J Exp Clin Med 2013;5(1):1e4

Contents lists available at SciVerse ScienceDirect

Journal of Experimental and Clinical Medicine

journal homepage: http://www.jecm-online.com

REVIEW ARTICLE

Etiology and Treatment Modalities of Anterior Open Bite Malocclusion

Li-Hsiang Lin 1, 2 *, Guo-Wei Huang 1, Chin-Sung Chen 1, 3
1
2
3

School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
Department of Orthodontics, Wang Fan Medical Center, Taipei, Taiwan
Sihjih Cathay General Hospital, Taipei, Taiwan

a r t i c l e i n f o
Article history:
Received: Jun 1, 2012
Revised: Sep 12, 2012
Accepted: Dec 21, 2012
KEY WORDS:
anterior open bite relapse;
dentofacial morphology;
orthognathic surgery;
overbite depth indicator

The complexity of anterior open bite is attributed to a combination of skeletal, dental, soft tissue, and
habitual factors. Multiple treatment strategies aimed at different etiologies of anterior open bite have
been proposed. However, the tendency toward relapse after conventional or surgical orthodontic
treatment has been indicated. Therefore, anterior open bite is considered one of the most challenging
dentofacial deformities to treat. The aim of this article is to review the etiologies, dentofacial morphology, treatment modalities, retention, and stability of anterior open bite. The etiology of anterior open
bite malocclusions is multifactorial and numerous theories have been proposed, including genetic,
anatomic and environmental factors. The diagnosis and treatment modalities are variable according to
the etiology. Failure of tongue posture adaptation subsequent to orthodontic and/or surgical treatment
might be the primary reason for relapse of anterior open bite. Prolonged retention with xed or
removable retainers is advisable and necessary in most cases of open bite treatment. The treatment of
anterior open bite remains a tough challenge to the clinician; careful diagnosis and timely intervention
with proper treatment modalities and appliance selection will improve the treatment outcomes and
long-term stability.
Copyright ! 2013, Taipei Medical University. Published by Elsevier Taiwan LLC. All rights reserved.

1. Introduction

2. Etiology

Anterior open bite is dened as no contact and vertical overlap

between the maxillary and mandibular incisors.1,2 The incidence of
anterior open bite ranges from 1.5% to 11% and varies between races
and with dental age.3 The complexity of anterior open bite is
attributed to a combination of skeletal, dental, soft tissue, and
habitual factors.4 Multiple treatment strategies aimed at different
etiologies of anterior open bite have been proposed. However, there
is a tendency toward relapse after conventional or surgical orthodontic treatment.5,6 Therefore, anterior open bite is considered one
of the most challenging dentofacial deformities to treat due to
difculties in determining the causes, formulating a diagnosis and
the potential for relapse after treatment.4 The aim of this article is
to review the etiologies, dentofacial morphology, treatment modalities, retention, and stability of anterior open bite.

Open bites are generally classied as either skeletal or dental. The

dental open bite is generally found in the anterior region within the
area of the cuspids and incisors and is associated with normal craniofacial pattern, proclined and undererupted anterior teeth, and
thumb or nger sucking habits. The skeletal open bite is often related
to excessive vertical growth of the dento-alveolar complex, especially in the posterior molar region. As anterior open bite is often the
result of a combination of both factors, it makes classication of open
bite as either skeletal or dental difcult. Therefore, it has been suggested that the most clinically useful classication of open bites
should be based on etiology. The etiology of anterior open bite
malocclusions is multifactorial and numerous theories, including
genetic, anatomic, and environmental factors, have been proposed.

3. Genetic and anatomic factors

* Corresponding author. Li-Hsiang Lin, School of Dentistry, College of Oral Medicine, Taipei Medical University, Number 250, Wu-Hsing Street, Taipei 11031,
Taiwan.
E-mail: L.-H. Lin <lisa@tmu.edu.tw>

An anterior open bite is related primarily to the patients unfavorable

growth potential and heredity.7e9 Obtaining a thorough family
history will help the clinician predict a patients growth pattern.
Based on cephalometric analyses, the steepness of the mandibular
plane is considered the key skeletal nding associated with a skeletal anterior open bite. An increased gonial angle, a downward and

1878-3317/$ e see front matter Copyright ! 2013, Taipei Medical University. Published by Elsevier Taiwan LLC. All rights reserved.
http://dx.doi.org/10.1016/j.jecm.2013.01.004

L.-H. Lin et al.

backward position of the mandibular ramus, and shortened posterior facial height are additive in the production of the high mandibular plane angle in an open bite population.10 It has been
suggested that the overbite depth indicator (ODI) index can be
a good predictor in the primary dentition of a skeletal open bite
tendency in the adolescent. The ODI is the arithmetic sum of the
angle of the AeB plane to the mandibular plane and the angle of the
Palatal plane to Frankfort horizontal plane. The study produced
a norm of 74.5! , with a standard deviation of 6.07!.11 A value of 68! or
less indicates a skeletal open bite tendency.12 Another useful
method to help predict vertical growth patterns is based Nahoums
diagnosis on the ratio of upper anterior facial height to lower anterior facial height (AUFH:ALFH). If a patient has an open bite and
a AUFH:ALFH ratio of less than 0.65, then the open bite is considered
skeletal which cannot be corrected by orthodontic treatment
alone.13 Anatomic conditions such as tongue size and position are
well known to affect skeletal and dental components.14 Macroglossia has been suggested as a possible cause of open bite.15 It has
been reported that in patients with anterior open bite, there are
signicant correlations between mandibular plane angle, ramus
height of the mandible, or anteroposterior dimension of the maxilla
and movement of the front part of the dorsal tongue during deglutition.16 Some anatomic conditions such as enlarged adenoids and/
or tonsils, swollen nasal turbinates, and deviated nasal septums may
impair normal upper respiratory nasal function.17 Mouth-breathing
as a result of upper airway obstruction may cause anterior open bite
but their direct relationship has not been proven.18 Mandibular
condylar resorption has also been identied as an etiologic factor of
anterior open bite. Many local and systemic pathologies or diseases
can cause mandibular condylar resorption. Local factors include
osteoarthritis, reactive arthritis, avascular necrosis, infection, and
traumatic injuries. Systemic connective tissue or autoimmune diseases that can cause condylar resorption include rheumatoid
arthritis, psoriatic arthritis, scleroderma, systemic lupus erythematosus, Sjgren syndrome, ankylosing spondylitis, etc.19

cranial base as measured from sella to nasion, in the cranial base

angle (NeSeBa).27 Richardson also suggested that there is no signicant difference in the cranial base as measured either from sella
to nasion or from sella to basion.28 However, Subtelny suggested
that the distance between sella and basion is less in their open bite
samples.9
There is agreement among the many investigators who have
studied skeletal open bite that the mandibular plane angle is consistently larger in skeletal open bite patients than in controls. The
high mandibular plane angle is found in open bite patients due to
a signicantly shorter mandibular ramus and an opening rotation
of the madibular ramus.28,29 An increased gonial angle, a downward and backward position of the mandibular ramus, and shortened posterior facial height are additive in the production of the
high mandibular plane angle in an open bite population.10 When
the total gonial angle (TGA) is divided by the line NeGo into two
parts, the upper part is termed the upper gonial angle (UGA) and
the lower part is the lower gonial angle (LGA). According to Siriwat
and Jarabak, the UGA reects the amount of the horizontal vector of
the facial growth, and the LGA reects that of the vertical vector.30
The anterior total facial height (ATFH) is greater than that in
a normal population, and the posterior facial height (PFH), the
distance between sella and gonion, is usually shorter in anterior
open bite patients than in normal individuals.9,29,31,32 In some
previous studies, the ALFH has been considered abnormally larger
than usual, while the AUFH remained normal, which entailed
smaller ratios of PFH:ATFH and AUFH:ALFH in anterior open bite
patients.13,29,32
An increase in posterior maxillary dento-alveolar height is
commonly mentioned in open bite cases,9,29, and that an overeruption of the mandibular molar teeth causes an opening rotation
of the mandible is also mentioned.27 However, no signicant differences in posterior maxillary dento-alveolar height and overeruption of the mandibular molar between open bite and normal
samples have been noted.9,32

4. Environmental factors

6. Treatment modalities

Various habits such as thumb and nger sucking, forward tongue

posture, as well as tongue thrust have been reported as causative
factors.20e23 Digit sucking can lead to an asymmetrical anterior open
bite which is worst on the side that the digit is sucked. Not all digit
suckers develop anterior open bite, the important factors being the
duration and frequency of the habit. Those who suck for more than 6
hours a day often develop signicant malocclusions. A forward
tongue posture, where the tongue rests between the incisors, may
obstruct incisor eruption and lead to the development of an anterior
open bite. This should not be confused with a secondary adaptive
tongue thrust, in which the tongue moves forward during swallowing to contact the lips and form an anterior oral seal secondary to
an anterior open bite. A diagnostic feature on the lateral cephalograph suggesting forward tongue posture is the presence of a reverse
curve of Spee in the lower arch caused by reduced incisor eruption.
Neuromuscular deciencies also contribute to the skeletal
characteristics of an open bite.24,25 Patients with generalized pathology of muscle such as muscular dystrophy maybe more prone
to an increased vertical dimension and anterior open bite.26 A
reduction in the force of contraction of the muscles of mastication,
at rest and during function, may lead to excessive vertical skeletal
growth and molar overeruption.

Treatment of anterior open bite is a great challenge in orthodontics,

and several approaches have been addressed. Following treatment,
patients can benet from improved ability to incise and chew food,
improved esthetics, and improved speech. However, it must be kept
in mind that treatment strategies should always address the etiology of the malocclusion.
It is common for children to have a nger or thumb habit and
they should be encouraged by their parents to stop their habit
before the age of 6 years for creating a favorable environment for
the eruption of permanent teeth. Therefore, it is important that
habits are terminated before commencing orthodontic treatment. If
initial attempts are unsuccessful, an intra-oral appliance with loops
that acts as a mechanical obstruction and reminder may be given.
Tongue thrusting can also adversely affect the teeth and mouth.
Tongue cribs have been used to modify tongue behavior and were
effective in closing open bite when worn for a minimum of 1
year.33,34 Myofunctional therapy is also useful in muscle retraining
by using a series of tongue exercises to correct the deleterious
resting and functional posture.35 Mastication exercises in conjunction with concentrated vertical control seemed to reduce
aberrant vertical growth patterns in patients, particularly those
suffering from neuromuscular deciencies.36 Patients were
instructed to clench on a soft bite wafer (GAC International, Bohemia, NY) for 1 minute, ve times a day. Each 1-minute session
included 5 seconds of isometric clenching (80% of maximum), followed by 5 seconds of rest. This cycle was repeated six times, for
a total of 1 minute.36

5. Dentofacial morphology
Many analyses comparing control samples to subjects with skeletal
open bite have shown no signicant difference in the anterior

Etiology and treatment modalities of anterior open bite

Tongue size and position affect skeletal and dental components,

and macroglossia has been suggested as a possible cause of open
bite and mandibular prognathism.15 Bernard and Simard-Savoie
have performed a medial glossectomy on a monkey with open
bite and the postsurgical observation of 52 months indicated
a steady increase of over bite.37 Hence, reduction of tongue mass by
partial glossectomy is an effective treatment for correcting open
bite with macroglossia.15
Because the direct relationship between anterior open bite and
mouth-breathing as a result of chronic respiratory obstruction has
not been proven, prolonged mouth breathing may not necessarily
be the main etiological factor for malocclusion.18 Therefore, diagnosis of upper airway obstruction should be made by an appropriate team of specialists and the decision for surgical intervention
such as adenoidectomy or tonsillectomy is not recommended in the
prevention of malocclusion and should be done for medical purposes only.
The treatment of skeletal open bites varies between growing
and adult patients. Treatment modalities in growing patients with
skeletal open bites are geared towards vertical growth modication. In adult patients, the options are more limited, and often
involve an orthognathic surgery. The overall goal of treatment in
growing patients aims to reduce or redirect vertical skeletal growth
with intra-oral or extra-oral forces. Several methods have been
proposed for controlling vertical growth. The vertical holding
appliance (VHA) is a modied transpalatal arch that has an acrylic
pad. The VHA uses tongue pressure to reduce the vertical dentoalveolar development of maxillary permanent rst molars.38
Posterior bite blocks impede posterior teeth eruption and studies
have suggested that posterior bite blocks modify the vertical skeletal pattern effectively.39 They can be made of wire or plastic to t
between the maxillary and mandibular teeth, or they can be springloaded,40 or tted with magnets.41 In correcting skeletal open bite
problems, functional appliances, such as activators, bionators, and
Frnkel regulators (most with the inclusion of posterior bite
blocks), have been used to control vertical maxillary growth of the
mixed dentition.42 A bionator can be used to treat open bite
problems, especially if accompanied by a class II molar relationship.43 Frnkel IV regulator was introduced and evaluated by
Frnkel among patients with a hyperdivergent skeletal pattern.
Frnkel believed that changes of the vertical components may have
resulted from lip-seal training, with the function regulator acting as
an exercise device and leading to postural balance between the
forward and backward rotating muscles.44 Another appliance
approach uses extra-oral devices, such as high-pull headgear, to
impede the vertical skeletal and dental growth pattern. Schudy and
Brandt have advocated a high-pull headgear along with a mandibular splint covering the second molars and anterior vertical
elastics to treat open bites.45 Ngan et al demonstrated that open
bite complicated by a class II vertical growth pattern can be treated
during the mixed dentition with favorable results by using a combination of an activator and high-pull headgear.46 The vertical chin
cup, together with xed appliances, has also been used to manage
anterior open bite in growing patients by controlling the vertical
growth. In a single case report, Pearson reported that the use of
a vertical-pull chin cup could result in a decrease in mandibular
plane angle and an increase in posterior facial height.47
Some mild cases of open bite can be corrected by xed appliances that only allow dental movements in a camouage method of
treatment. However, the skeletal prole and characteristics are
kept unchanged. Various extraction modalities have been suggested to correct anterior open bite, which aim to extrude the
anterior segment by the draw-bridge effect of reducing the inclination of both upper and lower incisors to increase over bite and
move the posterior teeth anteriorly by the wedge effect, or

a combination of the two. These extraction strategies include

extracting the second molars, rst molars, second premolars, or
rst premolars.48 Extrusion of the upper and lower incisors is
another common orthodontic modality for anterior open bite by
using vertical elastics, extrusion arches,49 or a multiloop edgewise
archwire (MEAW) appliance.50 However, correction of the malocclusion by extrusion of the upper incisors may result in an excessive
display of the incisors and gingival tissues, especially in patients
with anterior vertical maxillary excess. Thus, care must be taken
not to erupt the teeth extensively when the patient has increased
facial height. Molar intrusion for correction of anterior open bites
was challenging to orthodontists before the development of skeletal anchorage. Skeletal anchorage, including dental implants51,
surgical miniplates,52 and miniscrew or microscrew implants,53,54
are now growing in popularity due to their ability to provide absolute anchorage. The intrusion of molars with skeletal anchorage
produces counterclockwise rotation of the mandible and decrease
of the overbite.
Orthognathic surgery is often indicated for many non-growing
patients, particularly for esthetic needs, considerable open bite, or
skeletal problems in multiple planes of space.4 The surgical approaches include maxilla55,56 or mandible surgeries,57,58 surgery on
both maxilla and mandible,59,60 anterior maxillary and mandibular
surgeries,61,62 and mandibular surgeries combined with temporary
anchorage devices (TADs).63 Superior repositioning of the maxilla,
through total or segmental maxillary osteotomies, is indicated in
skeletal open bite patients with excess vertical maxillary growth.
Maxillary impaction allows auto-rotation of the mandible, therefore decreasing the lower face height and eliminating anterior open
bite. Closing rotation of the mandible using rigid xation is a viable
surgical option for the correction of anterior open bite in instances
in which maxillary osteotomies are not indicated to improve facial
esthetics. However, closing rotation of the mandible with only
mandibular surgery has been shown to be highly unstable because
it lengthens the ramus and stretches the muscles of the pterygomandibular sling.64 Therefore, a two-jaw surgery involving
superior repositioning of the maxilla with a Le Fort I osteotomy is
recommended to obtain more stable and predictable results for the
surgical correction of skeletal open bite.60 Mandibular surgeries
combined with TADs resolves the high level of surgical invasion and
the possibility of alar aring caused by superior repositioning of the
maxilla.63
7. Retention and stability
The importance of retention is to enhance stability, especially by
eliminating the cause of the open bite. Studies of long-term results
of open bite orthodontic treatment by Lopez-Gavito et al5 and
surgically treated cases by Denison et al6 indicate that the relapse
rate can range from 35% to 42.9%. Relapse after anterior open bite
treatment has been attributed to tongue posture, growth patterns,
treatment parameters, and surgical fragment instability, possibly
due to increased facial height and extrusion of maxillary molars.4
Surgical procedures, xation type, and maxillary transverse
relapse can be associated with open bite relapse.65 With regard to
the surgical procedures, greater over bite stability can be achieved
with maxillary surgical repositioning only, or with bimaxillary
surgery, whereas mandibular surgery only produces less stable
results.65 Failure of tongue posture adaptation subsequent to orthodontic and/or surgical treatment might be the primary reason
for relapse of anterior open bite. The relative increase in tongue
volume in the oral cavity would also cause a relapse of the mandibular position after the mandibular setback, resulting in
a decrease in overjet and over bite.63 Myofunctional therapy and
placement of a tongue crib may improve stability in patients,

especially with an anterior tongue rest posture.66 Clinicians

attempt to maintain the corrected open bite for growing patients by
applying a vertical chin cup or high-pull headgear to the upper
molars in conjunction with a standard removable retainer. Retainers with occlusal coverage to prevent further molar extrusions,
and wearing conventional retainers in the daytime, combined with
wearing a functional appliance with bite blocks (an open bite
activator or a bionator) at night time can also be used. Some clinicians even suggested that prolonged retention with xed or
removable retainers is advisable and necessary in most cases of
open bite treatment.65
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