Anterior

Open Bites © 2016 Spear Education, LLC.

INTRODUCTION

Dr. Darin Dichter, D.M.D.

Every practice has some patients that are difficult to treatment plan. Our patients with anterior open
bites can definitely fall into this category. Once an anterior open bite has been identified, clinicians
are often left to wonder:

How did this anterior relationship develop?

What can I do about?
Do I have to do something about it?

The collection of articles contained in this e-book will guide clinicians toward predictable esthetic and
functional treatment outcomes with anterior open bite cases.

In the book, Dr. Frank Spear reviews the possible etiologies of anterior open bites and how clinicians
can begin to harness the power of Facially Generated Treatment Planning to better understand where
the patient is now and where they might like to be following treatment.

Predictable outcomes with anterior open bite cases begin with confident treatment planning.
We trust that you will find this e-book to be a valuable resource for these challenging cases.

- Dr. Darin Dichter

Spear Education
Contents

Anterior Open Bites

02 Fundamental Concepts

06 Imaging the Joints

08 Open Bites, Stable Joints

10 Case Study: Maxilla–to–

Mandible Relationship

16 Facially Generated
Treatment Planning

04 Relationship of
the Mandible to
the Maxilla
20 Case Study:
Intra-Arch Issues

22 Case Study:
Tooth Wear

14 Case Study:
Excess Overjet
Anterior
Open Bites

1
 Fundamental Concepts
A
nterior open bites an often – a misunderstood entity in dentistry – from what
causes them, to when and how they should be treated. The purpose of this
series of articles is to hopefully provide a better understanding of how to
address this problem.

Anterior open bites can exist for several reasons, and it is helpful to identify the most
common etiologies. Open bites can occur due to alterations of tooth position within
an arch, or intra-arch. (Figures 1-2) Examples include:

• Thumb sucking
• Tongue posture issues potentially related to airway disorders
• Excessive wear of segmental appliances (NTI or anterior bite plane)
• Abnormal eruption from ankylosis

Open bites can also occur due to alterations in the relationship of the mandible to the
maxilla, or inter-arch. Examples include:

• Degenerative joint disease

• Class II or III skeletal relationship
• A steep mandibular plane angle, specifically in patients with a long face

Finally, open bites can occur if there is tooth wear without secondary or compensatory
eruption. A good example of this would be a patient who has erosive wear from
sucking on lemons – but the compensatory eruption doesn’t keep up with the rate of
wear. (Figures 3-4)

2
O
ne of the simplest tools to aid in diagnosing the etiology of an anterior open bite is the use
of study models that are hand-articulated. If the hand-articulated models fit well in terms
of their occlusal relationship, but the patient is unable to get their anterior teeth to touch,
you don’t have a problem of tooth position within the arch – you have a problem that is
related to the position of the mandible relative to the maxilla. (Figures 5-6)

In these patients the open bite is

typically very linear, meaning the
molars have contact, but the open
bite becomes progressively larger in
a linear fashion as you move from the
posterior to the anterior teeth.

A
(Figure 7)

If the patient has issues with intra-arch

tooth position, the hand-articulated

R
models will display an open bite
similar to what is seen in the mouth.
Typically, the models will show an

ntE
irregular pattern of eruption. In these
patients, it is common to see a well-
fitting posterior occlusion with just
the anterior teeth – or even some

o
of the anterior teeth not in
contact. In future articles, I’ll
discuss going further into
the diagnosis for each
of the typical causes of
anterior open bites and
the options that exist
for treatment.

r 3
Relationship
of the Mandible
to the Maxilla

4
P
reviously, I covered the possible etiologies of anterior open bites, and how hand-
articulated study models could be helpful in determining if the problem was
related to an intra-arch issue of tooth position or was likely due to the relationship
of the mandible to the maxilla.

In this article, I want to discuss the possibilities if the problem is due to the relationship
of the mandible to the maxilla. This usually means the hand-articulated models fit
well, but the patient can’t get their anterior teeth together. This is a common outcome
following degenerative joint disease, but can also be an outcome of having a significant
shift between the patient’s seated condylar position and their habitual occlusion. In
these instances, it is not uncommon for a patient to lose the muscle programming that
allowed them to find their intercuspal position. This can occur after an alteration to their
posterior occlusion, such as following the restoration or removal of a first or second
molar, wearing an occlusal appliance or the initiation of orthodontics.

Diagnosing the etiology of these open bites can be aided by examining the history of
the open bite. A key thing to look for would be the timing of the onset of the open
bite. It is not uncommon for the onset of an open bite from degenerative joint disease
to be progressive – and it can occur without symptoms other than the open bite. In
these patients, their anterior teeth would likely have touched at some point in time, and
will probably show evidence of some wear, such as a lack of mamelons. The open bite
may be progressively getting worse, with the rate being dependent upon the rate of
the progression of the degenerative process (as seen in the main image). In contrast, a
patient with an open bite that is related to a change in the relationship of the maxilla to
the mandible, from the lateral pterygoid muscle releasing and the mandible retruding,
will typically have a history of some dental treatment. It could have been a restoration
of a posterior tooth, extraction of a posterior tooth, appliance therapy, or the initiation
of orthodontic therapy.

No matter what the dental treatment is, the open bite will likely have developed more
quickly – and in some cases this will happen immediately following treatment, not slowly
and progressively. All of these possibilities make diagnosing the correct etiology critical
prior to starting on a path of treatment to correct the open bite. In future articles, I’ll
discuss how to more definitively diagnose if the joint condition is the etiology.

5
 IMAGING
the joints
I
n the previous two articles, I discussed the possibilities of developing an anterior open
bite from degenerative joint disease, as well as from the lateral pterygoid muscle releasing
in a patient with a significant shift from their seated condylar position to their habitual
occlusion. I recommended that history could be used as one tool to aid
in diagnosis.

If the open bite has been slowly developing, I would consider degenerative joint disease
as a strong possibility. If the open bite occurred after some recent dental treatment that
altered the posterior occlusion, the lateral pterygoid may be responsible. If you suspect
that degenerative joint disease is a possibility, it is best to have the patient’s joints imaged
to see the location and condition of the disk, as well as the form and condition of the bony
structures of the condyle and fossa.

An MRI is the gold standard for imaging of hard and soft tissue, but CBCT can reveal
the condition of the hard tissues, and tomograms can as well. The biggest concern is if a
degenerative process is occurring in the joints. Any treatment done to correct the open
bite may be a temporary correction, and the open bite will return as the joints continue to
degenerate. In this article, I included some photos of a patient I treated in the 1980s – a case
where I suspected the joints were the problem. (Figure 1)

6
The challenge was the patient refused any imaging – back then, it would have been tomograms. She was
convinced the problem had occurred because of a crown her dentist had recently placed. I placed her on
a lower full-coverage appliance she wore 24 hours a day to see if her occlusion was continuing to change.
After six months, the occlusion on the appliance remained stable. (Figure 2)

She informed me that she had told me it wasn’t her joints from the beginning – and since her bite on the
appliance hadn’t changed, she was convinced she was right. She then asked what I was going to do to
correct the open bite. I still didn’t have any joint images, and she refused them again. I mounted models
and discovered that if I restored her molars with occlusal coverage restorations and equilibrated her
premolars, that her anterior teeth would touch perfectly. (Figures 3-5)

The molars all needed restorations anyway, so we proceeded to treatment without any joint images.
The final result was perfect – the anterior teeth touching as predicted from the mounted models and
diagnostic wax-up. However, six months later, her open bite returned with the same pattern it had before
– contact on the second molars, then a linear opening increasing as it moved anteriorly. She now agreed
to get the joint images I had requested in the beginning, and both joints had acute degenerative changes.
(Figure 6)

The lesson here is, if the patient’s open bite and history fit the degenerative model, image before deciding
on a course of treatment. In my next article, I’ll discuss the options for correcting open bites in patients
who have stable joints.
7
Open Bites,
Bites Stable Joints

I
n this article, I would like to discuss the treatment options available
for patients who have anterior open bites due to the relationship of
their maxilla to mandible, but have stable joints – unlike the patient I
described in the Part III in this series. There may be several different
options available for these patients, all designed to close the anterior
open bite.

Prior to developing any plan to correct the occlusion, the starting

point is to determine the correct anterior tooth position relative to
the patient’s face. You can do this by using tooth exposure with the
lip at rest and images of a full smile to choose the desired anterior
tooth position. In some patients, correcting the anterior tooth position
may correct the open bite without any other occlusal changes being
necessary. The patient I will use as an example has an acceptable
maxillary and mandibular anterior tooth position esthetically, but has no
anterior tooth contact unless she protrudes her mandible into an end-
to-end occlusal relationship. She will require some occlusal alteration to
close the open bite. (Figure 1)

8
Her open bite is due to condylar fractures
secondary to being being kicked in the
face by a horse at age 18. Effectively
the condylar fractures had the same
impact on reducing joint height as the
degenerative joint disease did in the
patient I showed in previous articles. The
good news is her joints are stable and
asymptomatic now. (Figures 2-3)

The question that one may ask is, why

not leave the open bite since it has been
there for more than 15 years? To answer
that, it is helpful to understand the risks
associated with leaving a patient without
anterior contact. There are two primary
risks – one is secondary eruption of the anterior teeth to close the open bite. We notice in this patient
that there appears to have been no secondary eruption. This is visible first because the open bite is
still present – had the teeth erupted, the open bite most likely would not exist.

Figure 2 Figure 3

Secondly, because the anterior teeth are in an acceptable position, had the teeth erupted, they would
have appeared long or stepped down relative to her posterior teeth. The second risk of leaving the
anterior open bite is functional. We typically design our occlusions to have the anterior teeth contact
and posterior teeth separate, commonly known as posterior disclusion, when the mandible moves.
Without anterior contact, the posterior teeth are now in contact during excursions, potentially
producing wear, fractures or mobility of the posterior teeth. In addition, the lack of posterior disclusion
may result in muscle hyperactivity in some patients, producing exacerbated dental symptoms or pain.

This patient doesn’t present with over-eruption of the anterior teeth or pain, but she does have
significant posterior tooth wear, particularly on the right side. (Figure 4)

The reason she hasn’t had any secondary

eruption is quite simple – she wears a full-
coverage bite appliance every night when she
goes to sleep. It acts as a retainer, preventing
secondary eruption. In addition, she has
significant headaches if she forgets to wear the
appliance. Her goals are simple: improve the
appearance of her anterior teeth and correct
her occlusion so she can eliminate the nightly
appliance wear. In the next article, we will look at
her options for correction.
Figure 4
9
Case E
arlier in this series, I introduced a patient
who had an anterior open bite secondary
to condylar fractures at age 18. She is
now in her mid-30s and asymptomatic,
but she must wear a full-coverage bite appliance

Study:
every night or she risks secondary eruption of her
anterior teeth from the open bite. In addition, she
has significant posterior wear from the lack of any
anterior guidance, and gets headaches regularly if

Maxilla-to-
the appliance isn’t worn. (Figure 1)

Mandible
Relationship

10
 In her case, the intra-arch alignment of the
teeth is acceptable, and the position of her
anterior teeth in her face is reasonable. Her
anterior open bite is related to the relationship
of the maxilla to the mandible.

In cases like these, typically four treatment

options exist if the desire is to close the
anterior open bite.

The first option I generally consider for an

anterior open bite is occlusal equilibration;
altering the posterior occlusion by reshaping
the teeth, effectively closing the vertical
dimension and bringing the anterior teeth
into contact. The risk of equilibration is that
Figure 2 it may require excessive tooth reduction,
exposing dentin in the process, and it may
be inadequate to achieve the necessary closure to gain anterior contact. For these reasons, a trial
equilibration is typically performed on mounted models to see if the desired occlusion can be obtained
with just equilibration – and to evaluate the amount of alterations necessary to the posterior teeth.
(Figures 2-4)

Figure 3 Figure 4

If equilibration is incapable of achieving the desired result, a second option to close an anterior open
bite would be to add some restorations to the plan. This may be helpful to allow more posterior
reduction than equilibration alone, but restorations also can be placed on maxillary or mandibular
anterior teeth to gain contact. With the outstanding wear characteristics of modern composites, these
restorations are often simply bonded additions requiring no tooth preparation.

A third, and obvious option to close the anterior open bite is orthodontics – but this is not always as
simple as it seems. For an orthodontist to gain anterior contact, they have to reduce the anterior open
bite without over-erupting the anterior teeth relative to facial esthetics. In this patient, this leaves
reducing overjet or closing the posterior vertical dimension as the alternatives.

Thankfully this patient has crowded lower anterior teeth, and aligning them with orthodontics will
lengthen the lower arch, reduce overjet and increase the likelihood of closing the anterior open bite
with equilibration. If the anterior open bite still can’t be managed after orthodontic alignment of the
mandibular anterior teeth, intrusion of posterior teeth using mini-screws for orthodontic anchorage
could close the vertical dimension and gain anterior contact. (Figure 5)

11
 Of course, the orthodontics could only be successful if
the patient’s mandible is not excessively retrognathic,
otherwise known as Class II. If it is, then the final option
to correct the anterior open bite would be to consider
mandibular advancement. All of this is determined
by evaluating the patient’s tooth position and facial
esthetics from photographs, and performing the trial
equilibration on mounted models. If it is not successful,
an ortho set-up can be done and evaluated. In
addition, a diagnostic wax-up simulating any proposed
restorations can be included on the models as well.

Ultimately, this patient’s treatment did not require

orthognathic surgery. However, it did require
orthodontic correction of the mandibular anterior teeth,
occlusal equilibration, four full-coverage restorations for
esthetic reasons on the incisors, and bonded composite
on the lingual of the maxillary left canine. (Figure 6)

Figure 6
12
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symptoms of facial pain.

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1 4
Why occlusion can seem so complicated,
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looks like, and how efficiently it can
be done in any practice (with multiple
examples shown on video)

2 5
To gain confidence in understanding the
TMJ, and how easy it is to evaluate them
as a potential problem for your patients,
including possible solutions if they are a
problem, and how to have a conversation
with your patients about the TMJ
How to become confident in choosing
among all the different occlusal appliances
available, including a specific flow chart
of the appliance choices based upon your
patients’ symptoms and history, with an
emphasis on how to discuss appliance
therapy and fees with your patients

3
To efficiently evaluate your patients’
muscles, and predict whether any therapy
is necessary, which treatment, and how to
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0416_01SO_112216
 Case Study:
E XCE SS
OVERJ E T

Figure 1

I
n previous articles in this series, we have looked
at the potential etiologies of anterior open
bites, and specifically focused on anterior
open bites due to the relationship of the
maxilla to mandible. In Part 5 of this series, I
used a combination of orthodontics and occlusal
equilibration to close the anterior open bite in a
patient who had a history of condylar fracture.
In this article, we will look at a patient who has
normal joints, but excess overjet resulting in an
anterior open bite; she is also congenitally missing
multiple maxillary teeth. As is typical in patients
with excess overjet, she has an extremely deep
overbite, the mandibular anterior teeth impinging
on her palate. (Figures 1-2)

In these cases, the overjet will need to be reduced

to allow for the development of a normal anterior
relationship. Reducing overjet is typically done
by either retracting the maxillary anterior teeth,
or advancing the mandibular anterior teeth;
either can be done by orthodontics alone, or
orthodontics combined with orthognathic surgery.
14
 Figure 2 Figure 3

The Ideal Plan for Anterior Open Bite Patients With Excess Overjet
A very useful tool for deciding on what the ideal plan should be is a facial profile photograph of the patient
with their lips together, face at rest. On the photograph, identify glabella – the smooth area between the
eyebrows; subnasale – the junction of the base of the nose and upper lip; pogonion – the most prominent
point of the chin. Draw a line from glabella to subnasale, and subnasale to pogonion. Measure the angle
formed at the junction of the lines; a normal range would be 165 degrees to 175 degrees. The patient
illustrated measures 158 degrees, indicating her chin is retrognathic, skeletal Class II.

In addition, measure the vertical distance between the same points. If you use the distance from glabella
to pogonion as 100 percent, the distance from glabella to subnasale (midface) should be 45 percent to
50 percent; from subnasale to pogonion (lower face), 50 percent to 55 percent. In the patient shown, her
midface is 56 percent, and her lower face 44 percent. She is a patient who would benefit functionally and
esthetically from a mandibular advancement. The advancement would correct her retrognathic mandible,
as well as the vertical dimension of her face. (Figure 3)

Figure 4 Figure 5

The actual treatment consisted of orthodontics to idealize maxillary tooth position, followed by the
mandibular advancement and then the final orthodontic correction of the occlusion. (Figures 4-5)
Ultimately she had prosthetic treatment to replace the missing maxillary teeth. (Figure 6)

Figure 6
15
 Facially
Generated
Treatment
Planning

I
n this article I want to focus on the specific
treatment planning sequence necessary for
correcting both the esthetic and functional
components of anterior open bites. At Spear, we call
this process Facially Generated Treatment Planning
(FGTP), a term I first used in a lecture back in 1986.
The concept is simple. Even though there are issues
that are more serious to maintaining teeth than
esthetics – such as periodontal health, endodontic
status, caries, occlusion, etc. – we must treatment
plan the position of the maxillary teeth relative to the
face first (esthetics), before we develop the occlusion
(function), or decide how to treat the other areas of
concern (structure and biology), when we refer to as
EFSB for short. It is important to note that when we
talk about FGTP, we are talking about the sequence
of treatment planning, not the sequence in which the
patient will be treated.

The patient in Figure 1 is an ideal example of why the

FGTP process is necessary. She is 30 years old with an
anterior open bite, and desires an esthetic correction,
as well as anterior tooth contact.

16
Figure 2 identifies the options for closing the anterior open bite: lengthen the maxillary anterior teeth,
lengthen the mandibular anterior teeth, shorten or intrude the maxillary posterior teeth, shorten or
intrude the mandibular posterior teeth. The real question is, how will you know what to do? Mounted
models won’t help you any more than this photograph does; you have to evaluate the position of the
teeth relative to her face.

From a purely mechanical point of view, lengthening the maxillary and mandibular anterior
teeth would appear to solve the occlusal problem, but a look at a photo of her lip at rest and
full smile tells a different story. (Figure 3)

Her central display at rest and in a full smile is pleasing, but she has a reversed smile line. Again,
lengthening the anterior teeth would seem to solve the problem, but in reality, she has excessive posterior
tooth and gingival display from posterior over-eruption.

Figure 4 simulates what her smile would look like if the anterior teeth were lengthened to match the
posteriors correcting the smile line, excessive tooth display. She would now show 7 mm of central at rest.
The fifth photo (Figure 5) simulates what needs to happen – leave the anterior tooth position alone, correct
the posterior tooth position to correct the smile line. This will eliminate the excessive posterior gingival
display, and will most likely close the anterior open bite. Typically, there are four options for correcting
over-erupted posterior teeth: orthodontic intrusion using implant anchorage, crown lengthening and
restoration, orthognathic surgery, extract and replace with implants. In her case, the amount of change is
too great to consider crown lengthening. And at age 30, extractions seem to be a poor choice.
17
 How do you decide between intrusion and orthognathic? Intrusion would correct the maxillary
posterior tooth position, but in her case, she is dentally and facially Class III. (Figure 6)

Orthognathic surgery to impact the posterior maxilla and advance the maxilla is the ideal
treatment; the amount of movement determined esthetically. Figure 7 shows the before-and-
after views of the left and right sides following orthognathic surgery – maxillary impaction
and advancement – and restoration. But it was the posterior intrusion that was the significant
treatment event in correcting the anterior open bite. That movement was mediated by the
esthetic needs of correctly positioning the maxillary teeth in her face.

18
 Figure 8 shows the before-and-after facial images. It graphically shows the change in
posterior tooth and gingival position, as well as the improved smile line.

Esthetics. Function. Structure. Biology.

LEARN THE
3 STEPS
OF
OF FUNCTIONAL
FUNCTIONAL ANALYSIS
ANALYSIS
CHECKLIST
THE 3 STEPS OF
FUNCTIONAL ANALYSIS

1 JOINT SIGNS AND SYMPTOMS

1 1 PAIN – SOUNDS – RESTRICTED MOVEMENT
1 Pain with movement or loading is an indication that things are not functioning as
2
1 ESTHETIC designed. In normal situations it should never cause pain to move or load a joint.
2
2 FUNCTIONAL
3
2
2 Joint sounds occur when the functional parts of the TMJ are not in the appropriate
position throughout movement, creating “events” that are heard as a click (some
3 STRUCTURAL people call them a “pop”) or as crepitus, (movement on non-discal tissues). Every
3 joint that makes noise has been damaged. Understanding the anatomic changes
4
3 BIOLOGICAL
4 3 is key to diagnosis.
4
5
4 1 Restricted movement can be due to a structural joint problem or a problem with
muscle movement. Either way, something prevents normal function.
5
5
6
5
4
Functional
6 analysis is MUSCLE PAIN OR TENDERNESS
6 second part of
the
2 Muscle Pain is something identified by the patient prior to palpation, while
7
6 Muscle Tenderness is identified at the examination through palpation of the
the
7 Spear approach 5 muscle by the clinician.
7 systematic
to
8
7
8
treatment planning
3 Overworked muscles are frequently tender to palpation.

8
9
1
6 While occlusion is not the only possible etiology of muscle pain or tenderness in
8 the head, neck and shoulders, many of the muscles do have an occlusal
9 challenge for all treatment
The
9
planning is to pay attention to the 4 connection that can be investigated.

9
sequence of the planning process
and what order things get treatment
planned. The ideal order of treatment
planning is very linear and systematic
and not linked to the order in which
treatment might be sequenced.
The sequence of treatment is
variable from patient to patient
2
7
Routine palpation of muscles also serves as a differentiator since not many
dental practices routinely palpate the muscles as part of examination.
5 DENTAL SIGNS AND SYMPTOMS
3
8 WEAR – SENSITIVITY – CRACKS – MOBILITY – FRACTURES
Evaluating “tooth” is one of the skills most dentists come out of school well
6 prepared for.

based upon several factors such as 4 Evaluating for: the presence of wear, the “where” of the wear, pathway, end-to-
end, cross-over, multiple patterns, front teeth or back teeth; the etiology of the
acute problems and interdisciplinary
wear, attrition, bio-corrosion (erosion), or a combination of the two, will lead to an
therapy, but we want the sequence
of planning to be the same for
7 appropriate diagnosis and plan.

all patients. 5 Other presentations that impact teeth are noted and combined with other
findings to develop clear etiologies for what is seen. Sensitivity, cracks, mobility
8 and fractures can tell a story. With the wear present, there is a history of what this
patient has done and continues to do with his/her teeth.
6

7
7201 E. Princess Boulevard
Scottsdale, AZ 85255

Phone: 866.781.0072
8
SPEAREDUCATION.COM

Download Spear’s
Functional Analysis Checklist
www.speareducation.com/functional-analysis

19
Case
Study:
Intra- T
he majority of the cases I have shown in the
previous installments of this series were very
challenging to treat; they had combinations of
intra-arch and inter-arch issues. In this article,

arch I’ll focus on a patient who has an open bite from only
intra-arch issues, specifically the tooth position in the
maxillary arch due to a habit pattern. The good news

Issues
about this patient is she is young, has no tooth wear
and has a reasonably well-aligned mandibular arch. In
addition, she has a Class I molar relationship, no inter-
arch problems. (Figure 1)

What Caused This Open Bite?

The challenge in these patients is that the open bite is
due to under-eruption of some of the maxillary anterior
teeth and the under-eruption occurring from a habit
– which could be thumb sucking, tongue posture or
something placed between the teeth such as a pencil.
The problem with the under-eruption is it means the
gingival margins are also apically positioned on the
under-erupted teeth. (Figure 2)

20
Because of this, non-orthodontic treatment plans – specifically restorations to lengthen the under-
erupted teeth to close the open bite – will always end up esthetically challenged with the under-
erupted teeth, specifically her right lateral and central looking too long after restoration. (Figure 3)

If crown lengthening as done on the left to make

the gingiva match the right, all the incisors would
look excessively long. In addition, the left central
and lateral would need restorations to cover the
exposed root surfaces following surgery. The
obvious solution for these types of patients is
orthodontics to correct the tooth position by
extruding the under-erupted teeth into a normal
alignment. (Figure 4)

This brings the gingiva into the correct position

and, in her case, eliminates the need for any
restorations. Of course, the habit that caused
the under-eruption must be addressed or a
reoccurrence of the open bite may occur. This is
especially true in patients with tongue posture
issues. It is common that the orthodontics may
also have minor correction of the opposing tooth
position, since it may be altered from the habit as
well. (Figure 5)

Ultimately in a patient like this one, orthodontics

and behavior modification surrounding the habit
are by far the best choices of treatment, avoiding
any surgery or restorations. (Figure 6)

21
Case Study: Tooth Wear

The easiest open bite to correct is one that was

caused by tooth wear from erosion, not attrition
or grinding, and where the anterior tooth position
didn’t change with the tooth wear. These are also
very uncommon patients, as normally, eruption
will occur following the wear maintaining the
teeth in occlusal contact.

22
Open Bite Caused by Lemon Sucking
The patient in this open bite example is a male in his 50s, and he has a 25-year history of sucking
lemons. (Figure 1) A lateral view shows the posterior teeth from first premolar back are all in contact,
although they do show some evidence of facial erosion. (Figure 2) He bit through the lemon with his
incisors and sucked the juice out around them; in the process he actually devitalized three of the four
incisors. (Figure 3) Simply looking at this image doesn’t make it clear whether his anterior teeth have
extruded with the tooth wear or not. (Figure 4)

It will be necessary to identify the correct incisal edge position of his teeth, then evaluate how the
gingival levels relate to that position using width-to-length ratio as an assessment of whether the
gingival margins are correct or not. This will tell you whether the teeth have erupted with the wear or
not. In this case, the drawings are done to illustrate the correct incisal edge position for this open-bite
patient, basically level with his posterior occlusal plane. Measuring from the correct incisal edge to the
existing gingival margins gives a ratio of 77 percent, a very common ratio for a pleasing central incisor.
It appears he has no secondary eruption with the tooth wear, and will simply need the teeth restored
without any gingival level alterations. (Figure 5)

The good news is that because he had the open bite, there was room to place the restorations. The
even better news is that if he keeps sucking on lemons, the acid will have no impact on the porcelain
restorations. Of course it would be better for all his other teeth if he quit the habit. Ultimately, due
to finances, he only did the maxillary 6 anterior teeth; it would have been ideal if he could have gone
back to the first molars. (Figure 6)

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