1. The orthodontic management
of
open bite cases
Dr. Nabil Al-Zubair

2. INTRODUCTION
High angle cases
Covers a number of conditions that include:
1. Long face syndrome
2. Posterior growth rotation
3. Anterior open bite
4. Open bite tendency.

3. Many Orthodontists are concerned about the DIFFICULTIES of management of
high angle and open bite cases.
• It is usually neither clear
• which angle is increased nor
• what the relationship between facial morphology and open bite is.

4. • Some of the angles implicated in the term high angle are
• the SN/MnP angle,
• the FH/MnP angle,
• the SN/MxP angle and
•the MxP/MnP angle.

5. 'Long-face syndrome'.
"Children and adults who have excessive
vertical facial growth demonstrate a
characteristic facial appearance and have
been described as having 'long-face
syndrome'. (Proffet)
Because the disproportionately long
lower face is often accompanied by an
open bite, this condition has also been
labelled 'skeletal open bite'.

6. Not all long-faced patients have open bite and not all
open bite patients are long faced

7. Posterior growth rotation
Growth rotations of
the mandible occurs
when there is a
discrepancy in the
amount of growth in
anterior & posterior
facial heights

8. Open bite
Malocclusion can occur in three planes of space
Sagittal, Transverse and in the Vertical
plane.
Open bite is a malocclusion that occurs in
the vertical plane
Characterized by lack of vertical overlap between the maxillary
and mandibular dentition.

9. Open bites
Anterior region Posterior region
Anterior open bite Posterior open bite

10. Etiologic Factors
Many potential etiologic factors are
implicated as causes of open bite
including
(1) unfavorable growth patterns,
(2) digit-sucking habits,
(3) tongue and orofacial muscle activity,
(4) hereditary,
(5) orofacial functional matrices,
(6) imbalances between jaw posture, occlusal and eruptive forces and
head position.
A detailed understanding of its etiology and developmental
process is thus essential in its management.

11. Anterior Open Bite
Etiology Multifactorial
No single factor
Non- Hereditary HEREDITARY
Prolonged thumb-sucking habit (1) Increased tongue size
Tongue thrusting
(2) Abnormalskeletal
Nasopharyngeal Airway Obstruction And growth pattern of the
Associated Mouth Breathing. maxilla and mandible

12. Non- hereditary factors
Prolonged thumb-sucking habit
The posture of thumb positioning
The intensity
The frequency of sucking
Influence the NATURE and SEVERITY of the open bite
Lead to restriction of development of the jaw by the finger or thumb.

13. Non- hereditary factors
Tongue thrusting

14. Abnormal Swallowing/ Tongue Thrust Habit
􀁡 Protrusion of the tongue
against or between the anterior
dentition and
excessive circum-oral activity
during deglutition.
􀁡 Innate behavior
􀁡 Universal infant oral behavior for
children under the age of 6
years.
􀁡 Not a causative factor for
anterior open bite.

15. Tongue Thrust Habit
Delayed Transition
Infantile swallowing Adult swallowing.
Age Description
2 Begins to happen
6 50% completed the transition.
12 Most cases (80%) will self correct
10-15% estimated never to fully complete the transition
Mouth breathing
(Tongue Thrust Habit) associated with Anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping

16. Mouth Breathing
Of all the possible etiologic factors
Nasopharyngeal airway obstruction and associated mouth breathing.
The greatest importance
Mouth Breathing - can be caused by physiologic or anatomic conditions
- can be transitional when exercise induced or due to a nasal
obstruction.
- True mouth breathing when the habit
continues after the obstruction is removed.

17. Mouth Breathing
Nasal obstruction Habit
Lower tongue position
Abnormal muscles activity Increase inter-Maxillary space
Overdevelopment of the buccal segment teeth
Increase in the height of the lower third of the face
A greater incidence of AOP.

18. Adenoid Facies Skeletal Open Bite or
“Long Face Syndrome”

19. Mouth Breathing Habit
􀁡 Adenoid Facies 􀁡 Skeletal Open Bite or “Long
Face Syndrome”
⌧ Long narrow face ⌧Excessive eruption of posteriors
⌧Narrow nose and nasal airway ⌧Constricted maxillary arch
⌧Flaccid lips with short upper lip ⌧Excessive overjet
⌧Upturned nose exposing nares ⌧Anterior openbite
frontally ⌧Mandubilar down/forward
growth is poor

20. Constricted Arches of
Mouth Breathers

21. Enlarged Tonsils

22. ANTERIOR OPEN BITE
Anterior open bite is a condition where there is no vertical overlap
between the upper and lower anteriors
Esthetically unattractive
particularly during speech
when
Tongue is pressed between the teeth and lips

24. Causes of Anterior Open Bite
Cause Aetiology
Skeletal pattern - Increase in lower anterior facial height such
that the compensatory ability of the incisors to
erupt into contact is exceeded.
- This may be worsened by a downward &
backward pattern of facial growth
Soft tissues - Rarely endogenous tongue thrust
Habits - Persistence Digit sucking, which often leads to
an asymmetric anterior open bite
Localized failure of alveolar - Occurs in cleft lip & palate
development

25. Classification of anterior open bite
Anterior open bite can be classified as:
a. Skeletal anterior open bite
b. Dental anterior open bile

26. Skeletal anterior open bite
Features :
a. Increased lower anterior facial height
b. Decreased upper anterior facial height
c. Increased anterior and decreased
posterior facial height
d. A steep mandibular plane angle.
e. Small mandibular body and ramus
f. The patient may have short upper lip
with excessive maxillary incisor
exposure

27. Features of skeletal anterior open bite
“Long Face Syndrome”
a. Increased lower anterior facial height
b. Decreased upper anterior facial height
c. Increased anterior and decreased
posterior facial height
d. A steep mandibular plane angle.
e. Small mandibular body and ramus
f. The patient may have short upper lip
with excessive maxillary incisor
exposure

28. Features of skeletal anterior open bite
“Long Face Syndrome”
a. Increased lower anterior facial height
b. Decreased upper anterior facial height
c. Increased anterior and decreased
posterior facial height
d. A steep mandibular plane angle.
e. Small mandibular body and ramus
f. The patient may have short upper lip
with excessive maxillary incisor
exposure
‫منحدر‬

29. Skeletal anterior open bite
“Long Face Syndrome”
Features :
a. Increased lower anterior facial height
b. Decreased upper anterior facial height
c. Increased anterior and decreased
posterior facial height
d. A steep mandibular plane angle.
e. Small mandibular body and ramus
f. The patient may have short upper lip
with excessive maxillary incisor
exposure

30. Features of skeletal anterior open bite
“Long Face Syndrome”
g. The patient may often has a long &
narrow face
h. Divergent cephalometric planes
i. Steep anterior cranial base
j. Cephalometric examination may
revealed a downward & forward
rotation of the mandible. In some
patients, an upward tipping of the
maxillary skeletal base can be
observed. Another common feature is
a vertical maxillary increase

31. Features of skeletal anterior open bite
“Long Face Syndrome”
g. The patient may often has a long &
narrow face
h. Divergent cephalometric planes
i. Steep anterior cranial base
j. Cephalometric examination may
revealed a downward & forward
rotation of the mandible. In some
patients, an upward tipping of the
maxillary skeletal base can be
observed. Another common feature is
a vertical maxillary increase

32. Features of skeletal anterior open bite
“Long Face Syndrome”
j. Cephalometric examination may
revealed a downward &
backward rotation of the
mandible.
In some patients, an upward tipping
of the maxillary skeletal base can
be observed.
Another common feature is a
vertical maxillary increase

33. Features of skeletal anterior open bite
“Long Face Syndrome”
j. Cephalometric examination may
revealed a downward &
backward rotation of the
mandible.
In some patients, an upward tipping
of the maxillary skeletal base can
be observed.
Another common feature is a
Vertical Maxillary Increase

34. Features of dental anterior open bite
Dental anterior open bites Do Not present with the skeletal
complications mentioned above.
• The following are the features of dental open bite:
a. Proclined upper anterior teeth.
b. The upper and lower anteirors
fail to overlap each other
resulting in a space between the
maxillary and mandibular
anteriors.

35. Features of dental anterior open bite
Dental anterior open bites Do Not present with the skeletal
complications mentioned above.
• The following are the features of dental open bite:
c. The patient may have a narrow
maxillary arch, due to lowered
tongue posture due to a habit.

36. Diagnostic and treatment planning considerations:-

37. Successful management of AOP Diagnosis
A Simple Diagnostic Classification
A simple clinical diagnostic classification might be as follows:
1. Anterior open bite with increased facial proportions
2. Anterior open bite with history of digit sucking and normal
facial proportions
3. Anterior open bite with no history of digit sucking and normal
facial proportions

38. Favourable prognosis for treatment by orthodontic means alone
digit sucking habit is stopped

39. Patients with increased facial proportions frequently require
orthognathic surgery to close the open bite

40. Increased facial proportions
In the absence of other factors
Reaching the limit of
INCISORS
their eruptive potential
Before incisor contact is made
require
Surgery to correct their facial disproportion

41. Digit sucking
Characterized by an AOP
frequently
limited to the INCISOR REGION
Corresponds with the
Asymmetry
digit being sucked

42. Soft tissue habits and posture
The presence of an anterior open
Absence of
Tongue Thrust Habit
- Increased facial proportions or
- A digit sucking habit
AOP from canine – canine
Anterior tongue posture

43. Tongue movement during swallowing
The three stages of swallowing
Stage Description
Loss of contact of the dorsal tongue with the
1
soft palate
Passage of the bolus head across the
2 posterior/inferior margin of the ramus of the
mandible
3 Bolus head enters the oesophagus
During swallowing and compared to patients with normal occlusions, patients
with anterior open bite have:
1. tongue tip protrusion
2. slower movement of the dorsal part of the tongue
3. earlier closure of the nasopharynx

44. Management of anterior openbite:

45. Management of open bite tendency
The key to the management of open bite tendency is:
1. elimination of the aetiology
2. the avoidance of the extrusion of posterior teeth and if possible to
produce relative or real intrusion of these teeth.

46. • Removal of the cause:
Open bites
Thumb sucking or
Diagnosed due to habits Tongue thrusting
Require
INTERCEPTION
1.If habits stoped before 6-8 years,
(self correction)
2. Thumb devices
3. Educate proper swallowing

47. Passive Habit
Breaking
Appliances
If habit persists over 10 years
Psychological therapy

48. If habits stoped before 6-8 years,
(self correction)

49. Myofunctional therapy:
Skeletal anterior open bites
Functional appliances such as
Can be treated during GROWTH FR.IV or a modified
activator.
Incorporate Bite Blocks
interposed between the
posterior teeth
Intrusive Action on the
upper and lower posterior
teeth

50. Myofunctional therapy:
Skeletal anterior open bites
Patients exhibiting a downward
and backward rotation of
if treated during the mixed the mandible with increased
dentition period
vertical growth
vertical pull head gear
with chin cup

51. Myofunctional therapy:
Skeletal anterior open bites
Patients exhibiting a downward
and backward rotation of
if treated during the mixed the mandible with increased
dentition period
vertical growth
vertical pull head gear
with chin cup

52. Orthodontic therapy:
Extrusion of the upper and lower anteriors.
Intrusion of the posterior teeth.

53. Extrusion of the upper and lower anteriors.
Mild to moderate open bits
can be successfully managed
Fixed mechano-therapy
in conjunction with
Box Elastics
Stretched to extend between the upper and lower anteriars.
This brings about extrusion of the upper and lower anteriors.

54. Intrusion of the posterior teeth
Orthodontic Miniscrews

56. Surgical correction:
Skeletal open bites in adults
best treated by surgical
procedures
involving the maxilla and the mandible.
1.Once growth is complete for
severe problems with a skeletal
aetiology
2. In some patients an anterior
openbite is associated with a
‘gummy’ smile

57. POSTERIOR OPEN BITE
Characterized by
Lack of contact
between the posteriors when the teeth
are in centric occlusion

58. Causes of posterior open bite
two possible causes
either before or
after
(1) Mechanical interference with eruption,
The tooth emerges from the
alveolar bone
(2) failure of the eruptive mechanisms of the tooth
so that the expected amount of
eruption does not occur.

59. (1) Mechanical interference with eruption
Caused by
Ankylosis (spontaneously or as a result of trauma )
Obstacles in the path of the erupting tooth
Before Before
Supernumerary teeth Pressure from the soft
tissues interposed b/w the
Non-resorbing deciduous tooth roots or alveolar bone teeth (cheek, tongue, finger)

60. Treatment
Remove the cause
Habit intercepted Spontaneous improvement
Ankylosed teeth Crowns on posteriors
To restore normal occlusal level
The posteriors can be forcefully extruded

61. Thank you for your attention !
The End
Dr. Nabil Al-Zubair