INDIAN DENTAL ACADEMY
Leader in continuing dental education
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Open bite

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DEFINITIONS
CLASSIFICATIONS
ETIOLOGY
DIAGNOSIS
TREATMENT
FINISHING & RETENTION
www.indiandentalacademy.com
INTRODUCTION;
Open bite mal occlusion has long held
fascination in orthodontics.
It is difficult to treat and relapse
tend...
DEFINITIONS;
Normal bite: It is defined as vertical
overlap of the incisors. The lower incisal edges
in relation to the li...
OPEN BITE;

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ANTERIOR OPEN BITE;

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POSTERIOR OPEN BITE;

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SIMPLE OPEN BITE;

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COMPLEX OPEN BITE;

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COMPOUND OPEN BITE;

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IATROGENIC OPEN BITE;

Open bite as a consequence of
orthodontic treatment.

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Classificaton;
It used to visualize the problem,
diagnosis and treatment plan.

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Classified on developmental;
Primary;

Mixed;

Gum pads

Temporary

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Permanent;

Persistent ha...
Depend on site;
Anterior open bite;

Posterior open bite;

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Depend on position;
Intra arch
The tooth itself is
malpositioned within
arch creating open bite

- infraversion / inclinat...
Inter arch;
-No vertical overlap
-abnormality in
upper/lower or both
- Ant/post segment

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Ankerman profit;

vertical relation

Anterior open bite
dental

Posterior open bite

skeletal

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Depend on etiology;

Lateral
open bite

Compound
open bite

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Iatrogenic
open bite
ETIOLOGY OF OPEN BITE;
WHY OPEN BITE ?

- EPIGENETIC FACTORS
- ENVIRONMENTAL FACTORS
- HABITS
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Pre – disposing factors;
maxilla
Skeletal

Mandible

Dental

Excess eruption of posteriors
Decreased eruption of anteriors...
Various factors influencing open bite;
a) Disturbances in embryonic development;
1) Muscle dysfunction
2) Hemi mandibular ...
1) Muscle dysfunction;

Kiliaridis s, mejersjo c

- Etiology;

- Ejo 1989

- defect in the uterus.
- Pathology
- affect th...
Underdevelopment of
face

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Muscular dystropy.

&
Muscle weakness
syndrome.
Muscle tonicity

Open bite
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Mandible drops
downwards away
from maxilla

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Anterior open bite due to increased
eruption of posterior teeth.
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2) Hemi mandibular hypertrophy
Bilateral

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- unilateral

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b) Genetic influence;
- A strong influence of inheritence on
facial features is obvious at a glance.

- mal occlusion prod...
Long face pattern;

King L, Harris EF, Tolley EA
- AJO 1993

Long face syndrome;

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Ackerman, Isacson, Shapiro
- AJO 1970
Genetic inheritence

Skeletal influence

Dental influence

Open bite
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c) Environmental influence;

The open bite can be produced by
1) equilibrium forces
2) Functional forces

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1) Equilibrium forces;
It states that object subject to unequal
forces will be accelerated and there by
move to different ...
Altered equilibrium due to increased tonque
pressure.

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a) Juvenile equilibrium;

The teeth that are in function
parallels the rate of vertical
growth of mandibular ramus

www.in...
The rate of eruption is controlled by forces
opposing direction, not those promoting it.

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2) Functional forces;
Biting force and eruption
Downward growth
of mandible
Open bite

Masticatory muscle gains strength a...
HABITS
Definition;
It is the tendency towards an act of repeated
performance relatively fixed or consistent
and ease to pe...
Earliest writings;
- causes of irregularities through habits that
pushes teeth forward.
- Lefoulon 1839
- balance of force...
Classify;
1)

useful

Tongue thrusting

harmful

2)

When persists

Pressure

Sucking ( lip, thumb)

Non pressure

Mouth b...
Thumb sucking;
Definition;
It is defined as the placement of thumb
or one/more fingers in varying depths
into the mouth.
K...
Physiological condition;
-It is considered normal till 3 – 4 yrs.
- It is an non nutritive sucking habit
- Recent studies ...
Pathological condition;
&
Clinical features

It occurs through
altered equilibrium not
just pressure through
fingers.

www...
Sucking habits;

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Theories;
1) Freudan theory;
1- 3 years – oral and anal phase.
2) Oral drive theory of sears and wise;

1950

Prolonged ha...
4) Psychological aspects;
Children develop this habit as a feeling of
insecurity, when they are deprived of love,
care and...
Phases of thumbsucking;
Phase – 1;
- First three years of life.
- sub clinically significant.
Phase - 2;
- 3 – 6 yrs of li...
Phase - 3;
- beyond 5 – yrs.
- intractable sucking.
- Its an alert to an dentist.

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DIAGNOSIS;
- Check for childs emotional status.
- feeding habits
- Intra – oral examination;
- incissors
- open bite
- Cle...
TREATMENT;
1) Psychological approach;
Beta hypothesis theory by Dunlop
Consious purposeful repeatation.
2) Mechanical aids...
TONGUE THRUSTING
DEFINITION;
It is defined as the forward movement of
the tongue tip between the teeth to meet
the lower l...
Classification;
According to moyers;
Simple

complex

- To establish lip seal
- Anterior open bite

- Contraction of
circu...
Simple tongue thrust.

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According to James s. Braner and holt
Type 1 - Non deforming tongue thrust.
Type 2 – Deforming anterior tongue thrust.
Typ...
Etiology ;
According to fletcher;
1) Genetic factors;
Neuromuscular variations in oro
facial region.
2) Learned behaviour;...
4) Mechanical restrictions;
- macroglossia.
- arch constricted.
5) Neurological disturbances;
- motor disability
6) Psycho...
DIAGNOSIS;
- Size of the tongue
- posture of the tongue
- Structure of the tongue
- Function of the tongue

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1) Size of the tongue;
Variations in tongue size ,
Reaches its adult size by the age
of 8 years.
Why asses the variations ...
Macroglossia;
The whole oral cavity is filled with the
tongue mass, presence of indentations
on the periphery.

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Etiological factors;

congenital

Acquired

- muscular hypertrophy

- Acromegaly

- glandular hyperplasia

- myxedema
- am...
Pseudo macroglossia;
Forward posture of tongue

- Low palatal vault

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Etiological factors;
- habitual posturing of the tongue.
- hypertropied tonsils and adenoid tissue.
- arch deficiency in a...
Clinical assessment;
1) macroglossia.
2) microglossia.
- Tulley AJO 1969.

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MACROGLOSSIA;
Signs and symptoms.
- Open bite (ant/post)
- Diastema (mx/md)
- Accentuated curve of spee in maxillary arch
...
Cephalometric & Radiographic assessment.
- over angulation of upper and lower anteriors.
- Dispropotionately excessive man...
Cephalometric evaluation;
Lateral ceph with sufficient exposure to
evaluate the soft tissue.
Reference lines;
I,V,M,O.

ww...
Criteria for evaluation;
- The greatest possible area of tongue should
be above reference line.
- The base line is indepen...
Menstrual data through template;

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Template evaluation;

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2) Posture of tongue;
The posture is evaluated for various open
bite tendencies.

It can be flat/arched, protracted/retrac...
ANTERIOR POSTURE;

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LATERAL POSTURE;

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STRUCTURE OF TONGUE;
In infancy the extrinsic suspensory
muscles attach the tongue to various
osseous structures largely r...
FUNCTION OF TONGUE;
DEGLUTATION

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According to moyers;
Depend on the characteristic;
1) Infantile swallow ---- 12 - 18 mnths.
2) Mature swallow ----2 - 4 yr...
INFANTILE SWALLOW;

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Central furrow & gum pads.

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MATURE SWALLLOW;

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SHALLOW TONGUE;

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Do tongue thrust cause open bite ?
Pressure on teeth by swallow - 1 secs

Individual swallow – 800/dy - & few in sleep.
To...
Treatment;
Defect in posture;
- habit breaking appliance.
- muscle exercise through elastics.
Defect in size;
- Glossectom...
Glossectomy;
Pseudo macroglossia

True macroglossia

Procedures;
- Midline wedge resection with base in
the anterior tongu...
Keyhole technique;

Anterior wedge resection

Midline elliptical incision
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- AJO -96
SEQUENCE OF PROCEDURES;
STAGE I :
GLOSSECTOMY
ORTHOGNATHIC
SURGERY
- Psychological approach.
- No IMF
- No air way obstruc...
STAGE 2 :

ORTHOGNATHIC
SURGERY.
GLOSSECTOMY

- If occlusal stability is a concern.

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STAGE 3 :
COMBINED
- Both the procedures combined together at a
same surgical stage.

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MOUTH BREATHING;
Definition;
It is defined as the the pattern of
breathing totally / partially through oral
cavity due to ...
Classify;
a) Obstructive.
b) Habitual.
c) Anatomical.

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ETIOLOGY;
Mouth breathing primarily has effect on
- posture of jaws.
- Position of tongue
- posture of head.
Altered equil...
Mouth breathing
Mandible lowered

LFH

Tilted head

lowered tongue

Change of 5 degree
cranio vertebral
angle
Mandible rot...
Mandible lowered;

Ant; open bite.

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Change in cranio vertebral angle;

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Physiological variations;
All humans are some mouth breathers.
Average breathing air flow ------ 20 – 25/L/mnt
Partial mou...
Pathological variations;
It becomes a habit when the breathing
persists even when the obstruction is
removed.
Opposing pri...
Clinical features;
Malocclusion associated with the mouth
breathing.
Long face syndrome/classical adenoid facies;

www.ind...
DIAGNOSIS;
- Nasal obstruction.
- Adenoids.
- hyoid triangle analysis.

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NASAL OBSTRUCTION

- AJO 1998

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Choanal atresia & treacher collins syndrome in
infants ----- tracheostomy
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How much obstruction has to occur for effect on
growth ?
- It depends on location of the obstruction.
Anterior
Middle port...
Methods in assessing the nasal obstruction.
- Cross sectional area.
- Peak nasal air flow
- Nasal resistance.
- Respirator...
Rhinomanometric studies;
Study of air flow with flow meters, and
pressure gauges.

Cleft lip and palate patients increase ...
ADENOIDS;

Enlargement of adenoids relation to mouth
breathing.
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Hyoid bone position;

- AJO 1984.

In 1981 Bibby and Preston.
Hyoid bone is not fixed to a space by any
bony articulations...
- It is influenced by the tongue posture and
mandibular position.

it signifies
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TREATMENT;
- Removal of the cause.
- Interception of the habit.
- Rapid maxillary expansion.
- orthodontic + surgery

www....
Nasal obstruction;

- AJO 1998

- vertically repositioning of maxilla
predictably reduce the nasal resistance.
Not nasal a...
Adenoids;

- AJO -94

- Adenoidectomy.

Ten yr old

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No change in breathing pattern;

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Rapid maxillary expansion;
For maxillary deficiency
Increase nasal air flow
Reduction in nasal resistance was frequently
m...
DIAGNOSIS;
Early detection of symptoms is
recommended, so that treatment can be
provided in time whatever the cause may
be...
How to decide for open bite ?
It is the ability to recognize vertical growth
in routine treatment mechanics.
Commonly clin...
DIAGNOSIS;
- SKELETAL OPEN BITE
- DENTAL OPEN BITE.
- ANTERIOR OPEN BITE.
- POSTERIOR OPEN BITE.

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Skeletal open bite;

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Posterior open bite;
- Failure of posterior tooth to erupt fully
in occlusion producing lateral open bite.
Mechanical inte...
GROWTH PATTERN ;
Its purpose was to assess skeletal factors
associated with development of vertical
facial disproportions....
Steeper planes;

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1) Mandibular plane;
Favoured --- Nanda.
Not favoured --- Skiller/Bjork.
2) Gonial angle; Enlow - Angle.
3) Palatal plane;...
CEPHALOMETRIC EVALUATION;
There are six specific cephalometric
angular measurements for identifying the
vertical dysplasia...
1) SN --- (ANS – PNS);

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2) SN --- MANDIBULAR PLANE;

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3) GONIAL ANGLE;

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Resultant uprighting of the ramus.
4) PALATOMANDIBULAR ANGLE;

Bimler used this angle for describing facial types.
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5) SN --- OCCLUSAL PLANE;

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6) CRANIAL BASE ANGLE;

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LINEAR PARAMETERS;
GROUP 1;
PFH/AFH ----- Sum of angle
-Jarabak
GROUP 2;
UFH/LFH
Average --- 0.810
Open bite ---0.686
www....
OBJECTIVE OF OPEN BITE;
1) Creating sufficient overlap with molar relation;
Incisal overlap
0.5 --- 4.0 mm
Average – 2.8mm...
Central incisor relative to lip line;

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The dentition is placed in proper three
dimensional perspective to ensure stability.
- Antero – posterior aspect.
- Vertic...
Axial inclination; ------ open bite

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Axial inclination ----- deep bite.

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Eliminate Blocks:
In order to eliminate blocks the molar
are distally tipped.

Extraction ( 1/2/3) molar

www.indiandental...
TREATMENT;
It depends on etiology and location
- Dento alveolar open bite.
- skeletal open bite.
TIMING OF TREATMENT;
Not ...
TREATMENT DURING PRIMARY
DENTITION;
Dental open bite;
- Habits ---- after 3 yrs.
Screening therapy.
Skeletal open bite;
- ...
TREATMENT ON EARLY MIXED
DENTITION;
Dento alveolar open bite;
- Screening therapy
- Behavior modification.

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Screening appliances;
Vestibular screen ------------ digit sucking
Vestibular screen ------ Its modifications.
Tongue crib...
BEHAVIOR MODIFICATION;
COUNSELLING;
A straight forward discussion with the
child during eruption of permanent
incisors.
RE...
REMINDER;

For the child who wants to quit.

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QUAD HELIX;

Maxillary lingual arch with crib;

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OPEN BITE IN LATE MIXED DENTITION;
Skeletal parameters;
- Major diagnostic criteria is either,
maxilla

or both

Palatal p...
GROWTH MODIFICATION;
It varies depends on horrizontal/vertical growth;

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High pull head gear to molars;

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High pull head gear with maxillary splint;

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Bite blocks with functional appliance;

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Head gear with functional appliance and
bite blocks;

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Functional appliance;
Head gear with activator

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Bite registration;

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TREATMENT IN ADULT;
Correction of vertical relation

mandible

maxilla
Vertical
excess

anterior
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Maxillary excess;
Le Forte I

Reduce the nasal
septum
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Anterior open bite;

Anterior segment is moved more than posterior
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Posterior open bite;

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Segmental osteotomy
Mandibular surgery;
Surgery in the ramal part is done only to the
secondary aspect to the maxillary osteotomy
for the auto...
GENIOPLASTY;
Long face pts has excess
eruption of lower anterior
which is flared and unstable
Poor chin balance

Bony cut ...
PRE – SURGICAL ORTHODONTICS;

allignment
levelling
Antero posterior incisor position

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LEVELLING;
MAY OR MAY NOT BE DONE;
- Depend on facial type.
Stabilizing arch wire;
18 slot ------- 17 x 25
22 slot ------ ...
POST SURGICAL ORTHODONTICS;
Until stabilizing arch wire is removed
the teeth are held in tight position.
- four weeks

Lig...
RETENTION

Removable Appliance with high
pull head gear www.indiandentalacademy.com
Appliance with the bite
block.

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Force Amplified Retention
1997 JCO Sheridan

Low profile lingual caplin
Canine to canine
hooks
www.indiandentalacademy.com...
Conclusion;

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THANK

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Open bite sem [recovered] /certified fixed orthodontic courses by Indian dental academy

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Open bite sem [recovered] /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Open bite www.indiandentalacademy.com
  3. 3. DEFINITIONS CLASSIFICATIONS ETIOLOGY DIAGNOSIS TREATMENT FINISHING & RETENTION www.indiandentalacademy.com
  4. 4. INTRODUCTION; Open bite mal occlusion has long held fascination in orthodontics. It is difficult to treat and relapse tendencies are strong. - Young H. Kim AO 1987 www.indiandentalacademy.com
  5. 5. DEFINITIONS; Normal bite: It is defined as vertical overlap of the incisors. The lower incisal edges in relation to the lingual surface of the upper incisors present at or above the cingulam (normally there is 1-2 mm overbite) www.indiandentalacademy.com
  6. 6. OPEN BITE; www.indiandentalacademy.com
  7. 7. ANTERIOR OPEN BITE; www.indiandentalacademy.com
  8. 8. POSTERIOR OPEN BITE; www.indiandentalacademy.com
  9. 9. SIMPLE OPEN BITE; www.indiandentalacademy.com
  10. 10. COMPLEX OPEN BITE; www.indiandentalacademy.com
  11. 11. COMPOUND OPEN BITE; www.indiandentalacademy.com
  12. 12. IATROGENIC OPEN BITE; Open bite as a consequence of orthodontic treatment. www.indiandentalacademy.com
  13. 13. Classificaton; It used to visualize the problem, diagnosis and treatment plan. www.indiandentalacademy.com
  14. 14. Classified on developmental; Primary; Mixed; Gum pads Temporary www.indiandentalacademy.com Permanent; Persistent habits
  15. 15. Depend on site; Anterior open bite; Posterior open bite; www.indiandentalacademy.com
  16. 16. Depend on position; Intra arch The tooth itself is malpositioned within arch creating open bite - infraversion / inclination abnormally without root. www.indiandentalacademy.com
  17. 17. Inter arch; -No vertical overlap -abnormality in upper/lower or both - Ant/post segment www.indiandentalacademy.com
  18. 18. Ankerman profit; vertical relation Anterior open bite dental Posterior open bite skeletal www.indiandentalacademy.com dental
  19. 19. Depend on etiology; Lateral open bite Compound open bite www.indiandentalacademy.com Iatrogenic open bite
  20. 20. ETIOLOGY OF OPEN BITE; WHY OPEN BITE ? - EPIGENETIC FACTORS - ENVIRONMENTAL FACTORS - HABITS www.indiandentalacademy.com
  21. 21. Pre – disposing factors; maxilla Skeletal Mandible Dental Excess eruption of posteriors Decreased eruption of anteriors www.indiandentalacademy.com
  22. 22. Various factors influencing open bite; a) Disturbances in embryonic development; 1) Muscle dysfunction 2) Hemi mandibular hypertrophy www.indiandentalacademy.com
  23. 23. 1) Muscle dysfunction; Kiliaridis s, mejersjo c - Etiology; - Ejo 1989 - defect in the uterus. - Pathology - affect the particular muscle Bone formation in the origin of muscle Loss of musculature www.indiandentalacademy.com
  24. 24. Underdevelopment of face www.indiandentalacademy.com
  25. 25. Muscular dystropy. & Muscle weakness syndrome. Muscle tonicity Open bite www.indiandentalacademy.com
  26. 26. Mandible drops downwards away from maxilla www.indiandentalacademy.com
  27. 27. Anterior open bite due to increased eruption of posterior teeth. www.indiandentalacademy.com
  28. 28. 2) Hemi mandibular hypertrophy Bilateral www.indiandentalacademy.com
  29. 29. - unilateral www.indiandentalacademy.com
  30. 30. b) Genetic influence; - A strong influence of inheritence on facial features is obvious at a glance. - mal occlusion produced by inherited characteristic in 2 ways; What it has to do with open bite ? www.indiandentalacademy.com
  31. 31. Long face pattern; King L, Harris EF, Tolley EA - AJO 1993 Long face syndrome; www.indiandentalacademy.com
  32. 32. Ackerman, Isacson, Shapiro - AJO 1970 Genetic inheritence Skeletal influence Dental influence Open bite www.indiandentalacademy.com
  33. 33. c) Environmental influence; The open bite can be produced by 1) equilibrium forces 2) Functional forces www.indiandentalacademy.com
  34. 34. 1) Equilibrium forces; It states that object subject to unequal forces will be accelerated and there by move to different space. Proffit WR; AO 1978 Hence the equilibrium has to be maintained. www.indiandentalacademy.com
  35. 35. Altered equilibrium due to increased tonque pressure. www.indiandentalacademy.com
  36. 36. a) Juvenile equilibrium; The teeth that are in function parallels the rate of vertical growth of mandibular ramus www.indiandentalacademy.com
  37. 37. The rate of eruption is controlled by forces opposing direction, not those promoting it. www.indiandentalacademy.com
  38. 38. 2) Functional forces; Biting force and eruption Downward growth of mandible Open bite Masticatory muscle gains strength at puberty. www.indiandentalacademy.com
  39. 39. HABITS Definition; It is the tendency towards an act of repeated performance relatively fixed or consistent and ease to perform by an individual. We are just beginning to realize how common and varied the vicious habits of lip and tongue, and how power full and persist to overcome - Angle. www.indiandentalacademy.com
  40. 40. Earliest writings; - causes of irregularities through habits that pushes teeth forward. - Lefoulon 1839 - balance of force to retain teeth in position. - Desirabode 1843 - “lateral pressure theory” - Bridgeman 1859 - “Sim Wallace theory” - Bennett www.indiandentalacademy.com
  41. 41. Classify; 1) useful Tongue thrusting harmful 2) When persists Pressure Sucking ( lip, thumb) Non pressure Mouth breathing www.indiandentalacademy.com
  42. 42. Thumb sucking; Definition; It is defined as the placement of thumb or one/more fingers in varying depths into the mouth. Klein AJO 1979 www.indiandentalacademy.com
  43. 43. Physiological condition; -It is considered normal till 3 – 4 yrs. - It is an non nutritive sucking habit - Recent studies indicate that thumb sucking is practised even during the intra – uterine life. www.indiandentalacademy.com
  44. 44. Pathological condition; & Clinical features It occurs through altered equilibrium not just pressure through fingers. www.indiandentalacademy.com Open bite
  45. 45. Sucking habits; www.indiandentalacademy.com
  46. 46. Theories; 1) Freudan theory; 1- 3 years – oral and anal phase. 2) Oral drive theory of sears and wise; 1950 Prolonged habit leads to thumbsucking. 3) Benjamins theory; Thumbsucking develops in infants due to the rooting reflex/placing reflex. www.indiandentalacademy.com
  47. 47. 4) Psychological aspects; Children develop this habit as a feeling of insecurity, when they are deprived of love, care and affection. www.indiandentalacademy.com
  48. 48. Phases of thumbsucking; Phase – 1; - First three years of life. - sub clinically significant. Phase - 2; - 3 – 6 yrs of life. - clinically significant. www.indiandentalacademy.com
  49. 49. Phase - 3; - beyond 5 – yrs. - intractable sucking. - Its an alert to an dentist. www.indiandentalacademy.com
  50. 50. DIAGNOSIS; - Check for childs emotional status. - feeding habits - Intra – oral examination; - incissors - open bite - Clean nails www.indiandentalacademy.com
  51. 51. TREATMENT; 1) Psychological approach; Beta hypothesis theory by Dunlop Consious purposeful repeatation. 2) Mechanical aids; Basically reminders 3) Chemical approach; www.indiandentalacademy.com
  52. 52. TONGUE THRUSTING DEFINITION; It is defined as the forward movement of the tongue tip between the teeth to meet the lower lip in deglutition and in sounds of speech so that the tongue becomes interdental. Tulley www.indiandentalacademy.com AJO 1969
  53. 53. Classification; According to moyers; Simple complex - To establish lip seal - Anterior open bite - Contraction of circum – oral muscles. - abnormal mentalis - diffuse open bite. - poor occlusion. www.indiandentalacademy.com
  54. 54. Simple tongue thrust. www.indiandentalacademy.com
  55. 55. According to James s. Braner and holt Type 1 - Non deforming tongue thrust. Type 2 – Deforming anterior tongue thrust. Type 3 – Deforming lateral tongue thrust Type 4 – Deforming ant; & lat; tongue thrust www.indiandentalacademy.com
  56. 56. Etiology ; According to fletcher; 1) Genetic factors; Neuromuscular variations in oro facial region. 2) Learned behaviour; Prolonged action & gum tenderness. 3) maturational; Age – swallow pattern. www.indiandentalacademy.com
  57. 57. 4) Mechanical restrictions; - macroglossia. - arch constricted. 5) Neurological disturbances; - motor disability 6) Psychogenic factor; - discontinuation of other habits. www.indiandentalacademy.com
  58. 58. DIAGNOSIS; - Size of the tongue - posture of the tongue - Structure of the tongue - Function of the tongue www.indiandentalacademy.com
  59. 59. 1) Size of the tongue; Variations in tongue size , Reaches its adult size by the age of 8 years. Why asses the variations ? True macroglossia Pseudo macroglossia www.indiandentalacademy.com
  60. 60. Macroglossia; The whole oral cavity is filled with the tongue mass, presence of indentations on the periphery. www.indiandentalacademy.com
  61. 61. Etiological factors; congenital Acquired - muscular hypertrophy - Acromegaly - glandular hyperplasia - myxedema - amyloidosis - lymphangioma - Downs syndrome - tertiary syphylis Cyst/tumors involving tongue. www.indiandentalacademy.com
  62. 62. Pseudo macroglossia; Forward posture of tongue - Low palatal vault www.indiandentalacademy.com
  63. 63. Etiological factors; - habitual posturing of the tongue. - hypertropied tonsils and adenoid tissue. - arch deficiency in all dimensions. - severe mandibular deficiency. - cyts/tumors that displaces the tongue www.indiandentalacademy.com
  64. 64. Clinical assessment; 1) macroglossia. 2) microglossia. - Tulley AJO 1969. www.indiandentalacademy.com
  65. 65. MACROGLOSSIA; Signs and symptoms. - Open bite (ant/post) - Diastema (mx/md) - Accentuated curve of spee in maxillary arch - Reverse curve of spee in mandibular arch. - difficulty in swallowing - mandibular prognathism. - Larry M. WOLFORD, AJO 1996 www.indiandentalacademy.com
  66. 66. Cephalometric & Radiographic assessment. - over angulation of upper and lower anteriors. - Dispropotionately excessive mandibular growth. - increased gonial angle. - increased occlusal and mandibular plane angle. - David A. AJO 1996. www.indiandentalacademy.com
  67. 67. Cephalometric evaluation; Lateral ceph with sufficient exposure to evaluate the soft tissue. Reference lines; I,V,M,O. www.indiandentalacademy.com
  68. 68. Criteria for evaluation; - The greatest possible area of tongue should be above reference line. - The base line is independent of skeletal structures. - The tongue should not change with position of the mandible. www.indiandentalacademy.com
  69. 69. Menstrual data through template; www.indiandentalacademy.com
  70. 70. Template evaluation; www.indiandentalacademy.com
  71. 71. 2) Posture of tongue; The posture is evaluated for various open bite tendencies. It can be flat/arched, protracted/retracted, narrow/long. www.indiandentalacademy.com
  72. 72. ANTERIOR POSTURE; www.indiandentalacademy.com
  73. 73. LATERAL POSTURE; www.indiandentalacademy.com
  74. 74. STRUCTURE OF TONGUE; In infancy the extrinsic suspensory muscles attach the tongue to various osseous structures largely resposible for gross movements in horrizontal plane. - It has the property of elasticity & contractility ----- tongue thrust. Acts through all / none law. www.indiandentalacademy.com
  75. 75. FUNCTION OF TONGUE; DEGLUTATION www.indiandentalacademy.com
  76. 76. According to moyers; Depend on the characteristic; 1) Infantile swallow ---- 12 - 18 mnths. 2) Mature swallow ----2 - 4 yrs www.indiandentalacademy.com
  77. 77. INFANTILE SWALLOW; www.indiandentalacademy.com
  78. 78. Central furrow & gum pads. www.indiandentalacademy.com
  79. 79. MATURE SWALLLOW; www.indiandentalacademy.com
  80. 80. SHALLOW TONGUE; www.indiandentalacademy.com
  81. 81. Do tongue thrust cause open bite ? Pressure on teeth by swallow - 1 secs Individual swallow – 800/dy - & few in sleep. Total 1000/dy www.indiandentalacademy.com
  82. 82. Treatment; Defect in posture; - habit breaking appliance. - muscle exercise through elastics. Defect in size; - Glossectomy.. - surgical correction. www.indiandentalacademy.com
  83. 83. Glossectomy; Pseudo macroglossia True macroglossia Procedures; - Midline wedge resection with base in the anterior tongue. - Midline elliptical excision. - Marginal excision. - “Keyhole” or combined technique. www.indiandentalacademy.com
  84. 84. Keyhole technique; Anterior wedge resection Midline elliptical incision www.indiandentalacademy.com - AJO -96
  85. 85. SEQUENCE OF PROCEDURES; STAGE I : GLOSSECTOMY ORTHOGNATHIC SURGERY - Psychological approach. - No IMF - No air way obstruction. www.indiandentalacademy.com
  86. 86. STAGE 2 : ORTHOGNATHIC SURGERY. GLOSSECTOMY - If occlusal stability is a concern. www.indiandentalacademy.com
  87. 87. STAGE 3 : COMBINED - Both the procedures combined together at a same surgical stage. www.indiandentalacademy.com
  88. 88. MOUTH BREATHING; Definition; It is defined as the the pattern of breathing totally / partially through oral cavity due to anatomical / functional variations. www.indiandentalacademy.com
  89. 89. Classify; a) Obstructive. b) Habitual. c) Anatomical. www.indiandentalacademy.com
  90. 90. ETIOLOGY; Mouth breathing primarily has effect on - posture of jaws. - Position of tongue - posture of head. Altered equilibrium Growth Tooth position www.indiandentalacademy.com
  91. 91. Mouth breathing Mandible lowered LFH Tilted head lowered tongue Change of 5 degree cranio vertebral angle Mandible rotated Open bite www.indiandentalacademy.com Obstruction relieved
  92. 92. Mandible lowered; Ant; open bite. www.indiandentalacademy.com
  93. 93. Change in cranio vertebral angle; www.indiandentalacademy.com
  94. 94. Physiological variations; All humans are some mouth breathers. Average breathing air flow ------ 20 – 25/L/mnt Partial mouth breathing --------- 40 – 45 L/mnt Transitional stage ----------- 80 Mintz S, Shepard RJ. www.indiandentalacademy.com
  95. 95. Pathological variations; It becomes a habit when the breathing persists even when the obstruction is removed. Opposing principles; Total nasal obstruction Increased LFH Battgel J BJO - 1996 www.indiandentalacademy.com
  96. 96. Clinical features; Malocclusion associated with the mouth breathing. Long face syndrome/classical adenoid facies; www.indiandentalacademy.com
  97. 97. DIAGNOSIS; - Nasal obstruction. - Adenoids. - hyoid triangle analysis. www.indiandentalacademy.com
  98. 98. NASAL OBSTRUCTION - AJO 1998 www.indiandentalacademy.com
  99. 99. Choanal atresia & treacher collins syndrome in infants ----- tracheostomy www.indiandentalacademy.com
  100. 100. How much obstruction has to occur for effect on growth ? - It depends on location of the obstruction. Anterior Middle portion posterior - nasal function www.indiandentalacademy.com
  101. 101. Methods in assessing the nasal obstruction. - Cross sectional area. - Peak nasal air flow - Nasal resistance. - Respiratory mode (oral/nasal air flow ratio) -AJO 1998 www.indiandentalacademy.com
  102. 102. Rhinomanometric studies; Study of air flow with flow meters, and pressure gauges. Cleft lip and palate patients increase tendency of mouth breathing ? - AJO 1998 Posterior nasal obstruction by pharyngeal flaps. www.indiandentalacademy.com
  103. 103. ADENOIDS; Enlargement of adenoids relation to mouth breathing. www.indiandentalacademy.com
  104. 104. Hyoid bone position; - AJO 1984. In 1981 Bibby and Preston. Hyoid bone is not fixed to a space by any bony articulations. Hyoid bone is determined by muscles and ligaments attached to structures above and below it. www.indiandentalacademy.com
  105. 105. - It is influenced by the tongue posture and mandibular position. it signifies www.indiandentalacademy.com
  106. 106. TREATMENT; - Removal of the cause. - Interception of the habit. - Rapid maxillary expansion. - orthodontic + surgery www.indiandentalacademy.com
  107. 107. Nasal obstruction; - AJO 1998 - vertically repositioning of maxilla predictably reduce the nasal resistance. Not nasal air flow Breathing mode is behavioral determined than structurally determination The highest correlation between these parameters are 0.24 %---- 0.74% www.indiandentalacademy.com
  108. 108. Adenoids; - AJO -94 - Adenoidectomy. Ten yr old www.indiandentalacademy.com
  109. 109. No change in breathing pattern; www.indiandentalacademy.com
  110. 110. Rapid maxillary expansion; For maxillary deficiency Increase nasal air flow Reduction in nasal resistance was frequently measured. Rhinometric studies; No change in breathing mode. www.indiandentalacademy.com
  111. 111. DIAGNOSIS; Early detection of symptoms is recommended, so that treatment can be provided in time whatever the cause may be. - Subtenly, AO 1954 - Ricketts, AO 1968 www.indiandentalacademy.com
  112. 112. How to decide for open bite ? It is the ability to recognize vertical growth in routine treatment mechanics. Commonly clinicians evaluate Mandibular plane for open bite. www.indiandentalacademy.com
  113. 113. DIAGNOSIS; - SKELETAL OPEN BITE - DENTAL OPEN BITE. - ANTERIOR OPEN BITE. - POSTERIOR OPEN BITE. www.indiandentalacademy.com
  114. 114. Skeletal open bite; www.indiandentalacademy.com
  115. 115. Posterior open bite; - Failure of posterior tooth to erupt fully in occlusion producing lateral open bite. Mechanical interference. Disturbance of eruption mechanism. www.indiandentalacademy.com
  116. 116. GROWTH PATTERN ; Its purpose was to assess skeletal factors associated with development of vertical facial disproportions. Horrizontal facial planes tends to be steeper and more divergent with lower facial height. www.indiandentalacademy.com
  117. 117. Steeper planes; www.indiandentalacademy.com
  118. 118. 1) Mandibular plane; Favoured --- Nanda. Not favoured --- Skiller/Bjork. 2) Gonial angle; Enlow - Angle. 3) Palatal plane; Posterior dips 4) Occlusal plane; Bjork –no change Steeper 5) Cranial base; Larger cranial base and corresponding positional deviations of mandible associated with open bite. www.indiandentalacademy.com
  119. 119. CEPHALOMETRIC EVALUATION; There are six specific cephalometric angular measurements for identifying the vertical dysplasia. www.indiandentalacademy.com
  120. 120. 1) SN --- (ANS – PNS); www.indiandentalacademy.com
  121. 121. 2) SN --- MANDIBULAR PLANE; www.indiandentalacademy.com
  122. 122. 3) GONIAL ANGLE; www.indiandentalacademy.com Resultant uprighting of the ramus.
  123. 123. 4) PALATOMANDIBULAR ANGLE; Bimler used this angle for describing facial types. www.indiandentalacademy.com
  124. 124. 5) SN --- OCCLUSAL PLANE; www.indiandentalacademy.com
  125. 125. 6) CRANIAL BASE ANGLE; www.indiandentalacademy.com
  126. 126. LINEAR PARAMETERS; GROUP 1; PFH/AFH ----- Sum of angle -Jarabak GROUP 2; UFH/LFH Average --- 0.810 Open bite ---0.686 www.indiandentalacademy.com
  127. 127. OBJECTIVE OF OPEN BITE; 1) Creating sufficient overlap with molar relation; Incisal overlap 0.5 --- 4.0 mm Average – 2.8mm - Kim 1974 - AO 1998 www.indiandentalacademy.com
  128. 128. Central incisor relative to lip line; www.indiandentalacademy.com
  129. 129. The dentition is placed in proper three dimensional perspective to ensure stability. - Antero – posterior aspect. - Vertical aspect. - Transverse aspect. www.indiandentalacademy.com
  130. 130. Axial inclination; ------ open bite www.indiandentalacademy.com
  131. 131. Axial inclination ----- deep bite. www.indiandentalacademy.com
  132. 132. Eliminate Blocks: In order to eliminate blocks the molar are distally tipped. Extraction ( 1/2/3) molar www.indiandentalacademy.com Non extraction
  133. 133. TREATMENT; It depends on etiology and location - Dento alveolar open bite. - skeletal open bite. TIMING OF TREATMENT; Not too early not too late www.indiandentalacademy.com
  134. 134. TREATMENT DURING PRIMARY DENTITION; Dental open bite; - Habits ---- after 3 yrs. Screening therapy. Skeletal open bite; - Habit control secondary. - Growth modification not indicated www.indiandentalacademy.com
  135. 135. TREATMENT ON EARLY MIXED DENTITION; Dento alveolar open bite; - Screening therapy - Behavior modification. www.indiandentalacademy.com
  136. 136. Screening appliances; Vestibular screen ------------ digit sucking Vestibular screen ------ Its modifications. Tongue crib ------ tongue thrust. Posterior tongue crib -------- lateral tongue thrust Activator ----------- Tongue thrust and finger sucking ( work as a interceptor). www.indiandentalacademy.com
  137. 137. BEHAVIOR MODIFICATION; COUNSELLING; A straight forward discussion with the child during eruption of permanent incisors. REWARD; For not engaging in the habit. www.indiandentalacademy.com
  138. 138. REMINDER; For the child who wants to quit. www.indiandentalacademy.com
  139. 139. QUAD HELIX; Maxillary lingual arch with crib; www.indiandentalacademy.com
  140. 140. OPEN BITE IN LATE MIXED DENTITION; Skeletal parameters; - Major diagnostic criteria is either, maxilla or both Palatal plane mandible Ramus “ KEY “ www.indiandentalacademy.com
  141. 141. GROWTH MODIFICATION; It varies depends on horrizontal/vertical growth; www.indiandentalacademy.com
  142. 142. www.indiandentalacademy.com
  143. 143. High pull head gear to molars; www.indiandentalacademy.com
  144. 144. High pull head gear with maxillary splint; www.indiandentalacademy.com
  145. 145. Bite blocks with functional appliance; www.indiandentalacademy.com
  146. 146. Head gear with functional appliance and bite blocks; www.indiandentalacademy.com
  147. 147. Functional appliance; Head gear with activator www.indiandentalacademy.com
  148. 148. Bite registration; www.indiandentalacademy.com
  149. 149. TREATMENT IN ADULT; Correction of vertical relation mandible maxilla Vertical excess anterior www.indiandentalacademy.com posterior excess
  150. 150. Maxillary excess; Le Forte I Reduce the nasal septum www.indiandentalacademy.com
  151. 151. Anterior open bite; Anterior segment is moved more than posterior www.indiandentalacademy.com
  152. 152. Posterior open bite; www.indiandentalacademy.com Segmental osteotomy
  153. 153. Mandibular surgery; Surgery in the ramal part is done only to the secondary aspect to the maxillary osteotomy for the auto rotation of the mandible. Advancement genioplasty www.indiandentalacademy.com
  154. 154. GENIOPLASTY; Long face pts has excess eruption of lower anterior which is flared and unstable Poor chin balance Bony cut is given upward and forward angulated to advance it. www.indiandentalacademy.com
  155. 155. PRE – SURGICAL ORTHODONTICS; allignment levelling Antero posterior incisor position www.indiandentalacademy.com
  156. 156. LEVELLING; MAY OR MAY NOT BE DONE; - Depend on facial type. Stabilizing arch wire; 18 slot ------- 17 x 25 22 slot ------ 21 x 25 www.indiandentalacademy.com
  157. 157. POST SURGICAL ORTHODONTICS; Until stabilizing arch wire is removed the teeth are held in tight position. - four weeks Light vertical elastics www.indiandentalacademy.com
  158. 158. RETENTION Removable Appliance with high pull head gear www.indiandentalacademy.com
  159. 159. Appliance with the bite block. www.indiandentalacademy.com
  160. 160. Force Amplified Retention 1997 JCO Sheridan Low profile lingual caplin Canine to canine hooks www.indiandentalacademy.com intra oral elastics.
  161. 161. Conclusion; www.indiandentalacademy.com
  162. 162. THANK www.indiandentalacademy.com U

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