International Journal of Health Sciences and Research www.ijhsr.org ISSN: 2249-9571

Review Article

Open Bite: A Review

Nawal Khan1, Munaza Shafi2

1 Resident, Govt. Dental College, Srinagar. 2Senior Resident, JVC, Bemina, Srinagar.

Corresponding Author: Nawal Khan

Received: 23/06//2014 Revised: 29/07/2014 Accepted: 02/08/2014

ABSTRACT

The term anterior open bite, which means no contact between anterior teeth, stands out due to complexity of treatment, associated with high levels of instability and recurrence. Patients with open bite can be diagnosed clinically and cephalometrically, however, diagnosis should be viewed in the context of the skeletal and dental structure.

Key words: open bite, malocclusion, .

INTRODUCTION Synonyms: Apertognathia. Traditionally open bite means Definitions: The term “open bite” was opposing teeth do not meet. Vander Linder, coined by Caravelli in 1842 as a distinct however has indicated that the overlap classification of malocclusion [1] and can be criterion is arbitrary and is associated with defined in different manners. [2] the sagittal relation between teeth involved. Glossary of Orthodontic terms The absence of an occlusal stop between the defines open bite as a developmental or teeth with their antagonists or opposing acquired malocclusion whereby no vertical gingival is of greater significance. The same overlap exists between maxillary and view was held by Moyers, who stated that it mandibular anterior or posterior teeth. is important to use the term open bite for all An abnormal dental condition in conditions characterized by absence of an which anterior teeth in maxilla do not occlusal stop. occlude those in mandible in any mandibular Open bite must be considered as a position. (Mosby’s Medical Dictionary,8th deviation in the vertical relationship of Edition). maxillary and mandibular dental arches. In Open bite was defined by Subtelney an open bite there should be a definite lack and Sakuda [3] as open vertical dimension of contact, in vertical direction, between between the incisal edges of the maxillary opposing segments of teeth. The loss of and mandibular anterior teeth, although loss contact in vertical direction of segments of of vertical dental contact can occur between teeth can occur between anterior or buccal the anterior or the buccal segment. segments.

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Open bite is defined as the lack of c) Skeletal Class II open bite vertical overlap of the anterior teeth in d) Skeletal Class III open bite centric occlusion. [4,5] C) According to Proffit, Etiology: According to Dawson, [6] the Open bite (mm) major causes of an anterior open bite are >-4 extreme forces that result from thumb or finger -3 to -4 severe sucking, pacifier use; lip and tongue habits; 0 to -2 moderate airway obstruction; inadequate nasal airway creating the need for an oral airway; D) Open bite can be classified as allergies; septum problems and blockage a) Incomplete overbite from turbinates; enlarged tonsils and b) Simple open bite adenoids; and skeletal growth abnormalities. c) Complex open bite Prevalance: An open bite of greater than 2 d) Compound open bite mm occurs in less than 1% of the population e) Iatrogenic open bite and has five times greater prevalence in the E) Open bite is classified as black population than in the white or a) Anterior open bite-Anterior open bite Hispanic populations. [7] The incidence of is defined as no contact and vertical overlap anterior open bite ranges from 1.5% to 11% between the maxillary and mandibular [8] and varies between races and with dental incisors. [10,11] age. [9] In the mixed dentition the prevalence b) Posterior open bite-When teeth are in of the anterior open bite can reach up to occlusion there is a space between posterior 18.5%, decreasing with age. teeth. Classification: F) Open bite is classified by Sassouni [12] as A) According to Rakosi, four varieties of (Criterion-Angle of mandibular plane) open bite due to tongue posture may be a) Skeletal open bite differentiated as: b) Dentoalveolar open bite a) Anterior open bite-Open bite in a G) Open bite is classified as- deciduous dentition, caused by tongue a) Class I open bite dysfunction as a residuum of a sucking b) Class II open bite habit. c) Class III open bite b) Lateral open bite-Occlusion, in this type H) The open bite can be the simple type, of open bite on both sides is supported only without abnormal measures to the vertical anteriorly and by first permanent molars. , and complex, when c) Complex open bite-Severe vertical cephalometry shows disharmony in the malocclusion. The teeth occlude only on skeletal components of the anterior facial second molars. height. [13] d) Tongue dysfunction and malocclusion-in I) Open bites of following types are also mandibular prognathism, the downward known: forward displacement of tongue often causes Soft tissue open bite: Open bite caused by an anterior tongue thrust habit. the action of tongue is extremely rare. More B) A proper cephalometric analysis enables commonly the tongue may maintain an open classification of open bite : bite caused by a digit habit. This is more a) Dentoalveolar open bite likely when the habit is discontinued only b) Skeletal open bite after growth has ceased. A primary atypical 1) Positional deviation swallowing behavior is usually associated 2) Dimensional deviation International Journal of Health Sciences & Research (www.ijhsr.org) 289 Vol.4; Issue: 9; September 2014 with a marked anterior stigmatism and a Open bite results in oral breathing, degree of bimaxillary proclination. which in turn has been reported to cause True open bite of skeletal origin: Although changes in human head posture. The head the teeth and alveolar processes are position relative to cervical spine is the adaptable within limits and manage to result of integration at CNS level of compensate for moderate variation in different external and internal inputs, vertical height of lower part of face, including visual, cutaneous, examples are seen in which an anterior open musculotendinous and vestibular receptors. bite is seen to be associated with increase of Oral respiration alters the muscle infranasal height(vertical distance between forces exerted by tongue, cheeks and lips on nose and chin). maxillary arch. Oral breathing causes an Diagnosis(Methods of evaluation): increase in head elevation and a greater 1) Visual evaluation. extension of head relative to cervical spine 2) Cephalometric evaluation. and influences hyoid bone position and 3) Thin plate spine analysis intermaxillary divergence. ( Morphometric analysis) Sonnesan et al have recently Using visual examination, anterior described morphological deviations of open bite cases in postpubertal growth phase cervical vertebral column, in patients with can be grouped as morphometric, functional severe skeletal malocclusion traits such as or combination. The cephalograms and skeletal open bite, such as fusion occurred pretreatment records(i.e. extraoral and more often. Fusion was always seen in 2nd intraoral photographs and patient history)are and 3rd cervical vertebrae. to be evaluated. Lateral cephalograms are The malpositioning of C1 and C2, most commonly used. Using cephalometric through dental malocclusion, torques the evaluation, anterior open bite cases can be duramater because of frontal and dorsal classified according to mandibular plane attachments to C1,C2 and C3.Torquing of angle, as belonging to 3 groups: duramater causes scoliosis, cervical hyperdivergent, normovergent and hypolordosis, rotation of pelvis causing hypodivergent. uneven leg length, resulting in an abnormal Dentoalveolar Open Bite gait. Open bite caused due to thumb or Syndromal conditions associated with Open finger sucking habit would be correctly bite: A few syndromes associated with the defined as dentoalveolar open bite. presence of open bite, as one of the oral Open bite of dentoalveolar origin manifestations are listed below. occur as a result of underdevelopment  Crouzon syndrome anteriorly of maxillary and mandibular  Beckwith Wiedman Syndrome alveolar processes. The extent of open bite  Treacher Collin Syndrome depends on the eruption of teeth.  Down Syndrome Supraeruption of molars and infraocclusion  Turner Syndrome of incisors can be primary etiologic factors.  Gorlins Syndrome Dentoalveolar open bite can further be  Nooman Syndrome classified as:  Maroteaux Lamy Syndrome a) Anterior open bite

b) Posterior open bite  Lennox Gastant Syndrome Relationship of open bite to head  Moebus Syndrome position/airway and gait: International Journal of Health Sciences & Research (www.ijhsr.org) 290 Vol.4; Issue: 9; September 2014

Treatment used to prevent tongue thrusting or digit “Treatment of open bite is difficult but sucking. relapse is easy” Autonomous improvement can be Why should open bite be treated? expected only if the deforming muscle An open bite should be corrected because it activity is terminated and open bite is not usually affects- complicated by crowding of upper arch. Aesthetics-The dentoalveolar open bite Treatment by screening appliance is malocclusion is essentially unattractive indicated. particularly during speech when the tongue Treatment for preadolescents (early mixed is interposed between teeth and lips. dentition): Habit breaking should be primary Functioning of the mouth: Tongue posture objective of treatment in mixed dentition. and function should be primary For this purpose, behavior modification considerations in open bite problems. techniques are appropriate. The simplest According to Proffit, “If a patient has a approach to habit therapy is a forward thrusting posture of tongue the straightforward discussion between the child duration of this pressure even if very light and dentist that expresses concern and could affect tooth position vertically or includes an explanation by dentist. Another horizontally. level of intervention is reminder therapy. Another important reason to fix an One of the simplest approach is to secure an open bite is to prevent or alleviate TMJ adhesive bandage with waterproof tape on disorders, the malaligned jaw exerts the finger. If an intraoral appliance is excessive pressure on jaw joint. needed, the preferred method is a maxillary Early Management of Open bites-as given lingual arch with an anterior crib device. by Melanghlin. Treatment for Adolescents (late mixed and A number of treatment modalities early permanent dentition): By the time have been suggested for this early adolescence is reached, however, management. Some modalities in order of environmental causes of anterior open bite ease of application and treatment are finger are less important than skeletal factors. It is and thumb appliances, in rare for anterior open bite to be due solely to case of narrow maxilla, palatal bars and some habit, or for an open bite to correct lingual arches, posterior bite planes, high spontaneously at this age after habit has pull facebows and vertical chin cups and been corrected. removal of deciduous canines and In mixed dentition stage, functional sometimes premolars in cases with crowding appliances like activator, bionator and and/or protrusion. If adenoids and tonsils are frankel are indicated. The activator used in contributing factors to anterior open bite, the treatment of open bite include Open Bite their removal may aid in bite closure. Activator with tongue crib and Elastic Treatment of Dental Anterior open Bite: Activator. In deciduous dentition: Control of abnormal Retention after Anterior Open bite habits and elimination of dysfunction should correction: Relapse into anterior open bite be given top priority in deciduous dentition can occur by any combination of depression when open bites in children are related to of the incisors or elongation of molars. habits, these malocclusions can Active habits can produce intrusive forces spontaneously correct once habit ceases. on incisors, while at the same time leading Tongue spikes, either removable or fixed, is to an altered posture of jaw that allows posterior teeth to erupt. If thumb sucking International Journal of Health Sciences & Research (www.ijhsr.org) 291 Vol.4; Issue: 9; September 2014 continues after orthodontic treatment, Skeletal open bites are generally relapse is all but guaranteed. Controlling considered to be amongst the most difficult eruption of upper molars is the key to orthodontic cases to treat. retention in open bite cases. Treatment of Skeletal Open Bites: SOB is High pull headgear to upper molars, seldom observed in deciduous dentition. in conjunction with standard removable Habit control is of secondary consideration to maintain tooth position, is one in these cases, retarding the increasing effective way to control open bite relapse. A severity of dysplasia. Extraoral orthopaedic better tolerated alternative is an appliance appliance such as chin caps can be used with bite blocks between posterior teeth effectively to redirect growth. which stretches patients’ soft tissues to Treatment in Primary Dentition: Open bite provide a force opposing eruption. can be due to skeletal discrepancy of long A patient with severe open bite is face type, characterized by increased lower likely to benefit from having conventional anterior facial height. If the problem is maxillary and mandibular retainers for corrected in primary dentition, it is likely to daytime wear and an open bite bionator as a recur relatively quickly when active night time retainer, from beginning of treatment id discontinued. retention period. Treatment for Preadolescents: The key to Treatment of Posterior Open Bite: Early growth modification is treatment while treatment includes activator or bionator with adequate growth remains. Of the various flanges to prevent lateral tongue thrust. strategies available, high pull headgear to Fixed appliance can be used to close lateral maxillary first molar is effective. open bite by employing intermaxillary SOB is difficult to treat elastic traction. Posterior open bite is orthodontically. It is best treated by difficult to treat if tongue reflex gets fixed. orthagnathic surgery. The type of A permanent type of retention is required orthagnathic surgery that can be used to after correction. correct a SOB depends on the occlusal plane Skeletal Open Bite and magnitude of overbite, the relative Skeletal open bite is a symptom of antero-posterior position of the jaws and any serious skeletal dysplasia. Early diagnosis is transverse discrepancy of the maxilla. crucial since it helps to minimize the Implants: When the objective is to increase problem. the overbite, as in skeletal open bite Skeletal open bite occurs as a result correction, it would be ideal to close the bite of increased downward and backward by intruding posterior teeth. An intrusive inclination of mandible. The mandibular force on the molars can only occur when an angle is increased. On cephalometric extrusive force is placed elsewhere. [15] analysis, the major indicators of a skeletal Undesirable movements of units, relationship that predispose an individual to such as extrusion, can cause downward and open bite are a short ramus and downward backward rotation of the mandible, resulting rotation of posterior maxilla. Both tend to in poor treatment outcomes. Implants offer a increase anterior facial height and separate possibility of achieving a source of anterior teeth. Proffit characterized patients stationary anchorage in skeletal open bite with skeletal open bite and a large total face cases. Osseointegrated implants have been height manifested entirely in the elongation successfully used with intrusion mechanics of the lower third of the face as having long in open bite malocclusions to prevent face syndrome. [14] extrusion of posterior teeth. [16] In addition to International Journal of Health Sciences & Research (www.ijhsr.org) 292 Vol.4; Issue: 9; September 2014 single-tooth implants, a skeletal anchorage highly unstable because it lengthens the system using a titanium miniplate ramus and stretches the muscles of the temporarily implanted in the maxilla or pterygomandibular sling. [28] Therefore, a mandible has been reported to provide a two-jaw surgery involving superior source of immobile anchorage. Titanium repositioning of the maxilla with a Le Fort I miniplates implanted in the buccal cortical osteotomy is recommended to obtain more bone in the apical regions of the first and stable and predictable results for the surgical second molars have been shown to produce correction of skeletal open bite. Mandibular as much as 3 to 5 mm of molar intrusion. surgeries combined with TADs resolves the Counterclockwise rotation of the occlusal high level of surgical invasion and the plane is achieved. There is evidence that the possibility of alar flaring caused by superior skeletal anchorage system may be an repositioning of the maxilla. effective adjunctive biomechanical If chin retrusion remains a problem, procedure for correction of skeletal open it may be corrected by a combination bite malocclusion without many of the advancement and reduction genioplasty. unfavourable side effects. [17] With regard to the surgical Surgical Treatment: Surgical treatments for procedures, greater over bite stability can be AOB began in the 70s and were indicated achieved with maxillary surgical for extremely severe cases with mandibular repositioning only, or with bimaxillary plane above 50 degrees. Thereafter, these surgery, whereas mandibular surgery only treatments have become more common and produces less stable results. [29] Failure of usually include LeFort I osteotomy for tongue posture adaptation subsequent to superior repositioning of the maxilla. This orthodontic and/or surgical treatment might allows a counterclockwise rotation of the be the primary reason for relapse of anterior mandible, thus correcting AOB. [18] open bite. The relative increase in tongue The surgical approaches include volume in the oral cavity would also cause a maxilla [19,20] or mandible surgeries, [21,22] relapse of the mandibular position after the surgery on both maxilla and mandible, [23,24] mandibular setback, resulting in a decrease anterior maxillary and mandibular surgeries, in overjet and over bite. Myofunctional [25,26] and mandibular surgeries combined therapy and placement of a tongue crib may with temporary anchorage devices (TADs). improve stability in patients, especially with [27] Superior repositioning of the maxilla, an anterior tongue rest posture. [30] through total or segmental maxillary osteotomies, is indicated in skeletal open REFERENCES bite patients with excess vertical maxillary 1. Parker JH. The interception of the open growth. Maxillary impaction allows auto- bite in the early growth period. Angle rotation of the mandible, therefore Orthod. 1971 Jan;41(1):24-44. decreasing the lower face height and 2. 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How to cite this article: Khan N, Shafi M. Open bite: a review. Int J Health Sci Res. 2014;4(9):288- 295.

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