Retention of open bite

Retention and stability
of anterior open bite
Prof .dr .Maher Fouda
Mansoura Egypt

What are retention
considerations in open bite
cases?
An open bite
malocclusion may be
dental or skeletal in
nature. A dental open
bite may be caused by
depression of the
incisors because of a
habit such as thumb- or
finger-sucking or poor
tongue posture.

A good cephalometric
value to differentiate
between a dental and
skeletal open bite is
incision-stomion;
dental open bites have
intruded maxillary
incisors whereas
skeletal open bites
have a normal incisor
position.

NCISION -
STOMION
DISTANCE: A 3
to 4 mm
incision -
stomion
distance is
esthetically
pleasing.

The open
bite must
be
accurately
diagnosed
and treated
if relapse is
to be
prevented.
Treatment and retention of relapsed anterior openbite with low tongue
posture and tongue-tie: A 10-year follow-up
[Korean J Orthod 2014;44(4):203-216]

The open
bite must
be
accuratel
y
diagnose
d and
treated if
relapse is
to be
prevented
Facial and intraoral
photographs of relapse after
3-year post-treatment
Treatment and retention of relapsed anterior openbite with low tongue
posture and tongue-tie: A 10-year follow-up
[Korean J Orthod 2014;44(4):203-216]

In skeletal
open bite,
incisors are
in a normal
position,
but the
posterior
teeth have
elongated.

Controlling the
eruption of the
maxillary molars
with high-pull
headgears and a
transpalatal bar
with a midline
acrylic palatal
button 4 mm off of
the palate is useful
to control
extrusion
a Patient with Clark
Twinblock with flying
tubes to insert a
Headgear. b Patient
wearing Clark Twinblock
with high-pull headgear

Camouflage of a high-angle skeletal Class II
open-bite malocclusion in an adult after mini-
implant failure during treatment
American Journal of Orthodontics and
Dentofacial Orthopedics
March 2017 " Vol 151 " Issue 3

Retention
of closed
anterior
open bite
is a
major
problem.
After surgery
Pretreatment open bite
Presurgical orthodontics 1year after appliance
removal

One reason is that
vertical
growth and eruption
of posterior teeth
may
continue until the late
teenage years or
early
twenties, with vertical
growth of the maxilla
being the last stage
of maturation.

Recurrence of
the open bite
malocclusion
is possible and
that’s why a
long retention
phase appears
to be very
important,
particularly in
following
instances :
Nonsurgical approach to Class I open-bite malocclusion with extrusion mechanics: A 3-
year retention case report
American Journal of Orthodontics and Dentofacial Orthopedics
April 2015 Vol 147 Issue 4

Nonsurgical approach to Class I open-bite malocclusion with extrusion mechanics: A 3-
year retention case report
American Journal of Orthodontics and Dentofacial Orthopedics
April 2015 Vol 147 Issue 4
Three-year retention facial
and intraoral photographs
A fixed retainer was
attached to the lingual
surface of the
mandibular anterior
teeth. Overlayed Hawley
retainers were fabricated
and delivered to secure
the stability of both
arches. A tongue crib
was incorporated in the
maxillary Hawley
retainer to prevent
relapse of the tongue-
thrust habit. Total
treatment time for this
patient was 24 months.

Appearance pre-op
(top row), post-q
(middle row) and 36
months post-op
(hottom row).
1-Macroglossia.
2-Dolichofacial
growth after
the completion
of the
treatment.
RELAPSE
FOLLOWING
SURGICAL
TREATMENT OF
ANTERIOR OPEN
BITE
British Journal of
Oral and
Maxillofacial
Surgery (1986) 24,
391-404
long retention phase
appears to be very
important in

(A) Example of a high angle
case with mandibular
retrusion and anterior open
bite treated demonstrating
relapse of the orthognathic
surgical correction of a severe
anterior open bite. (B) Extra
and intraoral photographs
before orthognathic surgical
treatment after orthognathic
surgical treatment (C) and 2
years after orthognathic
surgical treatment

Orthodontic treatment of severe anterior open bite and alveolar bone defect
complicated by an ankylosed maxillary central incisor: a case report
Lin et al. Head & Face Medicine 2014, 10:47
Stages in the
orthodontic
tooth
alignment. (A–
F) Orthodontic
traction and
alignment of
the tooth; (G) A
modified
Hawley retainer
bonded with
resin to the
central incisors
to provide
retention for
the tooth in the
dental arch.
Pre-treatment photographs showing a
severe anterior open bite from the left
maxillary canine to the right lateral
incisor. The maxillary left central incisor
was severely infra-occluded and the
right central incisor had a fractured
crown.

Orthodontic treatment of severe anterior open bite and alveolar bone defect
complicated by an ankylosed maxillary central incisor: a case report Lin et al. Head & Face Medicine 2014, 10:47
intraoral
photographs of
patient at 2-
year follow-up
Post-
treatment
intraoral
photographs

3- Restart of
dysfunctional
habits.
4-Tongue
function was
not corrected
well.
long retention
phase appears to
be very important
in

Relapse of AOB has been
attributed to:
 Inappropriate
orthodontic tooth
movement, such as
extrusion of
incisors where their
eruption had not
been
previously impeded
,
Appearance
pre-op (top
row), post-
op (middle
row). and
36 months
post-op
(bottom

attributed to:
 Surgery that
has increased the
posterior face
height – as would
occur if the aob is
closed using a
mandibular
procedure only.
,
Appearance
pre-op (top
row). post-
op (middle
row) and 24
months
post-op
(bottom
row).

Surgical Orthodontic Treatment of Severe
Class Iii and Anterior Open Bite
World Journal of Oral and Maxillofacial
Surgery
2018 | Volume 1 | Issue 1 | Article 1004
Pre-surgical photographs.
Initial photographs.

Surgical Orthodontic
Treatment of Severe Class Iii
and Anterior Open Bite
World Journal of Oral and
Maxillofacial Surgery
2018 | Volume 1
| Issue 1 | Article
1004
The surgery
was performed
under general
anesthesia, with
nasal
intubation, and
the sagittal
surgical
technique for
the mandibular
setback with
counterclockwis
e rotation was
used.
photographs of 1 month after surgery.

Surgical Orthodontic
Treatment of Severe
Class Iii and Anterior
Open Bite
World Journal
of Oral and
Maxillofacial
Surgery
2018 | Volume 1 |
Issue 1 | Article
1004
Intermaxillary
elastics for
posterior and
anterior
intercuspation
were used,
such as post-
surgical
blockage, for
10 days. photographs of 1 month after surgery.

Surgical Orthodontic Treatment of Severe
Class Iii and Anterior Open Bite
World Journal of Oral and Maxillofacial
Surgery
2018 | Volume 1 | Issue 1 | Article 1004
After this time,
the elastics
continued to
be used at
night, for
maintenance
and
stabilization of
the occlusion
obtained after
surgery.
photographs of 1.5 years follow-up.

Relapse of open
bite can occur
because of
tongue size or
posture, digit-
sucking habits,
respiratory
problems,and
condylar
resorption.
Vertical relapse after orthodontic and orthognathic surgical
treatment in a patient with myotonic dystrophy
European Journal of Paediatric Dentistry vol. 20/1-2019
Intra-oral photographs before treatment.
Intra-oral photographs after active treatment.
13.5 years post-treatment: intra-oral photographs .

Anterior open bite
due to idiopathic
condylar resorption
during orthodontic
retention of a Class II
Division 1
malocclusion
American
Journal of
Orthodontics
and
Dentofacial
Orthopedics
October
2019 Vol
156 Issue 4
Pretreatment photographs and radiographs.

Anterior open bite due
to idiopathic condylar
resorption during
orthodontic retention of
a Class II Division 1
malocclusion
American
Journal of
Orthodontics
and
Dentofacial
Orthopedics
October
2019 Vol
156 Issue 4
Posttreatment photographs and radiographs

resorption during
malocclusion
American
Journal of
Orthodontics
and
Dentofacial
Orthopedics
October
2019 Vol
156 Issue 4
Radiographic imaging (CBCT) of the patient's condylar
resorption. A, 10 months posttreatment;

resorption during
malocclusion
American
Journal of
Orthodontics
and
Dentofacial
Orthopedics
October
2019 Vol
156 Issue 4
Radiographic imaging (CBCT) of the patient's condylar
resorption. B, 15 months posttreatment.

resorption during
orthodontic retention
of a Class II Division 1
malocclusion
American Journal of
Orthodontics and
Dentofacial
Orthopedics
October 2019 Vol 156
Issue 4
Lateral cephalograms and panoramic radiographs showing the
progress of ICR with aggravated open bite, condylar shape change, and
shortening of the mandibular length. A, pretreatment;B, posttreatment;

resorption during
malocclusion
American Journal of
Orthodontics and
Dentofacial
Orthopedics
October 2019
Vol 156 Issue 4
Lateral cephalograms and panoramic radiographs showing the progress of ICR with
aggravated open bite, condylar shape change, and shortening of the mandibular length. C,
10 months posttreatment; D, 15 months posttreatment.

Anterior open bite due to idiopathic condylar resorption during orthodontic retention of a
Class II Division 1 malocclusion
American Journal of Orthodontics and Dentofacial Orthopedics October 2019 Vol 156 Issue 4
Progress of anterior open bite over time shown in intraoral and profile photos. A, posttreatment (14.1
years old); B, 10 months posttreatment (14.11 years old); C, 15 months posttreatment (15.4 years old); D,
23 months posttreatment (16.0 years old).

Anterior open bite due to idiopathic condylar resorption during orthodontic retention of a
Class II Division 1 malocclusion
American Journal of Orthodontics and Dentofacial Orthopedics October 2019 Vol 156 Issue 4
. Phases of condylar degeneration from normal TMJ to destructive, repair, and finally stable stage. A, normal
TMJ; B, beginning of active/destructive phase; C, “cup” shaped defect in superior surface of condyle (B and C,
stages vulnerable to biomechanical force); D, beginning of repair stage; E, advanced repair phase; F, stable
stage.

Preoperative Occlusion. Demonstration of
Preoperativ
e Frontal
Repose.
Preoperative
Cephalometric
Radiograph
Preoperati
ve Frontal
Smile.
6-month Postoperative Occlusion
12-month Postoperative Occlusion
Stability and Relapse in Orthognathic Surgery Neeraj Panchal, DDS, MD, MA Christine Ellis, DDS, MSD Paul
Tiwana, DDS, MD, MS, FACS
Relapse Due
To Condylar
Resorption
One Year
After
Bilateral
Sagittal Split
Osteotomy
To Correct
Apertognat
hia and
Mandibular
Deficiency.

Tongue habits,
particularly
tongue–thrust
swallowing, are
often blamed
for relapse into
open bite, but
the evidence to
support this
contention is
not convincing
Patient with an anterior open
bite which was believed to be due to an
endogenous tongue thrust. Both upper and
lower incisors were proclined. The patient did
not have a digit-sucking habit.

Open-bile cases
present a great
challenge to the
orthodontist. It
is important lo
evaluate
tongue position
and
tongue habits
in the finishing
stages of
treatment.

Hopefully,
this problem
was observed
prior to this
stage, and
myofunclional
therapy
initiated if the
habit was not
corrected.

Active habits (of
which thumb
sucking is the best
example) can
produce intrusive
forces on the
incisors, while
at the same time
leading to an
altered posture of
the jaw that
allows posterior
teeth to erupt.
The occlusal effects of a persistent
digit-sucking habit. Note the anterior open bite
and the unilateral posterior crossbite.

If
thumbsucking
continues
after
orthodontic
treatment,
relapse is all
but
guaranteed.

attributed to:
 Unfavourable
growth (a posterior
mandibular growth
rotation)
 soft-tissue factors
such as an unfavourable
tongue posture
 Resumption of a
digit-sucking habit;
,

- Bite elevation
after eruption
of the second
molars. - After
an active
intrusion of
molars or
extrusion of
the front.

Severe open bite due to traumatic condylar
fractures treated nonsurgically with implanted
miniscrew anchorage
female patient
was 36 years 0
months of age at
the first
examination. She
had chief
complaint of
chewing
difficulties
associated with the
anterior teeth.

miniscrew anchorage
She had injured her
head and face in a traffic
accident 6 months before
her
visit. Initially, her frontal
facial appearance
showed left
deviation of the
mandible, and her lateral
profile exhibited
posterior mandibular
positioning.

miniscrew anchorage
Tongue
thrusting was observed during
conversation. The dental
midline of her mandible was
deviated 2 mm to the left
relative to the facial midline.
Her molars showed occlusal
interferences, and her
anteroposterior relationship
was
Angle Class II, with an overjet
of 5.2 mm and an overbite
of 4.0 mm .

miniscrew anchorage
On the
pretreatment 3-
dimensional
computed
tomography
images,
we found that
both condyles
were deformed;
however,
the fracture lines
were not clear .
Pretreatment 3-dimensional computed tomography scans.

The results
of an examination with a 3-dimensional, 6 degree of
freedom jaw movement measurement apparatus (Gnathohexagraph
system, version 1.31; Ono Sokki, Kanagawa,
Japan) showed that the movements of the
bilateral condyles during lateral sliding movements
and anterior movements were irregular, with the incisal
path unstable. With an occlusal force recording system
(Dental Prescale and Occluzer; Fuji Film, Tokyo, Japan),
her maximum occlusal force was found to be relatively
weak (201 N). No impacted teeth were seen on the panoramic
radiograph . The cephalometric analysis
showed that she had a skeletal Class II anteroposterior
jaw relationship with an ANB angle of 8.3

Pretreatment cephalogram and
panoramic radiograph.

Oral photographs obtained: A, at the start of treatment;

Oral
photographs
obtained: C,
16 months
later; D,
24 months
later; E, 32
months later.

Posttreatment
photographs.
The retention
involved the use
of
maxillomandibular
circumferential
retainers and the
attachment
of a lingual
bonded retainer to
the mandibular
incisors.

Posttreatment oral photographs: A, 6 months
posttreatment; B, 18 months posttreatment.

The fallacy of tongue thrust and non-surgical
treatment of a severe anterior open bite
Journal of Dental Health Oral Disorders & Therapy
Volume 4 Issue 4 - 2016
The patient is a 33-year old
female dentist who presents with
a chief complaint of an open bite
and poor posterior occlusion. As a
12-year old child growing up in
Serbia, the patient accompanied
by her parents first presented to
the private family dentist for
evaluation and treatment. She
was diagnosed with a skeletal
open bite secondary to a “tongue
thrust problem” which her
dentist described as continuous
suckling.

She was given a series of removable
habit correcting appliances which
she used as instructed but tapered
herself off in about a year because
treatment was ineffective. Several
years passed before the patient
returned to a public dentist for
treatment at the age of 19 where she
was given removable
orthodontic/orthopedic appliances
followed by application of brackets
prior to surgical orthodontic
treatment.

Once again her anterior open bite
was attributed to tongue thrust.
Because of the uncertain outcome
and difficulty associated with the
surgical orthodontic procedure as
described by her dentist and
surgeon she decided not to pursue
treatment and brackets were
removed. Shortly thereafter she
started dental school where she
was seen by a professor in the
department of orthodontics.

She was told that
surgical orthodontics
was the only viable
treatment option but
was once again
cautioned of the
difficulty and uncertain
outcome of the
procedure. She once
again decided to forgo
surgery and all
orthodontic treatment
for several years.

Treatment took 15 months with
appointments scheduled
approximately on a monthly
basis. Brackets were initially
placed on
the four maxillary incisors for
patient comfort for one month. At
the second appointment brackets
were placed on all remaining
maxillary teeth including the
properly occluding second
molars.

This set up provided
appropriate force and
adequate torque for both
the maxillary first molars
and all premolar roots to
upright and aligns the
maxillary arch by
inducing alveolar bone
growth in order to
provide proper occlusion
with opposing
mandibular teeth.

At the third visit and three
months into treatment,
brackets were placed on
the mandibular teeth with
elastics to close the anterior
bite. The treating co-
author notes that treatment
time could have been
substantially less had the
patient diligently complied
with the use of elastics.

Two-year post-treatment follow-
up, intra-oral frontal view.
Post-treatment photographs.
non-surgical, non-extraction
orthodontic treatment

A non-surgical
correction of
an open bite
was proven to
have a high
stability rate
as well as the
surgical
correction.

Most of the relapses
happen during the first
year of the retention.
Many studies showed
that extraction treatment
had greater stability than
a nonextraction
treatment. Still non-
extraction therapy
provided a reliable
stability of results.

Studies of
long-term
outcomes
following
orthodontic
treatment for open
bite, and following
surgically
treated cases
indicated that the
relapse
rate is about 40%.

If correction of severe
open bite is not started
in the mixed dentition,
it will most likely
require orthognathic
surgery in late
adolescence or
adulthood. The skeletal
open bite phenotype is
easily diagnosed in the
early mixed dentition.

Controlling the
eruption of
posterior teeth
during late
vertical growth
is the key to
preventing
open bite
relapse..

Essix-type retainers
with full-thickness
plastic posterior
coverage are the
best retainers for
open bites because
they maintain
intrusive force on
the posterior teeth,
which in turn
maintains good
anterior bite depth.

Clear and Fixed
Retainer's Outcomes
After Orthodontic Ally
Treated Open Bite
Cases : Clinical Study
Medical Journal of
Babylon Vol. 13- No.
2: 271 - 276 , 2016

There are another
two
major approaches to
accomplishing this: a
maxillary retainer
with bite
blocks (or a
functional appliance)
to impede eruption,
or high-pull
headgear.

Retention has been
directed towards
intrusion, or at
least prevention of
eruption, of
maxillary posterior
teeth, using
headgear attached
to an upper
removable retainer.
A high-pull headgear
device attached to a
removable maxillary
retainer to control the
post-orthopedic phase
of growth and retain
the dentoalveolar
correction
The removable
retainer incorporates
headgear tubes
attached to the
Adam’s clasps on the
upper molars to
facilitate insertion of
the facebow

However, this
should ideally
be continued
until the patient
ceases growing,
although
compliance is
obviously an
issue.

Although highpull
headgear can be quite
effective in a cooperative
patient, a removable
appliance with bite blocks
is a better choice for most
patients for two
reasons: it controls
eruption of both the upper
and lower molars, and
usually it is better
accepted because it is
easier to wear.

The removable
appliance with
bite blocks
stretches the
patient’s soft
tissues to
provide a force
opposing
eruption.

High-pull headgear to
the upper molars,
in conjunction with a
standard removable
retainer to maintain
tooth position, also can
be effective, but the
intraoral
appliance is better
tolerated and controls
eruption of lower
as well as upper
posterior teeth.
A high-pull
headgear device
attached to a
removable maxillary
retainer to control
the post-orthopedic
phase of growth and
retain the
dentoalveolar
correction.
he removable
retainer
incorporates head-
gear tubes attached
to the Adam’s
clasps on the upper
molars to facilitate
insertion of the
facebow.

following
orthodontic
treatment, more
than one third of
patients
demonstrated a
return of their
AOB .
Lopez- Gavito et al.
reported that,

Neither
the extent of the
pretreatment open
bite or mandibular
plane angle nor any
other single
parameter of
dentofacial
form was a reliable
predictor of post-
treatment stability.
Lopez- Gavito et al.
also reported that,

Relapse into
anterior open
bite can occur
by any
combination
of depression of
the incisors and
elongation of
the
molars.

There is general
agreement among
orthodontists that
patients with AOBs
are challenging to
treat, and relapse is
common after
treatment with
orthodontics alone or
combined with
orthognathic surgery.

However,
no known
characteris
tics are
clear
predictors
of relapse..

Thus, clinicians
should pay more
attention during
retention phase
and long-term
studies on post-
treatment changes
and stability
should be
encouraged.

Overcorrecting
the anterior
bite as much
as possible is
recommended,
owing to the
high incidence
of relapse.

The problem
of retaining
open bite
corrections is
the same
irrespective
of the
treatment
that closed
the open bite.
A new skeletal retention system for
retaining anterior open bites
APOS Trends in Orthodontics| March 2013 |Vol 3 | Issue 2

It is expected that
LeFort surgical
open bite closure
procedures will be
relatively stable,
and these
treatments
actually reduce
the space for the
tongue.

The extrusion
arches
probably have
no more nor
less ability to
be stable than
any other
treatment
procedure.

When
considering the
patient's
investment of
time, discomfort,
and money, the
issue of stability
becomes even
more important.

Conventional wraparound
retainer with a tongue grid
Skeletal class III and anterior open bite treatment with
different retention protocols: a report of three cases
Journal of Orthodontics, Vol. 39, 2012, 212–223
It is recommended that patients
wear this retainer during the
night while sleeping. The retainer
consists of a conventional
removable appliance made with
a 0.9- mm stainless steel labial
bow placed at the middle third of
the crown and with a tongue grid
fixed on the acrylic portion to
discourage abnormal tongue
posture, which is hopefully
corrected by the muscle exercises
during the day.

modified retainer adapted
at the cementoenamel
junction of the anterior
teeth
Daytime wraparound retention
with modified contour
It is recommended that patients
wear this retainer during the
day. It has a 0.8-mm stainless
steel wire that
contours around the gingival
margin of the anterior teeth.
The aim is to reduce relapse
due to intrusion or protrusion
of the anterior teeth

Case 1 — post-
treatment intra-oral
photographs (a)
frontal, (b) right side,
(c) left side, (d) upper
occlusal, (e) lower
occlusal, (f) daytime
wraparound
retention and (g)
night-time
wraparound
retention

Case 1 — 2
years post-
retention
intra-oral
photographs
: (a) frontal,
(b) right side
and (c) left
side

Case 2 — pre-
treatment
intra-oral
photographs:
(a) frontal,
(b) right side,
(c) left side,
(d) upper
occlusal and
(e) lower

Case 2 — post-
treatment
intra-oral
photographs:
(a) frontal, (b)
right side, (c)
left side, (d)
upper occulsal,
(e) lower
occlusal, (f)
and (g)
daytime
retention

Case 2 — 6-year post-retention intra-oral photographs:
(a) frontal, (b) right side and (c) left side

Case 3 —
pre-
treatment
intra-oral
photographs:
(a) frontal,
(b) right side,
(c) left side,
(d) upper
occlusal and
(e) lower
occlusal

Case 3 — post-
treatment intra-
oral
photographs P:
(a) frontal, (b)
right side, (c)
left side, (d)
upper occlusal,
(e) lower
occlusal and (f)
daytime
wraparound
retention

0 Case 3 — 5 years post-retention intra-oral photographs:
(a) frontal, (b) right side and (c) left side
These three cases demonstrate adequate stability with this retention
protocol, which we believe is suitable for open bite patients treated
with incisor extrusion.

Drawings showing the differences between the action of the
two retainers — conventional (a) and modified (b)

American Journal of Orthodontics and Dentofacial Orthopedics July 2010
Stability of anterior open-bite
treatment with occlusal adjustment
The sample consisted of 17 patients (7 male, 10
female). All patients originally had an anterior
open-bite malocclusion, had undergone
orthodontic treatment with fixed appliances, had
anterior open-bite relapse after a mean
posttreatment period of 4.15 years (range, 1-6
years), and were retreated with the occlusal
adjustment procedure.

If the intra-arch alignment of
the teeth is acceptable, and
the position of her anterior
teeth in the face is
reasonable the first option
generally consider for an
anterior open bite is occlusal
equilibration; altering the
posterior occlusion by
reshaping the teeth,
effectively closing the
vertical dimension and
bringing the anterior teeth
into contact
OCCLUSION & WEAR
A Guide to Anterior Open Bites
By Frank Spear on February 18, 2018
Intraoral photographs before occlusal
adjustment show the anterior open bite.
Intraoral photographs after occlusal adjustment
show the corrected anterior open bite

The risk of equilibration is that
it may require excessive tooth
reduction, exposing dentin in
the process, and it may be
inadequate to achieve the
necessary closure to gain
anterior contact. For these
reasons, a trial equilibration is
typically performed on mounted
models to see if the desired
occlusion can be obtained with
just equilibration - and to
evaluate the amount of
alterations necessary to the
posterior teeth
OCCLUSION & WEAR
A Guide to Anterior Open Bites
By Frank Spear on February 18, 2018

Dentofacial Orthopedics July 2010
Intraoral photographs
taken before the occlusal
adjustment show the
anterior open bite
Intraoral photographs taken
after the occlusal
adjustment show correction
of the anterior open bite,
with a positive overbite.
Intraoral photographs taken in the
long term after the occlusal
adjustment show clinical stability
of the open-bite correction with
the occlusal adjustment. However,
a slight reduction in the overbite
is obvious.

Dentofacial Orthopedics July 2010
CONCLUSIONS 1. There was a statistically significant
relapse of anterior open bite in the whole sample;
growth seemed to have contributed to a significant
amount of the relapse. 2. The primary factor that
contributed to the relapse was the increase in
posterior molar height, consequent to
compensatory posterior tooth eruption. 3. There
was clinically significant stability in 66.7% of the
patients. 4. Dentinal sensitivity remained within the
normal range in the long term.

Relapse tendency
can be minimized if
a habit-breaking
appliance or a
tongue crib is used
for at least 6
months prior to any
incisor extrusion
mechanics.

The selection
of retention
device
should be
based on
etiology and
the
mechanics
employed to
close the
bite.
Bluegrass Maxillary Hawley retainer

In this way, some
patients
learn to modify their
tongue position or
activity, by holding
the tip of the tongue
in the roof of the
palate during
swallowing and other
activities.

However, in some cases,
a
tongue will reassert
itself, despite the best
efforts of the
patient and the
orthodontist. The
patient should be
informed
of this possibility before
treatment.

These cases will
often benefit from
the use of
positioners to
help bite closure. If
a conventional upper
retainer is to be
used, a small hole can
be placed in the
palatal surface of the
acrylic, for tongue
positioning.

In patients who do
not place some object
between the front
teeth, return of open
bite is almost always
the result of
elongation of the
posterior teeth,
particularly
the upper molars,
without any evidence
of intrusion of
incisors
photographs of relapse
after 3-year post-
treatment

Controlling
eruption of
the upper
molars
therefore is
the key to
retention in
open bite
patients
photographs of relapse
after 3-year post-
treatment

.
Four years after
removal of the
orthodontic
appliances,
this 17-year-old has
an anterior open
bite, 5 mm of
overjet with
an end-on molar
relationship, and
severe crowding of
the mandibular
incisors..

Relapse of this type is
associated with little or no
mandibular
growth and a downward
and backward mandibular
rotation as the
maxilla grows downward
and upper posterior teeth
erupt, as shown in
the cephalometric
superimposition from the
end of treatment to 4-year
recall.

.
The incisor
crowding is due
to uprighting
and lingual
repositioning
of the incisors
as the
mandibular
rotation thrusts
them into the
lower lip.

The question of
retainers is
difficult
because the
typical Hawley
type retainer
has little impact
on open bites.
Bluegrass Maxillary Hawley retainer

Improving Retention of Anterior Open-Bite Cases
To improve the retention of
an anterior open-bite case or
recover an open-bite relapse,
small composite bumps can
be bonded to the labial
surfaces of the incisors.
Before light-curing,the paste
is shaped into smooth round
balls using a brush saturated
with primer solution

Improving Retention of
Anterior Open-Bite Cases
The labial wire of a
Hawley-type retainer
is slightly activated
incisally and placed
against the gingival
edges of the
composite bumps.

Improving Retention of
Anterior Open-Bite Cases
For more positive
retention, the gingival
edges can be shaped
into horizontal steps
with a fluted bur .
These steps are not
required when using
positioners or clear
plastic retainers.

A removable retainer
can keep teeth from
tipping to the facial,
which, if occurring,
will reduce overbite.
Removable retainers
cannot prevent
actual translation of
the center of
resistance in an
intrusive direction.

A) and (B):
Retention plate with
anterior tongue crib
to avoid tongue
thrust in the anterior
teeth, anterior
tongue posture, and
a posterior bite
block to
restrict vertical
development of the
posterior teeth.

(C) and (D):
Retention
plate with
an orifice in
the region of
incisive
papillae to
condition
correct tongue
position.

Positioners
can be
considered
during
retention,
because of
their bite-
closing
effect.
POSITIONER

A silicone
positioner is
often helpful
if used for 4
hours during
the day and
during sleep
for at least 6
months.

After the positioner
use, a wraparound
retainer for the
upper arch is better
than a conventional
Hawley, as the
objective should be
to prevent wires
between the
occluding surfaces

Using
lingual
upper
and lower
fixed
retainers
is
suggested
Resin fiberglass band retainer bonded to all
anterior teeth from first premolar to first
premolar

The removal of
acrylic from the
incisor area of the
upper retainer is
recommended,
along with the
placement of a
small hole in the
anterior region as
a reminder for the
tongue.
Upper Hawley style
removable retainer.
removal of acrylic from the
incisor area

Results achieved with
extrusion arches have
been generally positive.
The preferred method to
control relapse toward
anterior
open bite is an
appliance with bite
blocks between
the posterior teeth that
creates several
millimeters of jaw
separation (an open bite
activator or bionator.
Severe anterior open bites (front teeth that do not touch)

In a patient with
the long-face
growth pattern,
either must be
continued as a
nighttime
retainer through
the late teens.

Excessive vertical
growth
and eruption of the
posterior teeth often
continue until late
in the teens or early
twenties, so
retention also must
continue
well beyond the
typical completion
of active treatment.

Cephalometric
superimpositions showing the
chin position as a result of
growth changes in a patient
between 7 and 14 years of
age. It was observed that the
chin moved downward and
forward till the age of 11
years; thereafter, it was
displaced downward and
backward as a result of less
condylar growth and more
vertical growth in the molar
area

A patient with a severe
open bite problem is
particularly
likely to benefit from
having conventional
maxillary and
mandibular retainers
for daytime wear and an
open bite
bionator as a nighttime
retainer from the
beginning of the
retention period.

The
etiology of
the
anterior
open bite
should be
determine
d
before
treatment.
photographs of relapse after
3-year post-treatment
Treatment and retention of relapsed anterior
openbite with low tongue posture and
tongue-tie: A 10-year follow-up

Understanding Post-orthodontic Relapse and
Retention
by Eli Halabi, DMD the Journal: summer 2015
Feature
Article
Higher incidence
of relapse has
been noted
in cases when the
incisors are
extruded to close
an open bite
that is skeletal in
nature.

A more appropriate
approach for
such patients would
be orthognathic
surgery, or the use of
temporary
anchorage devices
(TADs) to intrude the
posterior
teeth so as to close
the anterior open
bite.

Further,
newfound
success has
been shown in
using Clear
Aligner Therapy
to intrude the
posterior teeth
to aid in closing
the anterior
open bite.

Accordingly,
Essix-type retainers
with full-thickness
plastic
posterior coverage are
the best retainers for
open bites because
they maintain intrusive
force on the posterior
teeth, which in
turn maintains good
anterior bite depth.

The postulated clinical
theory purports that
the thermoplastic
between the posterior
teeth causes a “bite-
block effect,” keeping
the posterior teeth
from extruding and
therefore preventing
open-bite relapse

Fabrication of the spur-implanted Essix Retainers
. Before the fabrication of Essix
plate on the upper cast, a small
amount of dental stone was
added near the incisive papilla
region in order to create space for
insertion and securing of the wire.
C type Essix plates (0.40) were
fabricated over the casts and
trimmed. A 0.9mm stainless steel
laboratory wire is bent in “U”
shape with a small helix at the
base for retention.
a) Upper cast. b) Bump on
the lingual side of incisors.
c) U shaped wire. d) Essix
plate for the upper cast. e)
Insertion of the wire. f)
Addition of self-curing
acrylic. g) Retainer after
polishing.
progress in orthodontics 1 1 (2010) 45–52
A new type of modified Essix Retainer for anterior
open bite retention

The wire is heated and inserted
to the space created on the
lingual side of incisors. The hot
wire easily punctures, and
when cooled, sticks to the Essix
plate. A small amount of self-
curing acrylic is applied to fill
the rest of the space in order to
keep the wire firmly in place.
The spurs are sharpened and
polished accordingly after the
curing of the acrylic (Fig. 9).

Retainers used after active phase of orthodontic
treatment. (a) Two
retainers with posterior bite blocks were constructed;
(b) Daytime retainer with an
orifice close to the incisive papillae and; (c)
Night-time retainer with a palatal crib
Wrap-around
retainers were
provided
for the maxillary
arch and a
0.028-inch
stainless-steel
arch wire segment
was bonded to the
mandibular
anterior teeth.
Nonsurgical treatment and
stability
of an adult with a severe anterior
open-bite malocclusion
2018 Journal of
Orthodontic Science

treatment. (a) Two
Two maxillary
appliances with
posterior
bite blocks to
retain the
posterior
intrusion were
constructed for
day and
night-time use

treatment. (a) Two
The daytime
retainer
incorporated
an orifice
close
to the incisive
papillae which
guided
correct
tongue
position

treatment. (a) Two
.The
night-time
retainer
contained
a palatal crib
to prevent
lingual
pressure on
the anterior
teeth .

A loop was
made in the
mandibular
retention wire to
allow
subsequent
restoration of the
left central
incisor

Relapse of the non-
extraction groups mainly
happened in the first
year after finishing
treatment. Many studies
showed that the post-
treatment phase of non-
extraction therapy was
longer in comparison to
extraction treatment,
therefore producing a
higher tendency for
relapse.

In some cases the wrap-around
retainer (in the maxilla) is used 24
h/day in the first 8 months, half a
day (at night) for an additional 3
months and every other night in the
last month of use. A lower retainer in
the six anterior teeth (3-3) are set for
undetermined ending time . The
patient is urged to maintain her
orofacial myofunctional therapy with
the speech therapist for additional
12 months.
Case report

Treatment and retention of relapsed anterior openbite with
low tongue posture and tongue-tie: A 10-year follow-up
pISSN 2234-7518 • eISSN 2005-372X
http://dx.doi.org/10.4041/kjod.2014.44.4.203
Design of the
tongue elevator:
The acrylic base
occupies the
entire mouth
floor except for
the region that
can disturb the
movement of the
lingual frenum.

Treatment and retention of relapsed anterior openbite with
low tongue posture and tongue-tie: A 10-year follow-up
pISSN 2234-7518 • eISSN 2005-372X
http://dx.doi.org/10.4041/kjod.2014.44.4.203
The occlusal rests
are placed on the
lingual occlusal
grooves of the
posterior teeth. In
a modified tongue
elevator , the
volume and height
of the resin part
are reduced for
tongue-tie.

If the open bite
is due to a
persistent low
tongue
posture,
a tongue elevator
is applied as an
active
retreatment
alternative, and
is used thereafter
as a retainer

A tongue
elevator is a
removable
appliance
comprising an
acrylic base,
occlusal rests,
and several
retentive
elements

The acrylic base
occupies the entire
sublingual space,
except for the lingual
frenum, and the
occlusal rests are
placed in the lingual
occlusal grooves of
the posterior teeth.
For retention, a labial
bow and other
retentive clasps can
be added.

The function of the
tongue elevator is to
keep the
tongue in a higher
than usual position,
which is accomplished
by the sheer volume
of the acrylic base. The
positional change
induced by the tongue
elevator brings about
three dentoalveolar
effects

First, the tongue tends to go
back to its original position
when elevated, which
generates a downward
force. This force is then
transmitted to the occlusal
rests of the appliance, which
results in intrusion of the
lower posterior teeth.
Second, when elevated, the
tongue occupies the space
under the palatal vault, and
contacts the upper dentition

In this position, the
tongue exerts an
outward force that
results in upper arch
expansion. Finally, the
pushing force exerted by
the elevated tongue can
be used in conjunction
with a transpalatal arch,
or upper removable
retainer with occlusal
rests, to intrude the
upper posterior teeth.

Thus, the anterior open-bite can
be corrected by inhibition of posterior alveolar growth

Journal of Orthodontic Science | 2018
Nonsurgical treatment and stability of an adult with a
severe anterior open-bite malocclusion

Wrap-around retainers
were provided for the
maxillary arch and a
0.028-inch stainless-steel
arch wire segment was
bonded to the mandibular
anterior teeth. Two
maxillary appliances with
posterior bite blocks to
retain the posterior
intrusion were constructed
for day and night-time use.
Retainers used after active phase of
orthodontic treatment. (a) Two retainers with
posterior bite blocks were constructed; (b)
Daytime retainer with an orifice close to the
incisive papillae and; (c) Night-time retainer
with a palatal crib

The daytime retainer
incorporated an orifice
close to the incisive
papillae which guided
correct tongue
position.The night-time
retainer contained a
palatal crib to prevent
lingual pressure on the
anterior Figure 4:
Miniscrews placed and
biomechanics employed
for molar intrusion teeth.
Retainers used after active phase of
orthodontic treatment. (a) Two retainers with
posterior bite blocks were constructed; (b)
Daytime retainer with an orifice close to the
incisive papillae and; (c) Night-time retainer
with a palatal crib

A loop was
made in the
mandibular
retention wire
to allow
subsequent
restoration of
the left central
incisor .

Retention of open bite

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