllho, Frcltas cCavassan+5,mostrouquc, cm2.+l6cscolarcsdarcglao Bauru,SaoPaulo,quccncon-travam-scnocstaglodcdcnta-dura mlsta, cntrc 7 c ll anos dc ldadc,csscpcrccntualalcanou l8,5%dototaldasmasoclu-socscncontradasncssalasc. Porcm,scgundoamalorlados autorcsl,ll,33,+Caporccntagcm dcssctlpodcmaoclusaotcndc adccrcsccrnalascdaadolcs-ccnclaocorrcndoumadlmlnul-aogradatlvadalncldcnclada mordldaahcrtaantcrlor,dcvldo aoproprlodcscnvolvlmcnto oclusal,amaturaaodolndlvl-duo, lacllltando a cllmlnaao dc hahltos dclctcrlos, a dlmlnulao dctamanhodasadcnoldcsco cstahclcclmcnto dc uma dcglutl-ao adulta normal.Comocmtodasasmas oclusocs,ahuscadcumunl-colatorctlologlcodamordlda ahcrtaantcrlorscrlacstcrll,|a quclndcpcndcntcmcntcdcsua gravldadc, cla aprcscnta orlgcm multllatorlal.Suaocorrcncla dcvc-scaumacomhlnaaodc multasvarlavcls,atuandono potcnclal dc crcsclmcnto lncrcn-tc a cada lndlvlduo.Emvlstadlsto,ohscrva-scquccstadlsplaslapodcscr multocomplcxa,naopodcndo scrmorlologlcaclunclonal-mcntcconsldcradacomouma cntldadc unlca, para a qual um mccanlsmo puramcntc gcnctlco crcsponsavcl.Comrcspcltoas lnLucnclashcrcdltarlas,osgc-ncsquccontrolamospadrocs lndlvldualsdccrcsclmcntosao dctcrmlnadosnaconccpao, mas o rcsultado do potcnclal dc crcsclmcntopodcscmanllcstar somcntcaoLnaldaadolcsccn-cla, o quc compllca sohrcmancl-ra a prcvlsao dc um crcsclmcnto lndlvldual,alcmdoqucmultas vczcsdclxamosdcconsldcrar comodcvcrlamos,opotcnclal gcnctlco dos tccldos molcs53.Nactlologladamordlda ahcrtacncontramoslatorcsrc-laclonadosahahltosdclctcrlos, alunaooutamanhoanormal da llngua, a rcsplraao hucal, ao padraodccrcsclmcntovcrtlcal prcdlsponcntc a mordlda ahcrta capatologlascongcnltasou adqulrldas.Apslcologlanoscnslnaquc os scntlmcntos lntcrlorcs dc to-das as pcssoas sao rcLctldos nas suascxprcssocslaclalscnos hahltosqucclasdcscnvolvcm, |aqucastcnsocssaoallvladas atravcsdcalgummovlmcnto muscular ou aao.Os hahltos quc mals prcocu-pam os ortodontlstas sao aquc-lcs rclaclonados com a cavldadc hucal.Asrcspostassohrcas causasdodcscnvolvlmcntodc umhahltocstaonasclrcuns-tnclasdcscuaparcclmcnto, qucquascscmprcdcnotaum scntlmcntodclnscguranaquc acrlanacxtcrna,procurando suhllma-lo atravcs dcssc ato53.Entrcoshahltosmalslrc-qcntcscncontramosasucao dlgltal,dachupcta,dolapls, dacanctacasposturasaltc-radasdamusculaturalahlal. Normalmcntc,nasmordldas ahcrtascausadasporhahltos, o lator causal csta cspclhado na dlsposlaocspaclaldosdcntcs. Quando cla csta llmltada a uma lncllnaao vcstlhular dos dcntcs supcrlorcs c llngual dos lnlcrlo-rcs,osuspcltocasucaodo 92R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 93polcgarl,2,l2,l6,+l.Schouvcrln-trusaodoslnclslvoscmamhos os arcos, lorma-sc uma conLgu-raaoclrcularcaractcrlstlcada sucao dc chupcta.Otccldoosscocascgunda suhstnclamalsduradoorga-nlsmo,mascmultomalcavcl quandosuhmctldoasloras malssuavcs,portanto,uma sucaodlgltalprolongadapodc lcvaraumhloquclodocrcs-clmcntodoproccssoalvcolar, com constrlao latcral da maxlla dcvldoaoaumcntodatonlcl-dadcdamusculaturapcrlhucal caoposlclonamcntolnlcrlor dallngua.Estasltuaao,na malorla dos casos, provoca uma mordldacruzadapostcrlor,um palatoprolundo,umacxtrusao dosdcntcspostcrlorcscum dcslocamcnto antcrlor da maxl-la, como um todo. Sc cstas con-dlocs pcrmancccrcm por multo tcmpo,asaltcraocsadvlndas podcmpcrslstlr,mcsmoaposa lntcrrupao do hahlto2l,53.Alntcrrupaodcumhahlto podcmultasvczcsscrtrau-matlcaparamultospaclcntcs, dcvldoasualmportnclana compcnsaaodasncccssldadcs pslcologlcas.Comoamadurccl-mcntopodcocorrcrumatrans-lcrcncladchahltos{dasucao domamlloparaachupcta, dcdos c oh|ctos, mascar gomas, lumar) c a prcocupaao csta no lato dc quc a lntcrrupao hrusca dcstcs hahltos podc lcvar a ou-tros mcnos accltos29.Emumpaclcntcmotlvado, qucslnccramcntcqucrlntcr-rompcrumhahltopslcologlca-mcntc nao slgnlLcantc, um apa-rclhoscrvlracomorccordatorlo coa|udaraalntcrrompc-lo. Massccstchahltolorcom-pulslvo,cntaoumtratamcnto comorlcntaaopslcologlcacsta lndlcado.Ncstcaspccto,uma lrascdcWatson53podcnortcar nossotratamcntoEprclcrlvcl dclxarumacrlanaalcgrccom amordldaahcrtaqucpslcotlca com hoa rclaao lnclslva.Atcquandoumhahlto dcvcscraccltocomonormal? Ccralmcntc, a sucao dlgltal por cxcmplo,cconsldcradanormal nosprlmclrosanosdcvldal6, |aquclazpartcdodcscnvol-vlmcntocmoclonaldacrlana, casposslvclsconsc-qcnclas dcntarlasprc|udlclalsnaosao pcrmancntcsparaaoclusao23. Ncstcpcrlodonaodcvcscr lcltancnhumatcntatlvapara cllmlnarohahltoporquccxlstc umalortctcndcncladacrlana ahandona-locspontancamcntc amcdldaqucamadurccccmo-clonalmcntc+3,5+.Outracausaapontadapara alnstalaaodcumamordlda ahcrtaantcrlorcalntcrposlao llngual,tamhcmconhcclda como dcglutlao atlplca, rcvcrsa oulnlantll.PodcmosclasslLcar alntcrposlaollngualcomo prlmarla,quandoclacolator dcscncadcantccsccundarla, quandoallnguascadaptaa umacondlaomorlologlcaprc-cxlstcntc,comonoscasoscom padraodccrcsclmcntovcrtlcal, quc aumcnta consldcravclmcntc o tcro lnlcrlor da lacc, dclxan-do o lahlo hlpotonlco ohrlgando olahlolnlcrlor,amusculatura darcglaodomcntocallngua, asccomportarcmdcmanclra atlplca,paraohtcrosclamcnto antcrlor ncccssarlo a dcglutlao, ocorrcndo a lntcrposlao da lln-gua cntrc os lnclslvos.Adcglutlaocomlntcrposl-aodallnguaclrcqcntccm crlanasatclCanosdcldadc, quctcnhamounaomordlda ahcrta,ohscrvando-scumadl-mlnulao da sua lncldcncla apos cstaldadc,atcatlnglr2,7%na adolcsccncla+9.Parccc-nosohvloqucsclaz ncccssarlotratarprlmclroa maoclusao,paraqucallngua tcnha condlocs dc lunao dcn-trodanormalldadc,scndoquc namalorladasvczcs,coma corrcaomorlologlcaohtcm-sc alunclonal+9,5C,53.Alcmdlsso, multasvczcscncccssarloum rctrclnamcnto da llngua cm scu novo amhlcntc, para quc cvltcm rccldlvas,scndolmportantc ncstcs casos o acompanhamcn-to lonoaudlologlco.Outroslatorcsqucdcscn-cadclamaquchradocqulll-hrlohucalcalntcr-rclaao cntrcalormacalunaosao asohstruocsdasvlasacrcas supcrlorcs{nasochucolarln-gc)qucpodcmscrcausadas porhlpcrtroLadaadcnoldcou amlgdalasc/oucornctos,dcs-vlo dc scpto, rlnltcs alcrglcas c corlza cronlca.Acausamalslrcqcntcco tccldoadcnoldcanohlpcrtroLa-do,qucquandonormalsolrc lnvoluaonaadolcsccncla, amcnlzandoasltuaao.Para quc a rcsplraao hucal possa scr clctuadanoscasosondccxlstc umaohstruaodanasolarlngc, dcvcraocorrcrumaadaptaao lunclonalcomoahalxamcnto damandlhula,poslclonandoa llnguaantcrlormcntccdcposl-tadanoassoalhodacavldadc hucal.Portanto,caaltcraao posturaldallnguacmandlhula qucprovocamodlLcaocsaos nlvclsdcntarlocossco,scmc-lhantcsaquclasprovocadas pclasucaodopolcgar,|aquc allnguanaomalsolcrcccra rcslstcnclaaaaodomusculo huclnadornarcglaodamaxl-la2,+l.Outraconscqcncladcsta posturamandlhularcolavorc-clmcntodalrrupaocontlnua dosdcntcspostcrlorcs,aumcn-tandoadlmcnsaovcrtlcaldo paclcntccporconscqcncla,a mordldaahcrtaantcrlor,vlsto quc cada mlllmctro do aumcnto dadlmcnsaovcrtlcalnarcglao postcrlordoarco,rcprcscnta 94R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 95FIGURA A- Indivduo com padro vertical pertencente ao estudo de Bjrk6.umaahcrturadc3mlllmctros na rcglao antcrlor5.Amalorladosauto-rcsl+,l5,l8,22,27 csta dc acordo quc a lntcrvcnao prccocc rcstaura a lunaonormaldasvlasacrcas contrlhulndo sohrcmanclra para quc a crlana possua a lacc quc hcrdougcnctlcamcntc,prcvc-nlndoasaltcraocsdclctcrlas, produzldaspclaslnLucnclas amhlcntals.Exlstcumagrandcvarlahlll-dadc dc slnals c slntomas aprc-scntadospclorcsplradorhucal, condlclonadaaograudcohs-truaodasvlasacrcas,postura mandlhular c llngual, padrao dc crcsclmcntolndlvldualcama-lcahllldadcosscalncrcntcdc cadaum,l8lstocxpllcaporquc algunsrcsplradorcshucalsdc-scnvolvcm uma mordlda ahcrta c outros nao.Asmordldasahcrtasan-tcrlorcspodcmscmanllcstar tamhcmcmconscqcncladc padrocscsquclctlcoshcrcdlta-rlosquccxcrccmumalnLucn-cladcclslvanocrcsclmcntoc dcscnvolvlmcnto das cstruturas hucolaclals, portanto, um lndlvl-duo com hcrana prcdlsponcntc a csta ma oclusao provavclmcn-tc a aprcscntara, c o grau dc sua manllcstaaopodcscraltcrado por latorcs amhlcntals dcslavo-ravcls ou nao.CLASSIFICAOAmordldaahcrtaantcrlor podcscrclasslLcadatantocom hascnasuactlologlaquantoa scvcrldadcdcsuacxprcssao. Rlchardson39,porcxcmplo, proposumaclasslLcaaoquc consldcraactlologla,dlvldlndo asmordldasahcrtasantcrlo-rcscml)transltorlas,quc ocorrcmquandooslnclslvos pcrmancntcscstaolrrompcndo cpclocrcsclmcntolncomplcto dasarcasdcnto-alvcolarcs,2) ascausadasporhahltos,3) pclaspatologlaslocals{dcntcs supranumcrarlos,clstoscdlla-ccraocs), +) por patologlas gc-rals com altcraocs csquclctlcas {Lssurapalatlnacdlsostoscs crnlo-laclals),5)pclopadrao dccrcsclmcntovcrtlcalnaopa-tologlcoc6)ascausadaspcla morlologla c comportamcnto da llngua c lahlos.Wormsctal.5+classlLcaram amordldaahcrtaquantoasua cxtcnsao,cmmordldaahcrta slmplcs{comprccndldadcca-nlnoacanlno),mordldaahcrta composta{dcprcaprc-molar) clnlantll{quandoatlngcos molarcs).Dawson8classlLcouaam-plltudcouograudcscparaao cntrcosdcntcsantcrlorcs,atrl-hulndovalorcsmordldaahcrta mlnlma {ahcrtura dc atc lmm), modcrada {dc l a 5mm) c scvc-ra {supcrlor a 5mm).Nahoum32, dlvldlu as mordl-dasahcrtascmduascatcgorlas dlstlntas dcntarla c csquclctlca.-Dcntarlaaquclaqucaprc-scnta um dcscnvolvlmcnto nor-mal dc toda a arca hasal, como cxcmplo, a lalta dc lrrupao dos dcntcs antcrlorcs.-Esquclctlcaquandoaprc-scntadlsplaslascranlolaclals cnvolvcndoaarcadahasc aplcal com outras caractcrlstlcas assocladas a ma oclusao.Almclda c Ursll, propuscram umaclasslLcaaocaractcrlzan-doasmordldasahcrtasantc-rlorcscmdcntarlas,dcnto-al-vcolarcs c csquclctlcas. Elas sao catcgorlzadascomodcntarlas quandorcsultamdaohstruao dalrrupaonormaldosdcntcs antcrlorcs, scm o cnvolvlmcnto do proccsso alvcolar. No caso da dcnto-alvcolarcxlstcumcom-promctlmcntododcscnvolvl-mcnto ossco, pols o lator causal csta hloqucado o scu curso nor-maldcdcscnvolvlmcnto,|aas mordldasahcrtascsquclctlcas, tcrmocunhadoporSuhtclny5C, comprccndcmasmordldas ahcrtasnasqualscxlstcuma dlsplasla cranlolaclal manllcsta-da,dcpadraoscmclhantcmas dc scvcrldadc varlavcl.A mordlda ahcrta csquclctlca caractcrlza-scporaprcscntar rotaaomandlhularhorarla, ngulogonlacoahcrto,ramo mandlhularcurto,dlvcrgcn-clacntrcosplanospalatlnoc mandlhular,supcr-lrrupaodos dcntcspostcro-supcrlorcs,c aumcntonaalturalaclalntc-ro-lnlcrlor{AFAI)lC,2+,26,3C,3l,+2,5l. O cstudo por mclo dc lmplantcs propostoporB|ork6clarlLcouo crcsclmcntomaxllomandlhular cmpaclcntcsvcrtlcals,ondcos acompanhoulongltudlnalmcntc por 5 anos {Flg. A). Evldcnclou quc a maxlla c a mandlhula ro-taclonam para halxo c para tras 94R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 95{scntldo horarlo), rcsultando no aumcntodongulodoplano mandlhular c na AFAI. O crcscl-mcnto condllar sc cxprcssa para clma c para postcrlor c a dlrcao dclrrupaodosdcntcslnlcrlo-rcsocorrcquascqucvcrtlcal. Ccralmcntc paclcntcs quc aprc-scntam cstc tlpo dc ma oclusao sao classlLcados como paclcntcs com a slndromc da lacc longa, cxlhlndo alnda constrlao maxl-lar c mordlda cruzada postcrlor, mandlhulacmaxllarctruldas cumamordldaahcrtaantcrlor comhlnada com o hahlto dc ln-tcrposlao dc llngua.Umaspcctolmportantcdlz rcspcltosohrcacpocaldc-aldclntcrvcnaodaMAA. Engllshll,cnlatlzouquco tratamcnto para paclcntcs com mordldaahcrtacsquclctlca dcvcscrrcallzadoprccocc-mcntcparascohtcrsuccsso cm |ovcns cntrc 7 c 8 anos dc ldadc.Otlpodccrcsclmcnto laclalccstahclccldoprcco-ccmcntcnocrcsclmcntoc dcscnvolvlmcntodopaclcntc. Sc um paclcntc com lacc longa nao lor tratado atc o cstaglo dc dcscnvolvlmcntodosdcntcs pcrmancntcs,aoportunldadc dc modlLcaao do crcsclmcnto podcscrpcrdlda,ncstccaso, acorrcaoclrurglcacaunlca posslhllldadc para o tratamcn-to.Para,llockc2Camclhor cpocadcsclntcrvlrnospa-clcntcs com MAA, c dc acordo comamalorladoscstudos,c nadcntaduramlsta,porquc alcmdclntcrlcrlrnocrcscl-mcntodalacc,otratamcnto prccoccmclhoraaaparcncla dacrlana,aumcntandoasua auto-cstlma.Sohcstcmcsmo prlsma,qualotratamcnto mals lavoravcl para a mordlda ahcrtacsquclctlca?Scgundo Engllshll, o controlc da dlmcn-sao vcrtlcal passa a scr o lator malslmportantcnosuccsso dotratamcntodcpaclcntcs comhlpcrdlvcrgcnclalaclal.O tratamcnto dcvcrla rcsultar no aumcnto laclal proporclonal dc postcrlorparaantcrlor,daro-taao da mandlhula no scntldo antl-horarlo,caumcntodo crcsclmcntovcrtlcaldocondl-lo.Umdosmccanlsmospara sc conscgulr a rotaao antl-ho-rarla da mandlhula c por mclo dalntrusaodosmolarcs, oudocontrolcvcrtlcaldcstcs dcntcs.Hamalsdcduasdccadas utlllzamos com succsso a mcn-tonclraassocladacomgradcs palatlnasLxasourcmovlvcls paraotratamcntodaMAA dcntarlaoucsquclctlca.Os paclcntcssaoorlcntadosautl-llzarcmamcntonclrasomcntc a noltc por l2 a l+ horas com loradc+CCa+5Cgramasdc cadalado.Estcprotocolodc tratamcnto nao c rcccntc, como scpodcohscrvarnoscstudos dcPcarson3+,35,36,Dclllngcr9 cHaasl7.Outroaspcctodc lntcrcssccqucgcralmcntco paclcntc com MAA possul atrc-slamaxllarcomosallcntado antcrlormcntc,oquclnsplra acolocaaodcumaparclho cxpansormaxllar.Nocntanto, cstcproccdlmcntogcraacx-trusaodosmolarcssupcrlorcs cconscqcntcmcntcarotaao horarlamandlhular.Paracstcs casos,amcntonclratorna-sc cxtrcmamcntcutll,controlan-domclhoradlmcnsaovcrtlcal comoaludldoporMa|ourauc Nanda28.Sankcyctal.+Cquc comhlnaram o uso do cxpansor colado na maxlla com a mcnto-nclra c a placa lahlo-atlva mo-dlLcadaparaotratamcntodc 38paclcntcshlpcrdlvcrgcntcs comldadcmcdlalnlclaldc8,2 anos. Os rcsultados apontaram qucl6paclcntcsqucpossu-lamMAAaprcscntaramum aumcntonotrcspasscvcrtlcal dc2,7mmcomrcstrlaono aumcntodaAFAIcrotaao mandlhularantcrlor2,7vczcs malorcomparando-sccomo grupo controlc. Flnallzando,conclulmos qucparaarcallzaaodcum dlagnostlcodllcrcnclal,alcm daohscrvaaodahcrcdlta-rlcdadc,dascvcrldadcdama oclusaocdoslatorcsamhlcn-tals,hancccssldadcdcuma anallsccclalomctrlcaquc auxlllcnadctcrmlnaaodo padraodccrcsclmcntolaclalc dograudccnvolvlmcntodos clcmcntososscoscdcntarlos. Com cstcs clcmcntos podcmos dctcrmlnarsccstamosdlantc dc uma ma oclusao com prog-nostlcolavoravclounaoc qual a mclhor ahordagcm para o tratamcnto.CASOS CLNICOSMordidaAbertaAnteriorDen-triaOcasocllnlconlrclcrc-scaumpaclcntccom9anos dcldadcnalascdcdcntadura mlsta,pcrlodolntcrtransltorlo, aprcscntandodcglutlaoatl-plcacomlntcrposlaollngual prlmarlarcsultandonuma cxccsslvalncllnaaoparavcs-tlhulardoslnclslvossupcrlorcs c lnlcrlorcs com o conscqcntc aparcclmcntodcdlastcmas, caractcrlzando uma hlprotrusao dcntarla.Podcmosohscrvar naLgural.lqucopaclcntc lntcrpocallnguacntrcosln-clslvos no lntcnto dc promovcr o sclamcnto antcrlor ncccssarlo adcglutlao.Paraalntcrccp-taaodcstamordldaahcrta antcrlor dcntarla o protocolo dc tratamcnto conslstlu na coloca-aodcumaparclhorcmovlvcl dotlpoplacadcHawlcycom gradcpalatlna{Flg.l.2,l.3). Rcssalta-sc quc a gradc palatl-nadcvcscrlongaosuLclcntc para lmpcdlr quc a llngua passc 96R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 97soh cla. A Lgura l.+ cvldcncla o lcchamcnto da mordlda ahcr-tacacstahllldadcdacorrcao trcs anos apos.Ocasocllnlcono2trata-sc dcumapaclcntccom+anos dcldadcaprcscntandodcn-taduradcclduaclntcrposlao llngualcommordldaahcrta dcntarlaantcrlor{lnclplcntc) cmordldacruzadapostcrlor {Flg. 2.l, 2.2). Dcvldo a ldadc dapaclcntccadlLculdadcdc colahoraao com aparclhos rc-movlvclsoptou-scpclalnsta-laao dc um arco cm W Lxo comgradcpalatlna{Flg.2.3). Apos 5 mcscs dc uso do aparc-lho nota-sc na Lgura 2.+ uma sohrcmordlda c um mclhor rc-laclonamcnto transvcrsal cntrc osarcossupcrlorclnlcrlor.A paclcntc lol acompanhada lon-gltudlnalmcntc atc os l5 anos dc ldadc scm a ncccssldadc dc usodcoutrosaparclhos.As Lguras2.5-2.l2dcnotamo dcscnvolvlmcntonormalda oclusaoatcadcntadurapcr-mancntc complcta.1.1 1.2 1.31.42.12.2 2.32.4 2.5 2.696R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 97MordidaAbertaAnteriorDen-to-alveolarNocasocllnlcono3ohscr-va-sc uma paclcntc com 6 anos clCmcscsdcldadcportadora dc uma mordlda ahcrta antcrlor dotlpodcnto-alvcolarcomos lnclslvossupcrlorcslncllnados paravcstlhularcdlastcmas gcncrallzadosdcvldoasucao dcpolcgar{Flg.3.l-3.3).A ahordagcmtcrapcutlcapara corrcao dcsta ma oclusao lol a lnstalaao dc uma gradc palatl-na Lxa {Flg. 3.+). Estc aparclho tcmduplaLnalldadc,alcmdc lmpcdlralntcrposlaosccun-darladallnguadurantcalala c a dcglutlao, clc atua tamhcm como rccordatorlo lcmhrando o paclcntc a nao sugar o polcgar. Apos6mcscsohscrva-scna Lgura3.5olcchamcntoda mordlda. As Lguras 3.6 - 3.ll mostramoacompanhamcnto longltudlnaldocasoutlllzando apcnasumaplacadcHawlcy comocontcnaoatcalrrupao complctadctodososdcntcs pcrmancntcs,quandosclns-2.72.8 2.92.10 2.11 2.123.1 3.2 3.33.4 3.598R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 993.6 3.7 3.83.9 3.10 3.113.12 3.133.143.15 3.16 3.173.18 3.1998R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 993.21 3.22 3.233.203.24 3.25talouaparclhagcmLxaparao rcLnamcntodaoclusao{Flg. 3.l2,3.l3).AsLguras3.l+ -3.l9mostramopcrLllaclal caLnallzaaodotratamcnto. Apos3anosdarcmoaodo aparclhoLxocvldcncla-sca cstahllldadc do tratamcnto nas Lguras3.2C-3.25.Ascq-cnclacacvoluaodctodoo tratamcnto podc scr ohscrvada nasradlograLaspanormlcas {Flg.3.26-3.3C),nastclcr-radlograLas {Flg. 3.3l - 3.35) cnatahclalcomasmcdldas cclalomctrlcas.3.26 3.273.28 3.29100R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 1013.31 3.32 3.333.303.34 3.35Medidas Inicial Interc. (1995)Final Interc. (1997)Inicial Corretiva (1999)Final Corretiva (2000)Controle 3 anos (2003)SNA 78 78 81 80 80SNB 76 76 78 78 78ANB 2 2 3 2 2SND 72 72 75 75 751.NA 36 34 25 27 261.NB 28 26 27 24 25FMA 28 28 28 30 30SN.GoGn 38 38 35 36 36SN.Gn 79 69 67 67 68Co-A 79 mm 82 mm 88 mm 89 mm 89 mmCO-Gn 101 mm 103 mm 112 mm 116 mm 120 mmAFP/AFA 58,9% 56,48% 59,82 mm 58,97% 59,50%TABELA 1 MEDIDAS CEFALOMTRICAS100R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 101Ocasocllnlcono+rclcrc-sc aumapaclcntcdc8anosc2 mcscs dc ldadc com ma oclusao dc Classc II, l dlvlsao com mor-dldaahcrtaantcrlorcmordlda cruzadapostcrlor.Ncstccasoo latorctlologlcoprlnclpallola sucao dc polcgar provocando a vcstlhulo-vcrsaodaprc-maxlla comlncllnaaodoslnclslvos supcrlorcs para vcstlhular c dos lnclslvoslnlcrlorcsparallngual {Flg.+.l-+.5).Inlclalmcntc corrlglu-sc a dlscrcpncla trans-vcrsalcvcrtlcalcomumapa-rclhoLxodotlpohlhcllcccom gradcpalatlna{Flg.+.6-+.8). A scgulr lol lnstalada uma placa lahlo atlva adaptada no scgundo molar dcclduo supcrlor com a L-nalldadc dc cstahlllzar a maxlla, lmpcdlralntcrposlaodolahlo lnlcrlor proplclando a lncllnaao dos lnclslvos lnlcrlorcs para vcs-tlhular pcla aao da llngua {Flg. +.9-+.ll).Aproxlmadamcntc lCmcscsaposousodaPLA vcrlLca-scumamclhoraslg-nlLcantcnasrclaocsvcrtlcal, transvcrsalcntcro-postcrlor comosmolarcsccanlnoscm chavcdcoclusao{Flg.+.l2, +.l3).AcorrcaodaClasscII 4.3 4.4 4.54.1 4.24.6 4.7 4.84.9 4.10 4.11102R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 1034.16 4.174.144.154.19 4.20 4.184.12 4.134.22 4.234.21provavclmcntcocorrcudcvldo a ancoragcm dos molarcs supc-rlorcscummalorcrcsclmcnto damandlhulaconlormctahcla {colunasl,2)cLguras+.l+ -+.l7.Apaclcntclolacompa-nhadalongltudlnalmcntccom controlcspcrlodlcoscscma utlllzaaodcqualqucroutro aparclhocomomostraasLgu-ras +.l8 - +.23. Apos l3 anos a oclusaopcrmanccccstavclnos trcs planos vcrtlcal, transvcrsal cntcro-postcrlor{Flg.+.2+- +.3C).Aproscrvaaopormclo dasradlograLaspanormlcasc tclcrradlograLascmnormala-tcralpodcscrcvldcncladanas Lguras +.3l - +.38 c os valorcs cclalomctrlcos dc todas as lascs cncontram-sc na tahcla 2.102R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 1034.27 4.28 4.264.24 4.254.29 4.304.31 4.324.33 4.34104R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 105Medidas Inicial (1990)Controle (1993)Controle (1997)Controle (2003)SNA 82 79 78 78SNB 75 76 76 76ANB 7 3 2 2SND 71 72 72 731.NA 29 21 15 151.NB 25 24 19 23FMA 28 24 25 25SN.GoGn 39 38 34 35SN.Gn 70 70 70 70Co-A 82 mm 88 mm 91 mm 91 mmCo-Gn 96 mm 106 mm 116 mm 117 mmAFP/AFA 55,55% 59,63% 60,34% 59,48%TABELA 2MEDIDAS CEFALOMTRICASNo caso cllnlco no 5 nota-sc umapaclcntccom7anoscl mcs dc ldadc portadora dc uma maoclusaodcClasscII,ladl-vlsaocommordldaahcrtaan-tcrlordcnto-alvcolar{Flg.5.l - 5.5). Para a corrcao da rcla-ao ntcro-postcrlor utlllzou-sc umspllntmaxllarmodlLcado {AEBcon|ugado){Flg.5.6, 5.7)qucalcmdcproporclo-nararcstrlaomaxllaratuou comoumhltchlockcorrlglndo a mordlda ahcrta antcrlor {Flg. 5.8,5.9).Aposaohtcnaodc umadcquadorclaclonamcnto maxllo-mandlhular,rcmovcu-scaloracxtrahucalcadap-tou-scumaplacadcHawlcy {Flg.5.lC)pararcduzlros dlastcmasgcncrallzados{Flg. 5.ll).AsLguras5.l2-5.l7 mostramocasoapos6anos scmousodcaparclhosLxos. Oacompanhamcntolongltu-dlnalpodcscrohscrvadonas radlograLaspanormlcas{Flg. 5.l8,5.l9),nastclcrradlo-graLas{Flg.5.2C,5.2l)cna tahcla 3.4.35 4.364.37 4.38104R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 1055.3 5.4 5.55.15.25.65.75.8 5.95.10 5.11106R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 1075.12 5.135.145.15 5.16 5.175.18 5.195.20 5.21106R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 107MEDIDAS Inicial (1984) Final (1990)SNA 82 78SNB 74 75ANB 8 3SN.Gn 69,5 70SN.GoGn 41 391.NA 29 231-NA 5mm 4mm1.NB 31 261-NB 5,5mm 4mmng. Nasolabial 90 102TABELA 3Medidas CefalomtricasA paclcntc do caso cllnlco no 6 com 7 anos dc ldadc cxlhla mor-dldaahcrtaantcrlordcnto-alvc-olarcomoslnclslvossupcrlorcs comdlastcmasclncllnadospara vcstlhular c os lnlcrlorcs vcrtlca-llzados,caractcrlzandoasucao dopolcgar.Apaclcntcaprcscn-tavaalndarcsplraaohucalo quctornavaamordldaahcrta malsscvcracdcdlllcllcorrcao dcvldo ao dcscqulllhrlo lunclonal, rcsultado dc uma hlpcrlunao da musculaturacxtcrna,provocan-do uma atrcsla maxllar {Flg. 6.l -6.5).Comoccomumohscrvar ncstcs casos, a sucao do polcgar cstavaacompanhadaporuma lntcrposlaollngualsccundarla, polsamorlologlacxlstcntcpro-vocada pclo hahlto dc sucao, laz comqucallnguasclntcrponha cntrc os lnclslvos, aumcntando a mordlda ahcrta. Para o tratamcn-todcstamaoclusaoutlllzou-sc umhlhcllcccomgradcpalatlna Lxa {Flg. 6.6, 6.7). Dcvldo a La-cldcz da musculatura pcrlhucal, a posturaanormaldallnguacna tcntatlva dc altcrar o crcsclmcnto da mandlhula do scntldo horarlo paraantl-horarlooptou-scpcla assoclaaodamcntonclracom usosomcntcnoturno{Flg.6.8). Nota-sc nas Lguras 6.9, 6.lC um homlormatodoarcosupcrlor cacorrcaodamordldaahcrta antcrlor cstahlllzada com a placa dcHawlcyquclolutlllzadaatc alrrupaodctodososdcntcs pcrmancntcs,quandolnlclou-sc otratamcntocomaparclhoLxo {Flg.6.ll,6.l2).AsLguras 6.l3-6.l6mostramaoclusao lmcdlatamcntcaposarcmoao do aparclho Lxo. O caso lol con-troladolongltudlnalmcntcpor 6anosmostrandocstahllldadc multosatlslatorlacomopodc scrohscrvadonasLguras6.l7 - 6.22, nas radlograLas panor-mlcas {Flg. 6.23 - 6.26) c tclcr-radlograLas {Flg. 6.27 - 6.3l) c na tahcla +. 6.3 6.4 6.56.16.2108R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 1096.86.9 6.106.6 6.76.11 6.126.13 6.146.15 6.16108R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 1096.176.18 6.196.20 6.21 6.226.23 6.246.25 6.26110R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 111Medidas Inicial Interc. (1989)Final Interc. (1992)FinalCorretiva (1995)Controle 2 anos (1997)Controle 6 anos (2001)SNA 80,5 81 82 82 83SNB 78 79 80 80 80ANB 2,5 2 2 2 3SND 74 76 76 76,5 771.NA 28 18,5 21 18 191.NB 36,5 17,5 21 24 25,5FMA 35 32 29 29 28SN.GoGn 40 34,5 35 35 35,5SN.Gn 67,5 68 69 69 69Co-A 86 mm 89 mm 92 mm 93 mm 95 mmCO-Gn 113 mm 117 mm 125 mm 128 mm 132 mmAFP/AFA 60% 62,2% 62,5% 63% 63,5%TABELA 4 MEDIDAS CEFALOMTRICAS6.27 6.28 6.296.30 6.31110R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 111O caso cllnlco no 7 pcrtcncc a uma paclcntc com 9 anos c 9 mcscs dc ldadc com ma oclusao Classc I c mordlda ahcrta dcnto-alvcolar{Flg.7.l-7.3).Ncstc casonaoscutlllzouagradc palatlna dcvldo a nao accltaao da paclcntc, optando cntao pclo protocolo dcscrlto antcrlormcntc quc consta do uso dc um hlhcll-cc assoclado a mcntonclra {Flg. 7.+,7.5).Aposolcchamcnto damordldacalrrupaodc todososdcntcspcrmancntcs lnstalou-scaparclhoLxo{Flg. 7.6, 7.7). As Lguras 7.8 - 7.ll mostram a paclcntc c sua oclu-sao apos a rcmoao do aparclho Lxo. Como norma acompanha-mos a paclcntc por longo prazo {l+anos)cacstahllldadcdo tratamcntopodcscrconlcrlda nasLguras7.l2-7.29,nas radlograLaspanormlcas{Flg. 7.3C - 7.33) c tclcrradlograLas {Flg.7.3+-7.39)cnatahcla 5.7.1 7.2 7.37.47.57.6 7.77.87.9 7.10 7.11112R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 1137.12 7.137.14 7.157.16 7.177.18 7.197.20 7.21112R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 1137.22 7.237.247.25 7.266.27 6.28 6.297.27 7.28 7.297.30 7.317.32 7.33114R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 115Medidas Inicial (1987)Final (1989)Controle (1990)Controle (1992)Controle (2000)Controle (2003)SNA 84 80 81 81 81 81SNB 77 77 77 77 77 76ANB 7 3 4 4 4 5SND 74 74 73 73 73 731.NA 19 20 21 21 20 201.NB 31 26 28 28 31 31FMA 30 31 28 28 28 28SN.GoGn 38 36 38 38 38 39SN.Gn 71 69 71 71 72 72CO-A 96 mm 91 mm 92 mm 94 mm 94 mm 94 mmCO-Gn 116 mm 117 mm 118 mm 124 mm 124 mm 124 mmAFP/AFA 60,68% 60,83% 58,87% 57,93% 58,13 58,91%TABELA 5Medidas Cefalomtricas7.34 7.35 7.367.37 7.38 7.39MORDIDAABERTAANTERIOR ESQUELTICAOcasocllnlcono8rclcrc-sc umapaclcntccomllanosc2 mcscs dc ldadc, na lasc dc dcnta-durapcrmancntc,aprcscntando umamordldaahcrtaantcrlorc postcrlor,comoclusaoapcnas nosmolarcs{Flg.8.l-8.7). Cclalomctrlcamcntc,apaclcntc aprcscntavacaractcrlstlcasdc umamordldaahcrtacsquclctlca comongulogonlacoohtuso, ramoasccndcntcdamandlhula curto, altura laclal postcrlor dlml-114R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 115nulda, altura laclal ntcro-lnlcrlor aumcntada,planoshorlzontals cxccsslvamcntcdlvcrgcntcsc padraodccrcsclmcntohlpcrdl-vcrgcntc {Tah. 5). A prlmclra op-ao para a soluao do caso lol a ahordagcmortodontlco-clrurglca, scndolmcdlatamcntcdcscartada pclospalscpclapaclcntc.Asc-gunda opao, tamhcm nao acclta, conslstla na lndlcaao da cxtraao dos quatro prlmclros molarcs pcr-mancntcs motlvados pclo cstudo dc Amstcrdam5 quc dclcndla quc para cada mlllmctro dc dcsgastcs nosdcntcspostcrlorcs{molarcs) otrcspasscvcrtlcalaumcnta-rlatrcsmlllmctros,oqucncstc casoscrlaaltamcntclavoravcl. Scndoasslm,outroprotocolodc tratamcnto lol olcrccldo c acclto, constandodacxtraaodosqua-troprlmclrosprc-molarcs,uma vcz quc o caso aprcscntava uma dlscrcpnclancgatlva{Flg.8.8, 8.9). Assoclada ao aparclho Lxo apaclcntcusouumatraaoalta vcrtlcal na rcglao do mcnto {Flg. 8.lC, 8.ll) por l6 horas/dla du-rantc todo o tratamcnto na tcnta-tlva dc rotaclonar a mandlhula no scntldo antl-horarlo ocaslonando ummovlmcntolntruslvonos molarcs.Comonaodlspunha-mosnaquclcmomcntodcuma mcntonclraccasquctcaproprla-do,utlllzamostrcsalmoladasc clastlcos dc traao ccrvlcal. Apos dolsanoscmclodctratamcnto, a mordlda lol lcchada {Flg. 8.l2 -8.l5),mclhorandosohrcma-nclra a cstctlca laclal c a oclusao Lnal quc sc mantcvc cstavcl atc o ultlmo controlc dols anos apos o tcrmlno do tratamcnto {Flg. 8.l6 -8.22).Podc-scnotarpormclo dasradlograLaspanormlcas {Flg. 8.23 - 8.26), tclcrradlogra-Las{Flg.8.27-8.3C)cvalorcs cclalomctrlcos {Tah. 6) o succsso do tratamcnto.8.1 8.2 8.38.4 8.58.6 8.7116R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 1178.8 8.98.10 8.118.12 8.138.14 8.158.16 8.17116R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 1178.18 8.19 8.208.21 8.228.23 8.248.25 8.268.27 8.29 8.28 8.30118R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 119CONSIDERAES FINAISAlntcrccptaaodamordlda ahcrta antcrlor, na lasc dc dcn-tadura mlsta, quando aprcscnta alnda um caratcr dcntoalvcolar, possulumprognostlcolavo-ravcl.Entrctanto,noscasos cmquchaocnvolvlmcntodc componcntcscsquclctlcosna suacomposlao,ncmscmprc ascompcnsaocsdcntarlas produzldaspclotratamcnto ortodontlcotrazcmrcsultados satlslatorlos. Multas vczcs, tor-na-scncccssarlocomhlnarum tratamcntoortodontlcocorrctl-vocomaclrurglaortognatlca, paraaohtcnaodcrcsultados mclhorcscmalscstavcls,cs-pcclalmcntcnospaclcntcsquc |a ultrapassaram a lasc dc crcs-clmcnto laclal lntcnso. Por Lm, dcvc-sc rcssaltar, alnda, quc, a dcspclto do tlpo dc lntcrvcnao rcallzada, a rccldlva podc ocor-rcr cm qualqucr caso dc mordlda ahcrta antcrlor, mcsmo quando tratadacomclrurglaortognatl-ca. Porcm, quando lntcrccptada adcquadamcntc cm uma cpoca prccocc,cllmlnando-sctodos osscuslatorcsctlologlcosc rcallzando um hom dlagnostlco assoclado a um tratamcnto com a mcntonclra, a cstahllldadc da corrcaoaumcntaslgnlLcantc-mcntc.AGRADECIMENTOOsautorcsagradcccma mcstrcAnaluClamplctro Brandaopclacolahoraaono prcparodaslmagcnsradlogra-Lcasctahclascontldasncstc trahalho.AbstractThcconccrnahoutthcvcrtlcal dysplaslaslcdthcauthorsto pcrlormarcvlcwonthcantcrlor opcnhltc,aswcllastocstahllsh atrcatmcntprotocoldurlngthc mlxcddcntltlonwhlchconslsts oluslngthcrcmovahlcorLxcd palatal crlh assoclatcd to thc usc ol thc chln cup all nlght long. Cllnlcal cascswlthlongltudlnallollow-up arc also prcscntcd, locuslng on thc corrcctlon stahlllty.Keywords:BuccalHahlts.Antc-rlor Opcn Bltc. Long Facc.REFERNCIAS l -ALMEIDA, R. R., URSI, W. }. S. Antc-rlor opcn hltc ctlology and trcatmcnt. Oral Hcalth, Toronto, v. 8C, no. l, p. 27-3l, }an. l99C.2 -ALMEIDA, R. R. ct al. Mordlda ahcr-ta antcrlor consldcraocs c aprcscn-taao dc um caso cllnlco. B Dcntal Prcss Ortodon Orto Facial, Ma-rlnga, v. 3, n. 2, p.l7-29, mar./ahr. l998.3 -ALMEIDA, R. R. ct al. Ortodontla prc-vcntlva c lntcrccptora mlto ou rcallda-dc. B Dcntal Prcss Ortodon Orto Facial, Marlnga, v. +, n. 6, p. 87-lC8, nov./dcz. l999.+ -ALMEIDA, R. R. ct al. Etlologla das mas oclusocs causas hcrcdltarlas c congcnl-tas, adqulrldas gcrals, locals c proxlmals {hahltos hucals). B Dcntal Prcss Orto-don Orto Facial, Marlnga, v. 5, n. 6, p.lC7-l29, nov./dcz. 2CCC.5 -AMSTERDAM, M. Pcrlodontal pros-thcsls twcnty-Lvc ycars ln rctrospcct. Alha Omcgan, Phlladclphla, v. 67, p. 8-52, l97+.6 -B}ORl, A. Varlatlons ln thc growth pattcrn ol thc human mandlhlc lon-gltudlnal radlographlc study hy thc lmplant mcthod. ) Dcnt Bcs, Chlcago, v. +2, p. +CC-+ll, l963.7 -CLEMENS, C. PrcValcncia da mor-dida abcrta antcrior cm cscolarcs dc Porto Alcgrc. l977. Dlsscrtaao {Mcstrado)-Unlvcrsldadc Fcdcral do Rlo Crandc do Sul, Porto Alcgrc, l977.8 -DAWSON, P. E. 5olVing antcrior ocn-bitc roblcm cvaluatlon, dlagnosls and trcatmcnt ol occluslon prohlcms. Salnt Louls Moshy, l97+. 9 -DELLINCER, E. L. A cllnlcal asscss-mcnt ol thc actlvc vcrtlcal corrcctor a nonsurglcal altcrnatlvc lor skclctal opcn-hltc. Am ) Orthod Dcntolacial Ortho, St. Louls, v. 89, p. +28-+36, l986.Medidas InicialCorretiva (1983)Tele Interm. (1984)FinalCorretiva (1986)Controle2 anos (1988)SNA 81,5 82 81 80SNB 76 75 75 75ANB 5,5 7,0 6 5SND 74,5 74,5 74 741.NA 31 5 5 131.NB 33,5 21 23 28FMA 35 36 36 34SN.GoGn 39 38 40 40SN.Gn 72 72 72 74Co-A 88 mm 90 mm 92 mm 89 mmCo-Gn 116 mm 114 mm 121 mm 120 mmAFP/AFA 58,8% 60,16% 56,59% 59,37%TABELA 6MEDIDAS CEFALOMTRICAS118R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 R Dental Press Ortodon Ortop Facial, Maring, v. 8, n. 4, p. 91-119, jul/ago. 2003 119lC - ELLIS, E. ct al. Componcnts ol adult Class II opcn hltc maloccluslon. ) Oral MaXillolacial 5urg, Phlladclphla, v. +2, p. 2l9-228, l985.ll - ENCLISH, }. D. ct al. Musclc cxcrclsc cllccts on thc carly trcatmcnt ol skclc-tal opcn-hltc maloccluslons. ANNUAL 5E55lON OF THE lNTEBNATlONAL A55OClATlON OF DENTAL BE-5EABCH, 8C, 2CC2, ]S. l|. Ahstract. ]S.l. s. n.|, 2CC2.l2 - ESTRIPEAUT, L. E., HENRIQUES, }. F. C., ALMEIDA, R. R. Hahlto dc sucao dlgltal c ma oclusao rclato dc um caso cllnlco. B Odontol UniV 5ao Paulo, Sao Paulo, v. 3, n. 2, p. 37l-376, l989.l3 - FRANlEL, R. Llp scal tralnlng thc trcatmcnt ol skclctal opcn-hltc. Eur ) Orthod, London, v. 2, no. 3/+, p. 2l9-228, l98C.l+ - FRANlEL, R., FRANlEL, C. A lunc-tlonal approach to trcatmcnt ol skclctal opcn-hltc. Am ) Orthod Dcntolacial Ortho, St. Louls, v. 8+, no. l, p. 5+-68, }uly l983.l5 - CESHATER, M. M. Thc propcr pcrs-pcctlvc ol opcn-hltc. Anglc Orthod, Applcton, v. +2, no. 3, p. 263-27l, }uly l972.l6.CRABER, T. M. Thumh and Lngcr-suklng. Am ) Orthod Dcntolacial Ortho, St. Louls, v. +5, no. +, p. 258-26+, Apr. l959.l7 - HAAS, A. }. A hlologlcal approach to dlagnosls, mcchanlcs, and trcatmcnt ol vcrtlcal dysplasla. Anglc Orthod, Applcton, v. 5C, p. 279-3CC, l98C.l8 - HARVOLD, E. P. ct al.Prlmatc cxpc-rlmcnts on oral rcsplratlon. Am ) Or-thod Dcntolacial Ortho, St. Louls, v. 79, no. +, p. 359-372, Apr. l98l.l9 - HUANC, C. }. ct al. Stahlllty ol antcrlor opcn-hltc trcatcd wlth crlh thcrapy. Anglc Orthod, Applcton, v. 6C, no. l, p. l7-25, l989.2C - lLOClE, A. Ask Us. Am ) Orthod Dcntolacial Ortho, St. Louls, v. l23, p.l3, 2CC3.2l - LARSSON, E. Dammy and Lngcr suklng hahlts wlth spcclal attcntlon to thc slgnlLcancc lor laclal growth and occluslon. 5wcd Dcnt ), Stockholm, v. 2, p. 23-33, l978.22 -LINDER-ARONSON, S. ct al. Mandlhular growth dlrcctlon lollowlng adcnouldcc-tomy. Am ) Orthod Dcntolacial Or-tho, St. Louls, v. 8+, p. 273-283, l986.23 - LEWIS, S. }. Thumh-sucklng a causc ol maloccluslon ln thc dcclduous tccth. ) Am Dcnt Assoc, Chlcago, v. l7, p. lC6C-lC73, l93C.2+ - LIEBERMAN, M. A. ct al. Corrcctlon ol a Class I skclctal opcn hltc malocclu-slon. ANCLE ORTHOD, Applcton, v. +8, no. 3, p. 2C6-2C9, }uly l978.25 - LIMA, R. S. Mordlda ahcrta rcvlsao dc lltcratura. Ortodontia, Sao Paulo, v. 5, p. l57-l63, l977.26 - LOPEZ-CAVITO, C. ct al. Antcrlor opcn hltc maloccluslon a longltudlnal lC ycars post rctcntlon cvaluatlon ol orthodontlcaly trcatcd patlcntcs. Am ) Orthod Dcntolacial Ortho, St. Louls, v. 87, no. 3, p. l75-l86, Mar. l985.27 - LOWE, A., }OHSTON, D.W. Tonguc and |aw musclc actlvlty ln rcsponsc to mandlhular rotatlon cvaluatlon ol orthodontlcaly trcatcd patlcnts. Am ) Orthod Dcntolacial Ortho, St. Louls, v. 76, no. 5, p. 565-576, Nov. l979.28 - MA}OURAU, A., NANDA, R. Blomc-chanlcal hasls ol vcrtlcal dlmcnslon control durlng rapld palatal cxpanslon thcrapy. Am ) Orthod Dcntolacial Ortho, St. Louls, v.lC6, p. 322-328, l99+.29 - MASSLER, M. Oral hahlts dcvclop-mcnt and managcmcnt. ) Pcdod, Bos-ton, v. 7, p. lC9-ll9, l983.3C - MIZRAHI, E. A rcvlcw ol antcrlor opcn-hltc. Br ) Orthod, London, v. 5, p. 2l-27, l978.3l - NAHOUM, H. I. Vcrtlcal proportlons and thc palatal planc ln antcrlor opcn hltc. Am ) Orthod, St. Louls, v. 59, no. 3, p. 273-28l, l97l.32 - NAHOUM, H.I Antcrlor opcn-hltc a ccphalomctrlc analysls and suggcstcd trcatmcnt proccdurcs. Am ) Orthod, St. Louls, v. 67, no. 5, p. 5l3-52l, l975. 33 - NCAN, P., FIELDS, H. W.Opcn-hltc a rcvlcw ol ctlology and managcmcnt. Pcdiatr Dcnt, Chlcago, v. l9, no. 2, p. 9l-98, l997.3+ - PEARSON, L. E.Vcrtlcal control ln lully handcd orthodontlc trcatmcnt. Anglc Orthod, Applcton, v. 56, p. 2C5-22+, l986.35 - PEARSON, L. E. Vcrtlcal control ln trc-atmcnt ol patlcnts havlng hackward-rotatlonal growth tcndcnclcs. Anglc Orthod, Applcton, v. +8, p.l32-l+C, l978.36 - PEARSON, L. E. Casc rcport lP. Trcat-mcnt ol a scvcrc opcn-hltc cxccsslvc vcrtlcal pattcrn wlth an cclcctlc non-surglcal approach. Anglc Orthod, Applcton, v. 6l, p.7l-76, l99l.37 - PINZAN, C.R.M. Habitos bucais. MonograLa aprcscntada ao programa cspcclal dc trclnamcnto {PET/CAPES). Faculdadc dc Odontologla dc Bauru-USP, l998.38 - RICHARDSON, A. A classlLcatlon ol opcn-hltc. Eur ) Orthod, London, v. 3, p. 289-296, l98l.39 - RICHARDSON, A. Skclctal lactors ln thc antcrlor opcn-hltc an dccp hltc. Am ) Orthod Dcntolacial Ortho, St. Louls, v. 56, no. 2, p.ll+-l27, Aug. l969.+C - SANlEY, W. ct al.Early trcatmcnt ol vcrtlcal skclctal dysplasla thc hypcr-dlvcrgcnt phcnotypc. Am ) Orthod Dcntolacial Ortho, St. Louls, v.ll8, p. 3l7-327, 2CCC.+l - SANTOS, E. C. A. ct al. Hahlto dc sucao dlgltal ctlologla, tratamcnto c aprcscntaao dc um caso cllnlco. B Paranacnsc dc Ortodontia, Curltlha, v.l2, n.l/2, p. 2l-29, l99l.+2 - SASSOUNI, V., NANDA, S. Analysls ol dcntolaclal vcrtlcal proportlons. Am ) Orthod Dcntolacial Ortho, St. Louls, v. 5C, no. ll, p. 8Cl-823, Nov. l96+.+3 - SILVA FILHO, O. C., CHAVES, A. S. M., ALMEIDA, R. R. Elcltos tcrapcutl-cos suscltados pclo uso da gradc pala-tlna um cstudo cclalomctrlco. B 5oc Paranacnsc Ortod, Curltlha, v. l, n. l, p. 9-l5, nov./dcz. l995/l996.++ - SILVA FILHO, O. C., FREITAS, S. F., CAVASSAN, A. O. Hahltos dc sucao - clcmcntos passlvcls dc lntcrvcnao. Estomatol Cult, Bauru, v.l6, n. +, p. 6l-7l, l986.+5 - SILVA FILHO, O. C., FREITAS, S. F., CAVASSAN, A. O. Prcvalcncla dc oclu-sao normal c ma oclusao cm cscolarcs da cldadc dc Bauru {Sao Paulo). Partc II lnLucncla da cstratlLcaao soclo-cconomlca. B Odontol UniV 5ao Paulo, Sao Paulo, v. +, n. 3, p.l89-l96, |ul./sct. l989.+6 - SILVA FILHO, O. C., CONALVES, R. M. C., MAIA, F. A. Sucklng hahlts cllnlcal managcmcnts ln dcntlstry. ) Clin Pcdiatr Dcnt, Blrmlngham, v.l5, no.3, p.l37-l56, l99l.+7 - SILVA FILHO, O. C., OlADA, T., SAN-TOS, S. D. Sucao dlgltal ahordagcm multldlsclpllnar ortodontla x pslcolo-gla x lonoaudlologla. Estomatol Cult, Bauru, v. l6, n. 2, p. 38-++, l986.+8 - SILVA FILHO, O. C. ct al. Hahltos dc sucao clcmcntos passlvcls dc lntcr-vcnao. Estomatol Cult, Bauru, v.l6, p. 6l-7l, l986.+9 - SPEIDEL, T.M. ct al. Tonguc thrust thcrapy and antcrlor dcntal opcn-hltc. Am ) Orthod Dcntolacial Ortho, St. Louls, v. 62, no. 3, p. 287-95, Scpt. l972.5C - SUBTELNY, }. D. Oral hahlts studlcs ln lorm, lunctlon and thcrapy. Anglc Orthod, Applcton, v. +3, no. +, p. 3+7-383, Oct. l973.5l - TROUTEN, }. C. ct al. Morphologlc lactors ln opcn-hltc and dccp hltc. Anglc Orthod, Applcton, v. 53, no. 3, p.l92-2ll, }uly l983.52 - VATTEONE, A. L. Mordlda ahlcrta lor-mas cllnlcas c tratamlcnto. B Circ Arg Odontol, Bucnos Alrcs, v. 32, p.l7-22, l969.53 - WATSON, W. C. Opcn-hltc, a multllac-toral cvcnt. Am ) Orthod Dcntola-cial Ortho, St. Louls, v. 8C, no. +, p. ++2-++6, Oct. l98l.5+ - WORMS, F.W. ct al. Opcn-hltc. Am ) Orthod Dcntolacial Ortho, St. Louls, v. 59, no. 6, p. 589-595, }unc l97l.Endereo para correspondnciaRcnato Rodrlgucs dc AlmcldaFaculdadc dc Odontologla dc Bauru - USPAlamcda Otavlo Plnhclro Brlsolla 9-75 l7Cl2-9Cl - Bauru - SPc-mall rcnatlnhaalmclda@uol.com.hr