Open bite malocclusion

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Open bite is a type of orthodontic malocclusion which has been estimated to occur in 0.6% of the people in the United States. This type of malocclusion has no vertical overlap or contact between the anterior incisors. [1] The term "open bite" was coined by Carevelli in 1842 as a distinct classification of malocclusion. [2] [3] Different authors have described the open bite in a variety of ways. [4] Some authors have suggested that open bite often arises when overbite is less than the usual amount. Additionally, others have contended that open bite is identified by end-on incisal relationships. Lastly, some researchers have stated that a lack of incisal contact must be present to diagnose an open bite. [5] [6]

Contents

Treatment of an open bite is complex and long-term stability is difficult to achieve, making it a challenging condition due to the high risk of vertical relapse, regardless of the treatment method used or the retention protocol followed. [7]

Causes

Open bite malocclusion can happen due to several reasons. The teeth and the alveolar bones are subject to opposing forces and pressures mainly due to muscle movement, which could potentially have an impact on the positioning of the teeth. On the contrary, the intrinsic forces of the lips and tongue while at rest create a necessary equilibrium to place the teeth in their correct position. Balance is when a body remains at rest, even when various forces are pushing it in different directions, and it doesn't accelerate or (in the case of teeth) move. [8] Whenever this equilibrium is changed, differences manifest, like, for example, the shrinkage of dental arches in animals which underwent glossectomy when compared to the control animals. [9] When a tooth is extracted, its antagonist continues the process of passive eruption, indicating that the mechanism of eruption remains essentially unchanged throughout life, and the tooth still seeks out occlusal or incisal contact until balance is achieved. [8] Based on this idea of balance several etio-logical factors related to oral function have been associated with AOB.

It may be genetic in nature, leading to a skeletal open bite or can be caused by functional habits which may lead to dental open bite. In the earlier age, open bite may occur due to a transitional change from primary to the permanent dentition.[ citation needed ] Some factors that may cause an open bite are: [10]

The link between AOB and non-nutritive sucking habits like finger and pacifier sucking has been proven. [15] Once these habits are removed, AOB generally corrects itself, as long as no additional dysfunctions have occurred. [4] These secondary dysfunctions can be caused by the protrusion of maxillary incisors due to sucking habits, which impedes the lip seal needed for swallowing and causes an abnormal resting tongue position. [16] During childhood, the tongue is proportionally bigger than the oral cavity, thus protruding beyond the alveolar ridges. The jaw bones grow quicker than the tongue during childhood and eventually, the oral cavity will adjust to accommodate the size of the tongue. [14] Some authors suggest that the muscular forces generated during swallowing and speaking could potentially warp the shape of the dental arches. [17] However, other studies suggest that these effects are temporary and insufficient to cause long-term changes in the dental arches. [16] [8] Hypertrophic adenoids and tonsils are the most common cause of nasal obstruction and consequently, mouth breathing in children. [1] The effect of airway obstruction on the occlusion was demonstrated by Harvold et al. [18] who, after placing acrylic blocks in the posterior region of the palate of rhesus monkeys, found that AOB had developed.

Types

Anterior open bite

Anterior open bite resulted from tongue thrusting in a 24 y.o. patient. Anterior upper teeth are not touching their counterpart. Anterior open bite.jpg
Anterior open bite resulted from tongue thrusting in a 24 y.o. patient. Anterior upper teeth are not touching their counterpart.

Anterior open bite (AOB) is defined as a condition in which there is no contact and no vertical overlap of the lower incisor crown with the upper incisor crown when the mandible is in full occlusion. [19] An anterior open bite occurs in humans when the front teeth fail to touch and there is no overlap between upper incisors and lower incisors. Anterior open can be caused by functional habits such as digit sucking, tongue thrust or long-term pacifier use. When digit sucking habit is present in the late primary to early mixed dentition stages, it can lead to different side-effects such as upper teeth flaring out, lower teeth flaring in, increase in the open bite and the overjet. [20] A posterior crossbite in these children along with decrease in intercanine and intermolar width is also found. The more intense (longer) the habit, the worse the malocclusion may be. [2] In a study of an adult Caucasian American population, it was reported that the prevalence of AOB (acute apical abscess) was approximately 3%, though this can vary from 1.5-11% depending on the ethnicity and age of the participant's teeth. [21] A complex AOB malocclusion is typically caused by a combination of habit, skeletal, dental, and functional factors. [10]

Pacifier use has also shown to cause anterior open bites in children. Pacifier use which lasts longer than 18 months, may cause this malocclusion. It is shown that as long as the sucking habit stops before the eruption of permanent teeth, the open bite self-corrects. [22] In some cases, behavior modification may be necessary to eliminate the dental habits. If all else fails, then a tongue crib can be used. [20]

Prevalence

The prevalence of AOB (Anterior Open Bite) can differ significantly between studies, as authors may define it differently. In the population, prevalence is estimated to be somewhere between 1.5% and 11%. [23] Age plays a role in how common AOB is, with prevalence decreasing as children age and develop better oral function. For example, at the age of six, 4.2% exhibit AOB, while by the time they are fourteen, this number has gone down to only 2%. The US population showed disparities in prevalence across different ethnicities, with 3.5% observed among Caucasian children and 16.5% among Afro-descendant children. [24]

Posterior open bite

Posterior open bite is caused when posterior teeth such as molars or premolars fail to touch their counterpart tooth. This is more likely to occur in segments where there may be unilateral open bite or open bite related to one or more teeth. Failure of eruption of teeth either due to primary failure or mechanical obstruction during eruption phase can cause the open bite. Sometimes lateral tongue thrust may also prevent the eruption of the posterior teeth, thus eliminating this habit maybe key to eruption in those instances. [2]

Skeletal open bite

Patient with skeletal open bites that accompany dental open bites may have Adenoid faces or Long face syndrome. [25] They are said to have what is known as Hyperdivergent Growth Pattern which includes characteristics such as:[ citation needed ]

Cephalometric analysis features of skeletal open bite may include:[ citation needed ]

Viken Sassouni developed Sassouni analysis which indicates that patient's with long face syndrome have 4 of their bony planes (mandibular plane, occlusal plane, palatal plane, SN plane) steep to each other. [26]

Dental open bite

Dental open bite occurs in patients where the anterior teeth fail to touch. However, this is not accompanied by the skeletal tendency of having an open bite. Thus this type of open bite may happen in patients who have horizontal or hypodivergent growth pattern. These patients have normal jaw growth and do not have the long face syndrome. The anterior open bite in these patients may be caused by Macroglossia, Tongue thrusting habit or digit sucking habits.[ citation needed ] Some of the characteristics of a dental open bite include:[ citation needed ]

Open bite correction

Primary/mixed dentition

Behavior modification

Behavior therapy is important especially when children are in their primary dentition in the pre-adolescent age. Improving habits at this time may lead to self-correction of open bite in many cases. Sometimes presence of infantile swallowing into early childhood may lead to an anterior open bite. Habit control through appliances such as Tongue crib or Tongue spurs may be used in adolescents if behavior modification fails to stop the habit. [27]

Tongue crib therapy

A tongue crib is a removable appliance placed in the maxillary arch to stop the tongue thrusting habit. This appliance may be used in patients with mixed dentition or permanent dentition. The tongue crib is attached through a bar to two bands placed on the upper 1st molars. The crib is shaped like a horseshoe with metal bars that prevent thrusting. The tongue crib eliminates the habit in approximately 90% of patients. .[ citation needed ] Huang et al. [28] published a study in 1990 which stated that patients who achieved a positive overbite during their tongue crib therapy had a good chance of maintaining that overbite after their orthodontic treatment. They credited this change to a change in the posterior positioning of the tongue due to the crib therapy.[ citation needed ]

Some of the side-effects of using a tongue-crib therapy is that this appliance may trap food, causing inflammation around the appliance. [29] Repeated contact of the tongue with the appliance may lead to an imprint on the tongue which will self-resolve when the appliance is removed. This type of therapy will only work in patients who do not have a skeletal open bite tendency. A skeletal open bite tendency may be addressed via surgery or other treatment.[ citation needed ]

Blue Grass appliance

It's a type of appliance which is similar to Nance appliance, but instead of acrylic pad that rests on the anterior palate, this appliance has a plastic roller that patient can use their tongue to break their habit. This appliance is banded to the upper 1st molars and bars extend the appliance to anterior palate where the plastic roller is placed. [30]

Vertical pull chin cup

Hakan Iscan and others used vertical pull chin cup in 17 patients for 9 months where they applied 400g of force on each side. [31] Compared to controls, they found that patients included in the experimental group had increased eruption of the mandibular incisors, decrease of the ramal inclination, decrease of the mandibular plane, increase of the overbite, decrease of the gonial angle and increase of the mandibular corpus inclination were found. They stated that vertical chin cup maybe effective in treating skeletal open bite patients. However, Pedrin et al. [32] used removable plate with palatal crib and combined it with a high-pull chin cup in 30 patients for 12 months and compared it to 30 patients who were followed with no treatment. They found that no positive skeletal influence on the vertical facial pattern of patients treated for open bite in the mixed dentition by their stated protocol. Another study [33] stated that there is no positive effect of vertical pull chin cup in controlling the vertical facial height and that close of an anterior open bite was mostly done by dentoalveolar changes.[ citation needed ]

Permanent dentition

Correction of open bite in permanent dentition may involve extrusion of the anterior teeth or intrusion of the posterior teeth. This decision depends on the incisor show on smiling for a patient. If a patient has normal incisor show at rest smile, than molar intrusion may be done in these type of faces. Extrusion of anterior teeth in these patients will lead to excessive gummy smile which in some cases is not desirable. If a patient does not have a normal incisor show at rest and smile, then anterior extrusion may be done in these patients.[ citation needed ]

High-Pull Headgear

This appliance can be used with patients who are growing and in permanent dentition. This appliance has been advocated to be used mainly for controlling the vertical dimension by applying force to intrude molars.

Elastics

Elastics have been used to correct anterior dental open bite. These elastics can be in configuration of triangular or anterior vertical elastics.[ citation needed ]

Bite blocks

R. Kuster and B. Ingerval in 1992, used two types of bite blocks to evaluate their effect on skeletal open bite patients. One group of patients had spring-loaded bite block for one year and other group had repelling magnets as bite blocks for 3 months. Both type of bite blocks exerted intrusive force on both upper and lower posterior teeth. They saw 3mm improvement in overbite with magnet group and 1.3mm improvement in overbite with spring-loaded group. They concluded that this effect resulted due to counter-clockwise rotation of mandible which was caused by intrusion of posterior teeth and increased eruption of incisors. [34]

Glossectomy

There are not systematic reviews or randomized clinical control trials related to correction of open bite with partial tongue glossectomy but several case reports have been published indicating successful treatment of open bite with this surgical approach. [35] [36] [37] Macroglossia has been reported to cause open bite and bimaxillary protrusion and is also known to be make orthodontic treatment unstable after its completion. [36]

Orthognathic surgery

An orthognathic surgical approach can be taken to correct an open bite once vertical growth has finished in male and female patients. At that time, a Le Fort I osteotomy to impact the maxilla is usually done. According to Proffit et al., [38] surgical movement that involves maxillary impaction is the most stable surgical movement in the hierarchy they established. A two jaw surgery can also be performed where Bilateral Sagittal Split Osteotomy can be done to correct any Antero-Posterior changes of the mandible. However, with two jaw surgery a relapse leading to bite opening may happen due to condylar remodeling and resorption. [39]

Stability and relapse

Surgery vs. non-surgery

Geoffrey Greenlee and others published a meta-analysis in 2011 which concluded that patients with orthognathic surgical correction of open bite had 82% stability in comparison to non-surgical correction of open bite which had 75% of stability after 1or more year of treatment. Both the groups started with 2–3 mm of open bite initially. [40]

Molar intrusion

Man-Suk Baek and others evaluated long-term stability of anterior open bite by intrusion of maxillary posterior teeth. Their results showed that the molars were intruded by 2.39 mm during treatment and relapsed back by 0.45 mm or 22.8%. The incisal overbite increased by 5.56 mm during treatment and relapsed back by 1.20 mm or 17%. They concluded that majority of the relapse occurred during first year of treatment. [41]

See also

Related Research Articles

<span class="mw-page-title-main">Orthodontics</span> Correctional branch of dentistry

Orthodontics is a dentistry specialty that addresses the diagnosis, prevention, management, and correction of mal-positioned teeth and jaws, as well as misaligned bite patterns. It may also address the modification of facial growth, known as dentofacial orthopedics.

<span class="mw-page-title-main">Malocclusion</span> Misalignment between upper and lower teeth as the jaws close

In orthodontics, a malocclusion is a misalignment or incorrect relation between the teeth of the upper and lower dental arches when they approach each other as the jaws close. The English-language term dates from 1864; Edward Angle (1855–1930), the "father of modern orthodontics", popularised it. The word derives from mal- 'incorrect' and occlusion 'the manner in which opposing teeth meet'.

Tongue thrust, also called reverse swallow or immature swallow, is a pseudo-pathological name for an adaptive lip seal mechanism, whereby normal nasal breathing or normal swallowing can occur. Tongue thrust can also be seen as an oral myofunctional disorder, a tongue muscle pattern that is perceived as clinically abnormal, in which the tongue protrudes anteriorly to seal the otherwise incompetent lips.

<span class="mw-page-title-main">Palatal expansion</span> Orthodontics device to widen the upper jaw

A palatal expander is a device in the field of orthodontics which is used to widen the upper jaw (maxilla) so that the bottom and upper teeth will fit together better. This is a common orthodontic procedure. The use of an expander is most common in children and adolescents 8–18 years of age. It can also be used in adults, although expansion is more uncomfortable and takes longer in adults. A patient who would rather not wait several months for the end result achieved by a palatal expander may be able to opt for a surgical separation of the maxilla. Use of a palatal expander is most often followed by braces to then straighten the teeth.

Orthodontic technology is a specialty of dental technology that is concerned with the design and fabrication of dental appliances for the treatment of malocclusions, which may be a result of tooth irregularity, disproportionate jaw relationships, or both.

Occlusion, in a dental context, means simply the contact between teeth. More technically, it is the relationship between the maxillary (upper) and mandibular (lower) teeth when they approach each other, as occurs during chewing or at rest.

<span class="mw-page-title-main">Overjet</span> Extent of horizontal overlap of the top and bottom front teeth (incisors)

In dentistry, overjet is the extent of horizontal (anterior-posterior) overlap of the maxillary central incisors over the mandibular central incisors. In class II malocclusion the overjet is increased as the maxillary central incisors are protruded.

<span class="mw-page-title-main">Crossbite</span> Left-right misalignment of upper and lower teeth

In dentistry, crossbite is a form of malocclusion where a tooth has a more buccal or lingual position than its corresponding antagonist tooth in the upper or lower dental arch. In other words, crossbite is a lateral misalignment of the dental arches.

Cephalometric analysis is the clinical application of cephalometry. It is analysis of the dental and skeletal relationships of a human skull. It is frequently used by dentists, orthodontists, and oral and maxillofacial surgeons as a treatment planning tool. Two of the more popular methods of analysis used in orthodontology are the Steiner analysis and the Downs analysis. There are other methods as well which are listed below.

Serial extraction is the planned extraction of certain deciduous teeth and specific permanent teeth in an orderly sequence and predetermined pattern to guide the erupting permanent teeth into a more favorable position.

Interproximal reduction is the practice of mechanically removing enamel from between the teeth to achieve orthodontic ends, such as to correct crowding, or reshape the contact area between neighboring teeth. After reducing the enamel, the procedure should also involve anatomic re-contouring and the protection of interproximal enamel surfaces.

Long face syndrome, also referred to as skeletal open bite, is a relatively common condition characterised by excessive vertical facial development. Its causes may be either genetic or environmental. Long face syndrome is "a common dentofacial abnormality." Its diagnosis, symptomology and treatments are complex and controversial. Indeed, even its existence as a "syndrome" is disputed.

Lingual braces are one of the many types of the fixed orthodontic treatment appliances available to patients needing orthodontics. They involve attaching the orthodontic brackets on the inner sides of the teeth. The main advantage of lingual braces is their near invisibility compared to the standard braces, which are attached on the buccal (cheek) sides of the tooth. Lingual braces were invented by Craven Kurz in 1976.

<span class="mw-page-title-main">Anchorage (orthodontics)</span> Way of resisting tooth movement in orthodontics

Anchorage a medical term in orthodontics is defined as a way of resisting movement of a tooth or number of teeth by using different techniques. Anchorage is an important consideration in the field of orthodontics as this is a concept that is used frequently when correcting malocclusions. Unplanned or unwanted tooth movement can have dire consequences in a treatment plan, and therefore using anchorage stop a certain tooth movement becomes important. Anchorage can be used from many different sources such as teeth, bone, implants or extra-orally.

Elastics are rubber bands frequently used in the field of orthodontics to correct different types of malocclusions. The elastic wear is prescribed by an orthodontist or a dentist in an orthodontic treatment. The longevity of the elastic wear may vary from two weeks to several months. The elastic wear can be worn from 12 to 23 hours a day, either during the night or throughout the day depending on the requirements for each malocclusion. The many different types of elastics may produce different forces on teeth. Therefore, using elastics with specific forces is critical in achieving a good orthodontic occlusion.

Activator Appliance is an Orthodontics appliance that was developed by Viggo Andresen in 1908. This was one of the first functional appliances that was developed to correct functional jaw in the early 1900s. Activator appliance became the universal appliance that was used widely throughout Europe in the earlier part of the 20th century.

Frankel appliance or Frankel Functional Regulator is an orthodontic functional appliance which was developed by Rolf Fränkel in 1950s for treatment to patients of all ages. This appliance primarily focused on the modulation of neuromuscular activity in order to produce changes in jaw and teeth. The appliance was opposite to the Activator appliance and Bionator appliance.

Intrusion is a movement in the field of orthodontics where a tooth is moved partially into the bone. Intrusion is done in orthodontics to correct an anterior deep bite or in some cases intrusion of the over-erupted posterior teeth with no opposing tooth. Intrusion can be done in many ways and consists of many different types. Intrusion, in orthodontic history, was initially defined as problematic in early 1900s and was known to cause periodontal effects such as root resorption and recession. However, in mid 1950s successful intrusion with light continuous forces was demonstrated. Charles J. Burstone defined intrusion to be "the apical movement of the geometric center of the root (centroid) in respect to the occlusal plane or plane based on the long axis of tooth".

Orthodontic indices are one of the tools that are available for orthodontists to grade and assess malocclusion. Orthodontic indices can be useful for an epidemiologist to analyse prevalence and severity of malocclusion in any population.

The Herbst appliance is an orthodontic appliance used by orthodontists to correct class 2 retrognathic mandible in a growing patient, meaning that the lower jaw is too far back. This is also called bitejumping. Herbst appliance parts include stainless steel surgical frameworks that are secured onto the teeth by bands or acrylic bites. These are connected by sets of telescoping mechanisms that apply gentle upward and backward force on the upper jaw, and forward force on the lower jaw. The original bite-jumping appliance was designed by Dr. Emil Herbst and reintroduced by Dr. Hans Pancherz using maxillary and mandibular first molars and first bicuspids. The bands were connected with heavy wire soldered to each band and carried a tube and piston assembly that allowed mandibular movement but permanently postured the mandible forward. The appliance not only corrected a dental Class II to a dental Class I but also offered a marked improvement of the classic Class II facial profile.

References

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  26. ↑ Sassouni, Viken (1955). "A roentgenographic cephalometric analysis of cephalo-facio-dental relationships". American Journal of Orthodontics. 41 (10): 735–764. doi:10.1016/0002-9416(55)90171-8.
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  31. ↑ İşcan, Hakan N.; Dinçer, Müfide; Gültan, Ali; Meral, Orhan; Taner-Sarisoy, Lale (2002-11-01). "Effects of vertical chincap therapy on the mandibular morphology in open-bite patients". American Journal of Orthodontics and Dentofacial Orthopedics. 122 (5): 506–511. doi:10.1067/mod.2002.128643. PMID   12439479. S2CID   24310791.
  32. ↑ Pedrin, Fernando; de Almeida, Marcio Rodrigues; de Almeida, Renato Rodrigues; de Almeida-Pedrin, Renata Rodrigues; Torres, Fernando (2006-03-01). "A prospective study of the treatment effects of a removable appliance with palatal crib combined with high-pull chincup therapy in anterior open-bite patients". American Journal of Orthodontics and Dentofacial Orthopedics. 129 (3): 418–423. doi:10.1016/j.ajodo.2005.04.035. PMID   16527639.
  33. ↑ Torres, Fernando; Almeida, Renato R.; de Almeida, Marcio Rodrigues; Almeida-Pedrin, Renata R.; Pedrin, Fernando; Henriques, José F. C. (2006-12-01). "Anterior open bite treated with a palatal crib and high-pull chin cup therapy. A prospective randomized study". European Journal of Orthodontics. 28 (6): 610–617. doi: 10.1093/ejo/cjl053 . ISSN   0141-5387. PMID   17101701.
  34. ↑ Kuster, R.; Ingervall, B. (1992-12-01). "The effect of treatment of skeletal open bite with two types of bite-blocks" (PDF). European Journal of Orthodontics. 14 (6): 489–499. doi:10.1093/ejo/14.6.489. ISSN   0141-5387. PMID   1486935.
  35. ↑ Tanaka, Orlando Motohiro; Guariza-Filho, Odilon; Carlini, João Luiz; Oliveira, Dauro Douglas; Pithon, Matheus Mello; Camargo, Elisa Souza (2013-07-01). "Glossectomy as an adjunct to correct an open-bite malocclusion with shortened maxillary central incisor roots". American Journal of Orthodontics and Dentofacial Orthopedics. 144 (1): 130–140. doi: 10.1016/j.ajodo.2012.08.029 . ISSN   1097-6752. PMID   23810054.
  36. 1 2 Hotokezaka, Hitoshi; Matsuo, Takemitsu; Nakagawa, Maki; Mizuno, Akio; Kobayashi, Kazuhide (2009-07-15). "Severe Dental Open Bite Malocclusion With Tongue Reduction After Orthodontic Treatment". The Angle Orthodontist. 71 (3): 228–36. PMID   11407776.
  37. ↑ Bernard, Christian L. P.; Simard-Savoie, Solange (2009-07-15). "Self-correction of Anterior Openbite After Glossectomy". The Angle Orthodontist. 57 (2): 137–43. PMID   3473949.
  38. ↑ Proffit, William R.; Turvey, Timothy A.; Phillips, Ceib (2007-04-30). "The hierarchy of stability and predictability in orthognathic surgery with rigid fixation: an update and extension". Head & Face Medicine. 3: 21. doi: 10.1186/1746-160X-3-21 . ISSN   1746-160X. PMC   1876453 . PMID   17470277.
  39. ↑ Hoppenreijs, T. J.; Freihofer, H. P.; Stoelinga, P. J.; Tuinzing, D. B.; van't Hof, M. A. (1998-04-01). "Condylar remodelling and resorption after Le Fort I and bimaxillary osteotomies in patients with anterior open bite. A clinical and radiological study". International Journal of Oral and Maxillofacial Surgery. 27 (2): 81–91. doi:10.1016/s0901-5027(98)80301-9. ISSN   0901-5027. PMID   9565261.
  40. ↑ Greenlee, Geoffrey M.; Huang, Greg J.; Chen, Stephanie Shih-Hsuan; Chen, Judy; Koepsell, Thomas; Hujoel, Philippe (2011-02-01). "Stability of treatment for anterior open-bite malocclusion: a meta-analysis". American Journal of Orthodontics and Dentofacial Orthopedics. 139 (2): 154–169. doi:10.1016/j.ajodo.2010.10.019. ISSN   1097-6752. PMID   21300243.
  41. ↑ Baek, Man-Suk; Choi, Yoon-Jeong; Yu, Hyung-Seog; Lee, Kee-Joon; Kwak, Jinny; Park, Young-Chel (2010-10-01). "Long-term stability of anterior open-bite treatment by intrusion of maxillary posterior teeth". American Journal of Orthodontics and Dentofacial Orthopedics. 138 (4): 396.e1–396.e9. doi:10.1016/j.ajodo.2010.04.023. PMID   20889043.
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