See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/237013506

A novel approach in treatment of open bite: a case report

Article  in  International journal of orthodontics (Milwaukee, Wis.) · June 2013

Source: PubMed

CITATIONS READS
0 467

3 authors, including:

Rahman Showkatbakhsh Abdolreza Jamilian

48 PUBLICATIONS   319 CITATIONS   
Islamic Azad University
108 PUBLICATIONS   702 CITATIONS   
SEE PROFILE
SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Separate projects View project

co-authors View project

All content following this page was uploaded by Abdolreza Jamilian on 10 July 2015.

The user has requested enhancement of the downloaded file.

F E A T U R E This article has been peer reviewed

A Novel Approach in Treatment of Open bite: A case report

By Rahman Showkatbakhsh,, DDS; Abdolreza Jamilian DDS and Ziba Mashayekhi DDS

Abstract: This case illustrates the treatment of a 12-year-old boy with an open bite, a slight Class II jaw relationship, Class I molar
relationship, and a steep lower occlusal plane. The patient needed a surgical procedure due to the severity of openbite; however the surgery
option was rejected. Therefore, he was treated by a Hyrax, fixed tongue appliance, posterior bite plate, reverse chin cup and fixed orthodontics.
His second premolars and lower second molars were extracted during treatment. The active treatment lasted for 34 months after which
favorable correction of the malocclusion was observed. The SNA angle increased by 4° and the GoGn-Sn decreased by 6°. This patient was
treated nonsurgically and favorable profile and occlusion were obtained.
Keywords: Open bite; Vertical growth pattern; Nonsurgical treatment; Increased anterior facial height; lip incompetency.

ntroduction
The anterior open-bite can be defined as the
presence of negative overbite between the incisal
edges of the maxillary and mandibular teeth, with
the posterior teeth in occlusion.1 Many factors
such as heredity, parafunctional habits, mouth breathing,
and unfavorable growth pattern can be associated with the
establishment of the open bite malocclusion. Various treatment
modalities have been proposed for the correction of an anterior
open bite. Some of these modalities are extrusion of the
anterior teeth by intermaxillary elastics,2 inhibition of molar
eruption during growth,3 palatal crib and high-pull therapy,1
bite blocks4 and repelling magnets.5 Another treatment option
is the repositioning of both the maxilla and mandible through Figures 1-2: Pre-treatment extraoral photo of the patient
a surgical correction.6 Recently, miniscrews have been used for
open bite closure.7,8 Zygomatic anchorage can also be used for Table 01 - Cephalometric analysis
open-bite correction through posterior dentoalveolar intrusion.9
Cephalometric Data Pre-treatment Post treatment
In light of our current knowledge on open bite correction,
the aim of this study was to report the nonsurgical treatment of SNA (°) 78 82
an open bite patient with a slight Class II jaw relationship, Class SNB (°) 72 79
I molar relationship, and a steep lower occlusal plane. ANB (°) 6 3
GoGn-SN (°) 39 33
Case History 1-SN (°) 107 108
A 12-year-old boy was initially referred to orthodontic IMPA (°) 92 85
department for treatment of openbite. He had no medical
Interincisal (°) 120 135
problems and there were no signs of temporomandibular joint
Y-Axis (°) 72 65
dysfunction.
Clinical examination revealed anterior open bite and lip
incompetency. Facially, soft tissues were imbalanced (Figures
1-2).
Intraoral examination showed an anterior open bite and Treatment Objectives
Class I relationship of right and left molars (Figures 3-7). In The treatment objectives for this patient were to:
fact the molars were in Class III relationship but they rotated to 1. Correct the openbite.
Class I relationship due to vertical growth pattern of the maxilla. 2. Obtain an ideal overjet and overbite.
Cephalometric analysis confirmed the patient was a vertical 3. Obtain lip competency.
grower (Table 01) (Figures 8-9).

IJO  VOL. 24  NO. 1  SPRING 2013 29


Figures 3-7: Pre-treatment in-
traoral photo of the patient
Figures 8-9: Pretreatment lateral
cephalometric and panoramic
image of the patient
Treatment Alternatives
Orthognathic surgery at 18 years-of-age was considered as
an alternative treatment. However, the patient and his parents
refused surgery. Therefore, this case was treated orthodontically.
Use of anterior vertical elastics could also be an alternative
method; nevertheless, they could have elongated the upper
incisors and caused a gummy smile. Use of High pull headgear
was another viable method in intrusion of posterior segment.
Use of vertical chin cup along with posterior bite plate could
enhance the effectiveness of posterior bite plate and be very
effective in reduction of openbite. Nevertheless, this patient
did not show good compliance in using further bulky extra oral
devices and was very reluctant to use them.
Treatment Progress
A hyrax combined with fixed tongue appliance was
mounted in the upper jaw (Figures 10-13). The patient was
instructed to open the screw of the hyrax 1/4 of a turn twice
a day for two weeks. At the same time a posterior bite plate
was mounted in the lower jaw. A reverse chin cup10 was used
during the night in order to increase the force used for forward
movement of maxilla. The hyrax, tongue appliance, posterior
bite plate and reverse chin cup were removed after 18 months.
Afterwards, all second premolars were extracted and the teeth
30
were bonded with 0.22 standard
edgewise system for 10 months.
After debonding, a posterior bite
plate was mounted for 6 months.
After removal of posterior bite
plane, the patient still had some
openbite due to the contacts of
second molars. The patient was
made aware of two possible treatments namely extraction of the
lower second molars and use of miniscrew for intruding them.
However, he rejected use of miniscrews; therefore, his lower
second molars were extracted after obtaining required informed
consent forms.
Treatment Results
Positive overjet and overbite were achieved after 34
months of active treatment and open bite was successfully
corrected (Figures 14-20). The post treatment cephalometric
radiograph and OPG showed a favorable increase of 4° in the
SNA angle and a favorable decrease of 6° in GoGn-Sn angle
(Figures 21-22). The superimposition of pre and post treatment
cephalometric tracing on the anterior cranial base is shown in
Figure 23.
Discussion
The openbite of a 12-year-old patient who needed surgery
was successfully corrected by means of hyrax, tongue appliance,
posterior bite plate, reverse chin cup and fixed orthodontics.
The patient had maxillary deficiency in three dimensions.
Fixed tongue appliance combined with hyrax was mounted in
the maxilla to train the tongue to function normally. Due to the
patient’s vertical growth pattern, a posterior bite plate was used
in the lower jaw to control the vertical growth. A Reverse chin
cup was also used during the nights in order to enhance forward
movement of the maxilla. After removal of these appliances,
second premolars were extracted in order to move first molars
mesially and reduce open bite. After debonding and use of
posterior bite plate, contact was seen in second molars. This
contact could be removed by means of miniscrew as an intrusion
device or extraction of lower second molars. Due to rejection
of miniscrew the lower second molars were extracted in order to
close the bite. Following the extractions, the eruption of upper
second molars was controlled by use of posterior bite plate.
Orthognathic surgery and numerous appliances such as
vertical holding appliance,11 high-pull headgear,12,13 vertical chin
cup,14 posterior bite blocks,15 spring-loaded bite block,16 active
vertical corrector,17 Fränkel IV regulator,18 mini-implants and
miniplates19,20 have been used to treat open bite. Extraction of
the first premolars has been accepted by many clinicians in the
management of skeletal open bite due to the draw-bridge effect
of reducing the inclination of both upper and lower incisors.
Molars can also be extracted to remove the wedge which has
caused the open bite.21 In addition elastics16 are also used for
treatment of this malocclusion. High pull headgear can intrude
upper first molars and reduce the open bite. Use of posterior bite
plate along with vertical chin cup could exert more pressure on
the upper posterior segment which is more effective in reduction
of openbite than the single use of posterior bite plate.
IJO  VOL. 24  NO. 1  SPRING 2013
 Figures 21-22: Posttreatment lateral cephalometric and
panoramic image of the patient.

Figure 23: Superimposition

of pretreatment (black)
and posttreatment (red)
cephalometric analysis
of the patient, on SN, reg-
Figures10-13: Hyrax in situ
istered at sella.

Generally, clinicians try their best to avoid extraction of

permanent teeth especially in horizontal growth pattern patients.
However, extraction of permanent teeth in vertical growth
pattern patients has proven to be beneficial and can often
help in achieving lip seal.22 This case, being a vertical grower
and rejecting surgery, use of miniscrew and further extra oral
appliances left the clinician with no other choice but to extract
Figures 14-15: Post-treatment extraoral photo of the permanent teeth.
patient
Conclusions:
• Positive overjet and overbite were achieved.
• Anterior Openbite was successfully corrected.
• A surgical case was treated nonsurgically.

Figures 16-20: Post-treat-
ment intraoral photo of the
patient
References
1. Torres F, Almeida RR, de Almeida MR, Almeida-Pedrin RR, Pedrin F,
Henriques JF. Anterior open bite treated with a palatal crib and high-
pull chin cup therapy. A prospective randomized study. Eur J Orthod
2006;28:610-617.
2. Kucukkeles N, Acar A, Demirkaya AA, Evrenol B, Enacar A.
Cephalometric evaluation of open bite treatment with NiTi arch wires and
anterior elastics. Am J Orthod Dentofacial Orthop 1999;116:555-562.
3. Gurton AU, Akin E, Karacay S. Initial intrusion of the molars in the
treatment of anterior open bite malocclusions in growing patients. Angle
Orthod 2004;74:454-464.
4. 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 Dentofacial Orthop 1997;112:171-
178.
5. Dellinger EL. Active vertical corrector treatment--long-term follow-up of
anterior open bite treated by the intrusion of posterior teeth. Am J Orthod
Dentofacial Orthop 1996;110:145-154.
6. Swinnen K, Politis C, Willems G, De Bruyne I, Fieuws S, Heidbuchel K et
al. Skeletal and dento-alveolar stability after surgical-orthodontic treatment
of anterior open bite: a retrospective study. Eur J Orthod 2001;23:547-557.

IJO  VOL. 24  NO. 1  SPRING 2013 31

 7. Kravitz ND, Kusnoto B. Posterior impaction with orthodontic miniscrews
for openbite closure and improvement of facial profile. World J Orthod
2007;8:157-166.
8. Xun C, Zeng X, Wang X. Microscrew anchorage in skeletal anterior open-
bite treatment. Angle Orthod 2007;77:47-56.
9. Erverdi N, Usumez S, Solak A, Koldas T. Noncompliance open-bite Sterilization standards
10.
treatment with zygomatic anchorage. Angle Orthod 2007;77:986-990.
Showkatbakhsh R, Jamilian A. A novel approach in treatment of maxillary
are changing...
deficiency by reverse chin cup. Int J Orthod Milwaukee 2010;21:27-31.
11. Deberardinis M, Stretesky T, Sinha P, Nanda RS. Evaluation of the vertical Are you ready?
holding appliance in treatment of high-angle patients. Am J Orthod
Dentofacial Orthop 2000;117:700-705.
12. Watson WG. A computerized appraisal of the high-pull face-bow. Am J
Orthod 1972;62:561-579.
13. Ngan P, Wilson S, Florman M, Wei SH. Treatment of Class II open bite in
the mixed dentition with a removable functional appliance and headgear.
Quintessence Int 1992;23:323-333.
14. Pearson LE. Vertical control in treatment of patients having backward-
rotational growth tendencies. Angle Orthod 1978;48:132-140.
15. Ngan P, Fields HW. Open bite: a review of etiology and management.
Pediatr Dent 1997;19:91-98.
16. Iscan HN, Akkaya S, Koralp E. The effects of the spring-loaded posterior
bite-block on the maxillo-facial morphology. Eur J Orthod 1992;14:54-60.
17. Dellinger EL. A clinical assessment of the Active Vertical Corrector--a
nonsurgical alternative for skeletal open bite treatment. Am J Orthod
1986;89:428-436.

Dockorth
18. Frankel R, Frankel C. A functional approach to treatment of skeletal open
bite. Am J Orthod 1983;84:54-68. Infection control
19. Umemori M, Sugawara J, Mitani H, Nagasaka H, Kawamura H. Skeletal inc.
tailored to Orthodontics
anchorage system for open-bite correction. Am J Orthod Dentofacial Orthop
1999;115:166-174.
20. Park HS, Kwon OW, Sung JH. Nonextraction treatment of an open bite
with microscrew implant anchorage. Am J Orthod Dentofacial Orthop

21.
2006;130:391-402.
Frankel R, Frankel C. Functional aspects of molar extraction in skeletal IDEALTM Orthodontic
open bite. In: Graber LW, Graber TM, editors. Orthodontics, state of the
art, essence of the science. St. Louis: Mosby; 1986. p. 184-199. Sterilization Pouch
22. Denny JM, Weiskircher MA, Dorminey JC. Anterior open bite and IDEALTM Orthodontic
overjet treated with camouflage therapy. Am J Orthod Dentofacial Orthop
2007;131:670-678. and Plier RackPouch
Sterilization System
Professor Rahman Showkatbakhsh finished his and Plier Rack System
post-graduate training in the school of dental and
oral surgery, Colombia University, in New York IDEALTM Circular Rack IDEALTM Mini Rack
City. He established the first post-graduate program
in orthodontics in the school of dentistry, Shahid
Beheshti medical sciences university where he
currently serves as associate professor and director of
Orthognathic surgery fellowship.

Professor Jamilian is an orthodontic specialist

serving now as associate professor of Islamic
Azad University in Tehran. He is a fellow of
Orthognathic surgery and craniofacial syndromes.
His practice is limited to orthodontics. He has
lectured in several international congresses and has
been a consultant for various journals. You can
reach him through info@jamilian.net

Dr. Ziba Mashayekhi is an orthodontic specialist Dockorth inc.

and has finished her post-graduate course in Islamic

Wrapping
For authorized instruments doesn’t
dealers or more information
Azad University in Tehran. Her practice is limited
to orthodontics. have
visit our to: www.dockorth.com
website be a compromise !
Tel.: 1-514 978-6784 • Fax: 1-514 271-3930 • info@dockorth.com

32 IJO  VOL. 24  NO. 1  SPRING 2013

View publication stats