Open bite /endodontic courses

MANAGEMENT OF OPEN BITE
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

CONTENTS
• Introduction
• Classification
• Diagnosis
• Treatment
– Decidous
– Mixed
– Permanent

• DIFFERENT TREATMENT
METHODS
• High pull headgear to
molars.
• High pull headgear to
maxillary splints.
• Functional Regulator IV
• Vertical corrector:
– Active vertical corrector.
– Rapid molar intruder.
• Modified functional
regulator (Albert H. Owen)
• Positive intermaxillary
pressure appliance
(Mirzahi )
• spring-loaded posterior
bite–block
• EXTRUSION TO
CORRECT AOB
• Intrusion of Posterior
Teeth with Miniscrews
• ORTHOGNATHIC
SURGERY

Introduction
• Malocclusion can occur in 3 planes of
space -
• Sagittal
• Transverse
• Vertical
• OPEN bite is a malocclusion that occurs
in vertical plane.

DEFINITION
Description of open-bite differ among
various authors and investigators.
1. Open-bite to be present when there is
less than an average overbite.
edge-to edge relationship.
definite degree of openness must be
present.

“A deviation in the vertical relationship of the
maxillary and mandibular dental arches
characterized by a definite lack of contact
between opposing segments of teeth.”
(Daniel Subtelny, 1964).
• Accepted Definitions:
“Failure of tooth or teeth to meet
antagonists in the opposite arch”.
“Localized absence of occlusion while
the remaining teeth are in occlusion”
(Moyer’s). www.indiandentalacademy.com

CLASSIFICATION
I. According to location Open bite divided into:-
• Anterior open bite
• Posterior open bite
2. According to cause:
– Dental or simple OPEN bite.
– Skeletal or complex OPEN bite.
3. According to extension:
– Simple
– Compound
– Infantile. www.indiandentalacademy.com

DIAGNOSIS OF Open
Bite
This can be discussed under 2 headings:
• Dentoalveolar Open bite
• Skeletal Open bite
DENTO ALVEOLAR OPEN BITE
It is characterized by good skeletal
proportions with the presence of one or
more local causal factors. In majority of
cases, the case is sucking habit.www.indiandentalacademy.com

Features of Skeletal Open
Bite:
Extra oral features:
– Long face due to increased
LAFH
– An increased mandibular plane
angle
– An increased gonial angle
– Marked antigonial notch
– A short mandible is a possibility
– Maxillary base may be more
inferiorly placed

Intra oral features
– Mild crowding
– Gingival hypertrophy
– Maxillary occlusal and
palatal plate tilt
upwards.
– Mandibular occlusal
plane canted
downwards www.indiandentalacademy.com

TREATMENT OF OPEN
BITE:
Therapy depends on localization and
etiology of MALOCCLUSION. Habit
control and elimination of abnormal
perioral muscle function are causal
therapeutic approaches to dentoalveolar
open bite.

The treatment approach can be grouped
as follows:
1. Treatment of Dentoalveolar OPEN
bite.
2. Treatment of Skeletal OPEN bite,
3. Treatment of Skeletodental OPEN
bite.

DENTOALVEOLAR OPEN BITE:
Includes-
Habit control + the elimination of abnormal
perioral muscle function.
• Treatment of local causes.
• Supernumerary teeth.
• Cysts.
• Ankylosis.
• Dileceration etc. www.indiandentalacademy.com

2. SKELETAL OPEN BITE :
Includes-
Redirection of growth during active growth
period.
Dento-alveolar compensation with
extraction and tooth movement.
Orthognathic surgery.
3. SKELETODENTAL OPEN BITE :

OPEN BITE in
DECIDUOUS DENTITION
I. DENTOALVEOLAR OPEN BITE:
An OPEN BITE should be diagnosed as
dental OPEN BITE when it is associated
with normal skeletal proportions.
It is usually associated with sucking habits.
Up to 5 years of age, sucking habit is
considered normal and does not produce
long term problems.

II. SKELETAL OPEN BITE:
OPEN BITE may also be due to skeletal
discrepancy of long face type,
characterized by increased lower anterior
facial height and increased FMA.
According to Nanda, the patterns of anterior
facial proportions are established at an
early age and maintained during the
progression of growth. Consequently it is
possible to anticipate the vertical facial

Spontaneous correction of an OPEN BITE
in these children is not likely to occur in
these children.
However, growth modification is not
indicated in deciduous dentition as it
reoccurs due to continued growth.

OPEN BITE in MIXED
DENTITION
During this period, the following treatment
regimen can be used -
- Habit control.
- Growth modulation

DIFFERENT TREATMENT
METHODS:
I. Methods described by Proffit-
• High pull headgear to molars.
• High pull headgear to maxillary splints.
II. Other methods:
• Functional Regulator : (Fr IV appliance,
Activator and Bionator)
• Vertical corrector:
– Active vertical corrector.
– Rapid molar intrude

• Modified functional regulator (Albert H.
Owen)
• Positive intermaxillary pressure
appliance (Mirzahi JCO 1985)
• Extrusion to correct Anterior open bite
• ORTHOGNATHIC SURGERY

I. HIGH PULL HEADGEAR TO THE
MOLARS:
This appliance Maintains the vertical
position of the maxilla.
• Inhibits eruption of the maxillary
posterior teeth.
• Duration : 14 hours, putting the
headgear right after dinner and wearing
it until next morning.www.indiandentalacademy.com

II. HIGH PULL HEADGEAR TO A
MAXILLARY SPLINT:
This appliance consists of an acrylic
splint to which a face bow and HP
headgear is attached.
This appliance appears to have
substantial maxillary skeletal and dental
effect with good vertical control.www.indiandentalacademy.com

Tongue Crib
1. A removal or fixed appliance can inhibit
tongue thrust.
2. The crib used with a removable
appliance for an anterior open bite
consists of a palatal plate with a
horseshoe-shaped wire crib.
3. The crib is placed in the area of localwww.indiandentalacademy.com

5.The acrylic also can be interposed
between the teeth, covering the occlusal
surfaces of the upper molars, to prevent
eruption of these teeth and enhance
anchorage of the plate. This is especially
beneficial in open-bite problems.
6.The bite-blocking here can be 3 to 4 mm,
which is usually beyond the postural
vertical dimension in open-bite patients.
7. In such cases a stretch reflex is elicited
from the closing muscles that enhanceswww.indiandentalacademy.com

Activator
1. The bite is opened 4 to 5
mm to develop a
sufficient elastic
depressing force and
load the molar that are in
premature contact.
2. Properly constructed
activators that follow this
principle can influence
the vertical growth
pattern in these cases.

Bionator
1. Used to inhibit abnormal posture
and function 0f the tongue.
2. The construction bite is as low as
possible, but a slight opening
allows the interposition of posterior
acrylic bite blocks for the posterior
teeth, to prevent their extrusion.
3. To inhibit tongue movements, the
acrylic portion of the lower lingual
part extends into the upper incisor
region as a lingual shield. Closing
the anterior space without touching
the upper teeth.

4. The palatal bar has the same configuration as the
standard bionator, with the goal of moving the
tongue into a more posterior or caudal position.
5. The labial bow differs from the standard appliance,
that the wire runs approximately between the
incisal edges of the upper and lower incisors.

FR IV
1. Normally, anterior open bite problems show
protracted tongue posture with
incompetence of lips. The tongue tooth
contact replaces the lip seal during
deglutition to create negative atmospheric
pressure.
2. FR IV along with lip exercises cause lip
contact, reducing tongue protrusion and
cause the tongue to move back into its
normally raised position in proximity with
palate, during deglutition.

3. The palatal bow is like that of
the FR-3 and is always placed
behind the last molar to permit
the appliance to shift in a
posterior direction.
4. This allows the mandible to
close up and forward into a
more favorable growth
direction reducing the
mandibular plane angle.

ACTIVE VERTICAL
CORRECTOR
1.Dellinger in 1987 reported an appliance
which he calls the AVC by using two
magnets.
2.AVC is a simple removable or fixed
orthodontic appliance that intrudes the
posterior teeth of both the maxilla and
mandible by reciprocal forces.
3.By effective intrusion of posterior teeth, thewww.indiandentalacademy.com

3. The uniqueness of this appliance is
that, it corrects anterior open bite
problems by actually reducing anterior
facial height.
4. Problems formerly thought to require
orthognathic surgery, can now be
treated successfully with AVC.

Method of Action :-
1. Force system -- generated by repelling
magnets,
2. AVC is considered superior to a static bite
block appliance energized only by the
intermittent force from the muscles of
mastication.
3. The constant force system of the AVC
results in greater rapidity of tooth

A RAPID MOLAR
INTRUDER:
Introduced by Carano A in 2002.
This appliance is a modification of Jasper
jumper. The ends of the modules are
angulated differently. The angulated
ends attached to the lower tube and the
straight end to the upper tube. They are
attached by means of L-shaped pins.
These pins automatically guide the
modules into positions parallel to the
occlusal plane. It can be adjusted for

• Intrusive force produced is 900 gm
against upper and lower molars.
• The buccal crown tipping produced is
controlled by the use of TPA.
Recommendation:
• When only 1st molars are to be intruded
in the mixed dentition. After adequate
intrusion is achieved, deciduous teeth to
be extracted closing OPEN BITE.www.indiandentalacademy.com

POSITIVE INTERMAXILLARY
PRESSURE APPLIANCE (MIZRAHI
JCO 1985):
• This appliance consists of maxillary and
mandibular component linked by an
intermaxillary spring mechanism.
• When the patient closes the mouth
the elevator muscles have to work
against the spring force, and hence are
strengthened.
• The force is transmitted to the
occlusal surfaces, which results in thewww.indiandentalacademy.com

METHODS OF
EXTRUSION
• 1. Box Elastics:
• Box elastics were commonly used
for correction of dentoalveolar OPEN
BITE.
• Disadvantage: Causes incisal
movement of both the upper and the
lower teeth.

2. Extrusion arch (Isaacson):
• This is a reliable biomechanical
technique for OPEN BITE closure that
does not require patient compliance.
• The extrusion arch produces reverse
action of well established intrusion arch. It
follows the principle of off-center bend or
asymmetrical V- bend.
Advantages:
• Patient compliance is not needed.
• Choice of OPEN BITE closure by

Open bite treatment with
mini-screw

Surgical Correction
• Two factors play major role.
– Severity as an indication for Orthognathic
surgery: the Envelope of discrepancy.
– Patient’s age.

HISTORY
• Hulliken in 1849 was the first to surgically correct
an open bite. He used anterior mandibular
subapical osteotomy to correct the OPEN BITE.
• Introduction of the sagittal split ramus osteotomy
through intra oral approach in 1959 by Trauner
and Obwegeser marked the beginning of the
modern era of Orthognathic surgery. (Proffit)
• In 1975, Bell and Epker and Wolford developed
the contemporary LeForte I down fracture
technique to reposition upper jaw in all 3 planes of
space.

HISTORY
• By 1980s, it was possible to reposition either or
both jaws, to move the chin in all 3 planes of
space, and to reposition dentoalveolar segments
surgically as desired.
• Proffit and Bell (1980) stated that approximately
90% of patients with skeletal type Anterior Open
Bite are best treated by a combination of surgery
and orthodontics.
• In 1990 an alternative approach to traditional
surgical methods of AOB closure was advocated
by Reitzik et al i.e. inverted ‘L’ mandibular
osteotomy combined with RIF (Rigid internal
fixation).

PRE SURGICAL
ORTHODONTICS:
• Objectives:
– Positioning the teeth presurgically in all three
planes of space so their position will facilitate
the surgical plan and the teeth will fit
appropriately when the surgery is completed.
• Duration-
– Up to 1 year

PRE SURGICAL
ORTHODONTICS:
– Procedure known as Dento-alveolar decompensation
– Most severe skeletal jaw discrepancies are partly
compensated by nature by bringing changes in axial
inclinations of the anterior teeth. This is known as dento-
alveolar compensation. The presurgical orthodontics will
decompensate the nature’s compensation.
• The steps involved are -
1. Alignment & leveling
2. Expansion
3. Space Management.

Leveling the Arches
• 1. Lower Arch:
The lower arch rarely has an aggravated curve of
space in the mandibular arch. It is preferable to
level the arches before surgery.
• 2. Upper Arch:
A long-face patient with severe anterior OPEN BITE
often has an extreme curve of Spee in the upper
arch to the point that vertical steps exist in an arch.
Usually, the steps are distal to the canines, but may
occur between the lateral incisors and canines.

Leveling the Arches
– The more severe the steps, the more
advantageous it is to segment the maxilla during
the surgery. In such case, it is better to level the
arch by repositioning surgically rather than
orthodontically.
– Hence, the orthodontists should level the arch
within the segments but not across the segment.
This can be done by using continuous arch wires
with steps at the planned osteotomy sites or by
using separate arch wires.
– It is mistake to the level the upper arch
presurgically in patients with sever OPEN BITE
because this produces relapse tendency.

Expansion of the Arch:
• If a LeForte I osteotomy with separate
posterior dento-alveolar segments is planned
and the expansion will be accomplished
surgically, the orthodontist should be careful
not to produce any orthodontic expansion.
• If arch expansion is to be done
orthodontically, it should be performed at the
very beginning of the presurgical orthodontics
and made stable by the time of surgery.

Space Management
• All space should be closed unless to be used by surgery.
• Space should be created at the sites of osteotomy.
Use of stabilizing arch wires:
• When any final orthodontic adjustment have been made, the
stabilizing arch wires should be placed at least 4 weeks before
surgery so that they are passive when the impression are taken
for the surgical splint (usually 1-2 weeks before surgery). This
ensures that there will be no tooth movement that would result
in a poorly fitting splint and compromise the surgical result.
• The stabilizing arch should be full dimensional edgewise
archwire i.e. 21x25 for 22 slot bracket and 17x25 for 18 slot
bracket.

SURGICAL TECHNIQUES
FOR SKELETAL OPEN
BITE:
• This can be accomplished in 3 ways.
– Maxillary surgery.
– Mandibular surgery.
– Superior positioning of the chin by a mandibular lower
border osteotomy.
• I. MAXILLARY SURGERY:
– LeForte I down fracture of maxilla, or.
– Segmental maxillary osteotomy, and
– Combination.

LEFORTE I
DOWNFRACTURE
• The contemporary surgical approach to
the skeletal OPEN BITE (long face)
deformity involves a LeForte I down
fracture of the maxilla and superior
repositioning of the maxilla after removal
of bone from the lateral walls of the nose,
sinus, and nasal septum. It is important to
shorten the nasal septum or free its base
so that the septum is not bent when the
maxilla is elevated.

II. MANDIBULAR SURGERY
2. INVERTED ‘L’ OSTEOTOMY OF RAMUS WITH RIF:
• This is an alternative approach to traditional surgical methods of
AOB closure and is advocated by Reitzik et al. (1990, AJO).
• He recommends this procedure as an alternative treatment
procedure to the LeForte I maxillary osteotomy when esthetic
demands surgery in mandible.
Mandibular Surgery: as an adjunct:
• The contemporary view is that a mandibular ramus osteotomy is
recommended only as a secondary procedure after the maxilla
has been repositioned vertically.

III. SUPERIOR REPOSITIONING
OF THE CHIN BY A MANDIBULAR
LOWER BORDER OSTEOTOMY
• This procedure is a useful adjunct to
either of the other two surgical
possibilities but is unlikely to be
adequate by itself in an adult.

SURGERY AND
STABILIZATION
• This is the step of real surgery. Surgical
fractioning and repositioning is done as
per the final presurgical planning.
• Proffit recommended that routine use of an
interocclusal splint made from the casts as
repositioned by the model surgery.
• Since this splint will define post-surgical
result, the orthodontist and surgeon should
review the model surgery together.

SURGERY AND
STABILIZATION
• Plaster mounting of the models on an articulator,
avoids the possibility of relationships changing
during the laboratory procedures.
• The splint is made with auto-polymerizing acrylic
and cured in pressure pot to prevent distortion. It
should be as thin as is consistent with adequate
strength i.e. 2 mm thick as the thinnest point.
• After repositioning of the bony segments, the teeth
of the upper and lower arches are wired in
occlusion to splints. The orthodontic arch wires and
brackets can be used for the intermaxillary fixation.

POST -SURGICAL
ORTHODONTICS
• Soon after the surgery, a phase of post-surgical orthodontic
treatment is initiated.
Goal:
• Final detailing of the occlusion
• Esthetic root paralleling
• With maxillary surgery only and rigid internal fixation orthodontic
treatment sometimes can resume as rarely as 2 to 3 weeks post
-surgically.
• With, 2 - jaw surgery, a longer healing time seems prudent,
even with the use of rigid internal fixation.
• When the stabilizing arch wires are removed, they should be
replaced at the same appointment with working archwires and
light vertical elastics.

Maintenance of expansion
of maxilla
• Take six months postsurgically for stabilization
in transverse plane.
Methods:
• i. Heavy labial auxiliary wires in the headgear
tubes along with the light working arch wires.
• ii. TPA:
– TPA cannot be placed at the time of surgery.
Hence labial auxiliary arch wire is placed until
splint is removed and is replaced by TPA.

REFERENCE
• Worms F.W, Meskin L.H, Isaacson R.J., Open bite. Am J Orthod: 1971;
59:589-95.
• Klein: The Thumb sucking habit: Meaningful or Empty. Am J Orthod:
1971:3;256-268.
• Clinical Biomechanics, Seminar Orthodontics; March 2001, Vol 7. No.1.
• Carano A., Machita W. A rapid molar intruder for `Non-compliances
treatment’. J Clinc Orthod: 2002 March; 8: 137-142.
• Iscan M.N. Akkaya Sevil and Koralp E. The effects of the spring -
loaded posterior bite-block on the maxillo-facial morphology. Eur J
Orthod 1992; 14:54-60.
• Contemporary Orthodontics by Proffit W.R, Fields H.W., third edition,
2000
• Orthodontics-Current principles and techniques by Graber T.M. and
Vanarsdall R.L., third edition, 2000

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