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Table of Contents
Definition ........................................................................................................................................ 3
Incidence ......................................................................................................................................... 3
True rotation, matrix rotation & apparent total rotation as described by Bjork 1969 .................... 5
In details ........................................................................................................................................ 14
Difficulty associated with the treatment of AOB, Burford 2003 Sandler 2011............................ 24
Caused by ...................................................................................................................................... 24
Treatment ...................................................................................................................................... 25
Incidence
In children is 4% at age 9 years, falling to 2% by the early teenagers (O’Brien, 1993).
One measure of the importance of the inherited characteristics is the incidence of AOB in
black and white individuals in the USA.
Blacks are 8 times more likely to have an AOB.
Worms 1971 showed 50% reduction from age of 7 till 12 (from 13.5% to 3.7%)
Nielsen et al 1991
1. Normally
B. Always there is a balance between APH and PFH growth to achieve normal FH. If this is
lost then either long or short face might develop
3. Condylar growth.
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
A. Bjork's structural signs help to predict type of growth rotation , (Skieller and Bjork, 1969)
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;
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.
Jarabak, 1972
C. UAFH-LAFH ratio: Nahoum (1975) believed that patients with a dental open bite and a UAFH-
LAFH 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).
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. PP-
FH is positive it is added this value from AB-MP and vice versa. A value of less than 68º 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 20°±4°), similarly describes possible
compensation.
If one or both of these measurements are increased in a patient with an increased vertical
jaw relation, favorable dentoalveolar compensation is indicated.
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.
Overbite measured from any of the lateral or central incisors with the largest
vertical discrepancy is recorded.
Indication of treatment
1. Difficulty with incision of food
2. Speech problems like lisping
3. Dental and facial appearance
2. Skeletal factors
3. Soft tissue factors
Muscle of mastication
Neurological disturbances
Chronic nasal obstruction
Adenoids
4. Habits,
Digit Sucking Habits.
Endogenous (primary) thrust
5. Pathology
Inflammatory
Hormonal
6. Traumatic
7. Local Dental factors
8. Iatrogenic factors
9. Combination
In details
Vertical growth pattern more genetically correlated than horizontal one; if you had the long face
in one generation then chances are high that you would have a long face in the next generation.
(Hunter 1968)
Methods of treatment
For sucking habit
For mouth breather
For tongue thrust
Myofunctional Therapy Muscle exercise
Vertical holding appliance
Spring-loaded bite block
Passive posterior bite-blocks
The functional regulator appliance (FR IV)
Myofunctional+EOA Teuscher activator
combination Therapy BIS
MIS
Concorde appliance
Van Beek appliance
Twin block appliance modifications including:
1. TB with high-pull headgear inserted in the flying spring
2. Thick Twin block appliance
3. TB with occlusal stopper
4. Avoid trimming the appliance
Extraoral Traction Vertical pull chin-cup
High-pull headgear
Fixed Appliances Extraction of terminal molars
Bracket set up
Wire bending
Tongue timer which act as a tongue thrust breaker
Vertical intermaxillary elastics
Segmental arch mechanics
Kim mechanics
Modified Kim mechanics
Molar intrusion using skeletal anchorage
Repelling magnets
Orthognathic Surgery
Adjunctive procedure
In details
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 first 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 3–4 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 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. 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
anteroposterior discrepancy while controlling the vertical dimension. Park 2001
Thick Twin block appliance: The ramps measure 5 mm to 8 mm in thickness in the premolar
region. This impinges on the patient's freeway space, which, in turn, results in increased masseter
tension. This tension not only restricts vertical descent of the maxillary posterior teeth, but also
produces a relative intrusion of the posterior aspect of the maxilla in growing patients." This
phenomenon, which is called the bite-block effect, provides excellent vertical control. Although
long-term studies documenting the results of this treatment are not yet available, the early results
are promising. Clark 2010
TB with occlusal stopper
Avoid trimming the appliance
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:
High pull headgear to a maxillary splint.
High pull headgear to buccal splint.
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
This technique showed that the pd is improved as the crestal bone is moved more coronal and
thus improving the crown root ratio. Byani 2012
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
Periodontal condition should be carefully considered.
For patients with a dual occlusal plane, segmental intrusion of the posterior buccal segments is
indicated. However, during the active intrusion phase, careful monitoring of the first, second,
and third order relationship of the intruded molars should be monitored.
Causes of relapse
Continued unfavorable posterior mandibular growth rotation
Unfavorable tongue position
Continued habit
Excessive extrusion of incisors
Relapse after surgery
Management of relapse
Overcorrection is recommended to compensate for any relapse.
Elimination of the habit
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
Daytime wraparound retention with modified contour,
in which the wire is engaged in the CEJ to counteract the
intrusion relapse of anterior teeth, usually this is used at
day time while at night a different appliance is used but with tongue crib.
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.
Fixed Modified Nance-Hyrake appliance to train the tongue
Caused by
1. Failure of eruption
2. Tongue interfere with eruption
3. Trauma and Ankylosis
4. Hemimandibualr hyperplasia when the vertical compensation is not sufficient
Treatment
1. Habit breaker posteriorly
2. Composite build up
3. Orthodontic extrusion by FA or TAD
4. Segemental dentoalveolar osteotomy
5. Segemental maxillary or mandibular surgery