Management of anterior open bite malocclusion during the permanent dentition by orthodontic extrusion of the anterior teeth

1. Anterior Open Bite
Treatment in the Permanent
Dentition
Incisors Extrusion
Dr.Marwan Mouakeh, Consultant Orthodontist
Academic Adviser, Al-Hokail Polyclinic – Khobar ( KSA)

2.  Leads to excessive wear of posterior teeth due to loss of
anterior contact and resulting lack of anterior disclusion
 Less of efficient mastication.
 Open bite can frequently be a functional
health related issue :
 Open bite is frequently associated with :
 Speech problems
Open Bite Treatment in the
Permanent Dentition

3.  Differential Diagnosis
Open Bite Treatment in the Permanent Dentition
 In the permanent dentition, most open
bite cases are characterized by greater
involvement of the dentoalveolar skeletal
structures and the whole facial skeleton.
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

4. Open Bite Treatment in the Permanent Dentition
 Differential Diagnosis
 Dentoalveolar OB :
 OB is less severe
 Restricted to the anterior region
 Growth pattern is normal
 Skeletal OB :
 OB is relatively severe with premolars / molars
involvement, and characterized by:
• Increased gonial and mandibular plane angles
• Increased lower anterior face height and
decreased posterior face height
• Anterior upward canting of the palatal plane.

5. Open Bite Treatment in the Permanent Dentition
Treatment Planning
Extrusion of Anterior Teeth Intrusion of Posterior Teeth
OB with insufficient
maxillary incisor
exposition upon smiling
OB with normal to
excessive maxillary incisor
exposition upon smiling

6. Open Bite Treatment in the Permanent Dentition
Treatment Planning
Without Extraction With Extraction
Extrusion of anterior teeth

7. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Indications
• Anterior open bite with :
 Normal vertical facial proportions
 Undererupted anterior teeth
 Insufficient exposure of the maxillary incisors ,at
rest and during smiling .
• Skeletal open bites with :
 Insufficient exposure of maxillary incisors
 About 16% of vertical excess patients have a significant
anterior open bite.

8. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Indications
• AOB with insufficient exposure of the maxillary incisors
,at rest and during smiling

9. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Indications
• AOB with undererupted anterior teeth

10. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Contra- indications
• AOB with normal to excessive exposure of the
maxillary incisors ,at rest and during smiling .

11. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Contra- indications
• AOB with normal to excessive exposure of the maxillary
incisors ,at rest and during smiling .

12. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Non – extraction Treatment
• Closure of the OB is obtained mainly by orthodontic
forces because of the reduced amount of vertical growth
 Fixed orthodontic appliances or Removable Aligners
• Vertical intermaxillary elastics 18 – 22 hs/day
• Extrusion archwires
• Tongue cribs or spurs are useful
 Clinical Means

13.  Extrusion of anterior teeth :
 Vertical intermaxillary elastics
 Extrusion archwires
 Multiloop edgewise archwire (MEAW) appliance.
Open Bite Treatment in the Permanent Dentition

14. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Non – extraction Treatment
• Anterior teeth should be bonded more cervically
in order to obtain additional vertical movement
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

15. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Non – extraction Treatment
• Anterior teeth should be bonded more cervically
in order to obtain additional vertical movement

16. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
• Vertical intermaxillary elastics
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

17. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Non – extraction Treatment
• Leveling and alignment achieved using traditional or
modern methods :
 Vertical elastics start at archwires :
- 0.018 S.S ,or
- 0.019 x 0.025 Thermoelastic NiTi

18. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Non – extraction Treatment
• Leveling and alignment achieved using traditional or
modern methods :
 Vertical elastics start at archwires :
- 0.018 S.S ,or
- 0.019 x 0.025 Thermoelastic NiTi

19. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
• Vertical intermaxillary elastics

20. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Non – extraction Treatment
• Objectives of vertical intermaxillary elastics :
 Extrusion of the incisors
 Correction of the occlusal
plane inclination
 Alignment of the maxillary
incisors in relation to the lip
line
 Uprighting the mesially tipped
posterior teeth .

21. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Non – extraction Treatment
• All archwires should be flat
• Correction of posterior crossbites should be achieved
before starting vertical elastics.
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

22. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Non – extraction Treatment
• Clinical tips:
 Results should be evident during 3-4 months
 Overcorrection is necessary in all cases
 Continue elastics use 3-4 months after OB
closure
 Active retention with vertical elastics use,
8 months after obtaining normal overbite.
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

23. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Non – extraction Treatment
 Additional Clinical Procedures :
 Brackets should be placed with a mesial
angulation on the mesially tipped posterior teeth
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

24. Open Bite Treatment in the Permanent Dentition
• Brackets should be placed with a mesial angulation on the
mesially tipped posterior teeth
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

25. Open Bite Treatment in the Permanent Dentition
• Brackets should be placed with a mesial angulation on the
mesially tipped posterior teeth
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

26. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Non – extraction Treatment
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014
 Association of tongue cribs or spurs to modify tongue
posture , enhance OB correction ,and increase treatment
stability.

27. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Non – extraction Treatment
 Association of tongue cribs or spurs to modify tongue
posture , enhance OB correction ,and increase treatment
stability.
Dr.M.MouakehDr.M.Mouakeh

28. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Non – extraction Treatment
 Additional Clinical Procedures :
 Association of tongue cribs or spurs to modify
tongue posture , enhance OB correction ,and
increase treatment stability.

29.  Extrusion of anterior teeth
- Non – extraction Treatment
Open Bite Treatment in the Permanent Dentition
Dr.M.Mouakeh
ME. A ,18y.

30. ME. A ,18y.
• Anterior open bite
• Posterior cross bite
• Mild Class III relationship
Open Bite Treatment in the Permanent Dentition
Dr.M.Mouakeh
Dr.M.Mouakeh Dr.M.Mouakeh
Dr.M.Mouakeh

31. • Normal vertical proportions
• Tendency to skeletal Class III
Open Bite Treatment in the Permanent Dentition
ME. A ,18y.

32. • Duration : 14 months
• Anterior vertical elastics
with RCS on the upper
arch .
 Treatment :
Dr.M.Mouakeh
Dr.M.Mouakeh
Dr.M.Mouakeh
Dr.M.Mouakeh
ME. A ,18y.

33. Dr.M.Mouakeh
Dr.M.Mouakeh
Dr.M.Mouakeh
ME. A ,18y.

34. Open Bite Treatment in the Permanent Dentition
ME. A ,18y.

35. Open Bite Treatment in the Permanent Dentition
Dr.M.Mouakeh
Dr.M.Mouakeh
Dr.M.Mouakeh
ME. A ,18y.

36. Open Bite Treatment in the Permanent Dentition
• Previous uncompleted
orthodontic treatment
• Anterior and lateral open
bite
• Crowding of the anterior
lower teeth .
Dr.M.Mouakeh
JA. C ,17y.

37. Open Bite Treatment in the Permanent Dentition
Dr.M.Mouakeh
Initial
Dr.M.Mouakeh Dr.M.MouakehDr.M.Mouakeh
JA. C ,17y.

38. Open Bite Treatment in the Permanent Dentition
Dr.M.Mouakeh
JA. C ,17y.

39. Open Bite Treatment in the Permanent Dentition
Dr.M.Mouakeh
Final
Alignment and leveling , vertical intermaxillary elastics (14 months)
Dr.M.Mouakeh
Dr.M.Mouakeh Dr.M.Mouakeh Dr.M.Mouakeh
Dr.M.Mouakeh
JA. C ,17y.

40. Open Bite Treatment in the Permanent Dentition
Dr.M.Mouakeh
Initial Final
JA. C ,17y.

41. Open Bite Treatment in the Permanent Dentition
Dr.M.Mouakeh
Dr.M.Mouakeh
Dr.M.Mouakeh
Dr.M.Mouakeh Dr.M.Mouakeh
Dr.M.Mouakeh Dr.M.Mouakeh
JA. C ,17y.

42. Open Bite Treatment in the Permanent Dentition
Initial
Final
Dr.M.Mouakeh
Dr.M.Mouakeh
Dr.M.Mouakeh
Dr.M.Mouakeh

43. • Treatment of anterior open bite without extraction
Incisor extrusion

44.  Treatment of Anterior Open Bites
 Extrusion of the anterior teeth, without extraction

45.  Treatment of Anterior Open Bites
 Extrusion of the anterior teeth , without extraction

46. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Non – extraction Treatment
 Additional Clinical Procedures :
 The MEAW technique may be used in order to
upright posterior teeth and extruding the anterior
teeth .
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

47.  Kim’s method - Multiloop Edgewise Archwire ( MEAW )
.
 Treatment of Anterior Open Bites

48.  Kim’s method - Multiloop Edgewise Archwire ( MEAW )
.

49.  Kim’s method - Multiloop Edgewise Archwire ( MEAW )
.

50. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- Non – extraction Treatment
 Additional Clinical Procedures :
 Use of active Reverse or Accentuated Curve of
Spee archwires with vertical elastics .

51. Open Bite Treatment in the Permanent Dentition
 Additional Clinical Procedures :
 Use of active Reverse or Accentuated Curve of
Spee archwires with vertical elastics .

52.  Extrusion arches :
 Treatment of Anterior Open Bites
• A one couple extrusion
arch with determinant
force system .
R. Nanda , Biomechanics and Esthetic Strategies in Clinical Orthodontics. 2005

53.  Extrusion arches – effects on the incisors :
A clockwise moment generated at the center of resistance of
the incisors plus the extrusive force .
 Treatment of Anterior Open Bites
R. Nanda , Biomechanics and Esthetic Strategies in Clinical Orthodontics. 2005

54. Extrusion arches force system :
The moment (M) generated on the 1st molar is counteracted by
another moment (M’) using vertical elastics .
 Treatment of Anterior Open Bites
R. Nanda , Current Therapy in Orthodontics . 2010

55.  Treatment of Anterior Open Bites
• The step bend creates equal and opposite forces on the anterior
and posterior segments .
• The moments are in same direction causing worsening of the
OB condition by canting the posterior occlusal plane.
R. Nanda , Current Therapy in Orthodontics . 2010

56.  Treatment of anterior open bite
 Elastics and Extrusion archwire
R. Nanda , Current Therapy in Orthodontics . 2010

57. • J H Park & T W Kim , A new approach to open bite treatment
Oral Health, September 2010
• Clear Aligners with Vertical intermaxillary elastics
 Treatment of Anterior Open Bites

58. • J H Park & T W Kim , A new approach to open bite treatment
Oral Health, September 2010
• Clear Aligners with Vertical intermaxillary elastics
 Treatment of Anterior Open Bites

59. • Clear Aligners with Vertical elastics
• J H Park & T W Kim , A new approach to open bite treatment
Oral Health, September 2010
 Treatment of Anterior Open Bites

60. • Clear Aligners with Vertical intermaxillary elastics
• J H Park & T W Kim , A new approach to open bite treatment
Oral Health, September 2010
 Treatment of Anterior Open Bites

61.  Treatment of Anterior Open Bite With
Invisalign Orthodontics
 The use of “ Optimized Attachments “ to enhance appropriate
extrusive movement of the anterior teeth
 The posterior teeth act as an “ anchorage unit”
 No need for vertical elastics .

62.  AOB case treated with Invisalign Orthodontics
Dr. R. Leach , Invisalign case gallery

63.  AOB case treated with Invisalign Orthodontics
Dr. R. Leach , Invisalign case gallery

64.  AOB case treated with Invisalign Orthodontics
Dr. K. C Hall , Invisalign case gallery

65.  R. Boyd, AAO , May 2013
How does Invisalign close the anterior open bite?
• Increased bite force on posterior teeth due to aligner
thickness and arc of closure
• Intrusive forces generated on the posterior teeth
• Slow extrusion of incisors with no eruption of molars
• Tongue is also blocked out during treatment and may move
distally.

66.  Treatment of Anterior Open Bite With Invisalign Orthodontics
Dr. Ramez Mostafa, Al-Hokail Polyclinic

67.  Treatment of Anterior Open Bite With Invisalign Orthodontics
Dr. Ramez Mostafa, Al-Hokail Polyclinic

68. Open Bite Treatment in the Permanent Dentition
Extrusion of Anterior Teeth
With Extraction

69. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- With Extraction
 Indications :
 Crowding
 Excessive biprotrusion
 Antero-posterior discrepancies ( Class II,
Class III malocclusions ).

70. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
- With Extraction
 Mechanics of AOB correction
 Draw-bridge effect
 Wedge effect

71.  Drawbridge effect ,related to extrusion of the
anterior teeth and increase overbite by reducing the
inclination of upper and lower incisors.
 Extrusion of anterior teeth
- With Extraction

72.  Wedge effect , related to mesial ( anterior )
movement of the posterior teeth.
 Extrusion of anterior teeth
- With Extraction
• Counter-clockwise mandibular
rotation consequent to
mesialization of the posterior
teeth.

73.  Vertical elastics
 Extrusion of anterior teeth
- With Extraction
• An additional mean to enhance the anterior open bite
closure and complement the wedge effect related to
posterior teeth extraction
• Applied with the rectangular archwires used to
perform anterior retraction
• After space closure, it is better to place S.S round wires
to finish bite closure .

74.  Extraction Strategies :
 second molars
 first molars
 second premolars
 first premolars

75. • Treatment of anterior open bite with 4 -1st premolars extraction

76. • Treatment of anterior open bite with 2maxillary 1st premolars
extraction

77.  Angle Class I malocclusion ,with anterior open bite ,treated with extraction of
permanent teeth
M.Matsumoto , Dental Press J Orthod 2011
Age:12y
• Class I molar relationship
• Overjet: 6mm
• Anterior open bite
• Mixed breathing
• Tongue thrust with adapted
swallowing & speech

78.  Angle Class I malocclusion ,with anterior open bite ,treated with extraction of
permanent teeth
M.Matsumoto , Dental Press J Orthod 2011
Maximum pubertal
growth spurt

79.  Angle Class I malocclusion ,with anterior open bite ,treated with extraction of
permanent teeth
M.Matsumoto , Dental Press J Orthod 2011
• Class 2 skeletal pattern ( ANB=6⁰ )
• Vertical facial growth pattern ( NS.GoGn = 43⁰)
• Protruded upper and lower incisors

80.  Angle Class I malocclusion ,with anterior open bite ,treated with extraction of
permanent teeth
M.Matsumoto , Dental Press J Orthod 2011
• 1st Phase :
 Modified Thurow appliance
with tongue crib
 Speech therapy
 Duration : 12 months

81.  Angle Class I malocclusion ,with anterior open bite ,treated with extraction of
permanent teeth
M.Matsumoto , Dental Press J Orthod 2011
• 2d Phase :
 Haas expander
 Vertical-pull chin cup
 Standard Edgewise fixed
appliance with extraction of
upper and lower 1st
premolars .

82.  Angle Class I malocclusion ,with anterior open bite ,treated with extraction of
permanent teeth
M.Matsumoto , Dental Press J Orthod 2011

83.  Angle Class I malocclusion ,with anterior open bite ,treated with extraction of
permanent teeth
M.Matsumoto , Dental Press J Orthod 2011
• Initial
• Final

84.  Angle Class I malocclusion ,with anterior open bite ,treated with extraction of
permanent teeth
M.Matsumoto , Dental Press J Orthod 2011
• Initial
• Final

85.  Angle Class I malocclusion ,with anterior open bite ,treated with extraction of
permanent teeth
M.Matsumoto , Dental Press J Orthod 2011
• Initial • Final

86.  Angle Class I malocclusion ,with anterior open bite ,treated with extraction of
permanent teeth
M.Matsumoto , Dental Press J Orthod 2011

87.  Angle Class I malocclusion ,with anterior open bite ,treated with extraction of
permanent teeth
M.Matsumoto , Dental Press J Orthod 2011
• 27 months after finishing

88.  Angle Class I malocclusion ,with anterior open bite ,treated with extraction of
permanent teeth
M.Matsumoto , Dental Press J Orthod 2011
• 27 months after finishing

89.  AOB extraction case treated with Invisalign Orthodontics
Dr.L . Crawford , Invisalign case gallery

90.  AOB extraction case treated with Invisalign Orthodontics
Dr.L . Crawford , Invisalign case gallery

91. Correction of Anterior Open Bite by
Occlusal Adjustment
• Not usual procedure, but it can provide satisfactory
result in specific situations
 Main Indication:
• Mild anterior open bite or relapsed open bite cases :
 Negative overbite ≤ 1mm
 Adult patient ( above 20 years)
 Acceptable anteroposterior and
transverse relationships

92. Correction of Anterior Open Bite by
Occlusal Adjustment
 Clinical Procedures :
• Start adjustment in CR and eliminate
initial premature occlusal contacts to
obtain a simultaneous posterior
contacts
• Then , perform adjustment in the
lateral and protrusive excursions .

93. Correction of Anterior Open Bite by
Occlusal Adjustment
 Clinical Tips :
• Adjustment should be achieved through 2 to 4 appointments
• Enamel thickness on the occlusal surfaces of the molars should
be around 2mm
• Avoid dentinal sensitivity by the application of Fluoride
solution for 5 minutes after each clinical session , and use
of 0.05% NaF mouthwash for 6 months.

94. • Relapsed anterior open bite non-extraction treatment, retreated with
occlusal adjustment.
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

95. Correction of Anterior Open Bite by
Occlusal Adjustment
 Clinical Tips :
• The amount of enamel to be removed by occlusal
adjustment is about half of the amount of the existing open
bite
• Each 1mm of enamel removal from the occlusal surfaces of
the posterior teeth will induce about 3 mm decrease in the
incisor overbite .

96. • Relapsed anterior open- bite four- premolar extraction treatment,
retreated with occlusal adjustment .
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

97. Correction of Anterior Open Bite by
Occlusal Adjustment
 Contra-Indications :
 Moderate to severe anterior open bites
 Children and young patients (potential unfavorable
remaining growth )
 Patients with excessive dentinal hypersensitivity
 Bruxing patients .

98. Correction of Anterior Open Bite by
Occlusal Adjustment
• In most adults , occlusal adjustment is considered
as an adjunct method to treatment of anterior
open bite ,especially in patients with high tendency
for relapse .
• Also, this procedure can enhance treatment
stability .
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

99. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
• Retention :
 Removable plate with anterior orifice ,
20 hrs/day
 Removable plate with tongue crib
 Speech therapy to ensure normal tongue
function and posture ( after OB correction ).
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

100.  Retention Methods
Anterior Open Bite Treatment
Hawley plate with anterior orifice Hawley plate with tongue crib
&posterior bite blocks
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

101.  Retention Methods
Anterior Open Bite Treatment
Hawley removable retainer
Hawley retainer with posterior bite blocks and tongue crib

102.  Retention Methods
Anterior Open Bite Treatment
Tooth positionerVacuum-formed Retainers

103. Anterior Open Bite Treatment
 Retention Methods
Invisible tongue-crib retention appliance
A Naragond etal , Orthodontic CYBERjournal 2013

104. Anterior Open Bite Treatment
 Retention Methods
Bonded fixed retainer

105. A new skeletal retention system for retaining anterior open bites
Albaker , Rabie and, Wong . APOS Trends in Orthodontics,March 2013
Anterior Open Bite Treatment
 Retention Methods

106. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
 Stability :
 Significant stability after 5 years of finishing in about 62% of
the cases ( Janson et al,2003)
 Extraction treatment would produce more stable results
compared to non-extraction treatment
 Myofunctional therapy after OB correction is recommended
to minimize relapse tendency .
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

107. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
 Stability :
 Most OB cases will show some decrease in the overbite
obtained at finishing stage
 The primary factors of this relapse are :
- the smaller vertical development of the upper and
lower incisors , and
- the vertical development of the posterior teeth.
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

108. Open Bite Treatment in the Permanent Dentition
 Extrusion of anterior teeth
 Stability :
In the long-term , about two thirds of the OB
cases treated by extrusion of the incisors in adult
patients show significant stability .
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

109.  R, Boyd, AAO , May 2013
Long-Term Stability with Invisalign for mild to
moderate open bite cases:
• Transition to retainers easier for clear aligner patients as it is
the same appliance
• Open bite treatment may be more stable than fixed appliance
only .
Open Bite Treatment in the Permanent Dentition
G. Janson &F.Valarelli , Open –Bite Malocclusion Treatment and Stability . 2014

111. Anterior Open Bite
Treatment in the Permanent
Dentition
Molars Intrusion
Dr.Marwan Mouakeh, Consultant Orthodontist
Academic Adviser, Al-Hokail Polyclinic – Khobar ( KSA )
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