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Management of Open Bite  - Dr. Nabil Al-Zubair
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Management of Open Bite - Dr. Nabil Al-Zubair Presentation Transcript

  • 1. The orthodontic management of open bite cases Dr. Nabil Al-Zubair
  • 2. INTRODUCTION High angle cases Covers a number of conditions that include:1. Long face syndrome2. Posterior growth rotation3. Anterior open bite4. Open bite tendency.
  • 3. Many Orthodontists are concerned about the DIFFICULTIES of management of high angle and open bite cases.• It is usually neither clear • which angle is increased nor • what the relationship between facial morphology and open bite is.
  • 4. • Some of the angles implicated in the term high angle are • the SN/MnP angle, • the FH/MnP angle, • the SN/MxP angle and •the MxP/MnP angle.
  • 5. Long-face syndrome."Children and adults who have excessivevertical facial growth demonstrate acharacteristic facial appearance and havebeen described as having long-facesyndrome. (Proffet)Because the disproportionately longlower face is often accompanied by anopen bite, this condition has also beenlabelled skeletal open bite.
  • 6. Not all long-faced patients have open bite and not all open bite patients are long faced
  • 7. Posterior growth rotation Growth rotations of the mandible occurs when there is a discrepancy in the amount of growth in anterior & posterior facial heights
  • 8. Open biteMalocclusion can occur in three planes of space Sagittal, Transverse and in the Vertical plane.Open bite is a malocclusion that occurs in the vertical plane Characterized by lack of vertical overlap between the maxillary and mandibular dentition.
  • 9. Open bites Anterior region Posterior regionAnterior open bite Posterior open bite
  • 10. Etiologic FactorsMany potential etiologic factors areimplicated as causes of open biteincluding (1) unfavorable growth patterns, (2) digit-sucking habits, (3) tongue and orofacial muscle activity, (4) hereditary, (5) orofacial functional matrices, (6) imbalances between jaw posture, occlusal and eruptive forces and head position.A detailed understanding of its etiology and developmentalprocess is thus essential in its management.
  • 11. Anterior Open Bite Etiology Multifactorial No single factor Non- Hereditary HEREDITARY Prolonged thumb-sucking habit (1) Increased tongue size Tongue thrusting (2) AbnormalskeletalNasopharyngeal Airway Obstruction And growth pattern of the Associated Mouth Breathing. maxilla and mandible
  • 12. Non- hereditary factors Prolonged thumb-sucking habit The posture of thumb positioning The intensity The frequency of sucking Influence the NATURE and SEVERITY of the open biteLead to restriction of development of the jaw by the finger or thumb.
  • 13. Non- hereditary factors Tongue thrusting
  • 14. Abnormal Swallowing/ Tongue Thrust Habit 􀁡 Protrusion of the tongue against or between the anterior dentition and excessive circum-oral activity during deglutition. 􀁡 Innate behavior 􀁡 Universal infant oral behavior for children under the age of 6 years. 􀁡 Not a causative factor for anterior open bite.
  • 15. Tongue Thrust Habit Delayed Transition Infantile swallowing Adult swallowing. Age Description 2 Begins to happen 6 50% completed the transition. 12 Most cases (80%) will self correct 10-15% estimated never to fully complete the transition Mouth breathing(Tongue Thrust Habit) associated with Anterior open bite Functional adaptation of malocclusion and not the etiology Can cause speech problems - lisping
  • 16. Mouth Breathing Of all the possible etiologic factors Nasopharyngeal airway obstruction and associated mouth breathing. The greatest importanceMouth Breathing - can be caused by physiologic or anatomic conditions - can be transitional when exercise induced or due to a nasal obstruction. - True mouth breathing when the habit continues after the obstruction is removed.
  • 17. Mouth Breathing Nasal obstruction Habit Lower tongue positionAbnormal muscles activity Increase inter-Maxillary space Overdevelopment of the buccal segment teeth Increase in the height of the lower third of the face A greater incidence of AOP.
  • 18. Adenoid Facies Skeletal Open Bite or “Long Face Syndrome”
  • 19. Mouth Breathing Habit 􀁡 Adenoid Facies 􀁡 Skeletal Open Bite or “Long Face Syndrome”⌧ Long narrow face ⌧Excessive eruption of posteriors⌧Narrow nose and nasal airway ⌧Constricted maxillary arch⌧Flaccid lips with short upper lip ⌧Excessive overjet⌧Upturned nose exposing nares ⌧Anterior openbitefrontally ⌧Mandubilar down/forward growth is poor
  • 20. Constricted Arches of Mouth Breathers
  • 21. Enlarged Tonsils
  • 22. ANTERIOR OPEN BITE Anterior open bite is a condition where there is no vertical overlap between the upper and lower anteriors Esthetically unattractive particularly during speech whenTongue is pressed between the teeth and lips
  • 23. Causes of Anterior Open Bite Cause AetiologySkeletal pattern - Increase in lower anterior facial height such that the compensatory ability of the incisors to erupt into contact is exceeded. - This may be worsened by a downward & backward pattern of facial growthSoft tissues - Rarely endogenous tongue thrustHabits - Persistence Digit sucking, which often leads to an asymmetric anterior open biteLocalized failure of alveolar - Occurs in cleft lip & palatedevelopment
  • 24. Classification of anterior open biteAnterior open bite can be classified as: a. Skeletal anterior open bite b. Dental anterior open bile
  • 25. Skeletal anterior open biteFeatures : a. Increased lower anterior facial height b. Decreased upper anterior facial height c. Increased anterior and decreased posterior facial height d. A steep mandibular plane angle. e. Small mandibular body and ramus f. The patient may have short upper lip with excessive maxillary incisor exposure
  • 26. Features of skeletal anterior open bite “Long Face Syndrome”a. Increased lower anterior facial heightb. Decreased upper anterior facial heightc. Increased anterior and decreased posterior facial heightd. A steep mandibular plane angle.e. Small mandibular body and ramusf. The patient may have short upper lip with excessive maxillary incisor exposure
  • 27. Features of skeletal anterior open bite “Long Face Syndrome”a. Increased lower anterior facial heightb. Decreased upper anterior facial heightc. Increased anterior and decreased posterior facial heightd. A steep mandibular plane angle.e. Small mandibular body and ramusf. The patient may have short upper lip with excessive maxillary incisor exposure ‫منحدر‬
  • 28. Skeletal anterior open bite “Long Face Syndrome”Features : a. Increased lower anterior facial height b. Decreased upper anterior facial height c. Increased anterior and decreased posterior facial height d. A steep mandibular plane angle. e. Small mandibular body and ramus f. The patient may have short upper lip with excessive maxillary incisor exposure
  • 29. Features of skeletal anterior open bite “Long Face Syndrome” g. The patient may often has a long & narrow face h. Divergent cephalometric planes i. Steep anterior cranial base j. Cephalometric examination may revealed a downward & forward rotation of the mandible. In some patients, an upward tipping of the maxillary skeletal base can be observed. Another common feature is a vertical maxillary increase
  • 30. Features of skeletal anterior open bite “Long Face Syndrome” g. The patient may often has a long & narrow face h. Divergent cephalometric planes i. Steep anterior cranial base j. Cephalometric examination may revealed a downward & forward rotation of the mandible. In some patients, an upward tipping of the maxillary skeletal base can be observed. Another common feature is a vertical maxillary increase
  • 31. Features of skeletal anterior open bite “Long Face Syndrome” j. Cephalometric examination may revealed a downward & backward rotation of the mandible. In some patients, an upward tipping of the maxillary skeletal base can be observed. Another common feature is a vertical maxillary increase
  • 32. Features of skeletal anterior open bite “Long Face Syndrome” j. Cephalometric examination may revealed a downward & backward rotation of the mandible. In some patients, an upward tipping of the maxillary skeletal base can be observed. Another common feature is a Vertical Maxillary Increase
  • 33. Features of dental anterior open bite Dental anterior open bites Do Not present with the skeletal complications mentioned above. • The following are the features of dental open bite:a. Proclined upper anterior teeth.b. The upper and lower anteirors fail to overlap each other resulting in a space between the maxillary and mandibular anteriors.
  • 34. Features of dental anterior open bite Dental anterior open bites Do Not present with the skeletal complications mentioned above. • The following are the features of dental open bite:c. The patient may have a narrow maxillary arch, due to lowered tongue posture due to a habit.
  • 35. Diagnostic and treatment planning considerations:-
  • 36. Successful management of AOP Diagnosis A Simple Diagnostic Classification A simple clinical diagnostic classification might be as follows: 1. Anterior open bite with increased facial proportions 2. Anterior open bite with history of digit sucking and normal facial proportions 3. Anterior open bite with no history of digit sucking and normal facial proportions
  • 37. Favourable prognosis for treatment by orthodontic means alone digit sucking habit is stopped
  • 38. Patients with increased facial proportions frequently require orthognathic surgery to close the open bite
  • 39. Increased facial proportions In the absence of other factors Reaching the limit ofINCISORS their eruptive potential Before incisor contact is made require Surgery to correct their facial disproportion
  • 40. Digit sucking Characterized by an AOP frequently limited to the INCISOR REGION Corresponds with the Asymmetry digit being sucked
  • 41. Soft tissue habits and posture The presence of an anterior open Absence of Tongue Thrust Habit - Increased facial proportions or - A digit sucking habitAOP from canine – canine Anterior tongue posture
  • 42. Tongue movement during swallowing The three stages of swallowing Stage Description Loss of contact of the dorsal tongue with the 1 soft palate Passage of the bolus head across the 2 posterior/inferior margin of the ramus of the mandible 3 Bolus head enters the oesophagusDuring swallowing and compared to patients with normal occlusions, patientswith anterior open bite have: 1. tongue tip protrusion 2. slower movement of the dorsal part of the tongue 3. earlier closure of the nasopharynx
  • 43. Management of anterior openbite:
  • 44. Management of open bite tendencyThe key to the management of open bite tendency is:1. elimination of the aetiology2. the avoidance of the extrusion of posterior teeth and if possible to produce relative or real intrusion of these teeth.
  • 45. • Removal of the cause:Open bites Thumb sucking or Diagnosed due to habits Tongue thrusting Require INTERCEPTION 1.If habits stoped before 6-8 years, (self correction) 2. Thumb devices 3. Educate proper swallowing
  • 46. Passive Habit Breaking AppliancesIf habit persists over 10 years Psychological therapy
  • 47. If habits stoped before 6-8 years, (self correction)
  • 48. Myofunctional therapy: Skeletal anterior open bites Functional appliances such asCan be treated during GROWTH FR.IV or a modified activator. Incorporate Bite Blocks interposed between the posterior teeth Intrusive Action on the upper and lower posterior teeth
  • 49. Myofunctional therapy: Skeletal anterior open bites Patients exhibiting a downward and backward rotation of if treated during the mixed the mandible with increased dentition period vertical growthvertical pull head gear with chin cup
  • 50. Myofunctional therapy: Skeletal anterior open bites Patients exhibiting a downward and backward rotation of if treated during the mixed the mandible with increased dentition period vertical growthvertical pull head gear with chin cup
  • 51. Orthodontic therapy:Extrusion of the upper and lower anteriors.Intrusion of the posterior teeth.
  • 52. Extrusion of the upper and lower anteriors. Mild to moderate open bits can be successfully managed Fixed mechano-therapy in conjunction with Box Elastics Stretched to extend between the upper and lower anteriars. This brings about extrusion of the upper and lower anteriors.
  • 53. Intrusion of the posterior teeth Orthodontic Miniscrews
  • 54. Surgical correction: Skeletal open bites in adults best treated by surgical procedures involving the maxilla and the mandible.1.Once growth is complete forsevere problems with a skeletalaetiology2. In some patients an anterioropenbite is associated with a‘gummy’ smile
  • 55. POSTERIOR OPEN BITE Characterized by Lack of contact between the posteriors when the teeth are in centric occlusion
  • 56. Causes of posterior open bite two possible causes either before or after (1) Mechanical interference with eruption, The tooth emerges from the alveolar bone(2) failure of the eruptive mechanisms of the tooth so that the expected amount of eruption does not occur.
  • 57. (1) Mechanical interference with eruption Caused by Ankylosis (spontaneously or as a result of trauma ) Obstacles in the path of the erupting tooth Before Before Supernumerary teeth Pressure from the soft tissues interposed b/w theNon-resorbing deciduous tooth roots or alveolar bone teeth (cheek, tongue, finger)
  • 58. TreatmentRemove the cause Habit intercepted Spontaneous improvement Ankylosed teeth Crowns on posteriors To restore normal occlusal level The posteriors can be forcefully extruded
  • 59. Thank you for your attention ! The End Dr. Nabil Al-Zubair