The openbite malocclusion is one of the most difficult
dentofacial deformities to treat. The complexity of this
malocclusion is attributed to a combination of skeletal ,
functional and habit related factors.
Accurate diagnosis is essential for proper treatment
planning , which in combination with patient specific
mechanics, is needed to achieve stable results.
Incidence of anterior openbite varies among the races and
with dental age. It is more common in african americans
(6.6%) than in caucasians (2.9%). chronologically as
children develop dentally , the incidence of anterior
openbite decreases, as it tends to self correct during mixed
The “ Glossary of Orthodontic Terms ” defines open bite as
a developmental or acquired malocclusion whereby no
vertical overlap exists between maxillary and mandibular
anterior or posterior teeth.
Open-bite must be considered as a deviation in the vertical
relationship of the maxillary and mandibular dental
In an open-bite there should be a definite lack of
contact, in the vertical direction, between opposing
segments of teeth.
The degree of openness can vary from patient to
patient, but an edge-to-edge relationship or some
degree of overbite cannot be rightfully categorized as
The loss of contact in the vertical direction of segments
of teeth can occur between the anterior segments or
between the buccal segments.
Open bite creates significant problems such as
1. Difficulty in speech (dysphonia).
2. TMJ disorders.
3. Functional imbalance.
4. Bad aesthetics.
5. Alteration of incisor guidance.
6. Reduction of normal functional activity.
1 . Skeletal Open Bite.
2. dental openbite.
Skeletel Openbite Dental Openbite
It is a result of increased
downward and backward
inclination of the mandible. The
mandibular angle is increased.
It is a result of underdevelopment
anteriorly of the maxillary and
mandibular alveolar processes.
DIEEFRENCE BETWEEN SKELETAL AND DENTAL OPENBITE
Skeletel anterior openbite Dental anterior openbite
It is related to excessive vertical
growth of dentoalveolar complex,
especially in posterior molar
It has occlusal contacts only at
molar level, with both occlusal
planes diverging anteriorly.
It is primarly due to reduced
incisor dentoalvelor vertical
It has occlusal contacts in
premolar and molar region, with
Occlusal plane diverge from the
first premolar forward.
DENTO ALVEOLAR OPEN BITE
The extent of the dentoalveolar open bite depends on
the extent of the eruption of the teeth.
Eg: Supraocclusion of the molars and
infraocclusion of the incisors can be primary
In vertical growth patterns the dentoalveolar
symptoms include a protrusion in the upper
anterior teeth with lingual inclination of the lower
incisors and over eruption of posterior teeth and
steeper than normal mandibular plane angle.
In horizontal growth patterns, tongue posture and
thrust may cause proclination of both upper and
Dental openbite is a openbite without facial disfigurements.it is
associated with some or following characteristics ,
1.Normal craniofacial pattern.
3.Under Erupted anterior teeth.
4.Normal or slightly excessive molar height.
5.Mesial inclination of posterior dentition.
6.failure of eruption of teeth with unknown etiology.
7.Divergent of upper and lower occlusal planes.
8.No gummy smile.
9.No vertical maxillary excess.
10. Habits like thumb ,finger suking and tongue thrusting.
11.Without remarkable cephalometric findings.
12.There may be spacing between anteriors.
13. Speech defects can be found with lisping of voice.There may be
associated upper respiratory infections . Lisping associated with
Anterior openbite and spacings is called Interdental Stigmatism.
VARIOUS FORMS OF ANTERIOR OPENBITE
1. An overjet combined with an open bite of less than
1mm can be designated as pseudo-open bite
2. A “ simple open bite ” exists in cases in which more
than 1 mm of space may be observed between the
incisors, but the posterior teeth are in occlusion.
3. A “ complex open bite ” designates those cases in
which the open bite extends from the premolars or
deciduous molars on one side to the corresponding
teeth on the other side.
4. The “ compound or infantile ” open bite is completely
open, including the molars.
5. The “ iatrogenic ” open bite is the consequence of
orthodontic therapy, which produces atypical
configurations because of appliance manipulation or
adaptive neuromuscular response.
In mixed dentition period , various therapeutic measures
may causes an Open bite :
1. An open activator with a high construction bite causes a
tongue thrust habit and resultant anterior openbite.
During intrusion of posterior teeth a posterior openbite
also may be created , especially in the deciduous
2. In expansion treatment the buccal segments can be
tipped excessively buccally , with elongation of the lingual
cusps. This creates prematurity and effectively opens the
3. In distalisation of maxillary first molars with extraoral
force the molars are often tipped down and back ,
elongating the mesial cusps. This creates a molar fulcrum
that open the bite and is of particular concern in
downward and backward growing faces that already have
excessive anterior face heights.
It is a condition characterized by lack of contact between
the posteriors when the teeth are in occlusion. It is
mostly occurs in the segment of posterior teeth.
Causes of posterior openbite :
1.Mechanical interference with eruption either before or
after the tooth emerge the alveolar bone.
2.Failure of eruptive mechanism of tooth so that excepted
amount of tooth eruption does not occur.
Mechanical interference with eruption may be caused by
ankylosis of the tooth to the alveolarbone, which can occur
spontaneously or as a result of trauma, or by obstacles in
the path of the erupting tooth. Examples of such
obstructions prior to emergence are supernumerary teeth
and non resorbing deciduous tooth roots or alveolar bone.
After the tooth emerges from the bone, pressure form soft
tissues interposed between the teeth (cheek, tongue, finger)
can be obstacles to eruption . Ankylosed teeth are usually in
infra occlussion and are said to be submerged. The most
commonly submerged tooth is retained lower deciduous
The second possible cause of eruption failure is a disturbance of the
eruption mechanism itself. These patients have no other recognizable
disorder, and no mechanical interferences with eruption seem to exist.
The condition may be the cause of posterior open-bite which does not
respond to orthodontic treatment.
The primary aim of treatment should be to remove the cause. Lateral
tongue spikes are a valuable aid in control of lateral tongue thrust.Once
the habit is intercepted, a spontaneous improvement often follows. The
posteriors can be forcefully extruded. In cases of posterior open bite due
to infra occlusion of ankylosed teeth, it is best treated by crowns on
posteriors to restore normal occlusal level.
SKELETAL OPEN BITE
According to Sassouni
1. The four bony
planes of the face
are steep to each
other, bringing the
center 0 close to
2. The anterior arc, therefore
follows the convexity of the
3.The posterior vertical chain
of muscles is arcuate, and
the masseter muscle is
posterior to the buccal teeth,
thus creating a mesial
component of forces
responsible for the dental
4. The cranial base angle and the gonial angle are
1.The total posterior
facial height (S-Go)
tends to be half the
size of the anterior
total facial height (N-
3.The facial breadths tend
to be narrow, giving a
long, ovoid appearance in
the frontal view.
5. The ramus is short with an
antegonial notch at its lower
6. The mandibular symphysis is
narrow antero posteriorly and
7. Maxillary base : Upward
tipping of the forward end of
the maxillary base and
Downward tipping of the
posterior end of the maxillary
8. There is a lack of chin mental protuberance development.
9.According to the Sheldonian somatotyping, the open-bite type
rates high in ecto-morphs.
10.The palatal vault is high and narrow and anteriorly tipped-up
palatal plane and divergent occlusal planes.
11.Nasal apparatus are narrow.
12.The temporal fossa is small, suggestive of weak musculature.
13.The cranium is sometimes dolichocephalic.
14.Distal condylar inclination.
15. Proportionally large teeth characterize the dentition.
16. Crowding and bi-dental protrusion are often present.
17. The mouth is wide. The broad lips, short vertically
relative to their skeletal support, are kept apart at
rest, leading to mouth breathing.
18. When the lips are forcibly closed, the mentalis muscle is
displaced upward. This further increases the
“chinless” appearance of these persons.(weak perioral
19. Large interlabial gap and gummy smile present.
SKELETAL CLASS II OPEN BITE
1. This combination is primarily an open-bite type,
positionally and dimensionally.
2. The major variant is in the antero-posterior dimensions
of the jaws. The palate may be longer, and the mandible
3. The differential evaluation of these two possibilities is
important, as the prognosis and the treatment approach
may be different.
4. In this respect, it points out that a given dental Class II
malocclusion may be present in opposite facial types.
5. In this type, in some instances, the rotation of the
mandible may be purely positional. Often this is due
to a downward and backward rotation of the
6. This rotation is associated with excessive extrusion of
the molars. If these interferences were removed, the
mandible could be permitted to rotate in a closing
direction, improving the Class II and the open-bite
SKELETAL CLASS III OPEN BITE
This combination consists primarily of an open-bite with
a palatal deficiency or a large mandible.
Among the facial deformities, these have probably the
worst prognosis in terms of dentofacial orthopedics.
If correction of this open-bite is attempted by rotating
the mandible in a closing direction, the protrusion of
the chin is increased.
On the other hand, the reduction of the mandibular
protrusion is attempted by rotating the mandible
downward and backward, the open-bite is increased.
Even surgical correction of the mandible is of limited
benefit here, as the teeth interfere in the closing of
the lower face height.
A) Epigenetic factors.
1. Posture, morphology and size of the tongue.
2. Skeletal growth patterns of the maxilla and the mandible.
3. The vertical relationship of the jaw bases.
B ) Environmental factors
1. Abnormal function .
1. Thumb or Digit sucking habit.
2. Tongue thrusting habit.
2. Improper respiration.
1. Mouth breathing.
C ) Genetics.
D) Other factors
- Trauma (to condyle)
- Idiopathic condylar resorption.
- Jevenile rheumatoid arthritis.
Open bite develops as result of the interaction of many
1. In young children, digit habits and pacifiers are the
most common etiologic agents.
2. In the mixed dentition years other than the normal
transitional open bite, some openbites are probably
attributable to lingering habits, where others are
clearly skeletal in nature.
3. In the adolescent and the adult, it is difficult to
assign singular causation. The influence of the tongue,
lip, and airway on the development of malocclusion
remains to be substantiated. Variations in growth
intensity, the function of the soft tissues and the jaw
musculature, and the individual dentoalveolar
development influence the evolution of open bite
SKELETAL FACTORS IN THE DEVELOPMENT OF AN
OPEN BITE TYPE:
The combination of
1. Excessive development of the upper mid-face
heights. (cranial base to molars)
2. A lack of development of posterior facial heights (S-
Go) results in the downward and backward
rotation of the mandible.
2. The posterior half of the palate is tipped downward,
carrying the molars further downward. This gives rise to a
large palato mandibular plane angle.
3.Because of the short ramus and the lower palate, the
pharyngeal space is constricted. In order to breathe, these
persons keep their tongues forward. Further enhanced by
the dental open-bite, there is a tongue-thrusting
4. When enlarged tonsils are present, the tongue is further
confined anteriorly. As the narrow palatal vault reduces
the necessary space, there is a tendency towards tongue
protrusion. This, in turn, may be a factor in the creation of
Sucking the right thumb involving the
The patient presses the thumb onto
the palate on both the front section of
the maxilla and the upper anterior
teeth.the finger also rest on the lower
inncisors as a fulcrum.
Intra oral symptoms
Sucking or pressing the thumb
against the maxilla promotes the
development of a class 2 malocclusion.
If the finger rest on the mandible ,the
lower teeth are often moved forwards
resulting in an edge to edge bite or
Apposition of sucking finger on the maxilla
APPOSITION OF SUCKING ON THE MANDIBLE
The Ring finger and little finger
are pressed onto the lingual side
of the mandibular alveolar
process and the lower anterior
teeth ; the index and middle
fingers rest on the cheek.
This type of suckling habit tilts
the upper and lower teeth
toward the labial. The change in
position of the upper teeth is
mostly mechanical and that of
the lower teeth a secondary
effect of the forward downward
1.Tongue posture and function should be primary
considerations in Open-bite problems.
According to Proffit “ if a patient has a forward
thrusting posture of the tongue, the duration of this
pressure even if very light could affect tooth position
vertically or horizontally”.
2. Differentiation between primary causal and secondary
adaptive or compensatory tongue dysfunction is
According to Proffit “A tongue thrust swallow is a useful
physiologic adaptation if you have an open bite, which is
why an individual with an open bite also has a tongue
thrust swallow” (i.e.Secondary adaptive tongue
ACCORDING TO BAHR AND HOLT, FOUR VARIETIES OF
TONGUE THRUST MAY BE DIFFERENTIATED
1. Tongue thrust causing anterior deformation:- i.e
anterior open bite, sometimes coupled with bilateral
narrowing of the arch and a posterior crossbite.
Moyers (1964) terms this a simple open bite.
2. Tongue thrust without deformation :- Despite the
abnormal function, no deformations ensues.
3. Tongue thrust causing buccal segment deformation
with a posterior open bite is often seen clinically.
Lateral tongue thrust activity also can be responsible
for a functional deep bite, a variation of the posterior
open bite. Some Class II, division 2 malocclusion fit
this category. Invagination of the cheek into the
interocclusal space also may be a factor in this
4. Combined tongue thrust:- causing both an anterior and
a posterior open bite, is another common dysfunction.
This is called a complex open bite by Moyers and is
more difficult to treat.
ACCORDING TO RAKOSI, FOUR VARIETIES OF OPEN BITE
DUE TO TONGUE POSTURE MAY BE DIFFERENTIATED:
1.Anterior Open Bite
Openbite in a deciduous dentition,
caused by a tongue dysfunction as a
residum of a sucking habit.
Habitual position :
The tongue positioned forward during
functioning, thus impeding the vertical
development of the dento alveolar
structures around the upper and lower
2.. Lateral Openbite
In this type of open bite the
occlusion on both sides is supported
only anteriorly and by the first
The tongue thrusts between the
teeth laterally. The tongue
dysfunction occurs in conjunction
with a disturbance in the
physiologic growth processed
around the first and second
3.Complex open bite:
Severe vertical malocclusion.
The teeth occlude only on the
Habitual Position :
Tongue-thrusting occurs during function.
4.Tongue dysfunction and malocclusion:
In mandibular prognathism, the downward forward
displacement of the tongue often causes an anterior
Visceral swallowing (infantile swallowing ) has time
linked etiology for tongue thrust.
It is physiologically normal until the child 4 years of
age. After this time , the visceral swallowing act is
considered an orofacial dysfunction, should this type of
deglutition , with tongue thrust and contraction of the
facial musculature, persist in older children and adults,
it may be among others a result of a long term sucking
habit associated with an open bite.
MOUTH BREATHING HABIT
The mode of respiration influences the posture of the
jaws, the tongue and to a lesser extent, the head. Hence
mouth breathing can result in altered jaw and tongue
posture thereby altering the oro - facial equilibrium
leading to malocclusion.
Chronically disturbed nasal respiration represents a
dysfunction of the orofacial musculature; it can restrict
development if the dentition and hinders the
The extra oral appearance of these patients is often
conspicuous. And is termed “adenoid facies”
Classification of mouth breathers ,
Complete or partial obstruction of the nasal passage.
Unconsciously performed act whereby breathing occurs
despite removal of obstruction.
Lip morphology does not permit complete closure of
OCCLUSAL AND DENTAL FINDINGS IN CASE
OF ORONASAL RESPIRATION
1. Upper jaw is constricted.
2. Mandibular arch is well formed
3. bilateral cross-bite.
4. high palate and narrow upper arch.
5. Long and narrow face.
6. Narrow nose and nasal passage.
7. Short and flaccid upper lip.
8. Contracted maxillary arch.
9. Flaring of incisors.
10. Anterior marginal gingivitis.
The genetic component of an open bite is related
primarly to the patients inheriting growth potential.
Studies have shown that traits such as anterior
facial heights are to a high degree ,inherited.
Obtaining thorough family history will help the
clinician predict a patients growth potential.
THE ASSOCIATION BETWEEN ANTERIOR
OPEN-BITE AND AMELOGENESIS
1. Amelogenesis imperfecta were investigated clinically,
and with cephalometric radiography in order to
determine the prevalence and nature of the anterior
2. It is suggested that the frequent association of anterior
open-bite and amelogenesis imperfecta is caused by a
genetically determined anomaly of craniofacial
development, rather than by local factors influencing
This anomaly characterized by an anterior infra occlusion
or anterior open-bite.
Issel believe that the co-existence of the two conditions
may be attributed to a pleiotropic action of the
amelogenesis imperfecta genes, influencing the growth of
the craniofacial skeleton.
Witkop and his co-workers, postulated that rough and
sensitive teeth lead to abnormal tongue activity which,
displaces the anterior teeth to produce a open-bite,
Locally interfere with the growth of the alveolar processes,
and could alter the morphology of the craniofacial complex
OPEN BITE DUE TO RICKETS
Enamel hypoplasia of the upper and lower anterior
teeth as well as of the first molars results from a
vitamin D deficiency which occurred at the age of about
1 year of age. The skeletal and dento alveolar open bite
is aggravated by the adaptive tongue dysfunction.
Management is based on etiology and localization of
1. Management in dento-alveolar open bite
Habit control and elimination of abnormal perioral muscle
2. Management in skeletal open bite
1. During active growth phase.
Redirection of growth.
2. After active growth phase.
Extraction and orthodontics or orthognathic surgery
The timing of treatment and determination of growth
pattern are crucial. Based on type of dentition , the
management can be divided into
1. Management in deciduous dentition.
2. Management in mixed dentition.
3.Management in permanent dentition.
TREATMENT IN DECIDUOUS DENTITION
1. Control of abnormal habits and elimination of
dysfunction should be given top priority in the
2. The anterior open bite improves as soon as the habit is
3. Autonomous improvement can be expected only , if the
deforming muscle activity is terminated and the open
bite is not complicated by crowding or cross bite of the
4. Treatment with screening appliances is indicated in such
open- bite cases.
5. A skeletal open bite is seldom observed in the deciduous
dentition. Habit control is of only secondary
consideration in these cases, retarding the increasing
severity of the dysplasia.
6. Extra oral orthopaedic appliances such as chin cups can
be used effectively to redirect the growth.
1. Screening appliances intercept and eliminate all
abnormal peri-oral muscle function in acquired
malocclusions resulting from abnormal habits, mouth
breathing, and nasal blockage.
2. Open bite created by finger sucking and retained
visceral deglutition-pattern, tongue function can be
helped with vestibular screens.
Management of mixed dentition
1. Early mixed dentition.
- Screening appliances and habit breaking
2. Late mixed dentition
- Multi-attachment fixed appliances.
- Extended retention phase.
- Swallowing and lip exercises.
Management depends on severity of malocclusion and
possibility of a Dento -Alvelolar compensation.
The inclination of the maxillary base plays a vital role in
the management. If the jaw bases are divergent, the
prognosis is poor.
If the maxillary base is tipped downward and forward,
functional appliance therapy may be successful.
If the jaw bases are divergent, fixed appliance therapy is
In severe cases, orthognathic surgery with impaction of
buccal segments is performed. If the lip sealing ability is
disturbed, surgical resection of the mentalis muscle is
performed to reduce the ‘golf ball’ chin effect. Schili
insists on surgery after eruption of lower canines to
3.Combined dento-alveolar and skeletal
- Elimination of abnormal perioral function
Screening and habit breaking appliances, serial
extraction, activators, etc.
- Improvement of the skeletal relationship
Fixed appliances or orthognathic surgery (severe)
MANAGEMENT IN PERMANENT DENTITION
Treatment approaches can be divided into
1.Habit control , lip seal and swallowing exercises.
2. Growth modification to control vertical growth
and posterior dento alveolar development.(early
permenent dentition period.)
3.Orthodontic camouflage(only orthodontics)
4.Orthognathic surgery (combined orthodontic and
The spur appliance is constructed from 0.045-inch stainless
Steel wire to which eight short, sharpened 0.026-inch spurs,
3 mm in length, are soldered to the anterior part. The spurs
are positioned 3 mm away from the cingulae of the maxillary
incisors and are directed at an angle (downward & backward)
to encourage correct tongue posture, with the tip of the tongue
behind the maxillary central incisor papilla. The spur appliance
is soldered to maxillary molar bands and cemented.
The anterior open bite usually takes 6 to 8 months to close
after appliance cementation, but may take longer in some
The maxillary lingual arch with spurs is a more versatile
appliance for modifying anterior tongue rest posture for the
1. It allows expansion or reduction in inter molar width.
2. It inhibits molar eruption.
3. Spurs can be placed anywhere along the arch (which allows
correction of both anterior and posterior open bites).
4. It permits headgear wear by welding buccal tubes on the
molar bands to which the lingual arch is soldered.
5. It can arrest finger habits.
6. It is inexpensive.
7. It is easy to construct in the office
BLUE GRASS APPLIANCE
Haskell was introduced, to conjunction with a program of
positive reinforcement in managing thumb sucking in
children 7-13 years of age.
It consist of a modify six sided roller machined from teflon
(Beveled on 3 sides, 5/8 inch in length , ¼ inch in
diameter) to permit purchase of tongue. This is slipped
over 0.045 stainless steel wire soldered to maxillary first
permanent or deciduous second molar orthodontic bands.
This appliance is placed for three to six months.
The patient believes they have acquired a new “ toy ” with
which to play with their tongue, as instructions have
given him to roll the roller , instead of sucking the digit.
Long-term familiarity with the roller reduced the oral
gratification and depending upon appliance use. Thus,
digit sucking was eliminated and the dependency upon a
positive reinforcement was slowly removed.
It may be a fixed or removable appliance. The removable appliance is
made of acrylic, like a fence.
The cribs are long vertical cribs, made in the anterior palatal
aspect, resting lingually to the upper anterior, long aspect, resting
lingually to the upper anteriors ,long enough, not to interfere with
the mandibular movements.
It is made up of 020 inch ss wire , lies 3-4mm from the incision,
having a length of 6-12mm. The cribs act as
1) To break the suction and force of the digit on the
2) To remind the patient of his habit.
3) To make the habit a non-pleasurable one.
QUAD HELIX WITH CRIBS APPIANCE
The quad helix is fixed appliance used to expand the constricted
The palatal cribs is designed to interrupt a digit sucking habit
by interfering with finger placement as sucking satisfaction.
This can also be used as retainer following maxillary
expansion with quad helix.
A heavy lingual archwire (0.038 inch) is bent to fit passively in
the palate and is soldered to the molar bands. Additional wire
is soldered into base wire to from crib as mechanical
obstruction for the digit.
Introduced by Newell .
Most effective way to reestablish nasal breathing is to
prevent air from entering the oral cavity.
Oral screen should be constructed with acrylic material
compatible with the oral tissues.
Reduction in the anterior open bite is obtained after
treatment for 3-6 months.
It acts in a number of ways.
1. Prevents the habit.
2. Corrects the open-bite.
3. Exercises the hypo tonic lip and the mentalis muscle.
THERMOPLASTIC THUMB POST
A thumb device is usually made of nontoxic plastic
and is worn over the child's thumb.
It is held in place with straps that go around the
wrist. A thumb device prevents a child from being
able to suck thumb and is worn all day.
It is removed after the child has gone 24 hours
without trying to suck a thumb. The device is put
back if the child starts to suck his or her thumb
again. Thumb devices need to be fitted by a health
MYOFUNCTIONAL AND ORTHOPAEDIC THERAPY (GROWTH MODIFICATION
The openbites can be intercepted by growth modulation. The aim is
to achieve counter clockwise mandibular rotation and clock wise
rotation of maxilla for closure of an open bite, in order to control
the increase in anterior face height and achieve improved
occlusal outcomes and a balanced profile.Treatment approach
is directed at vertical control of facial growth and / or ‘real’ or
relative intrusion of the posterior teeth.
1.High pull head gear.
2. Frankel 4 Regulator.
4 . Activator.
5. Posterior bite blocks.
7. Active vertical corrector.
HIGH PULL HEAD GEAR (KUHN, 1976)
The occipital headgear consists of a long outer bow which fits
over the occiput of the head. The force generated by a high pull
(occipital) has both distalising and intrusive forces since the
force is exerted above the occlusal plane. Such forces are used in
conditions where vertical control of the molars is important.
The maxillary posterior segment can be intruded by an occipital
headgear which rotates the maxilla in clock wise direction
thereby closing the open bite .
VERTICAL PULL CHIN CUP
Patients exhibiting a downward and backward rotation
of the Mandible with increased vertical growth, benefit
from therapy using a vertical pull head gear with chin
cup if treated during the mixed dentition period.
Vertical chin cup inhibits the vertical growth in the
mandibular posterior dentoalveolar region. It decreases
mandibular plane angle and helps in closure of gonial
angle indicating anterior rotation of mandible.
FRANKEL ǀѴ REGULATOR((FRÄNKEL, 1980)
It is used as Exercise device for an early interference
with functional deviation in the presence of Openbite
and bimaxillary protrusion in deciduous and early
It is indicated in cases where the incompetence of an
anterior oral seal is associated with a poor behaviour of
the lip musculature.
Therapeutic effect with Frankel 4 can only be expected
when the child is co-operative in lip exercises and mode
of action of the labial pads are context with that of the
FR – 4 has two buccal
shields , two lower lip pads ,
a palatal bow , an upper
labial wire and four occlusal
rests made of 20 guage
stainless steel wire.
The main purpose of the
acrylic components is to
interfere with abberent
functions of the cheek and lip
important aim is to establish
a structural and functional
balance between the various
muscle group of the Circum
The lower lip pads should restrict an hyperactive
mentalis muscle and train the lip musculature for
establishing a proper anterior seal.
The labial bow may be used to correct proclination of
Occlusal rests should individually be adapted to the
anatomy of the Occlusal surfaces of the maxillary buccal
teeth and are to stabilize the appliance vertically.
Palatal bow placed behind the last molar allowing the
appliance to shift in a dorsal direction. Any notching inter
proximally has to be avoided to make sure that a dorsal
shifting of the appliance is not impeded by lodging of
occusal rests interdentally.
Buccal shields should extend deep into the sulci,
particularly in the apical region of the maxillary first
premolar and the maxillary tuberosity. The thickness of
the acrylic shields should not exceed 2.5 mm.
Labial pads : It have rhomboid shape which best fits the
labial surface of the lower frontal alveolar process. The
upper edges of the lip pads should have a distance of at
least 5mm from the gingival margin which is important for
preventing stripping of the labial gingiva. Distal edge of the
pads should not overlap the labial protuberance of the
canine root which would render speaking difficult and
irritate the mucosa of the lower lip. Main purpose of lip
pads is to prevent a hyper active mentalis muscle from
raising the lower lip.
Working principle of FR – 4
The working principle is established forward rotation with the
posterior edge of the buccal shield as the rotational centre. Anterior
the mandible is raised by the force vector of anterior vertical muscle
that are strengthen by lip exercise.
1. Aimed at correcting the poor lip valve mechanism.
2. Marked activity of temporalis and masseter when lips are closed
3.According to Frankel tongue thrust is compensatory.
Proper lip seal function of anterior valve
depends on postural equilibrium between
muscles located circularly and those
located radially around the mouth.
LIP AND SWALLOWING EXERCISES
Lip exercises (Eg: holding a paper or cardboard between
lips, button holding method ) can improve the lip seal.
These exercises are repeat several times a day.
Children’s in school are asked to hold the lips together
while in class , they can practice at home with small
piece of paper.
swallowing exercises (i.e, swallowing without tongue
thrusting, putting the tip of the tongue behind the
upper or lower incisors ) may reinforce the
establishment of a mature deglutitional and functional
pattern for the tongue during both treatment and
The open bite appliance is used to inhibit the abnormal
posture and function of the tongue.
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.
To inhibit the tongue movements the acrylic portion of
the lower lingual part extends into the upper incisor
region as lingual shield, closing the anterior space
without touching the upper teeth.
The labial bow wire runs approximately between the
incisal edges of the upper and lower incisors. The labial
part of the bow is placed at the height of correct lip
closure , thus stimulating the lips to achieve a
component seal and relationship.
The vertical strain on the lips tends to encourage the
extrusive movement of the incisors after eliminating the
The activator is not indicate for treatment of skeletal
open bite. It may be used treatment of open bite
tongue thrust and finger sucking habit.
The activator is constructed so that eruption of
posterior teeth prevented, where as elongation of
anterior teeth encouraged.
The incisor area is ground away for extrusion and the
molar area ground away for extrusion.
Besides the correcting vertical development, activator
act as a habit appliance by intercepting tongue – lip
POSTERIOR BITE BLOCK
Posterior bite blocks impede posterior teeth eruption and
their design has been continuously modified. They can be
made of wire or plastic to fit between the maxillary and
Mandibular teeth, or they can be spring-loaded or fitted
The blocks are usually set at a slightly elevated position
vertically, so that, in theory, the stretched muscles place
an intrusive force on the posterior teeth, which in turn
helps control eruption and permits an upward and forward
autorotation of the Mandible.
ACTIVE VERTICAL CORRECTOR
The active vertical corrector , designed by Dellinger,
has a two occusal bite block with cobalt – samarium
Magnets, in repulsion produces 600 – 700 grams of force per
magnet. Acrylic shields prevent lateral jaw deviations and
the corrector can be used together with head gear or
vertical chin cup.
In each arch, two circular (1.5 ×10 mm) neodymium-
Iron- boron magnets (high energy Magnetics) were inserted
in repelling mode in the first molar region.
The appliance itself consisted of a posterior maxillary and
mandibular occlusal bite block. The right and left bite
blocks were connected by a 1.0-mm steel bar ; both bite
blocks were retained by two Adams clasps in each quadrant.
To prevent the development of a cross bite due to shearing
forces, buccal shields that extended occlusally were added to
the mandibular bite block.
One magnet per distal quadrant was used, with the exception
is if all the permanent teeth erupted, where two magnets
In Bite-block group, the appliance had the same thickness as
the two components of the magnet splints.
The appliance was removable except for one case where bite-
blocks were fixed with glass-ionomer cement because the
patient was concerned that he might forget to use the
The repelling magnets transfers the continuous forces to the
posterior teeth, varying in magnitude according to the
distance between the magnets ; the closer the magnets, the
higher the force, while the bite-block appliance transferred
intermittent forces to the teeth only when it was in contact
Correction of open bites was achieved by the intrusion
of the posterior teeth in both arches by Reciprocal
forces; this resulted in a reduction in Anterior facial
height, which allowed the mandible to rotate in upward
and forward directions after 4–7 months of treatment.
VERTICAL HOLDING APPLIANCE (WILSON)
The vertical holding appliance (VHA) is a modified
transpalatal arch that has an acrylic pad. The VHA uses
tongue pressure to reduce the vertical dentoalveolar
Development of maxillary permanent first molars.
Some researchers have concluded that the VHA is useful
in restricting and helping reduce the percentage of lower
anterior facial height in growing patients.
The VHA was fabricated with banded maxillary permanent
first molars connected with a 0.040 - inch chrome cobalt wire
with a dime-size acrylic button at the sagittal and vertical
level of the gingival margin of the molar bands. Four helices
were incorporated into the wire configuration for flexibility.
The appliance was cemented in place.
SPRING-LOADED BITE BLOCK
The construction bite was taken by hinging the mandible
open 3 to 4 mm beyond the rest position in centric
relation. This resulted in 6.0 to 8.0 mm of vertical
opening in the second premolar region.
The spring-loaded bite block has helical springs made of
0.9 mm stainless steel wire that are placed both lingually
and buccally between the first premolar region and the
last molar region.
The lower end of the buccal spring was soldered to an Adam’s
clasp (0.8 mm, stainless steel), whereas its occlusal end was
completely embedded into the occlusal bite block .
The lingual spring was inserted with both ends in the acrylic
resin of the occlusal bite block and mandibular plate.
Two, a 0.9-mm stainless steel hook was placed buccally into
the occlusal bite block in the molar region to measure the
amount of activation with a Dontrix gauge .
During each appointment (every 4 weeks), the springs were
activated to apply an intrusive force of 450 grams.
Patients are instructed to use the appliance for an
Average of 14 hr Daily for 6 months.
Intrusive forces are generated by masticatory muscles
(anterior temporalis , posterior temporalis and
masseter) leads to intrusion of posterior teeth , there
by autorotating the mandible , leads to reducing the
Early growth modification of midfacial deficiency with
expansion and facemask therapy has been the standard
treatment for Class III malocclusions.
A disadvantage of this approach is that it alters both the
anteroposterior and vertical planes; the desired downward
and forward movement of the maxilla is often accompanied
by downward and backward clockwise rotation of the
Although such mandibular rotation is desirable in deep-bite
cases with Hypodivergent growth patterns, it is
inappropriate for Patients with anterior open bites and
hyperdivergent Growth patterns.
The vertical dimension can be managed in hyperdivergent-
growth patients by utilizing appliances with interocclusal
acrylic, such as a bonded expander, bite blocks and tandem
Dr. Klempner (2011) is the inventor of this appliance.
Tandem Appliance comprises three separate components,
one fixed and two removable. The upper section is a fixed
Hyrax, Haas, Quad Helix, or Max-2000 expander with
buccal arms soldered for attachment of protraction Elastics.
The lower section is similar to a removable retainer,
with posterior occlusal coverage and buccal headgear
tubes embedded in the lower first-molar regions . An
.045" headgear face bow, with the outer bows bent out
For elastics attachment, is inserted into the lower tubes.
Posterior finger clasps are placed mesial and distal to the
second deciduous molars, with C-clasps on the lower
deciduous canines for mechanical retention. The bonding
small composite buttons to the labial surfaces of the lower
canines to engage the C - clasps and thus ensure stability of
the appliance during traction.
In the deciduous dentition, where adequate retention may be
a particular concern, a lower midline expansion screw can be
added, with instructions given to the parents to activate the
screw one quarter turn as needed between visits.
At the beginning of treatment, patients are instructed to
wear the appliance with light, 8 oz elastics from the outer
face bow to the buccal arms of the upper expander.
Subsequently, heavy orthopaedic traction with 14 oz
elastics effectively delivers the protraction force to the
The posterior acrylic coverage of the lower appliance
prevents maxillary extrusion during protraction, resulting
in closure of the mandibular plane angle and the anterior
open bite by Mandibular autorotation.
RAPID MOLAR INTRUDER APPLIANCE
Drs. Aldo Carano and William C. Machata (2007)
The RMI is a noncompliance appliance that can deliver
continuous intrusion forces to the maxillary and
mandibular molars. Besides the high patient acceptance
and hygienic advantages, the appliance is easy to use
with fixed appliances.
The greatest advantage of starting treatment in the
Permanent dentition is to combine the RMI with fixed
Appliances so that both maxillary and mandibular
Arches will be aligned simultaneously.
The RMI uses flexible spring modules to deliver intrusion
forces to the maxillary and mandibular first molars. The
appliance consists of one spring module and two ball
connectors per side. The terminal ends of the flexible spring
modules are designed to attach the ball connectors, which
will insert into Headgear or lip bumper tubes welded on
The Rapid Molar Intruder is available in two different sizes
and force levels:
Size M for mixed dentition cases - 800 gms of intrusive force.
Size A for adult cases - 1000 gms of intrusive force.
The straight terminal ends attach to upper Headgear tubes,
and the angulated terminal ends attach to lower lip bumper
tubes. The ball pin connectors were inserted mesially into
both maxillary and mandibular molar tubes.
Mechanism of the appliance
When the patient tends to close jaws, the intrusion force
created by the flexion of the elastic spring modules is
transferred to the maxillary and mandibular first molars,
which will produce an upward and forward mandibular
Because the force is applied buccal to the center of resistance
of the molar teeth, buccal tipping of the molar crowns will be
inevitable. To prevent this side effect, a transpalatal arch in
the maxillary arch and a lingual arch in the mandibular arch
should also be utilized.
The lingual and palatal arches were then soldered to the
molar bands. For those patients with fully erupted second
molars in the RMI plus fixed appliance group, a 1-mm
stainless steel wire occlusal rest was added that extended
from the transpalatal and lingual arches to the occlusal
surface of the second molar to avoid elongation of these
After molar intrusion is completed, leave the soldered
palatal and lingual arch in place for retention.
ELASTIC ACTIVATOR (KINETOR)
It is a modified activator ,is similar to activator,difference
is posterior bite blocks are replaced by rubber tubes.
The rigid intermaxillary part of the lateral occlusal zones
is replaced by elastic rubber tubes which is Pushed on a
wire loop with a diameter of 8 mm and thickness of
It is advisable to use highly resilient wire to avoid
breakage during mastication. The rubber tubes are
exchanged every 2–3 months for maintaining continuous
tension in the neuromuscular system .
Mechanism of action
Through tight fitting of the rubber tubes to the posterior
teeth in rest position they exert an intrusive vertical force
when swallowing or chewing. By stimulating orthopaedic
gymnastics (chewing gum effect) counterclockwise rotation of
the mandible was accomplished by a decrease of the gonial
The design of the activator incorporates labial bows for
control of the upper and lower anterior teeth. Facets cut in
the acrylic help directing the eruption of the anterior teeth.
The upper and lower front teeth should be at least 2 mm
away from the acrylic when the patient has the appliance
in the mouth and bites on it with the maximum force.
The anteroposterior position is controlled with posterior
clasps pressing against the mesial surface of the first
molars.If there is a history of tongue hyperactivity a crib is
Incorporated for behaviour modification by interfering with
An anterior tongue position.
MULTILOOP ARCHWIRE EDGEWISE TECHNIQUE
Kim(1987) introduced multiloop archwire edwise
technique to correct openbite malocclusion.
It uses a combination of multiloops in boot shape on
.016 × .022 inch ss wire in .018 edgewise slot and short
heavy anterior 3/16 inch, 6 ounze elastic.
The vertical loop segment serves as a break between
the teeth, lowers the load/deflection rate and provides
The horizontal loop further reduces the load/ deflection
rate and provides vertical control.
There are five loops on either side vertical loop components
are centered at interproximal areas and the horizontal loop
components are directed mesially.
Before the placement of MAEW teeth must be well aligned.
The treatment changes with this technique mimimally
effect the skeletal pattern ,mainly in the dento alveolar
region by increasing upper and lower anterior dento
Recently so called modified MAEW or upper accuntuated
and lower reverse curve Niti archwires combined with
intermaxillary elastics was introduced by Enacar et al.
Kim suggested to wear anterior elastics at the first loop
of upper and lower arches to intrude the posterior teeth.
In case of upper midline shift or canine relation ship
problem need to be corrected , direction of wearing
elastics modified to attach between first and second loops,
which depends upon type of malocclusion. In this case
anterior elastics were worn at the first loop as kim
The lower dental midline improved from the original by
closing lower anterior spacing, but finally it shifted to
the right by 0.5mm,which indicates that use modified
anterior elastics as mentioned.
Made of .016 x .022 SS or .017 X .025 TMA with 900 offset
bend at the molars.
The extrusion arch is a one couple system that applies a
single extrusive force to the anterior teeth and crown
mesial/root distal moment and intrusive force to the
When the anterior end of the extrusion arch wire is brought
up and tied to the incisors, a second-order couple is
produced at the molar which tends to rotate the molar
crown mesial/root distal with a center of rotation located
exactly at the center of resistance.
EXTRUSION ARCH MECHANICS
The equilibrium is achieved because the anterior end of the
wire wants to extrude the incisors and the wire in the molar
tube tends to intrude the molar. Both these forces are equal
and opposite and define another couple tending to rotate the
whole system clockwise in an amount equal and opposite to
the tendency of the couple at the molar bracket to rotate the
system counter clockwise .
When the extrusion arch wire is seen from the frontal plane, it is
clear that the intrusive force at the molar tube is acting buccal to
the Center of resistance.This result in a tendency to intrude the
molar and rotate it around the center of resistance in a crown
facial/root lingual direction.
This side effect can be minimized by stabilizing the molars with
the help of a passive transpalatal arch. An alternative is the use of
stiff 0.019x0.025 SS wire in the brackets of the anchor unit .
Use of vertical elastics can counter the tip forward moment on the
buccal segment. This will stabilize the buccal segment and
minimize the adverse effect on the molars.
Action at the Incisors
When a group of teeth is to be extruded, a segment of heavy
arch wire (0.019x0.025 SS) may be used in the brackets of
the anterior teeth, to consolidate them .
The extrusion arch can be tied either to a segment of wire in
the incisor brackets, a continuous arch wire in all of the
brackets, or placed directly into the brackets of the incisors.
If the extrusion arch is tied to a segment of wire in the
anterior brackets, the segment of wire moves the teeth
attached as a unit. This will move readily, but will move the
incisor brackets to different heights than the rest of the teeth
in the arch.
If the extrusion arch is tied to a continuous wire, the
bracket heights are better maintained with respect to
Point of Application of Force
If the extrusion arch is tied at the central incisors as
single point contact, it is probably acting anterior to the
center of resistance . Such a force, in addition to
extruding the incisors, will act anterior to the center of
resistance of the anterior segment.
PREADJUSTED EDGEWISE TECHNIQUE
During bracket placement in open bite cases , upper and
lower anterior brackets are placed 0.5 mm more gingivally
than normal. It is helps to closure of bite.
If second molars are need to banded for improving position
or torque control later in the treatment, it is benificial to
leave curve of spee in posterior aspect of lower arch and to
step the archwire upto the second molars of the upper
arch. This will minimize extrusion of first molars and
If class ǀǀ or class ǀǀǀ elastics are required , they should be
attached to the posteriorly to the premolars rather than
molars.These short elastics minimize the extrusive effect
on the back of the arches.
If upper and lower arch crowding is present and or
protrusion , upper and lower premolar extraction
If the lower arch does not require extraction for lower
incisor retroclination and the molars are more than the 3-4
mm class ǀǀ , extraction of only upper bicuspids can be
considered, this will allow for the retraction and
retroclination of the upper incisors.
If the lower arch does not require extraction for incisor
retroclination and the molars are less than the 3mm class
ǀǀ extraction of upper premolars are considered. It is most
difficult to move upper molars forward 4-7 mm and keep
their roots in uprigth position.This is required for proper
class ǀǀ molar occlusion, upper second molar extraction
considered in such cases, if good third molars are present.
This allows for easy distalisation of first molars without
opening of mandibular plane.
The tongue spurs effect
7 th Generation brackets are very thick in the bucco - lingual
dimension (in-out), and are the main reason for patients
discomfort, tongue irritation and speech problems. This is one
of the most discouraging problems of the lingual system related
to long hooks stabbing the tongue like spurs.
In open bite patients this disadvantage is used as an
advantage . After bonding these big irritating brackets, the
patient experiences a sudden intraoral environmental change
forcing him to modify his tongue posture due to the spiky
brackets to a more backward position which is a normal tongue
posture, and enables normal peri-oral seal and functional
adaptation to the corrected open bite follows.
This may contribute to the stability of the open bite
correction as was shown using crib therapy . However the
posterior G7 brackets, premolars and molars, have no
contribution regarding the tongue crib effect or the bite
plate effect and may be replaced with flatter and more
7th Generation brackets are highly recommended in the
anterior segment (canine to canine) for open cases.
Clear Aligners with elastics (3/6 – 4 ounce)represent an
easy way to treat open bite patients when a relapse
occurs during the retention phase or when a minor
extrusive tooth movement is necessary (extrusion of less
than 2 to 3 mm) during aligner treatment.
The aesthetics is excellent with the aligner since it is
hardly visible. This can be a definite psychological
advantage to teenagers and adults alike. The Clear
Aligner with elastics can be used as an effective
alternative in certain open bite cases for those who
refuse to wear conventional fixed appliances.
In order to fabricate Clear Aligners to correct an open bite,
impression are taken to create a working cast which is
used with a plastic sheet of .030" in thickness (Duran,
Scheu-dental, Germany) and a pressure molding machine
(Biostar, Scheu-dental, Germany) or a vacuum machine
(Dentsply Raintree Essix, Metairie, LA). Clear Aligners
made from the set-up model with ideal occlusion are
connected to the opposite arch with elastics using buttons
attached to the Clear Aligner.
Cow-Catch Clear Aligners could be used for finishing and
detailing during aligner treatment or for relapse treatment
Clear Aligners with Intermaxillary Elastics (Cow-Catch Clear Aligners)
When the target tooth achieves its expected extrusion, it
touches the surface of the Clear Aligner and no additional
extrusion occurs. It has the advantage of being a fail-safe
appliance. The main benefit of Cow-Catch Clear Aligners
over a tooth positioner is the ability to extrude the teeth
more rapidly with elastics .
MODIFIED COW-CATCH CLEAR ALIGNER
(INTRA MAXILLARY ELASTICS)
If the patient cannot open their mouth fully while
wearing Cow-Catch Clear Aligners, this can be easily
corrected using lingual buttons on the target teeth . A
modified Cow-Catch Clear Aligner can be used just as
the Cow-Catch Clear Aligner. It is also more convenient
and comfortable for the patient because it allows for
normal function to continue .
Cow catch aligner Modified
Cow catch aligne
After the anterior open bite treatment is finished, a 0.0175
inch multiflex wire can bonded lingually canine-to-canine
as a fixed retainer on the target arch.
Furthermore, the new Clear Aligners were delivered as a
removable appliance. In order to prevent the intrusive
movement of the anterior teeth due to relapse, small
projections could be added into the interproximal areas of
the target teeth using the Clear Aligner Plier.
A potential disadvantage of this type of appliance is that it
is highly dependent on patient compliance.17 The aligner
should be worn with elastics at least 17 hours per day
including sleeping time.
In upper molar intrusion clockwise rotation of upper
occlusal plane and lower molar intrusion produces counter
clock rotation of occlusal plane and intrusion of upper and
lower molar maintain the rotation of occlusal plane.
In this way decision between upper and lower molar
intrusion depends on initial angle of occlusal plane.
In incial intrusion , the decision among the intrusion or
extrusion in both arches depends upon incisal and gingival
exposure with lips in rest and smiling.
VERTICAL ADJUSTABLE CORRECTOR
Using a double tube in molars a rectangular intraoral arch
wire can be ligated to all brackets. In gingival molar tube
vertical adjustable corrector is used as second arch. The
anchorage reinforced with three implants . One in
midline , another two between first and second molar on
each side.VAC is ligated to anterior micro implant to
reinforce the anchorage and intrusion is carried out with
elastic pull between the intraoral arch and VAC.
It essentially consists of titanium miniplates, which are
stabilised in the maxilla or the mandible using screws.
Different designs of miniplates are available, the 'L' shaped
miniplates have been the most commonly used ones, while the
'T' shaped ones have been proposed for usage while intruding
anterior teeth . The screws used for fixing the miniplate are
usually 2-2.5mm in diameter .
Intrusion of the lower molars was achieved with the application
of power chain or closed coil spring.
One method of surgical correction is to extract second
and/or third molars if they are the only source of centric
Glossectomies have been used to correct open bite
problems associated with abnormal tongue habits. Their
effectiveness in closing anterior or posterior open bite
problems has not been substantiated.
Surgical procedures to improve the patency of the airway
must be undertaken with caution. Documenting the
amount and location of the obstruction is a prerequisite
This is especially important because it is recognized
that a reduction in tonsilar and adenoid tissue occurs
near adolescence, and other children appear to
"outgrow" certain allergies.
Severe skeletal open bites in patients who are not
growing are often treated by combined orthodontic-
Superior repositioning of the maxilla, via total or
segmental maxillary osteotomies, is indicated in
skeletal open bite patients with excess vertical
Maxillary impaction allows forward and upward rotation
of the mandible, therefore decreasing the lower face
height and eliminating anterior open bite.
This upward and forward autorotation often makes
mandibular reduction or reduction genioplasty necessary
Superior repositioning of the maxilla is one of the most
stable orthognathic surgical procedures.
The treatment of open bite remains a challenge to the
clinician, and careful diagnosis and timely
intervention will improve the success of treating this