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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 2–4%,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
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:
Dental Update – June 2003
in which there is impedance of incisor eruption by the digit. l interpremolar or intermolar angle. Lateral cephalogram of a patient with a skeletal open bite. They concluded that. the open bite being greater on the side the thumb is sucked. l curvature of the mandibular canal. When the tongue is naturally kept in a forward position.O R T H O D O N T I C S a b Figure 1. l primary (endogenous) tongue thrust. A patient with a posterior growth rotation tending to give rise to a Skeletal Factors Figure 2. l interincisal angle. which is particularly apparent on a lateral cephalogram. 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. overlying the lower incisors. Note the asymmetric appearance. only 13% had actual anterior open bites. The Frankfort Mandibular Planes Angle (FMPA) is usually increased. Anterior open bite due to aberrant tongue function and posture. l lower anterior face height. These are usually more severe in nature than dental open bites. which is a feature of ‘long face syndrome’. Hence. Dental Update – June 2003 . Bjork12 identified seven structural signs related to significantly abnormal mandibular growth rotations: l inclination of the condylar head. (a) Mild dental anterior open bite.9 Tongue function is also modified to aid speech. Tongue reduction is sometimes considered in these cases. l inclination of the symphysis. 236 Open bites that develop due to excessive vertical growth are termed ‘skeletal open bites’ (Figure 4). in 250 patients who exhibited traditional cephalometric indicators of an excessive vertical dimension. There is a significant increase in the lower anterior facial height (LAFH) and there may be vertical maxillary excess. l secondary (adaptive) tongue thrust. Figure 3. Endogenous tongue thrust is often associated with excessive circumoral contraction on swallowing. Proffit10 suggested that the resting position of the tongue has much greater influence on tooth position than any tongue thrust. Note the characteristic reverse curve of Spee in the lower arch. especially if it is abnormally large (macroglossia). (b) Severe skeletal anterior open bite. although it still Figure 4. 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. an open bite tendency is in large part synonymous with a backward rotation to mandibular growth. often with only the terminal molars in contact. as relapse will almost certainly occur. This is often a warning sign that closure of the AOB is unlikely to be stable owing to the adverse soft tissue pattern. such as an increased FMPA or LAFH. then a reverse curve of Spee is present in the lower arch (Figure 3). as the duration of any thrusting activity would be too short to have a significant effect. Treatment for AOB in a patient with an endogenous tongue thrust should not be carried out. In contrast to open bites caused purely by habit. l shape of the lower border of the mandible. Severe anterior open bite due to avid thumbsucking. in growing patients. Dung and Smith11 reported that. in true skeletal open bite incisor eruption may be increased in relation to the underlying basal bone. fails to compensate for the excessive vertical development of the jaws.
resulting in increased anterior facial height. l a reduced interincisal angle. The Index of Orthodontic Treatment Need (IOTN) is commonly used in the hospital service. Anterior open bite caused by a condylar fracture. normalization of the overbite can take between 3 and 5 years. l orthodontic mechanotherapy (using fixed or removable appliances). Dealing with Sucking Habits In the deciduous dentition. INDICATIONS FOR TREATMENT Patients seek treatment mainly on aesthetic grounds. l a straight mandibular canal. and may in the future be used in the General Dental Services. 237 .3% in patients with learning disabilities. excessive eruption of the posterior teeth. his/her concerns and expectations. l an antegonial notch. and the aetiology of the malocclusion. 6: reduced intermolar angle. unless some other aspect of the malocclusion took precedence. to determine the needs of patients for orthodontic treatment. Pathological Open Bite Localized AOB may be associated with cleft lip and palate. narrowing of the maxillary arch and AOB that worsens with growth7 (Figure 6). Patient with muscular dystrophy. Figure 5. a posterior growth rotation of the mandible. Bjork’s features illustrating a posterior mandibular growth rotation. Although closure of an AOB may help with eating.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. Dental Update – June 2003 METHODS OF TREATMENT Treatment is dependent on the age of the patient.14 However. l a reduced intermolar angle. l an increased lower anterior face height. which open the bite. l a receding chin. there may be functional problems such as difficulty incising food and problems with speech. 2: straight mandibular canal.O R T H O D O N T I C S Iatrogenic Open Bite Poor mechanics during fixed-appliance treatment may cause extrusion of the molar teeth or ‘hanging’ palatal cusps. However. An AOB less than 4 mm would be borderline or be considered not to be in need of treatment. such as a lisp. As the patient gets older (and providing the habit stops) a significant proportion of cases improve spontaneously. Gershater 13 reported an incidence of 32. It is important to determine which form of treatment is the most suitable for each individual case. 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. Figure 7. Only patients with an AOB greater than 4 mm fall into the ‘need’ treatment category (IOTN 4). unless there is evidence of trauma. 1: Backward inclination of condylar head. 3: antegonial notch. there is little evidence to show that it helps with speech. Failing to prevent overeruption of second molars when biteplanes or functional appliances are used may also give rise to an AOB.16 usually during the changeover from the mixed to the permanent dentition. such as condylar fractures or Le Fort fractures of the maxilla (Figure 7).14 and certainly this should not be promised to the patient. acromegaly or trauma to the facial skeleton. 4: receding chin. Mizrahi15 described four modalities of treatment: l myofunctional therapy. l surgical therapy. 5: reduced interincisal angle. l combination of two or more of the above. 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. Figure 6. skeletal AOB may have some or all of the following signs (Figure 5): l backward inclination of condylar head. 7: increased lower anterior face height.
18 In this case further orthodontic treatment may be indicated (see below). however. l Use simple aides memoire or daily rewards.22 ‘Orthodontic’ dummies are now available. l May need orthodontic expansion of upper arch. A protocol for management of sucking habits is shown in Table 1. The child. who reported that. but has the additional advantage of being able to expand the upper arch. This is supported by Larsson. 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. it is 238 essential that any digit habit is stopped first. This may be necessary in avid thumbsuckers. Alternatively. and the AOB may be maintained by the soft tissue pattern and/or failure of further alveolar development anteriorly. If this is ineffective but the child wants to stop the habit. Hence dummy sucking has been advocated in preference to digit sucking.5–9 years) should be actively discouraged from doing so. Initially this should take the form of advice. as up to 80% of children who have a tongue thrust and AOB at 8 years show improvement without therapy by age 12.24 Highpull headgear to the biteblocks may increase their efficiency. The appliance is either a removable or a fixed appliance which prevents sucking of the digit. l Reassure parents that AOB should resolve when habit stops. Permanent dentition l Spontaneous resolution of AOB unlikely. resulting in malocclusions in the permanent dentition. These methods are likely to produce good spontaneous resolution of the AOB in a pre-teen patient. as excessive cheek pressure produced during sucking causes constriction of the upper arch.O R T H O D O N T I C S Figure 8. otherwise not only will the treatment be unsuccessful. Late mixed dentition l Consider deterrent appliance if advice has not worked. Stability depends on the thrust being adaptive rather than endogenous. 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. thumb as the upper permanent incisors erupt (7. a small tangible reward can be offered on a daily basis for not engaging in the habit. However. Table 1. Fixed thumb dissuader. Passive posterior biteblocks are functional appliances that are used to open the bite 3–4 mm beyond the rest position. Primary dentition l No treatment indicated. but there is also a risk of root resorption of the upper incisors due to the competing forces to which they will be subjected. thus preventing undesirable effects on the deciduous occlusion. Modifications have included spring loading the biteblocks and use of repelling magnets embedded in the acrylic of the biteblocks. being treated with a Twin Block myofunctional appliance with EOT tubes for highpull headgear. whereas the group that sucked digits continued with the habit in significant numbers. l Refer for specialist opinion. possibly in conjunction with an aide memoire such as a plaster on the associated finger.23 it also allows differential eruption to occur as the labial segments can erupt unhindered. Dental Update – June 2003 . l If dummy-related advise use of ‘orthodontic dummy’. the open bite will not usually correct spontaneously. thus preventing a downwards and backwards rotation of the mandible. providing it is not skeletal in nature. to ensure the habit has truly stopped (Figure 8). A patient with a Class II division 1 malocclusion and AOB tendency. when the sucking habit is prolonged beyond the pubertal growth spurt. Early mixed dentition l Advise patient to give up habit. In growing patients this inhibits the increase in height of the buccal dento-alveolar processes. but in an older patient the proclined upper labial segment is held forwards by mesial movement of the buccal segments. these flatten on use. Sometimes a quadhelix appliance is used. a deterrent appliance can be used. Proffit and Mason20 suggest limiting use of tongue guards to patients who have reached puberty. which not only discourages the habit. a glove or foultasting nail polish. Management protocol for digit-sucking habits. and must be retained in place for a minimum of 6 months after sucking has apparently ceased. hence closing the AOB. does not always accept such dummies. a b Figure 9. The fixed variety is more assured of success.
Use of anterior elastics may be successful in patients in whom a digit-sucking habit 240 has artificially inhibited eruption. with retroclination of incisors and increase in the interincisal angle. as the crown is rotated around the centre of rotation of the tooth. This form of treatment is based on the assumption that overdevelopment of the posterior maxilla is responsible for the deformity. Extra-Oral Traction Vertical Pull Chincup Vertical pull chincup therapy has been used to limit excessive vertical growth. which could cause the bite to be propped open on their palatal cusps. 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. and further extrusion would be aesthetically inappropriate and highly prone to relapse. and some authors have reported a change in mandibular rotation from a downward and backward direction to upwards and forwards.O R T H O D O N T I C S Figure 10. Richardson and Richardson28 reported that the extraction of four second permanent molars caused an increase in the overbite compared with a control group. Frequently bimaxillary surgery is required. Retraction of proclined upper incisors results in an extrusive movement as the crown is rotated around the centre of rotation of the tooth. Treatment should not be commenced until growth has ceased. This may be combined with a transpalatal arch (TPA) and highpull headgear to limit vertical development of the maxillary molar teeth. Although this method has proved successful. as further growth is very likely to be unfavourable.25 Fixed Appliances Anterior open bites can be closed using fixed appliances and vertical intermaxillary elastics to extrude the anterior teeth. Where anterior open bites are associated with proclined incisors. such as some bimaxillary proclination cases and Class II/I malocclusions. Where the AOB is associated with a Class II skeletal pattern. Distal movement of teeth using headgear is contraindicated. Surgery may be segmental or involve the whole jaw. However. thus leaving total face height unaltered. He showed that chincup therapy was effective in reducing the angle between the maxillary and mandibular planes and at closing all anterior open bites. 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. An obvious step in the occlusal plane should not be levelled but maintained using segmental mechanics. Mizrahi15 suggested limiting extractions to the posterior region of the arch where crowding was present. retardation of eruption of posterior teeth and redirection of condylar growth. Molar extractions have been performed in an attempt to reduce the magnitude of the open bite by forward mandibular rotation. a Twin Block appliance with highpull headgear can be used to correct the anteroposterior discrepancy whilst controlling the vertical dimension (Figure 9). The TPA functions to prevent buccal rolling of the first molars. 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. Pearson30 reported on 20 growing patients with backward rotational tendencies treated by the extraction of four first premolars. Dental Update – June 2003 . The FR-4 works by allowing vertical eruption of upper and lower incisors and retraction of the maxillary incisors. However. chincup therapy and fixed appliances. but is unlikely to work if the aetiology is primarily skeletal. retraction of the incisors results in an extrusive movement.31 Orthognathic Surgery A combination of fixed-appliance orthodontics and orthognathic surgery may be required to treat skeletal open bites. the physiological rest position of the mandible would not change. Similarly. In this situation the incisors have frequently erupted further than normal as part of natural compensation. they attributed this to a slight distal movement of the dentition.26 This reduces/eliminates the open bite (Figure 10). although this may close the anterior open bite. as this will tend to worsen any AOB. Mandibular autorotation was attributed to reduction in the ‘wedging’ effect by premolar extraction. Stability depends on the tongue adapting to a new functional position after treatment. chincup therapy generally has poor compliance rates and there is some concern that it may cause condylar damage. The distance between the parallel lines indicates the increase in overbite. Presurgical orthodontics is aimed at individual arch alignment and arch co-ordination. The posterior teeth are distally uprighted using this technique. 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. Class II or Class III elastics should not be used as they cause molar extrusion. excellent compliance with elastic wear is essential and long-term stability has yet to be determined. Nahoum27 suggested that.
Anterior open bite. and l surgery that has increased the posterior face height – as would occur if the AOB is closed using a mandibular procedure only. 55: 585–599. Richardson A. Washington DC National Centre for Health Statistics. Proffit WR. 7. Proffit WR. Bowden BD. Ferguson JW. 16. (HRA) 771644.V. Kelly J. Vertical proportions: A guide for prognosis and treatment in anterior open-bite. 48: 175–186. and overjet: A longitudinal study. A review of anterior open bite. Angle Orthod 1978. London: British Orthodontic Society. O’Brien M. 33. 22: 163– 168. Anterior openbite and its treatment with multiloop edgewise archwire. Bjork A. The effects of digital and dummy sucking on arch widths. 26. The assessment and treatment of anterior open bite. Am J Orthod 1977. Int Dent J 1991. 3. and a joint orthodontic/ surgical approach for skeletal open bites. 19.15 LopezGavito et al. 5. Dent Update 1995. Eastman Dental Hospital (Figures 2 and 3). Many open bites will resolve spontaneously before the age of 12 due to ceasing of digit habits and maturation in the swallowing pattern. 2000. such as extrusion of incisors where their eruption had not been previously impeded. Senior Specialist Registrar. Br J Orthod 1978. Children’s Dental Health in the United Kingdom 1993. 64: 667–672. 171: 357–362. Anterior open-bite malocclusion: longitudinal 10-year postretention evaluation of orthodontically treated patients. However. Nonsurgical treatment of open bite in nongrowing patients. 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. Ulgen M. 71: 278–299. Any associated digit habit should be ceased before active orthodontic treatment is commenced. DHEW Publ No. 17. particularly if the open bite is small and there are no functional problems. the more the skeletal elements contribute to the aetiology of the malocclusion the poorer the prognosis for orthodontic treatment alone. Consultant Orthodontist. 13.14 Relapse rates after treatment of AOB are high. Angle Orthod 1987. Sven Tandlak Tidskr 1971. Larsson E. Vertical control in treatment of patients having backward-rotational growth tendencies. Prediction of mandibular growth 1. Angle Orthod 1972. Long-term retention is recommended. l resumption of a digit-sucking habit. The effect of finger-sucking on the occlusion: a review. Erbay E. 22. Is digit sucking of significance? Br Dent J 1991. 32. Mosby. Dung DJ. following orthodontic treatment. Myofunctional therapy for tongue-thrusting: background and recommendations. 12. 14. 241 . Nahoum H. An assessment of the teeth of youths 12–17 years. 42: 263–272. Joondeph D. Proffit WR. Am J Orthod 1969. The performance of bonded magnets used in the treatment of anterior open bite. A CKNOWLEDGEMENTS We would like to thank the following people for providing illustrations for this article: Mrs Elizabeth Horrocks. Little R. Surgical-orthodontic correction of open-bite deformity. an AOB should have the high risk of relapse of treatment explained and. of maxillary posterior teeth. Kim Y. Noar JH. Subtelny JD. Tulley WJ. Sarver DM. this should ideally be continued until the patient ceases growing. 11: 147–160. thought should be given to accepting the malocclusion. Whitworth A. 72: 128–146. Am J Orthod Dentofac Orthop 1995. Am J Orthod Dentofac Orthop 1995. 23. 9: 279– 282. 10. Class 1 malocclusions. Contemporary Orthodontics. Aust Dent J 1966. 2nd ed. Aust Orthod J 1990. 17: 519– 523. 27. 57: 291–321. 41: 142–148. 4. Cephalometric and clinical diagnoses of open bite tendency. Finlay JA. Mizrahi E. Am J Orthod 1977. Eur J Orthod 1995. 2. Hunt NP. Epker B. Heggie AAC. Pearson L. Miss Helen Tippett. The proper perspective of open bite. 24. Eastman Dental Hospital (Figures 6 and 8). 29.216. 25. Fish L. CONCLUSION Anterior open bite has multiple aetiologies and accurate diagnosis is the key to determining the best management strategy for the individual patient. Gershater MM. 15: 291– 296. De Almeida RR. l soft-tissue factors such as an unfavourable tongue posture. Ugur T. Fields HW. 8. 94: 484–490. Larsson E. Adult Dental Health in Scotland 1972. As a rule. Lawry DM. Stephens CD. 51: 16–182. Incidence study. 15. Am J Orthod 1965. 90: 403–411. 48: 132–140. p. Eur J Orthod 1987. Sarisoy L. Older patients with Dental Update – June 2003 rotation. Crawford EC. 1996. where there are no other anomalies to be corrected. Guidelines for Dummy and Digit-Sucking Habits. Weissman SM. 11. Treatment options include attempting to redirect growth using myofunctional appliances. Oral Health 1990. The effect of extraction of four second permanent molars on the incisor overbite. Equilibrium theory revisited: Factors influencing the position of the teeth. 109: 549–556. l inappropriate orthodontic tooth movement. or at least prevention of eruption. 31. Lopez-Gavito G. use of conventional fixed appliances with highpull headgear and/or vertical anterior elastics. 5: 21–27. Ursi WJS. 80: 27–31. In: A Textbook of Orthodontics. Aetiology and treatment. more than onethird of patients demonstrated a return of their AOB. Eur J Orthod 1993. Retention has been directed towards intrusion. overbite. Am J Orthod Dentofac Orthop 1988. A review of the management of anterior open bite malocclusion. 6. Harvey C. Noar JH. Mason RM. although compliance is obviously an issue.O R T H O D O N T I C S STABILITY Prediction of the response to treatment and the stability of the outcome is generally unreliable. Am J Orthod Dentofac Orthop 1997. St Louis: C. Richardson A. Dummy and finger-sucking habits with special attention to their significance for facial growth and occlusion. J Am Dent Assoc 1975. Ruljancich MK. Dummy. Am J Orthod Dentofac Orthop 1996.32 reported that. Larsson E. 1977. Portnoy S. 108: 9–21. Angle Orthod 1978. 2001. Todd JE. 108: 651–659. R EFERENCES Houston WJB. 21. Dental status of children in a primary and secondary school in rural Zambia.and finger-sucking habits with special attention to their significance for facial growth and occlusion. Brenchley ML. Swed Dent J 1978. 2: 23– 33. London: HMSO. 28. Oxford: Wright. Outcome prediction in open bite cases. 9. 112: 171–178. Relapse of AOB has been attributed to: l unfavourable growth (a posterior mandibular growth rotation). Smith RJ. London: HMSO. Comparison of the effects of passive posterior bite-blocks with different construction bites on the craniofacial and dentoalveolar structures. 11: 396–404. 18. Richardson ME. Iscan HN. Examination of current philosophies associated with swallowing behaviour. 30. The effects of Frankel’s function regulatory therapy (FR-4) on the treatment of Angle Class I skeletal anterior open bite malocclusion. 1.33 using either headgear attached to an upper removable retainer or a retainer with passive posterior biteblocks. 20. 87: 175–186. Am J Orthod 1985.