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Definition.........................................................................................................................................2
Incidence..........................................................................................................................................2
True rotation, matrix rotation & apparent total rotation as described by Bjork 1969.....................5
Predictors of skeletal open bite........................................................................................................6
Features of high angle or long face syndrome.................................................................................8
Overbite and Open bite..................................................................................................................10
Indication of treatment...................................................................................................................11
The etiology can be classified into.................................................................................................11
Treatment is dependent on the.......................................................................................................14
Methods of treatment.....................................................................................................................14
In details.........................................................................................................................................15
1.
3.
4.
Myofunctional Therapy..........................................................................................................18
5.
Extraoral Traction...................................................................................................................20
6.
Fixed Appliances....................................................................................................................20
8.
9.
Repelling magnets..................................................................................................................23
10.
Orthognathic Surgery..........................................................................................................23
11.
Adjunctive procedure..........................................................................................................23
Stability of AOB............................................................................................................................23
Management of relapse..................................................................................................................24
Difficulty associated with the treatment of AOB, Burford 2003 Sandler 2011.............................24
Posterior open bite.........................................................................................................................25
Caused by.......................................................................................................................................25
Treatment.......................................................................................................................................25
Summary of the evidences.............................................................................................................25
Anterior open bite & high angle case
Definition
Dental AOB: It is present when there is no incisor contact and no vertical overlap of the lower
incisors by the uppers (Houston, 1996). The severity varies, from almost an edge-to-edge
Pseudo pen bite which means that there is positive vertical overlap between U and L incisors
with no contact.
True open bite: loss of vertical overlap
Incidence
If the incisor occlusion is stable, the overbite remains unchanged during the
growth period & the fulcruming point is located at the front teeth.
If the incisor occlusion is unstable, the fulcruming point is located further back
along the occlusal plane. In this situation the bite normally becomes increasingly
deep over time as the result of greater posterior face height increase in
combination with lack of anterior tooth contact. This deterioration of the
occlusion is most pronounced during puberty when growth intensity is at its
greatest, but continues throughout the growth period. Patients with a pronounced
tendency to anterior growth rotation and a deep bite should therefore be treated
early and the occlusion supported throughout the growth period. Retention,
especially in the mandibular arch, must also be maintained until mandibular
growth is completed.
This posterior growth rotation may result in an anterior open bite, depending on
the extent of vertical dentoalveolar compensation.
The associated dental eruption pattern of the posterior teeth is generally distal &
vertical and in some instances the anterior teeth may even become more
retroclined with time. Late crowding is common finding in this pattern of growth
due to soft tissue maturation.
Because the centre for the growth rotation is located near the mandibular
condyles, treatment should be postponed until after puberty or at least until the
potential for backward or posterior rotation is reduced. The reason for late
treatment is that
A. The tendency to extrude the posterior teeth decreases when there is less active
growth.
B. In addition when treated orthodontically these patients are at increased risk for
further mechanically induced posterior rotation by acceleration of their molar
eruption and require careful control.
C. The increased risk of extrusion in these patients is associated with their weaker
masticatory musculature making vertical control an important consideration.
True rotation, matrix rotation & apparent total rotation as described by Bjork 1969
This surface modelling causes, in most instances, the lower border of the
mandible to appear almost unchanged in its inclination to the cranial base and has
led to misinterpretations of the actual growth changes and tooth movements in
humans.
A. Bjork's structural signs help to predict type of growth rotation , (Skieller and Bjork, 1969)
1. A backward inclination of the condyles;
2. A flat mandibular canal;
3. A lower border that is thinner anteriorly and convex, due to minimal remodelling along the lower
border of the mandible and bony deposition at the posterior border of the ramus;
4. The symphysis is inclined backward within the face and the chin is receding;
5. The interincisor angle decreased
6. Interpremolar and intermolar angles are all decreased;
7. The lower anterior face height is increased and there is an anterior open bite.
The authors reported that a combination of four variables ccounted for 86% of the variability
observed.
B. PFH:AFH ratio (Jarabak ratio)
Jarabak, 1972
C. UAFH-LAFH ratio: Nahoum (1975) believed that patients with a dental open bite and a UAFHLAFH ratio of less than 65% (normally they are equal) are considered to be poor risks for
conventional orthodontic treatment alone.
D. Increased dentoalveolar height in molar region and reduced dentoalveolar height in incisor
region due to strong muscle allowing molar eruption. (Neilsen, 1991).
E. Dung and Smith
Dung and Smiths sample (1988).
SN/MP angle
OP/MP angle
MxP/MnP angle
AOB
PFH/AFH (Jarabak ratio
UFH/LFH (Nahoum ratio)
A seventh measurement was used, namely, the overbite depth
40 or greater
22 or greater
32 or greater
negative overbite
58% or less
0.65 or less
68
indicator (ODI)
This was described by Kim in 1974, and is described as the angle the A-B plane makes with the
mandibular plane combined with the angle of the palatal plane to the Frankfort horizontal. PPFH is positive it is added this value from AB-MP and vice versa. A value of less than 68 is said
to indicate an open bite tendency. The value of this analysis is that it proposes to identify those
patients who have an open bite tendency and identifies open bite
patients who have a good potential for orthodontic correction.
In the mandible, the mandibular zone, measured between the mandibular plane
(GO-GN) and the mandibular occlusal plane (mean 204), similarly describes
possible compensation.
On the other hand, if these measurements are normal or reduced in the same
patient, either no compensation or dysplastic development has taken place.
This will help in determine the type of treatment. Eg. If the high angle case has
no compensation or has dysplastic development, then treatment can be achieved
through orthodontic treatment to initiate this compensation, but if the
compensation is already present then the case is surgical.
3.
4.
5.
6.
B.
1.
2.
Long maxilla
Short mandible
Short ramus
Class II skeletal relationship
Cephalometric feature.
Enlarged adenoid seeing in the ceph
Increased dentoalveolar height in molar region and reduced dentoalveolar height in incisor
3.
4.
5.
6.
C.
1.
2.
3.
4.
5.
6.
7.
D.
1.
2.
3.
4.
5.
E.
due to dentoalveolar compensation of the anterior part of the maxilla to compensate for AOB.
Retruded chin
Intraoral features
Open bite
Class 2 tendency
Increased overjet
Narrow upper arch
Crowded LLS
Growth feature
Usually posterior growth rotation
F. Path of closure
Usually normal or may be associated with unilateral cross bite and mandibular displacement
G. IOTN and OB
Overbite measured from any of the lateral or central incisors with the largest
vertical discrepancy is recorded.
Open bite
Grade and
Grade and
qualifier
qualifier
2f
3f
4f
mm
bite 0-2mm
bite 2.1 mm 4 mm
greater than 4 mm
Indication of treatment
4.
5.
6.
7.
8.
9.
3e
II.
pituitary tumour causes gigantism in children and acromegaly in adults. In both circumstances,
the patient presents with a worsening class III malocclusion characterized by mandibular excess
and AOB.
Traumatic:The condyle is the commonest site of fracture in the mandible during childhood and
III.
many go undiagnosed. In severe cases with bilateral fracture and dislocation from the glenoid
fossa, an anterior open bite can be one of the presenting features due to a loss in ramus height. A
long-term sequelae of early trauma to the mandibular condyle can be asymmetry, with an
ipsilateral decrease in ramus height and deviation of the chin point to the affected side.The
severity of outcome is in part related to the age at the time of injury. However, a high percentage
of children sustaining a condylar fracture have normal mandibular growth due to the reparative
capacity of the condyle, even when displaced from the glenoid fossa.
3. Soft tissue factors
I.
Muscle of mastication: Hunt 1997 & Benington 1999 showed large muscle fibres in deep bite
and small size muscle fibres in AOB. This again is classified under the genetic effect
II.
III.
IV.
Adenoids (Aronson, 1979). However, Vig (1985) that the magnitude of the morphological
difference attributed to adenoid removal was far too small to be of any clinical significance
I.
4. Habits,
Digit Sucking Habits.
The incidence of digit sucking is around 30% at 1 year of age, reducing to 12% at 9 years and
II.
III.
in the upper. The diagnosis is therapeutic which means the high tendency to relapse after
treatment.
5. Local Dental factors
Proclination of incisors
Methods of treatment
For sucking habit
For mouth breather
For tongue thrust
Myofunctional Therapy
Muscle exercise
Myofunctional+EOA
combination Therapy
1.
2.
3.
4.
Extraoral Traction
In details
Fixed appliance like palatal appliance with crib or Blue grass appliance (Huang 1990)
Removable appliance
Functional appliance can stop habit
Parker (1971) used spurs soldered to upper central incisor bands to produce dramatic changes in
anterior open bite and posterior crossbite by altering tongue posture. The suggestion is that
anterior tongue posture is responsible for anterior open bites in cases of normal skeletal
proportions with no history of a digit sucking habit. The tongue spurs should be placed
approximately 3-4 mm behind the upper incisors and should be angled backwards and
downwards so that they establish a positive overlap with the lower incisors. Tongue spurs might
cause psychological problems Haryett et al (1967, 1970). Careful explanation of the purpose of
tongue spurs is therefore essential before embarking on treatment. Huang et al (1990) showed a
similar results. Tongue cribs or spurs should be worn for six months after a positive over bite is
achieved; careful patient motivation is required and sharpened spurs are preferred to smooth
4. Myofunctional Therapy
1. Muscle exercise described by Laurie Park 2007 (Patients were instructed to clench their teeth
together as hard as possible for 15 seconds and to repeat this process at least four times for a total
of one minute; this one-minute exercise was to be performed as often as possible throughout the
day).
2. Vertical holding appliance (TPA with acrylic pad that kept away from palate and rely on the
tongue force to intrude the posterior teeth.
3. Spring-loaded bite block, the spring-loaded bite block has helical springs that are placed both
lingually and buccally between the rst premolar region and the last molar region. The ends of
the springs are embedded occlusally in the molar regions of the acrylic part of the device. The
upper and lower acrylic occlusal blocks are connected by palatal and lingual wires, which are
activated to a force of 450 g bilaterally. Patients are instructed to use the appliance for an average
of 16 h daily
4. Passive posterior bite-blocks are functional appliances that are used to open the bite 34 mm
beyond the rest position. In growing patients, this inhibits the increase in height of the buccal
dentoalveolar processes, thus preventing a downwards and backwards rotation of the mandible. It
also allows differential eruption to occur as the labial segments can erupt unhindered, hence
closing the AOB.
5. The functional regulator appliance (FR IV) It works by allowing vertical eruption of upper and
lower incisors and retraction of the maxillary incisors, and may also encourage upward and
forward mandibular rotation. Cochrane review, by Oliveira , 2007 showed that there is weak
evidence that the interventions FR-4 with lip-seal training and palatal crib associated with highpull chin cup are able to correct anterior open bite. Given that the trials included have potential
bias, these results must be viewed with caution.
6. Teuscher activator
7. BIS
8. MIS
9. Concorde appliance
10. Van Beek appliance
11. Twin block appliance modifications including:
TB with high-pull headgear inserted in the flying spring can be utilized to correct the
5. Extraoral Traction
1. Vertical pull chin-cup therapy has been used to limit excessive vertical growth and has been
shown to close AOBs when combined with premolar extractions and fixed appliances as well as
palatal crib
2. High-pull headgear applied to the maxillary molar teeth worn for 14 hours per day has been
used to inhibit eruption of the posterior teeth and hence limit vertical growth. Many strategies
available including:
Headgear can be applied directly to the upper molar bands of a fixed appliance .
Cochrane review, by Oliveira , 2007 showed that there is weak evidence that the interventions
FR-4 with lip-seal training and palatal crib associated with high-pull chin cup are able to correct
anterior open bite. Given that the trials included have potential bias, these results must be viewed
with caution.
6. Fixed Appliances
Anterior open bites can be closed using fixed appliances with
A. Extraction of terminal molars
B.
C.
D.
E.
1987).
Therefore, by uprighting the molars the anterior open bite
can be closed. This can be achieved using multi-loop
archwires or curved nickel titanium wires, creating an
increased curve of Spee in the maxillary arch and a reduced
recommended.
Using a multiloop edgewise archwire appliance in conjunction with heavy anterior elastics has
been shown to achieve molar intrusion and simultaneous incisor extrusion in the closure of
are obscure.
Use of the technique with an 0.022 straight-wire appliance system has produced no problems.
The archwires are an ideal shape with five L-lopps on each side starting from between the lateral
incisors and canine and working distally until between 6s and 7s.
The vertical dimensions of the loops should be 2-3 mm and the horizontal dimensions 5 mm
except in the molar region where it is increased to 8 mm. Tip backs of 3-5 are placed on each
loop.
This effectively produces a curve of Spee in the upper arch and a reverse curve of Spee in the
lower arch.
These are counteracted by placing 3/16 heavy elastics vertically between the most anterior
loops in the maxilla and mandible.
This transfers all the active force in the archwire to the posterior segments thus intruding and
wires and they seem to work well. Enacar et al (1996) and (Harradine and Birnie, 2000).
Hooks are provided by using crimpable hooks.
consider the skeletal relationship including the vertical, transverse, and anterior-posterior
relations. For example, a skeletal class 2 open bite with a long anterior facial height can be
treated successfully by the intrusion of the posterior teeth as this would produce a closing
counterclockwise rotation of the mandible with a shortening of the anterior facial height and a
correction of the open bite. Sugawara et al (2002) reported that during intrusion of the molars
with a skeletal anchorage system, the anterior lower facial height, mandibular plane angle, and
ANB difference reduced significantly, whereas the overbite and Wits appraisal increased
significantly. Hence, the intrusion of the molars is best suited to skeletal open bite patients who
show long face types with class 1 or mild class 2 skeletal patterns whereas in class 3 open bites,
the class 3 malocclusion would get worse as the anterior open bite closed
Incisor exposure at rest and smile are important objectives to consider before treatment. Patients
who do not show sufficient incisor exposure should not be treated by molar intrusion, making the
more conventional method of incisor extrusion a more suitable option for open bite correction
9. Orthognathic Surgery
Where there is an obvious step in the occlusal plane, two piece maxilla
No step, one piece maxilla.
Subapical osteotomy of the anterior (Kole technique) or posterior segment (Schuchart
Glossectomies. Their effectiveness in closing anterior or posterior open bite problems has not
been substantiated (Proffit, 1990).
Stability of AOB
1. In general: AOBs treatment is stable in approximately 80% of treated cases with slightly better
with surgical treatment than non-surgical (5% differences).(Huang, 2002). Lopez-Gavito 1985
showed that 1/3 is lost.
2. Extraction: There is also evidence of greater stability of open bite correction when orthodontic
treatment is undertaken with extractions (Janson et al., 2006).
3. Extrusion or intrusion: In treatment resulting in molars intrusion, the rate of relapse ranges
from 17 to 30%: whilst in treatments with incisor extrusion, relapse may be even greater,
reaching sometimes 40% of treated cases. (Suguwara 2011)
Causes of relapse
Management of relapse
Using headgear attached to a URA with a high pull direction of force untile growth cessed.
Retainer with passive bite blocks, which supposedly place intrusive forces on the posterior
teeth, could be used &should be continued until facial growth has almost ceased and this is often
well into late teens.
Some recommend lip and tongue muscle exercises once a day, which was supervised once a
week by a speech and language therapist
PFR can be used as removable retainer with posterior bite plane. If the tongue play a role in the
open bite then holes or spur in the palate can help to minimize the relapse.
Difficulty associated with the treatment of AOB, Burford 2003 Sandler 2011
1. Tendency to vertical growth rotation which worsens the class 2 and makes the use of functional
appliance challenging
2. Most of the orthodontic treatment are extrusive which make the treatment worse
3. Quick loss of the extraction space for two reasons: the masticatory muscles restrict the
posterior mandibular teeth more than their maxillary counterparts; and the thin cortices and
trabecular bone of the maxilla provide less resistance to movement than the thick cortices and
more dense trabeculae of the mandible
4. Poor soft tissue compliance that make stability poor
Failure of eruption
Tongue interfere with eruption
Trauma and Ankylosis
Hemimandibualr hyperplasia when the vertical compensation is not sufficient
Treatment
1. Habit breaker posteriorly
2.
3.
4.
5.
Composite build up
Orthodontic extrusion by FA or TAD
Segemental dentoalveolar osteotomy
Segemental maxillary or mandibular surgery
Definition: Dental AOB: It is present when there is no incisor contact and no vertical overlap of
1993).
Type of growth of the mandible: Nielsen et al 1991
True rotation, matrix rotation & apparent total rotation as described by Bjork 1969
Bjork's structural signs help to predict type of growth rotation , (Bjork, 1969)
PFH:AFH ratio (Jarabak ratio) Jarabak, 1972, 58 high angle case, reduced OB
UAFH-LAFH ratio: Nahoum (1975) believed that patients with a dental open bite and a UAFHLAFH ratio of less than 65% (normally they are equal) are considered to be poor risks for
12% at 9 years and 2% by 12 years. Most persistent suckers are female (Brenchely, 1992).
The severity of the malocclusion depends on the age of the patient, the intensity, frequency and
there is weak evidence that the interventions FR-4 with lip-seal training and palatal crib
associated with high-pull chin cup are able to correct anterior open bite. Given that the trials
included have potential bias, these results must be viewed with caution.
TB with high-pull headgear inserted in the flying spring can be utilized to correct the
are not yet available, the early results are promising. Clark 2010
Kim mechanics, (Kim, 1987).
Modified Kim mechanics, for some years clinicians have used reverse curve nickel-titanium
arch-wires instead of multiloope wires and they seem to work well (Harradine and Birnie, 2000).
Molar intrusion using skeletal anchorage: Like Dental implants, mini-plates, mini-screws ,
ankylosed teeth (Cousely 2008 use TPA with two palatal TAD for posterior teeth intrusion, while