TREATMENT OF OPEN BITE

DEFINITION
 An open bite is said to exist when there is a lack of
vertical overlap between the maxillary and mandibular
teeth. In normal circumstances the mandibular dental
arch is contained within the maxillary arch. In other
words the maxillary teeth overlap the mandibular teeth
labially and buccally. Depending upon the lack of this
overlap an open bite is said to exist
CLASSIFICATION OF OPEN BITE

1. Based on the location of the open bite, they may

be classified as:
 Anterior open bite
 Posterior open bite.
2. Based on the dental or skeletal components invol­
ved, open bites can be classified as:
 Skeletal open bite,
 Dental open bite.
 ETIOLOGY OF ANTERIOR OPEN BITE
1. Habits
 Anterior tongue thrust
 Digit sucking habits
• Mouth breathing
With majority of these habits the patient disocclu­des
his/her jaw, in other words keeps his mouth
perpetually open. This over a period of time either
causes the posterior teeth to supra-erupt and/ or
flaring and infra-occlusion of the anterior teeth
2. Abnormally increased tongue size
3. Abnormal growth pattern
short mandibular ramus or an increased gonia I angle.
ANTERIOR OPEN BITE

 is the most commonly encountered severity of open

bite.
 are mostly dental in nature can be skeletal sometimes.
 They are usually associated with a local cause, which has
to be removed for the correction of the malocclusion
 The persistence of pernicious habit can lead to the
malocclusion acquiring a skeletal component or it could
be the result of a hereditary skeletal pattern
 Skeletal anterior open bite can occur if there
is incoherent growth of the maxilla and/or
mandible and/ or anterior cranial base

e
d
 e

Skeletal anterior open bite (A) Due to upward maxillary rotation, (8) Due to downward
mandibular rotation, (C) Due to combination of downward rotation of mandible and upward
rotation of maxilla, (D) Due to vertical maxillary excess, (E) Due to an increased flexure
angle
FEATURES OF DENTAL ANTERIOR OPEN BITES

 Intraoral features:
1. Open bite limited to the anterior segment, often
asymmetrical.
2. Proclined maxillary and/or mandibular incisors.
3. Spacing between maxillary and / or mandibular
anteriors.
4. Narrow maxillary arch is a possibility.
5. "Fish mouth" appearance.
 Extraoral features:
 No unusual features.
FEATURES OF SKELETAL ANTERIOR OPEN BITES
 Extraoral features
1. Long face due to increased lower anterior face height
2. Incompetent lips
3. An increased mandibular plane angle
4. An increased gonial angle
5. Marked antegonial notch
6. A short mandible is a possibility
7. Maxillary base may be more inferiorly placed (vertical
maxillary excess)
8. The angle formed by the mandibular and maxillary
planes is also increased
FEATURES OF SKELETAL ANTERIOR OPEN BITES

INTRAORAL FEATURES:
1. Mild crowding with upright incisors
2. Gingival hypertrophy
3. Maxillary, occlusal and palatal planes tilt
upwards
4. Mandibular occlusal plane canted
downwards
 CORRECTION OF ANTERIOR OPEN BITE
 The appliances used for the corrections of anterior open bites are
usually used in conjunction with the habit breaking appliances used
for the elevation of the underlying Etiology .
CORRECTION OF ANTERIOR OPEN BITE

 In young patients anterior open bites have a

tendency to regress spontaneously with the
removal of the underlying cause
CORRECTION OF ANTERIOR OPEN BITE

 In cases with a minor skeletal component or

where the correction is not seen
spontaneously, fixed appliances should be
used in conjunction with a removable or fixed
habit-breaking appliance
CORRECTION OF ANTERIOR OPEN BITE

 Box elastics of medium to heavy forces may

be used for the correction of mild to
moderate open bites
CORRECTION OF ANTERIOR OPEN BITE
 A chin cup with a vertical pull
head cap may be used for the
correction of anterior open bites
in the pre adolescent age group

 Adults should be treated

surgically after the correction of
the existing habit. Surgery
generally involves the Le-Fort I
osteotomy to impact the maxilla
posteriorly. Muscle-retraining
exercises may be required
following the surgical correction.
 POSTERIOR OPEN BITE
DEFINITION

 Posterior open bites are characterized by a lack of

contact between the posterior teeth when the teeth are
brought in occlusion Posterior open bites are relatively
rare

 ETIOLOGY
 lateral tongue thrust habit or
 CORRECTION OF POSTERIOR OPEN BITE

 The elevation of the etiology remains the

main stay of treatment. IF lateral tongue
thrust is the etiologic factor, the use of lateral
tongue spikes either fixed or incorporated in a
removable appliance, form the first line of
treatment
CORRECTION OF POSTERIOR OPEN BITE

 Most of the posterior open bites close

spontaneously following the cessation of the
tongue thrust habit.
 Vertical elastics used along with fixed
orthodontic appliances can be used once the
lateral tongue thrust habit has been controlled.
 Fixed appliances are the most frequently used
means for the correction of submerged and
impacted teeth.
TREATMENT OF CROSS BITE
 DEFINITION

 Graber defined cross bites as a condition where one

or more teeth may be malposed abnormally,
buccally or lingually or labially with reference to the
opposing tooth or teeth.
 Under normal circumstances the maxillary arch
overlaps the mandibular arch both labially and
buccally. But when the mandibular teeth, single
tooth or a segment of teeth, overlap the opposing
maxillary teeth labially or buccally, depending
upon their location in the arch, a cross bite is said
to exist
 CLASSIFICATION OF CROSS BITES

 Cross bites can be classified according to their

location in the arch as
 Anterior cross bites and
 Posterior cross bites
 Anterior cross bites is basically a condition where
a reverse overjet is seen. Anterior cross bites can
be further classified according to the number of
teeth involved as
 - Single tooth cross bite or
 - Segmental cross bite
 Posterior cross bites can also be further
classified according to the number of teeth
involved as ,
single tooth cross bite segmental cross bite
Posterior cross bites may be further classified
according to the existence of the cross bite on
one side or both the sides of the arch as

 Unilateral cross bite  Bilateral cross bite

 Posterior cross bites can also be classified accord­ing to
the extent of the cross bite as
Simple posterior cross bite
most frequently seen
the buccal cusps of one or
more posterior teeth occlude lingual
to the buccal cusps of the mandibular teeth
 Buccal non-occlusion : scissors bite
The palatal cusp of the
maxillary posterior teeth are
placed buccal to the buccal cusp
of the mandibular posterior teeth.
Scissors bite (maxillary left first pre-
 Lingual non-occlusion Here the maxillary
posterior tooth or teeth are placed
completely palatal to the lingual aspect of the
mandibular posterior teeth
 Based on the location of the etiologic factors the
 cross bites can be classified as .
 Dental cross bite
 Skeletal cross bite
 Functional cross bite.
 Dental cross bites
 are generally single tooth or sometimes-segmental
cross bites.
 usually result from arch length discrepancy or an
abnormal path of eruption.
 are usually not accompanied by any threat to general
health of the patient
 the problems arising due to such cross bites are
periodontal or esthetic in nature
Dental cross bites
 ETIOLOGY OF DENTAL CROSS BITES
1. Anomalies of number
i. Supernumerary teeth
ii. Missing teeth
2 . Anomalies of tooth size
3. Anomalies of tooth shape
4 . Premature loss of deciduous and / or permanent teeth
5 . Prolonged retention of deciduous teeth
6 . Delayed eruption of permanent teeth
7 . Abnormal eruptive path
8 . Ankylosis
 Skeletal cross bite primarily due to mal-positioning or
malformation of the jaws
 They are capable of causing appreciable damage to a person's
health and personality as the appearance may be
compromised to a larger extent.
Etiology of skeletal cross bites
 Hereditary (Class III skeletal structure).
 Congenital (cleft lip and palate).
 Trauma at birth (forcep injury causing ankylosis of the TMJ).
Trauma during growth
(ankylosis of the TMJ or
retardation of growth in the
traumatized bone).
 Trauma after completion of
 Functional cross bites
 caused due to the presence of occlusal interferences
during the act of bringing the jaws into occlusion.
 These can be caused by the early loss of deciduous
teeth, decayed teeth or ectopically erupting teeth. If
not corrected early, these can ultimately lead to
skeletal cross bites.
 CORRECTION OF ANTERIOR CROSS BITES

The method chosen depends on :

 the age of the patient

 the eruption status of the teeth and
 the space availability
CORRECTION OF ANTERIOR CROSS BITE
IN THE PREADOLESCENT AGE GROUP

 Tongue Blade
 Lower Inclined plane/Catalans appliance
 Z spring
 Screw
 Face mask
 Frankel III
 Chin cup appliance
 CORRECTION OF ANTERIOR CROSS BITE IN THE
PREADOLESCENT AGE GROUP
 Use of Tongue Blade
 used to correct the developing cross bites –
i.e if a cross bite is seen at the time the
permanent teeth are making an appearance in
the oral cavity.

 It should be placed inside the mouth,

contacting the erupting tooth in cross bite on
its palatal aspect.
 Upon slight closure of the jaw the opposing
side of the stick comes in contact with the
labial aspect of the opposing mandibular tooth.
 This point acts as a fulcrum and if light forces
are exerted over a couple of weeks the
erupting tooth can be easily made to attain a
better position.
 Force can be generated by rotating the
oral part of the blade labially or holding
the blade stiffly and closing the jaw
slightly (till it is tolerable).
 The appliance is most effective till the
clinical crown is not completely visible in
the oral cavity
 It is to be used only if sufficient space is
available for the correction.
 The proper use of tongue blade for an
hour or two, for 10 to 14 days is usually
sufficient.
 The tongue blade should only engage the
tooth in crossbite.
 Drawback : the patient has to be
cooperative for any correction to be
 CATALANS APPLIANCE OR LOWER ANTERIOR INCLINED PLANE

 Catalan's appliance basically

consists of an inclined plane
cemented on the mandibular
incisors.
 The name Catalan's appliance is
generally associated with
appliances which are cemented,
hence, not removable in nature.
 The lower inclined plane is
constructed at an angle of 45° to
the maxillary occlusal plane.

Wrong inclinations

Very shallow incline Very steep incline

 It may be
constructed for a
single tooth or a
group of teeth and
can be made of
acrylic or cast metal.
PREREQUISITES FOR THE USE OF A MANDIBULAR
ANTERIOR INCLINED PLANE

 Enough space in the maxillary arch to align the tooth/

teeth.
 The maxillary tooth/teeth to be corrected should be
retroclined or erupting posterior to actual tooth
position.
 The developmental status of the mandibular incisors
should be such that they can tolerate the forces
generated.
 The mandibular incisors should be relatively well
aligned to allow appliance fabrication.
 The patient should be cooperative.
 THE ADVANTAGES ASSOCIATED
WITH THE APPLIANCE ARE:
 Ease of fabrication.
 Rapidity of correction using functional and
muscle forces.
 Lack of soreness or looseness of the teeth
during movement.
 Rarity of relapse.
 THE DISADVANTAGES ASSOCIATED WITH THE
APPLIANCE ARE:
 Strong limitations on diet during the wearing for the appliance.
 The patient has difficulty with speech and chewing.
 The appliance acts as an anterior bite-plane and prevents the posterior
teeth from coming into contact
 The appliance cannot be given if the mandibular incisors are
periodontally compromised.
 The appliance cannot be fabricated if the mandibular incisors are
maligned.
 Wearing the appliance for a long duration can affect the periodontal
status of the teeth on which the appliance is retained and/or the tooth
being corrected.
 Prolonged usage of the appliance can also lead to and anterior open-bite
(because of posterior supra­eruption).
 The appliance may need to be recemented frequently.
 DOUBLE CANTILEVER SPRING/'Z' SPRING

 Is one of the most frequently used appliance to correct anterior

tooth/ teeth cross bites.
 The spring consists of a double helix between two parallel arms and
the inferior arm extends as the retentive component in the acrylic
base plate.
 The parallel arms can be activated as per the requirement to either
push the entire tooth labially or just the mesial or distal aspect of
the tooth to correct a mesio-palatal/lingual or disto-palatal/lingual
rotation of the tooth respectively.
 The spring is effective only when there is enough space for aligning
the teeth. It is advisable to use the spring along with a posterior
bite-plane when the teeth in cross bite and show an overbite of
more than 2 mm or the opposing teeth are periodontally
compromised. The use of a posterior bite plane decreases or at
times even eliminates the forces exerted on the teeth in the
opposing arch.
The spring is effective only when there is enough space for
aligning the teeth.

It is advisable to use the spring along with a posterior bite-

plane when the teeth in cross bite :
show an overbite of more than 2 mm or
the opposing teeth are periodontally compromised.
 SCREW APPLIANCES

 Acrylic appliances incorporating various size screws can be

used to correct either individual tooth or segmental cross
bites.
 Micro-screws are the most comfortable for the patient and
can be used on individual teeth.

MICRO SCREWS MINI SCREWS

 Multiple micro-screws can be used to correct individual
teeth in a segmental cross bite.
 Mini-screws are also used for the same purpose but are
capable of moving up to two teeth.
 Medium screws are used to correct segmental cross bites. They are
larger and are capable of moving 4-6 teeth in a segment.
 3-D (three dimensional) screws are capable of correcting posterior
as well as anterior cross bites simultaneously.

 Appliances incorporating a 3-D screw, achieve an overall increase

in the circumference of the maxillary arch. They are ideal to treat
the anterior cross bites associated with pseudo-Class III
malocclusions.
 FACE MASK OR FACE MASK ALONG WITH RME
 Used in cases of anterior cross bite due to an actual
skeletal deficiency of the maxilla
The appliance mesializes the maxilla using a
protraction facemask (reverse head gear).

If the maxilla is narrow a rapid maxillary expansion

screw may be employed simultaneously to aid in
the transverse expansion of the maxilla.
 FRANKEL III APPLIANCE

 Is used to correct a developing Class III

skeletal jaw structure.
 The appliance stretches the soft tissue
envelop around the maxilla stimulating its
anterior growth as well as prevents the
mandible from growing any further
anteriorly.
 CHIN CUP APPLIANCE
A chin cup appliance may be used to redirect
the growth of the mandible to prevent or
correct the anterior cross bite due to a
prominent mandible.
 The chin cup appliance tends to rotate the
mandible backward and downward.
 CORRECTION OF ANTERIOR CROSS BITES IN ADOLESCENTS AND ADULTS

1 SCREW APPLIANCES
2 FIXED APPLIANCES

 SCREW APPLIANCE
 Mini or medium screws may be used to
correct single tooth or segmental anterior
cross bites in adults
 FIXED APPLIANCES
 Fixed appliances can be used to correct single
tooth or multiple tooth of segmental anterior
tooth/teeth cross bites at practically any age.
The appliance therapy may or may not be
accompanied by the use of extractions to
create space
 CORRECTION OF POSTERIOR CROSS BITES
 Screw Appliances
 Coffin Spring
 Quad Helix Appliance
 The RME Appliance
 NiTi Expanders
 Fixed Orthodontic Appliances
 SCREW APPLIANCES

 The various types of screws can be used to

correct single tooth or segmental posterior
tooth cross bites in patients of all age groups.
The patient has to be cooperative enough to
maintain the appliance and activate the screw
or at least get it activated at regular intervals.
 Coffin Spring

 Omega shaped wire appliance

 Capable of correcting cross
bites in the young developing
dentition.
 Is removable
 Usually well tolerated by the
patients.
 Expansion produced is slow and
bilaterally symmetrical.
 Is capable of producing skeletal
changes in the mixed dentition.
 Quad Helix Appliance
 Is a fixed appliance
 Soldered to molar bands &
cemented.
 It produces slow expansion in
adolescent and adult patients.
 Skeletal effects in the
preadolescents.
 It is a versatile appliance and can
be used along with the usual
fixed appliance therapy.
 The RME(rapid maxillary expansion)appliance

 Involves a hyrax screw type of appliance

 Produces high forces capable of splitting the mid-
palatine suture
 Brings about skeletal changes within a matter of
days (0.2-0.5 mm/day).
 The appliance produces rapid expansion over 3-4
weeks.
 Two type of appliances-
 banded RME
 cemented RME.
 The RME(rapid maxillary expansion)appliance

 In the banded RME the expansion screw is soldered

to bands which are cemented on to the first
premolar and the first permanent molar in the
maxillary arch
 The RME(rapid maxillary expansion)appliance

 The cemented RME has a meshwork of wires which

are incorporated in acrylic or cast metal splints
which are cemented to the posterior segment.
 The RME(rapid maxillary expansion)appliance

 Surgically assisted expansion using the RME can

be achieved in adults. Generally used procedure is
the buccal corticotomy or Le-Fort I osteotomy
and/or mid­palatal splits. The benefits of
postsurgical results following RME use are still
debatable.
 NiTi Expanders
 These are nickel titanium wire
shapes which can be attached to
lingual sheath that are welded to
molar bands cemented to the
maxillary first permanent molars.
 Various sizes are available and
need to be selected depending
upon the amount of expansion
desired and the pretreatment
width of the palate.
 Bring about slow expansion
(dental changes) in the
adolescent and adult patients.
 Fixed Orthodontic Appliances
 Cross-elastics can be used to bring about correction of
individual tooth cross bites in the posterior segment.
 Fixed orthodontic appliances are ideal for the
accurate placement of teeth in a dental arch as they
provide a three dimensional control over the tooth.