BIOMECHANICS

OF OPEN BITE
TREATMENT
Dr. Maitreye Priyadarshini
3rd Year
Contents-

 Introduction
 Correction of dental open bite
 Correction of skeletal open bite
 Extraction in the treatment of open bite
 Introduction-
 “Open bite”- coined by Caravelli in 1842 as a distinct classification of
malocclusion.
 Glossary of Orthodontic terms defines open bite as a developmental or
acquired malocclusion whereby no vertical overlap exists between
maxillary and mandibular anterior or posterior teeth.
 Open bite is a condition where there is no vertical overlap between the
upper and lower teeth. Thus, a gap may exist between the upper and
lower teeth when the patient bites in centric occlusion. Open bite can be
in the anterior or posterior region.
 An abnormal dental condition in which anterior teeth in maxilla
do not occlude those in mandible in any mandibular position.
(Mosby’s Medical Dictionary,8th Edition).
 Open bite was defined by Subtelney and Sakuda as open vertical
dimension between the incisal edges of the maxillary and
mandibular anterior teeth, although loss of vertical dental contact
can occur between the anterior or the buccal segment
Etiology:

According to Dawson,
 Thumb or finger sucking
 Pacifier use;
 Lip and tongue habits;
 Airway obstruction;
 Inadequate nasal airway creating the
need for an oral airway;
 Allergies;
 Septum problems and blockage from
turbinates;
 Enlarged tonsils and adenoids;
 Skeletal growth abnormalities.
Prevalance:

 The incidence of anterior open bite ranges from 1.5%

to 11%
 Has five times greater prevalence in the black
population than in the white or Hispanic populations
 In the mixed dentition the prevalence of the anterior
open bite can reach up to 18.5%, decreasing with age
 Classification:
A) According to Rakosi –

a) Anterior open bite-Open bite in a deciduous dentition,

caused by tongue dysfunction as a residuum of a sucking
habit.
b) Lateral open bite-Occlusion, in this type of open bite on
both sides is supported only anteriorly and by first
permanent molars.
c) Complex open bite-Severe vertical malocclusion. The
teeth occlude only on second molars.
d. Tongue dysfunction and malocclusion-in mandibular prognathism,
the downward forward displacement of tongue often causes an
anterior tongue thrust habit.

B) According to Proffit-
 Open bite (mm) >-4 extreme
 -3 to -4 severe
 0 to -2 moderate

C) Open bite is classified by Sassouni as (Criterion-Angle of

mandibular plane)
a) Skeletal open bite
b) Dentoalveolar open bite
D) Open bite is classified as:
a) Anterior open bite-Anterior open
bite is defined as no contact and
vertical overlap between the
maxillary and mandibular incisors.
b) Posterior open bite-When teeth are
in occlusion there is a space
between posterior teeth.
The mandibular plane angle, Jarabak ratio, and palatomandibular
plane angle were observed to be above the normal limits, indicating
a skeletal open bite.
Features of dental anterior open bite
a. Proclined upper anterior teeth.
b. The upper and lower anteriors fail to overlap each
other resulting in a mild open bite.
c. The patient may have a narrow maxillary arch due to
lowered tongue posture due to a habit.
d. There may be spacing between the upper and lower
anteriors
e. Fish mouth appearance
f. Speech defects can be found with lisping of voice.
Lispisng associated with anterior openbite and
spacings is called interdental stigmatism.
Functional treatments

 Myofunctional therapy is used to alter function and consists of

a set of exercises to reeducate orofacial muscles in
swallowing, speech and resting posture.
 It is believed that voluntary activities such as swallowing and
speech are easier to correct using myofunctional exercises
while involuntary activities such as tongue posture habits are
hard to automate.
 Another way to correct functional habits is through
mechanisms that prevent the tongue from resting on the
teeth. The best known are palatal or lingual cribs and spurs.
Orthodontic treatments
 There are several types of treatment involving orthodontic movement
for correction of open bite, with different therapeutic goals.
 Extraoral appliances, vertical chincups, bite-blocks and functional
appliances are designed to reduce the extrusion of molars, allowing a
counterclockwise rotation of the mandible.
 The same mechanism can be implemented with the aid of anchorage to
intrude molars. Mechanics with intraoral elastics are used both for
incisor extrusion and molar intrusion, as well as for rotation of the
occlusal plane combined with multiloop archwires.
Correction of dental open bite
due to tongue thursting habit
 A habit-breaking appliance.
 As a tongue crib, in combination
with maxillary and mandibular 2 X
4 mechanics.
 Lip and tongue exercises that train
the tongue muscle and strengthen
the surrounding musculature, used
in conjunction with the crib, are
also important to ensure long-term
stability.
DIFFERENT POSTURES OF THE
TONGUE AT REST
 The position considered normal for the tongue at rest is
one in which the tip of the tongue rests on the incisal
papilla and its back lies along the palate, keeping the
anterior teeth in balance while preserving the transverse
dimension of the upper arch.
 However, some AOBs show changes in the positions
assumed by maxillary incisors and others display changes
in the positions of mandibular incisors.
 Based on these morphological characteristics some
different resting positions of the tongue are suggested:
High, horizontal, low and very low.
Figure: Classification for posture of
the tongue at rest: A. Normal, B.
High, C. Horizontal, D. Low and E.
Very low
 A high posture of the tongue at rest is associated with slightly protruded
maxillary incisors and anterior open bite may exhibit vertical overlap and
positive horizontal overlap. Tongue rests on the palatal surface of the
incisors, beneath the incisal papilla, upper incisors are positioned above
the occlusal plane. Leveling of the mandibular arch is unaffected and
displays a single occlusal plane while maintaining the transverse
dimension of the upper arch.
 In the horizontal posture of the tongue at rest, the tongue appears
lower than in the high position, although with greater protrusion,
resting on the palatal surface of the upper incisors and on the incisal
edges of the lower incisors. The protrusion of maxillary incisors in the
upper arch was more prominent, which prevented their extrusion, thus
causing anterior open bite.
 In the low posture of the tongue, it rests on the lingual surface of the
crowns of mandibular incisors, thereby protruding these teeth and
preventing their eruption, which establishes a moderate open bite. Due to
protrusion in the lower incisors, horizontal overlap may be zero or negative.
A gap can be seen between the occlusal surfaces of posterior teeth and the
incisal surfaces of anterior teeth in the lower arch only, with lower incisors
positioned below the occlusal level.
 A very low tongue posture occurs when the tongue rests below the crowns
of the mandibular incisors in the lingual region of the lower alveolar ridge.
The direction of tongue pressure produces retroclination of mandibular
incisors and prevents their eruption, positioning them below the occlusal
level. The open bite is more severe and associated with posterior crossbite
due to the fact that the tongue moves away from the palate. The tongue
sprawls across the mouth floor, expanding the lower arch in the transverse
direction.
TREATMENT CHOICE BASED ON TONGUE POSITION AT
REST: RESTRAINING AND ORIENTING TREATMENTS
 If the open bite has been caused by an abnormal posture of the tongue,
orthodontists should classify tongue posture through an analysis of the
morphological features of the malocclusion.
 High and horizontal tongue postures are positioned very close to normal
posture and require control in the horizontal direction only. It is suggested
that blocking mechanisms such as cribs are sufficient to produce this tongue
retraction and adapt it to its correct posture at rest. This type of treatment
will be referred to as restraining treatment. Like Hawley retainer with a
crib.
 However, in the low and very low tongue postures, the tongue is not only
protruded but it is positioned below its correct position and needs to be
retracted and elevated. This process is difficult to learn and automate,
requiring educating devices which force the direction of the tongue, such as
spurs. They are generally placed segmentally and in the lingual arch. This
type of treatment will be referred to as orienting treatment.
Correction of skeletal open bite

 Vertical growth pattern,

 Adenoid vegetation,
 Polyps,
 Tumors,
 Septum deviation, and
 Narrow nostrils
 Blocked nasal airway

Tongue stands on the mouth floor with slightly anterior

position

Tongue position prevents the anterior teeth from erupting, or

at least intrudes them while the posterior teeth erupt freely

Results in clockwise rotation of the mandible and an increase

in lower facial height.
Two biomechanically efficient ways to
obtain selective incisor extrusion
The goals of skeletal open bite treatment:

Encourage the mandible to rotate counterclockwise

• Encourage the palatal plane to rotate clockwise
• Expand the constricted maxillary dental arch
• Parallel the maxillary and mandibular occlusal
planes
• Improve the upper lip-incisor relationship and
smile line
• Eliminate the soft tissue parafunctions and correct
speech (consult with a speech therapist)
• Reduce lower facial height to facilitate lip closure
• Achieve a normal (or deep) anterior overbite
Bionator for class I open bite or shield
appliance in growing patients:

 1. The purpose is to allow both upper and lower front teeth to slightly
retrocline with pressure of the lips while they are not influenced by
the tongue.
The palatal-lingual acrylic shield of the appliance keeps the
tongue away and at the same time relief is provided for retroclination of
both maxillary and mandibular incisors in dento-alveolar area on palate
and lingual side.
 2. The labial bow is similar to class II rype but vertically lies
somewhat in the middle of anterior open bite, therefore not in
contact with either upper or lower incisors.
Balters' bionator for class I open bite:
The shield appliance has a similar labial bow as the base appliance.
Because of the open bite, for example, in patients with tongue dysfunction, the
labial wire is located in the middle between the upper and lower incisors. This
bow hinders the introduction of the lower lip between the arches.
The acrylic base of the shield appliance is closed in the front but it should not
contact the incisors or the dento-alveolar margin so that the open bite can
close.
This area can be blocked out with wax before the application of the acrylic, or
be trimmed free after its finishing.
Extraction in the treatment of open bite

 In growing patients, controlling the vertical movements

of the posterior teeth
 Eliminating premature contacts between the primary
molars, or extraction, can help control a vertical growth
pattern
 Mesial movement of the posterior teeth after extraction
promotes counterclockwise rotation of the mandible and
reduces lower facial height
Posterior bite block
 raising the bite over the freeway space will use
muscle activity to control vertical movement of
the molars, thus helping control lower facial
height as well as vertical growth
Transpalatal arch and high-pull
headgear combination
Erupting second molars

In open bite cases, erupting second molars can be

controlled using a 0.016 x 0.022—inch SS segmented arch
that passes through the auxiliary tube of the first molar
 Arches with reverse curve of Spee

Reverse-curved archwire and anterior box elastics- prevent

eruption of the premolars and extrude the anteriors

The elastics should not be worn longer than 2 months because

of the possibility of gingival recession and a gummy smile from
overeruption of the incisors.
 Molar intrusion with
microimplant anchorage
 Surgical Treatment:

 Indicated for extremely severe cases with mandibular

plane above 50 degrees
 LeFort I osteotomy for superior repositioning of the
maxilla. This allows a counterclockwise rotation of the
mandible, thus correcting AOB
 Mandibular surgeries combined with TADs
 If chin retrusion remains a problem, it may be corrected
by a combination advancement and reduction genioplasty.
References

 Biomechanics in Orthodontics: Principles and Practice –

Ram Nanda
THANK YOU !