O R T H O D O N T OC S H O D O N T I C S I R T

The Causes, Diagnosis and Treatment of Anterior Open Bite

DANIEL BURFORD AND JOE H. NOAR
Abstract: Anterior open bite has multiple aetiologies, but can be broadly described as
being dental or skeletal in origin. Accurate differentiation is essential in determining the appropriate treatment plan: dental open bites may close spontaneously in the growing patient and are generally amenable to orthodontic treatment, whereas skeletal open bites frequently worsen with growth and usually require a combination of orthodontics and orthognathic surgery. The incidence of post-treatment relapse is high, making these malocclusions a challenge to treat successfully. Dent Update 2003; 30: 235-241

Clinical Relevance: Anterior open bite is frequently seen in general practice, so

knowledge of its causes and management is important.

nterior open bite (AOB) is present when there is no incisor contact and no vertical overlap of the lower incisors by the uppers.1 The severity varies, from an almost edge-to-edge relationship to a severe handicapping open bite (Figure 1). The incidence of AOB also varies according to age and ethnic group. In the UK the reported incidence in children is 24%,2 falling from the age of nine to the early teens. This reduction is accounted for by normal occlusal development, neural maturation of the child favouring the cessation of oral habits, decrease in size of the adenoids and the establishment of a normal adult swallowing pattern. The incidence then increases again during the mid-teens, presumably as a consequence of late vertical growth. The prevalence in
Daniel Burford, BDS, MSc, MOrth, FDS(Orth) RCS, Senior Specialist Registrar (FTTA), Eastman Dental Hospital, London and Kingston Hospital, and Joe H. Noar, BDS, MSc, FDS MOrth RCS, Consultant Orthodontist, Eastman Dental Hospital, London and Watford Hospital.

adults is 4%.3 AOB is more common in Africans and Afro-Caribbeans (5 10%).4,5

AETIOLOGY
Anterior open bite can be broadly divided into two categories: l Dental open bite the vertical skeletal pattern is not contributory. l Skeletal open bite the open bite is at least partly due to the vertical facial form. The causes of AOB can be subdivided into a number of areas.

Digit Sucking Habits

Digit sucking is a common cause of AOB (Figure 2). The incidence of digit sucking is around 30% at 1 year of age, reducing to 12% at 9 years and 2% by 12 years. Most persistent suckers are female.6 The influence made by the digit depends on the age of the patient and

the intensity, frequency and duration of the habit. Open bites produced in the primary dentition are of little consequence as they resolve spontaneously once the child gives up the habit. The open bite caused by digit sucking is frequently asymmetrical, being greater on the side where the digit is inserted. The thumb or finger effectively acts as a barrier to the incisors erupting, whilst allowing excessive eruption of the posterior teeth. The upper incisors are invariably proclined whereas the effect on the lower incisors is more variable. Not infrequently there is a crossbite due to narrowing of the upper arch. How much the teeth are displaced correlates better with the number of hours per day of sucking than the magnitude of pressure. Children who digit suck for 6 hours or more each day, particularly those who sleep with a digit between the teeth all night, can develop a significant malocclusion.7 There is some evidence that, as well as dentoalveolar effects, persistent digit sucking can have a minor effect on the skeletal pattern, causing tilting of the maxillary plane in an anti-clockwise direction6 and anterior displacement of the maxilla.8 However, these effects are thought to be transient, and if the habit ceases during growth the underlying growth pattern will be re-established.

Abnormal Tongue Function

A tongue thrust on swallowing is often noted in patients with an AOB. Two types of tongue thrust have been described:
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Figure 1. (a) Mild dental anterior open bite. (b) Severe skeletal anterior open bite.

l primary (endogenous) tongue thrust; l secondary (adaptive) tongue thrust. Nearly all tongue thrusting falls into the second category the tongue is thrust forward on swallowing as an adaptive response to the presence of an anterior open bite to prevent food/ liquid/saliva escaping from the front of the mouth.9 Tongue function is also modified to aid speech. Proffit10 suggested that the resting position of the tongue has much greater influence on tooth position than any

tongue thrust, as the duration of any thrusting activity would be too short to have a significant effect. When the tongue is naturally kept in a forward position, overlying the lower incisors, then a reverse curve of Spee is present in the lower arch (Figure 3), which is particularly apparent on a lateral cephalogram. This is often a warning sign that closure of the AOB is unlikely to be stable owing to the adverse soft tissue pattern. Tongue reduction is sometimes considered in these cases, especially if it is abnormally large (macroglossia). Endogenous tongue thrust is often associated with excessive circumoral contraction on swallowing. Treatment for AOB in a patient with an endogenous tongue thrust should not be carried out, as relapse will almost certainly occur.

fails to compensate for the excessive vertical development of the jaws. Dung and Smith11 reported that, in 250 patients who exhibited traditional cephalometric indicators of an excessive vertical dimension, such as an increased FMPA or LAFH, only 13% had actual anterior open bites. They concluded that, in growing patients, an open bite tendency is in large part synonymous with a backward rotation to mandibular growth. Hence, attention to the structural features as identified by Bjork12 may be more useful than conventional cephalometric analyses in predicting how patients will grow and how they will respond to orthodontic treatment. Bjork12 identified seven structural signs related to significantly abnormal mandibular growth rotations: l inclination of the condylar head; l curvature of the mandibular canal; l shape of the lower border of the mandible; l inclination of the symphysis; l interincisal angle; l interpremolar or intermolar angle; l lower anterior face height. A patient with a posterior growth rotation tending to give rise to a

Skeletal Factors
Figure 2. Severe anterior open bite due to avid thumbsucking. Note the asymmetric appearance, the open bite being greater on the side the thumb is sucked.

Figure 3. Anterior open bite due to aberrant tongue function and posture. Note the characteristic reverse curve of Spee in the lower arch. 236

Open bites that develop due to excessive vertical growth are termed skeletal open bites (Figure 4). These are usually more severe in nature than dental open bites, often with only the terminal molars in contact. There is a significant increase in the lower anterior facial height (LAFH) and there may be vertical maxillary excess, which is a feature of long face syndrome. The Frankfort Mandibular Planes Angle (FMPA) is usually increased. In contrast to open bites caused purely by habit, in which there is impedance of incisor eruption by the digit, in true skeletal open bite incisor eruption may be increased in relation to the underlying basal bone, although it still

Figure 4. Lateral cephalogram of a patient with a skeletal open bite. Dental Update June 2003

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Iatrogenic Open Bite

Poor mechanics during fixed-appliance treatment may cause extrusion of the molar teeth or hanging palatal cusps, which open the bite. Failing to prevent overeruption of second molars when biteplanes or functional appliances are used may also give rise to an AOB.

Pathological Open Bite

Localized AOB may be associated with cleft lip and palate, acromegaly or trauma to the facial skeleton, such as condylar fractures or Le Fort fractures of the maxilla (Figure 7).

Figure 5. Bjorks features illustrating a posterior mandibular growth rotation. 1: Backward inclination of condylar head; 2: straight mandibular canal; 3: antegonial notch; 4: receding chin; 5: reduced interincisal angle; 6: reduced intermolar angle; 7: increased lower anterior face height.

Figure 6. Patient with muscular dystrophy.

INDICATIONS FOR TREATMENT

Patients seek treatment mainly on aesthetic grounds. However, there may be functional problems such as difficulty incising food and problems with speech, such as a lisp. Although closure of an AOB may help with eating, there is little evidence to show that it helps with speech,14 and certainly this should not be promised to the patient. The Index of Orthodontic Treatment Need (IOTN) is commonly used in the hospital service, and may in the future be used in the General Dental Services, to determine the needs of patients for orthodontic treatment. Only patients with an AOB greater than 4 mm fall into the need treatment category (IOTN 4). An AOB less than 4 mm would be borderline or be considered not to be in need of treatment, unless some other aspect of the malocclusion took precedence.

l surgical therapy; l combination of two or more of the above. It is important to determine which form of treatment is the most suitable for each individual case.

skeletal AOB may have some or all of the following signs (Figure 5): l backward inclination of condylar head; l a straight mandibular canal; l an antegonial notch; l a receding chin; l a reduced interincisal angle; l a reduced intermolar angle; l an increased lower anterior face height.

Dealing with Sucking Habits

In the deciduous dentition, unless there is evidence of trauma, the AOB is most probably due to a habit such as dummy or digit sucking. No intervention is indicated apart from encouraging the child to stop the habit. As the patient gets older (and providing the habit stops) a significant proportion of cases improve spontaneously,16 usually during the changeover from the mixed to the permanent dentition.14 However, normalization of the overbite can take between 3 and 5 years.17 A child who is still sucking his/her

Neurological Disturbances
Neurological disturbances that affect the oral or facial musculature may give rise to AOB. Gershater 13 reported an incidence of 32.3% in patients with learning disabilities.

Muscular Dystrophy
The decrease in tonic muscle activity that occurs in muscular dystrophy allows the mandible to rotate downwards away from the rest of the facial skeleton, resulting in increased anterior facial height, a posterior growth rotation of the mandible, excessive eruption of the posterior teeth, narrowing of the maxillary arch and AOB that worsens with growth7 (Figure 6).
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METHODS OF TREATMENT
Treatment is dependent on the age of the patient, his/her concerns and expectations, and the aetiology of the malocclusion. Mizrahi15 described four modalities of treatment: l myofunctional therapy; l orthodontic mechanotherapy (using fixed or removable appliances);

Figure 7. Anterior open bite caused by a condylar fracture. 237

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Figure 8. Fixed thumb dissuader.

thumb as the upper permanent incisors erupt (7.59 years) should be actively discouraged from doing so. Initially this should take the form of advice, possibly in conjunction with an aide memoire such as a plaster on the associated finger, a glove or foultasting nail polish. Alternatively, a small tangible reward can be offered on a daily basis for not engaging in the habit. If this is ineffective but the child wants to stop the habit, a deterrent appliance can be used. The appliance is either a removable or a fixed appliance which prevents sucking of the digit, and must be retained in place for a minimum of 6 months after sucking has apparently ceased, to ensure the habit has truly stopped (Figure 8). The fixed variety is more assured of success. Sometimes a quadhelix appliance is used, which not only discourages the habit, but has the additional advantage of being able to expand the upper arch. This may be necessary in avid thumbsuckers, as excessive cheek pressure produced during sucking causes constriction of the upper arch. These methods are likely to produce good spontaneous resolution of the AOB in a pre-teen patient, but in an older patient the proclined upper labial segment is held forwards by mesial movement of the buccal segments, and the AOB may be maintained by the soft tissue pattern and/or failure of further alveolar development anteriorly. This is supported by Larsson, who reported that, when the sucking habit is prolonged beyond the pubertal growth spurt, the open bite will not usually correct spontaneously.18 In this case further orthodontic treatment may be indicated (see below). However, it is
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essential that any digit habit is stopped first, otherwise not only will the treatment be unsuccessful, but there is also a risk of root resorption of the upper incisors due to the competing forces to which they will be subjected. A protocol for management of sucking habits is shown in Table 1. Use of a tongue guard has been advocated as a means of treating an AOB in a patient with a tongue thrust:19 this frequently allows spontaneous correction of the AOB, providing it is not skeletal in nature. Stability depends on the thrust being adaptive rather than endogenous. Proffit and Mason20 suggest limiting use of tongue guards to patients who have reached puberty, as up to 80% of children who have a tongue thrust and AOB at 8 years show improvement without therapy by age 12.

Primary dentition l No treatment indicated. l If dummy-related advise use of orthodontic dummy. l Reassure parents that AOB should resolve when habit stops. Early mixed dentition l Advise patient to give up habit. l Use simple aides memoire or daily rewards. Late mixed dentition l Consider deterrent appliance if advice has not worked. l May need orthodontic expansion of upper arch. Permanent dentition l Spontaneous resolution of AOB unlikely. l Refer for specialist opinion.

Table 1. Management protocol for digit-sucking habits.

Myofunctional Appliances
Posterior Biteblocks

Prevention of Habits
In a study by Larsson21 the majority of children who sucked dummies stopped using them by the age of 6 years and showed no tendency to suck digits, whereas the group that sucked digits continued with the habit in significant numbers, resulting in malocclusions in the permanent dentition. Hence dummy sucking has been advocated in preference to digit sucking.22 Orthodontic dummies are now available; these flatten on use, thus preventing undesirable effects on the deciduous occlusion. The child, however, does not always accept such dummies.

Passive posterior biteblocks 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 dento-alveolar processes, thus preventing a downwards and backwards rotation of the mandible;23 it also allows differential eruption to occur as the labial segments can erupt unhindered, hence closing the AOB. Modifications have included spring loading the biteblocks and use of repelling magnets embedded in the acrylic of the biteblocks.24 Highpull headgear to the biteblocks may increase their efficiency.

Figure 9. A patient with a Class II division 1 malocclusion and AOB tendency, being treated with a Twin Block myofunctional appliance with EOT tubes for highpull headgear.

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Figure 10. Retraction of proclined upper incisors results in an extrusive movement as the crown is rotated around the centre of rotation of the tooth. The distance between the parallel lines indicates the increase in overbite.

Where the AOB is associated with a Class II skeletal pattern, a Twin Block appliance with highpull headgear can be used to correct the anteroposterior discrepancy whilst controlling the vertical dimension (Figure 9). Functional Regulator Appliance (FR-4) These are thought to be effective where the open bite is at least partly due to faulty postural activity of the orofacial musculature. The FR-4 works by allowing vertical eruption of upper and lower incisors and retraction of the maxillary incisors, and some authors have reported a change in mandibular rotation from a downward and backward direction to upwards and forwards.25

Fixed Appliances
Anterior open bites can be closed using fixed appliances and vertical intermaxillary elastics to extrude the anterior teeth. This may be combined with a transpalatal arch (TPA) and highpull headgear to limit vertical development of the maxillary molar teeth. The TPA functions to prevent buccal rolling of the first molars, which could cause the bite to be propped open on their palatal cusps. Use of anterior elastics may be successful in patients in whom a digit-sucking habit
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has artificially inhibited eruption, but is unlikely to work if the aetiology is primarily skeletal. In this situation the incisors have frequently erupted further than normal as part of natural compensation, and further extrusion would be aesthetically inappropriate and highly prone to relapse. Distal movement of teeth using headgear is contraindicated, as this will tend to worsen any AOB. Similarly, Class II or Class III elastics should not be used as they cause molar extrusion. Where anterior open bites are associated with proclined incisors, such as some bimaxillary proclination cases and Class II/I malocclusions, retraction of the incisors results in an extrusive movement, as the crown is rotated around the centre of rotation of the tooth.26 This reduces/eliminates the open bite (Figure 10). Stability depends on the tongue adapting to a new functional position after treatment. Molar extractions have been performed in an attempt to reduce the magnitude of the open bite by forward mandibular rotation. However, Nahoum27 suggested that, although this may close the anterior open bite, the physiological rest position of the mandible would not change, thus leaving total face height unaltered. Mizrahi15 suggested limiting extractions to the posterior region of the arch where crowding was present. Richardson and Richardson28 reported that the extraction of four second permanent molars caused an increase in the overbite compared with a control group; they attributed this to a slight distal movement of the dentition, with retroclination of incisors and increase in the interincisal angle. Kim29 reported on the use of a multiloop edgewise archwire together with heavy anterior elastics to achieve molar intrusion and simultaneous incisor extrusion to close anterior open bites. The posterior teeth are distally uprighted using this technique. Although this method has proved successful, excellent compliance with elastic wear is essential and long-term stability has yet to be determined.

Extra-Oral Traction
Vertical Pull Chincup Vertical pull chincup therapy has been used to limit excessive vertical growth. Pearson30 reported on 20 growing patients with backward rotational tendencies treated by the extraction of four first premolars, chincup therapy and fixed appliances. He showed that chincup therapy was effective in reducing the angle between the maxillary and mandibular planes and at closing all anterior open bites. Mandibular autorotation was attributed to reduction in the wedging effect by premolar extraction, retardation of eruption of posterior teeth and redirection of condylar growth. However, chincup therapy generally has poor compliance rates and there is some concern that it may cause condylar damage. Highpull Headgear Highpull headgear applied to the maxillary molar teeth and worn for 14 hours per day has been used to inhibit eruption of the posterior teeth and hence limit vertical growth. Headgear can be applied directly to the upper molar bands of a fixed appliance or used in conjunction with a functional appliance or an upper removable appliance such as a maxillary intrusion splint. This form of treatment is based on the assumption that overdevelopment of the posterior maxilla is responsible for the deformity.31 Orthognathic Surgery A combination of fixed-appliance orthodontics and orthognathic surgery may be required to treat skeletal open bites. Treatment should not be commenced until growth has ceased, as further growth is very likely to be unfavourable. Presurgical orthodontics is aimed at individual arch alignment and arch co-ordination. An obvious step in the occlusal plane should not be levelled but maintained using segmental mechanics. Surgery may be segmental or involve the whole jaw. Frequently bimaxillary surgery is required.
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STABILITY
Prediction of the response to treatment and the stability of the outcome is generally unreliable.14 Relapse rates after treatment of AOB are high. As a rule, the more the skeletal elements contribute to the aetiology of the malocclusion the poorer the prognosis for orthodontic treatment alone.15 LopezGavito et al.32 reported that, following orthodontic treatment, more than onethird of patients demonstrated a return of their AOB, and neither the extent of the pretreatment open bite or mandibular plane angle nor any other single parameter of dentofacial form was a reliable predictor of post-treatment stability. Relapse of AOB has been attributed to: l unfavourable growth (a posterior mandibular growth rotation); l soft-tissue factors such as an unfavourable tongue posture; l resumption of a digit-sucking habit; l inappropriate orthodontic tooth movement, such as extrusion of incisors where their eruption had not been previously impeded; and l surgery that has increased the posterior face height as would occur if the AOB is closed using a mandibular procedure only. Retention has been directed towards intrusion, or at least prevention of eruption, of maxillary posterior teeth,33 using either headgear attached to an upper removable retainer or a retainer with passive posterior biteblocks. However, this should ideally be continued until the patient ceases growing, although compliance is obviously an issue.

an AOB should have the high risk of relapse of treatment explained and, where there are no other anomalies to be corrected, thought should be given to accepting the malocclusion, particularly if the open bite is small and there are no functional problems. Any associated digit habit should be ceased before active orthodontic treatment is commenced. Treatment options include attempting to redirect growth using myofunctional appliances, use of conventional fixed appliances with highpull headgear and/or vertical anterior elastics, and a joint orthodontic/ surgical approach for skeletal open bites. Long-term retention is recommended.

A CKNOWLEDGEMENTS
We would like to thank the following people for providing illustrations for this article: Mrs Elizabeth Horrocks, Consultant Orthodontist, Eastman Dental Hospital (Figures 2 and 3), Miss Helen Tippett, Senior Specialist Registrar, Eastman Dental Hospital (Figures 6 and 8).

R EFERENCES
Houston WJB, Stephens CD, Tulley WJ. Class 1 malocclusions. In: A Textbook of Orthodontics, 2nd ed. Oxford: Wright, 1996; p.216. 2. OBrien M. Childrens Dental Health in the United Kingdom 1993. London: HMSO. 3. Todd JE, Whitworth A. Adult Dental Health in Scotland 1972. London: HMSO. 4. Noar JH, Portnoy S. Dental status of children in a primary and secondary school in rural Zambia. Int Dent J 1991; 41: 142148. 5. Kelly J, Harvey C. An assessment of the teeth of youths 1217 years. DHEW Publ No. (HRA) 771644, Washington DC National Centre for Health Statistics, 1977. 6. Brenchley ML. Is digit sucking of significance? Br Dent J 1991; 171: 357362. 7. Proffit WR, Fields HW. Contemporary Orthodontics. St Louis: C.V. Mosby, 2000. 8. Larsson E. Dummy- and finger-sucking habits with special attention to their significance for facial growth and occlusion. Swed Dent J 1978; 2: 23 33. 9. Subtelny JD. Examination of current philosophies associated with swallowing behaviour. Am J Orthod 1965; 51: 16182. 10. Proffit WR. Equilibrium theory revisited: Factors influencing the position of the teeth. Angle Orthod 1978; 48: 175186. 11. Dung DJ, Smith RJ. Cephalometric and clinical diagnoses of open bite tendency. Am J Orthod Dentofac Orthop 1988; 94: 484490. 12. Bjork A. Prediction of mandibular growth 1.

CONCLUSION
Anterior open bite has multiple aetiologies and accurate diagnosis is the key to determining the best management strategy for the individual patient. Many open bites will resolve spontaneously before the age of 12 due to ceasing of digit habits and maturation in the swallowing pattern. Older patients with
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rotation. Am J Orthod 1969; 55: 585599. 13. Gershater MM. The proper perspective of open bite. Angle Orthod 1972; 42: 263272. 14. Ferguson JW. The assessment and treatment of anterior open bite. Dent Update 1995; 22: 163 168. 15. Mizrahi E. A review of anterior open bite. Br J Orthod 1978; 5: 2127. 16. Finlay JA, Richardson A. Outcome prediction in open bite cases. Eur J Orthod 1995; 17: 519 523. 17. Bowden BD. The effects of digital and dummy sucking on arch widths, overbite, and overjet: A longitudinal study. Aust Dent J 1966; 11: 396404. 18. Larsson E. The effect of finger-sucking on the occlusion: a review. Eur J Orthod 1987; 9: 279 282. 19. De Almeida RR, Ursi WJS. Anterior open bite. Aetiology and treatment. Oral Health 1990; 80: 2731. 20. Proffit WR, Mason RM. Myofunctional therapy for tongue-thrusting: background and recommendations. J Am Dent Assoc 1975; 90: 403411. 21. Larsson E. Dummy and finger-sucking habits with special attention to their significance for facial growth and occlusion. 1. Incidence study. Sven Tandlak Tidskr 1971; 64: 667672. 22. Guidelines for Dummy and Digit-Sucking Habits. London: British Orthodontic Society, 2001. 23. Iscan HN, Sarisoy L. Comparison of the effects of passive posterior bite-blocks with different construction bites on the craniofacial and dentoalveolar structures. Am J Orthod Dentofac Orthop 1997; 112: 171178. 24. Noar JH, Hunt NP. The performance of bonded magnets used in the treatment of anterior open bite. Am J Orthod Dentofac Orthop 1996; 109: 549556. 25. Erbay E, Ugur T, Ulgen M. The effects of Frankels function regulatory therapy (FR-4) on the treatment of Angle Class I skeletal anterior open bite malocclusion. Am J Orthod Dentofac Orthop 1995; 108: 921. 26. Sarver DM, Weissman SM. Nonsurgical treatment of open bite in nongrowing patients. Am J Orthod Dentofac Orthop 1995; 108: 651659. 27. Nahoum H. Vertical proportions: A guide for prognosis and treatment in anterior open-bite. Am J Orthod 1977; 72: 128146. 28. Richardson ME, Richardson A. The effect of extraction of four second permanent molars on the incisor overbite. Eur J Orthod 1993; 15: 291 296. 29. Kim Y. Anterior openbite and its treatment with multiloop edgewise archwire. Angle Orthod 1987; 57: 291321. 30. Pearson L. Vertical control in treatment of patients having backward-rotational growth tendencies. Angle Orthod 1978; 48: 132140. 31. Epker B, Fish L. Surgical-orthodontic correction of open-bite deformity. Am J Orthod 1977; 71: 278299. 32. Lopez-Gavito G, Little R, Joondeph D. Anterior open-bite malocclusion: longitudinal 10-year postretention evaluation of orthodontically treated patients. Am J Orthod 1985; 87: 175186. 33. Lawry DM, Heggie AAC, Crawford EC, Ruljancich MK. A review of the management of anterior open bite malocclusion. Aust Orthod J 1990; 11: 147160.

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