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J Exp Clin Med 2013;5(1):1e4

Contents lists available at SciVerse ScienceDirect

Journal of Experimental and Clinical Medicine


journal homepage: http://www.jecm-online.com

REVIEW ARTICLE

Etiology and Treatment Modalities of Anterior Open Bite Malocclusion


Li-Hsiang Lin 1, 2 *, Guo-Wei Huang 1, Chin-Sung Chen 1, 3
1
School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
2
Department of Orthodontics, Wang Fan Medical Center, Taipei, Taiwan
3
Sihjih Cathay General Hospital, Taipei, Taiwan

a r t i c l e i n f o
The complexity of anterior open bite is attributed to a combination of skeletal, dental, soft tissue, and
Article history: habitual factors. Multiple treatment strategies aimed at different etiologies of anterior open bite have
Received: Jun 1, 2012 been proposed. However, the tendency toward relapse after conventional or surgical orthodontic
Revised: Sep 12, 2012 treatment has been indicated. Therefore, anterior open bite is considered one of the most challenging
Accepted: Dec 21, 2012 dentofacial deformities to treat. The aim of this article is to review the etiologies, dentofacial mor-
phology, treatment modalities, retention, and stability of anterior open bite. The etiology of anterior open
KEY WORDS: bite malocclusions is multifactorial and numerous theories have been proposed, including genetic,
anterior open bite relapse; anatomic and environmental factors. The diagnosis and treatment modalities are variable according to
dentofacial morphology; the etiology. Failure of tongue posture adaptation subsequent to orthodontic and/or surgical treatment
orthognathic surgery;
might be the primary reason for relapse of anterior open bite. Prolonged retention with fixed or
overbite depth indicator
removable retainers is advisable and necessary in most cases of open bite treatment. The treatment of
anterior open bite remains a tough challenge to the clinician; careful diagnosis and timely intervention
with proper treatment modalities and appliance selection will improve the treatment outcomes and
long-term stability.
Copyright Ó 2013, Taipei Medical University. Published by Elsevier Taiwan LLC. All rights reserved.

1. Introduction 2. Etiology

Anterior open bite is defined as no contact and vertical overlap Open bites are generally classified as either skeletal or dental. The
between the maxillary and mandibular incisors.1,2 The incidence of dental open bite is generally found in the anterior region within the
anterior open bite ranges from 1.5% to 11% and varies between races area of the cuspids and incisors and is associated with normal cra-
and with dental age.3 The complexity of anterior open bite is niofacial pattern, proclined and undererupted anterior teeth, and
attributed to a combination of skeletal, dental, soft tissue, and thumb or finger sucking habits. The skeletal open bite is often related
habitual factors.4 Multiple treatment strategies aimed at different to excessive vertical growth of the dento-alveolar complex, espe-
etiologies of anterior open bite have been proposed. However, there cially in the posterior molar region. As anterior open bite is often the
is a tendency toward relapse after conventional or surgical ortho- result of a combination of both factors, it makes classification of open
dontic treatment.5,6 Therefore, anterior open bite is considered one bite as either skeletal or dental difficult. Therefore, it has been sug-
of the most challenging dentofacial deformities to treat due to gested that the most clinically useful classification of open bites
difficulties in determining the causes, formulating a diagnosis and should be based on etiology. The etiology of anterior open bite
the potential for relapse after treatment.4 The aim of this article is malocclusions is multifactorial and numerous theories, including
to review the etiologies, dentofacial morphology, treatment mo- genetic, anatomic, and environmental factors, have been proposed.
dalities, retention, and stability of anterior open bite.

3. Genetic and anatomic factors

An anterior open bite is related primarily to the patients’ unfavorable


growth potential and heredity.7e9 Obtaining a thorough family
history will help the clinician predict a patient’s growth pattern.
* Corresponding author. Li-Hsiang Lin, School of Dentistry, College of Oral Med-
icine, Taipei Medical University, Number 250, Wu-Hsing Street, Taipei 11031,
Based on cephalometric analyses, the steepness of the mandibular
Taiwan. plane is considered the key skeletal finding associated with a skel-
E-mail: L.-H. Lin <lisa@tmu.edu.tw> etal anterior open bite. An increased gonial angle, a downward and

1878-3317/$ e see front matter Copyright Ó 2013, Taipei Medical University. Published by Elsevier Taiwan LLC. All rights reserved.
http://dx.doi.org/10.1016/j.jecm.2013.01.004
2 L.-H. Lin et al.

backward position of the mandibular ramus, and shortened poste- cranial base as measured from sella to nasion, in the cranial base
rior facial height are additive in the production of the high man- angle (NeSeBa).27 Richardson also suggested that there is no sig-
dibular plane angle in an open bite population.10 It has been nificant difference in the cranial base as measured either from sella
suggested that the overbite depth indicator (ODI) index can be to nasion or from sella to basion.28 However, Subtelny suggested
a good predictor in the primary dentition of a skeletal open bite that the distance between sella and basion is less in their open bite
tendency in the adolescent. The ODI is the arithmetic sum of the samples.9
angle of the AeB plane to the mandibular plane and the angle of the There is agreement among the many investigators who have
Palatal plane to Frankfort horizontal plane. The study produced studied skeletal open bite that the mandibular plane angle is con-
a norm of 74.5 , with a standard deviation of 6.07.11 A value of 68 or sistently larger in skeletal open bite patients than in controls. The
less indicates a skeletal open bite tendency.12 Another useful high mandibular plane angle is found in open bite patients due to
method to help predict vertical growth patterns is based Nahoum’s a significantly shorter mandibular ramus and an opening rotation
diagnosis on the ratio of upper anterior facial height to lower ante- of the madibular ramus.28,29 An increased gonial angle, a down-
rior facial height (AUFH:ALFH). If a patient has an open bite and ward and backward position of the mandibular ramus, and short-
a AUFH:ALFH ratio of less than 0.65, then the open bite is considered ened posterior facial height are additive in the production of the
skeletal which cannot be corrected by orthodontic treatment high mandibular plane angle in an open bite population.10 When
alone.13 Anatomic conditions such as tongue size and position are the total gonial angle (TGA) is divided by the line NeGo into two
well known to affect skeletal and dental components.14 Macro- parts, the upper part is termed the upper gonial angle (UGA) and
glossia has been suggested as a possible cause of open bite.15 It has the lower part is the lower gonial angle (LGA). According to Siriwat
been reported that in patients with anterior open bite, there are and Jarabak, the UGA reflects the amount of the horizontal vector of
significant correlations between mandibular plane angle, ramus the facial growth, and the LGA reflects that of the vertical vector.30
height of the mandible, or anteroposterior dimension of the maxilla The anterior total facial height (ATFH) is greater than that in
and movement of the front part of the dorsal tongue during deglu- a normal population, and the posterior facial height (PFH), the
tition.16 Some anatomic conditions such as enlarged adenoids and/ distance between sella and gonion, is usually shorter in anterior
or tonsils, swollen nasal turbinates, and deviated nasal septums may open bite patients than in normal individuals.9,29,31,32 In some
impair normal upper respiratory nasal function.17 Mouth-breathing previous studies, the ALFH has been considered abnormally larger
as a result of upper airway obstruction may cause anterior open bite than usual, while the AUFH remained normal, which entailed
but their direct relationship has not been proven.18 Mandibular smaller ratios of PFH:ATFH and AUFH:ALFH in anterior open bite
condylar resorption has also been identified as an etiologic factor of patients.13,29,32
anterior open bite. Many local and systemic pathologies or diseases An increase in posterior maxillary dento-alveolar height is
can cause mandibular condylar resorption. Local factors include commonly mentioned in open bite cases,9,29, and that an over-
osteoarthritis, reactive arthritis, avascular necrosis, infection, and eruption of the mandibular molar teeth causes an opening rotation
traumatic injuries. Systemic connective tissue or autoimmune dis- of the mandible is also mentioned.27 However, no significant dif-
eases that can cause condylar resorption include rheumatoid ferences in posterior maxillary dento-alveolar height and over-
arthritis, psoriatic arthritis, scleroderma, systemic lupus erythe- eruption of the mandibular molar between open bite and normal
matosus, Sjögren syndrome, ankylosing spondylitis, etc.19 samples have been noted.9,32

4. Environmental factors 6. Treatment modalities

Various habits such as thumb and finger sucking, forward tongue Treatment of anterior open bite is a great challenge in orthodontics,
posture, as well as tongue thrust have been reported as causative and several approaches have been addressed. Following treatment,
factors.20e23 Digit sucking can lead to an asymmetrical anterior open patients can benefit from improved ability to incise and chew food,
bite which is worst on the side that the digit is sucked. Not all digit improved esthetics, and improved speech. However, it must be kept
suckers develop anterior open bite, the important factors being the in mind that treatment strategies should always address the eti-
duration and frequency of the habit. Those who suck for more than 6 ology of the malocclusion.
hours a day often develop significant malocclusions. A forward It is common for children to have a finger or thumb habit and
tongue posture, where the tongue rests between the incisors, may they should be encouraged by their parents to stop their habit
obstruct incisor eruption and lead to the development of an anterior before the age of 6 years for creating a favorable environment for
open bite. This should not be confused with a secondary adaptive the eruption of permanent teeth. Therefore, it is important that
tongue thrust, in which the tongue moves forward during swal- habits are terminated before commencing orthodontic treatment. If
lowing to contact the lips and form an anterior oral seal secondary to initial attempts are unsuccessful, an intra-oral appliance with loops
an anterior open bite. A diagnostic feature on the lateral cephalo- that acts as a mechanical obstruction and reminder may be given.
graph suggesting forward tongue posture is the presence of a reverse Tongue thrusting can also adversely affect the teeth and mouth.
curve of Spee in the lower arch caused by reduced incisor eruption. Tongue cribs have been used to modify tongue behavior and were
Neuromuscular deficiencies also contribute to the skeletal effective in closing open bite when worn for a minimum of 1
characteristics of an open bite.24,25 Patients with generalized pa- year.33,34 Myofunctional therapy is also useful in muscle retraining
thology of muscle such as muscular dystrophy maybe more prone by using a series of tongue exercises to correct the deleterious
to an increased vertical dimension and anterior open bite.26 A resting and functional posture.35 Mastication exercises in con-
reduction in the force of contraction of the muscles of mastication, junction with concentrated vertical control seemed to reduce
at rest and during function, may lead to excessive vertical skeletal aberrant vertical growth patterns in patients, particularly those
growth and molar overeruption. suffering from neuromuscular deficiencies.36 Patients were
instructed to clench on a soft bite wafer (GAC International, Bohe-
5. Dentofacial morphology mia, NY) for 1 minute, five times a day. Each 1-minute session
included 5 seconds of isometric clenching (80% of maximum), fol-
Many analyses comparing control samples to subjects with skeletal lowed by 5 seconds of rest. This cycle was repeated six times, for
open bite have shown no significant difference in the anterior a total of 1 minute.36
Etiology and treatment modalities of anterior open bite 3

Tongue size and position affect skeletal and dental components, a combination of the two. These extraction strategies include
and macroglossia has been suggested as a possible cause of open extracting the second molars, first molars, second premolars, or
bite and mandibular prognathism.15 Bernard and Simard-Savoie first premolars.48 Extrusion of the upper and lower incisors is
have performed a medial glossectomy on a monkey with open another common orthodontic modality for anterior open bite by
bite and the postsurgical observation of 52 months indicated using vertical elastics, extrusion arches,49 or a multiloop edgewise
a steady increase of over bite.37 Hence, reduction of tongue mass by archwire (MEAW) appliance.50 However, correction of the maloc-
partial glossectomy is an effective treatment for correcting open clusion by extrusion of the upper incisors may result in an excessive
bite with macroglossia.15 display of the incisors and gingival tissues, especially in patients
Because the direct relationship between anterior open bite and with anterior vertical maxillary excess. Thus, care must be taken
mouth-breathing as a result of chronic respiratory obstruction has not to erupt the teeth extensively when the patient has increased
not been proven, prolonged mouth breathing may not necessarily facial height. Molar intrusion for correction of anterior open bites
be the main etiological factor for malocclusion.18 Therefore, diag- was challenging to orthodontists before the development of skel-
nosis of upper airway obstruction should be made by an appro- etal anchorage. Skeletal anchorage, including dental implants51,
priate team of specialists and the decision for surgical intervention surgical miniplates,52 and miniscrew or microscrew implants,53,54
such as adenoidectomy or tonsillectomy is not recommended in the are now growing in popularity due to their ability to provide ab-
prevention of malocclusion and should be done for medical pur- solute anchorage. The intrusion of molars with skeletal anchorage
poses only. produces counterclockwise rotation of the mandible and decrease
The treatment of skeletal open bites varies between growing of the overbite.
and adult patients. Treatment modalities in growing patients with Orthognathic surgery is often indicated for many non-growing
skeletal open bites are geared towards vertical growth mod- patients, particularly for esthetic needs, considerable open bite, or
ification. In adult patients, the options are more limited, and often skeletal problems in multiple planes of space.4 The surgical ap-
involve an orthognathic surgery. The overall goal of treatment in proaches include maxilla55,56 or mandible surgeries,57,58 surgery on
growing patients aims to reduce or redirect vertical skeletal growth both maxilla and mandible,59,60 anterior maxillary and mandibular
with intra-oral or extra-oral forces. Several methods have been surgeries,61,62 and mandibular surgeries combined with temporary
proposed for controlling vertical growth. The vertical holding anchorage devices (TADs).63 Superior repositioning of the maxilla,
appliance (VHA) is a modified transpalatal arch that has an acrylic through total or segmental maxillary osteotomies, is indicated in
pad. The VHA uses tongue pressure to reduce the vertical den- skeletal open bite patients with excess vertical maxillary growth.
toalveolar development of maxillary permanent first molars.38 Maxillary impaction allows auto-rotation of the mandible, there-
Posterior bite blocks impede posterior teeth eruption and studies fore decreasing the lower face height and eliminating anterior open
have suggested that posterior bite blocks modify the vertical skel- bite. Closing rotation of the mandible using rigid fixation is a viable
etal pattern effectively.39 They can be made of wire or plastic to fit surgical option for the correction of anterior open bite in instances
between the maxillary and mandibular teeth, or they can be spring- in which maxillary osteotomies are not indicated to improve facial
loaded,40 or fitted with magnets.41 In correcting skeletal open bite esthetics. However, closing rotation of the mandible with only
problems, functional appliances, such as activators, bionators, and mandibular surgery has been shown to be highly unstable because
Fränkel regulators (most with the inclusion of posterior bite it lengthens the ramus and stretches the muscles of the pter-
blocks), have been used to control vertical maxillary growth of the ygomandibular sling.64 Therefore, a two-jaw surgery involving
mixed dentition.42 A bionator can be used to treat open bite superior repositioning of the maxilla with a Le Fort I osteotomy is
problems, especially if accompanied by a class II molar relation- recommended to obtain more stable and predictable results for the
ship.43 Fränkel IV regulator was introduced and evaluated by surgical correction of skeletal open bite.60 Mandibular surgeries
Fränkel among patients with a hyperdivergent skeletal pattern. combined with TADs resolves the high level of surgical invasion and
Fränkel believed that changes of the vertical components may have the possibility of alar flaring caused by superior repositioning of the
resulted from lip-seal training, with the function regulator acting as maxilla.63
an exercise device and leading to postural balance between the
forward and backward rotating muscles.44 Another appliance 7. Retention and stability
approach uses extra-oral devices, such as high-pull headgear, to
impede the vertical skeletal and dental growth pattern. Schudy and The importance of retention is to enhance stability, especially by
Brandt have advocated a high-pull headgear along with a man- eliminating the cause of the open bite. Studies of long-term results
dibular splint covering the second molars and anterior vertical of open bite orthodontic treatment by Lopez-Gavito et al5 and
elastics to treat open bites.45 Ngan et al demonstrated that open surgically treated cases by Denison et al6 indicate that the relapse
bite complicated by a class II vertical growth pattern can be treated rate can range from 35% to 42.9%. Relapse after anterior open bite
during the mixed dentition with favorable results by using a com- treatment has been attributed to tongue posture, growth patterns,
bination of an activator and high-pull headgear.46 The vertical chin treatment parameters, and surgical fragment instability, possibly
cup, together with fixed appliances, has also been used to manage due to increased facial height and extrusion of maxillary molars.4
anterior open bite in growing patients by controlling the vertical Surgical procedures, fixation type, and maxillary transverse
growth. In a single case report, Pearson reported that the use of relapse can be associated with open bite relapse.65 With regard to
a vertical-pull chin cup could result in a decrease in mandibular the surgical procedures, greater over bite stability can be achieved
plane angle and an increase in posterior facial height.47 with maxillary surgical repositioning only, or with bimaxillary
Some mild cases of open bite can be corrected by fixed appli- surgery, whereas mandibular surgery only produces less stable
ances that only allow dental movements in a camouflage method of results.65 Failure of tongue posture adaptation subsequent to or-
treatment. However, the skeletal profile and characteristics are thodontic and/or surgical treatment might be the primary reason
kept unchanged. Various extraction modalities have been sug- for relapse of anterior open bite. The relative increase in tongue
gested to correct anterior open bite, which aim to extrude the volume in the oral cavity would also cause a relapse of the man-
anterior segment by the draw-bridge effect of reducing the incli- dibular position after the mandibular setback, resulting in
nation of both upper and lower incisors to increase over bite and a decrease in overjet and over bite.63 Myofunctional therapy and
move the posterior teeth anteriorly by the wedge effect, or placement of a tongue crib may improve stability in patients,
4 L.-H. Lin et al.

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