Open bite sem [recovered]

Open bite
www.indiandentalacademy.com

DEFINITIONS
CLASSIFICATIONS
ETIOLOGY
DIAGNOSIS
TREATMENT
FINISHING & RETENTION

INTRODUCTION;
Open bite mal occlusion has long held
fascination in orthodontics.
It is difficult to treat and relapse
tendencies are strong.
- Young H. Kim AO 1987

Normal bite: It is defined as vertical
overlap of the incisors. The lower incisal edges
in relation to the lingual surface of the upper
incisors present at or above the cingulam
(normally there is 1-2 mm overbite)
DEFINITIONS;

OPEN BITE;

ANTERIOR OPEN BITE;

POSTERIOR OPEN BITE;

SIMPLE OPEN BITE;

COMPLEX OPEN BITE;

COMPOUND OPEN BITE;

IATROGENIC OPEN BITE;
Open bite as a consequence of
orthodontic treatment.

Classificaton;
It used to visualize the problem,
diagnosis and treatment plan.

Classified on developmental;
Primary; Mixed; Permanent;
Gum pads Temporary Persistent habits

Depend on site;
Anterior open bite; Posterior open bite;

Depend on position;
Intra arch
The tooth itself is
malpositioned within
arch creating open bite
- infraversion / inclination abnormally without
root. www.indiandentalacademy.com

Inter arch;
-No vertical overlap
-abnormality in
upper/lower or both
- Ant/post segment

Ankerman profit; vertical relation
Anterior open bite Posterior open bite
dental skeletal dental

Depend on etiology;
Lateral
open bite
Compound
open bite
Iatrogenic
open bite

ETIOLOGY OF OPEN BITE;
WHY OPEN BITE ?
- ENVIRONMENTAL FACTORS
- HABITS
- EPIGENETIC FACTORS

Pre – disposing factors;
Skeletal
Dental
Mandible
Excess eruption of posteriors
Decreased eruption of anteriors
maxilla

Various factors influencing open bite;
a) Disturbances in embryonic development;
1) Muscle dysfunction
2) Hemi mandibular hypertrophy

1) Muscle dysfunction;
- defect in the uterus.
- Etiology;
- Pathology
- affect the particular muscle
Bone formation in the origin of
muscle
Loss of musculature
Kiliaridis s, mejersjo c
- Ejo 1989

Underdevelopment of
face

Muscular dystropy.
&
Muscle weakness
syndrome.
Muscle tonicity
Open bite

Mandible drops
downwards away
from maxilla

Anterior open bite due to increased
eruption of posterior teeth.

2) Hemi mandibular hypertrophy
Bilateral

- unilateral

b) Genetic influence;
- A strong influence of inheritence on
facial features is obvious at a glance.
- mal occlusion produced by inherited
characteristic in 2 ways;
What it has to do with open bite ?

Long face pattern;
King L, Harris EF, Tolley EA
- AJO 1993
Long face syndrome;

Genetic inheritence
Skeletal influence Dental influence
Open bite
Ackerman, Isacson, Shapiro
- AJO 1970

c) Environmental influence;
The open bite can be produced by
1) equilibrium forces
2) Functional forces

1) Equilibrium forces;
It states that object subject to unequal
forces will be accelerated and there by
move to different space.
Proffit WR; AO 1978
Hence the equilibrium has to be
maintained.

Altered equilibrium due to increased tonque
pressure.

a) Juvenile equilibrium;
The teeth that are in function
parallels the rate of vertical
growth of mandibular ramus

The rate of eruption is controlled by forces
opposing direction, not those promoting it.

2) Functional forces;
Biting force and eruption
Downward growth
of mandible
Open bite
Masticatory muscle gains strength at puberty.www.indiandentalacademy.com

HABITS
Definition;
It is the tendency towards an act of repeated
performance relatively fixed or consistent
and ease to perform by an individual.
We are just beginning to realize how common
and varied the vicious habits of lip and tongue,
and how power full and persist to overcome
- Angle.www.indiandentalacademy.com

Earliest writings;
- causes of irregularities through habits that
pushes teeth forward.
- Lefoulon 1839
- balance of force to retain teeth in position.
- Desirabode 1843
- “lateral pressure theory”
- Bridgeman 1859
- “Sim Wallace theory”
- Bennett

Classify;
1) useful
harmful
Tongue thrusting
When persists
2) Pressure Sucking ( lip, thumb)
Non pressure Mouth breathing

Thumb sucking;
Definition;
It is defined as the placement of thumb
or one/more fingers in varying depths
into the mouth.
Klein AJO 1979

Physiological condition;
-It is considered normal till 3 – 4 yrs.
- It is an non nutritive sucking habit
- Recent studies indicate that thumb
sucking is practised even during the intra –
uterine life.

Pathological condition;
&
Clinical features
It occurs through
altered equilibrium not
just pressure through
fingers.
Open bite

Sucking habits;

Theories;
1) Freudan theory;
1- 3 years – oral and anal phase.
2) Oral drive theory of sears and wise; 1950
Prolonged habit leads to thumbsucking.
3) Benjamins theory;
Thumbsucking develops in infants due
to the rooting reflex/placing reflex.www.indiandentalacademy.com

4) Psychological aspects;
Children develop this habit as a feeling of
insecurity, when they are deprived of love,
care and affection.

Phases of thumbsucking;
Phase – 1;
- First three years of life.
- sub clinically significant.
Phase - 2;
- 3 – 6 yrs of life.
- clinically significant.

Phase - 3;
- beyond 5 – yrs.
- intractable sucking.
- Its an alert to an dentist.

DIAGNOSIS;
- Check for childs emotional status.
- feeding habits
- Intra – oral examination;
- incissors
- open bite
- Clean nails

TREATMENT;
1) Psychological approach;
Beta hypothesis theory by Dunlop
Consious purposeful repeatation.
2) Mechanical aids;
Basically reminders
3) Chemical approach;

TONGUE THRUSTING
DEFINITION;
It is defined as the forward movement of
the tongue tip between the teeth to meet
the lower lip in deglutition and in sounds
of speech so that the tongue becomes
interdental.
Tulley AJO 1969

Classification;
According to moyers;
Simple complex
- To establish lip seal
- Anterior open bite
- abnormal mentalis
- Contraction of
circum – oral muscles.
- diffuse open bite.
- poor occlusion.

Simple tongue thrust.

According to James s. Braner and holt
Type 1 - Non deforming tongue thrust.
Type 2 – Deforming anterior tongue thrust.
Type 3 – Deforming lateral tongue thrust
Type 4 – Deforming ant; & lat; tongue thrust

Etiology ;
According to fletcher;
1) Genetic factors;
Neuromuscular variations in oro
facial region.
2) Learned behaviour;
Prolonged action & gum tenderness.
3) maturational;
Age – swallow pattern.

4) Mechanical restrictions;
- macroglossia.
- arch constricted.
5) Neurological disturbances;
- motor disability
6) Psychogenic factor;
- discontinuation of other habits.

DIAGNOSIS;
- Size of the tongue
- posture of the tongue
- Function of the tongue
- Structure of the tongue

1) Size of the tongue;
Why asses the variations ?
Variations in tongue size ,
Reaches its adult size by the age
of 8 years.
True macroglossia Pseudo macroglossia

Macroglossia;
The whole oral cavity is filled with the
tongue mass, presence of indentations
on the periphery.

Etiological factors;
congenital Acquired
- muscular hypertrophy
- glandular hyperplasia
- lymphangioma
- Downs syndrome
- Acromegaly
- myxedema
- amyloidosis
- tertiary syphylis
Cyst/tumors involving
tongue.

Pseudo macroglossia;
Forward posture of tongue
- Low palatal vault

Etiological factors;
- habitual posturing of the tongue.
- hypertropied tonsils and adenoid tissue.
- arch deficiency in all dimensions.
- severe mandibular deficiency.
- cyts/tumors that displaces the tongue

Clinical assessment;
1) macroglossia.
2) microglossia.
- Tulley AJO 1969.

MACROGLOSSIA;
Signs and symptoms.
- Open bite (ant/post)
- Diastema (mx/md)
- Accentuated curve of spee in maxillary arch
- Reverse curve of spee in mandibular arch.
- difficulty in swallowing
- mandibular prognathism.
- Larry M. WOLFORD, AJO 1996www.indiandentalacademy.com

Cephalometric & Radiographic assessment.
- over angulation of upper and lower anteriors.
- Dispropotionately excessive mandibular
growth.
- increased gonial angle.
- increased occlusal and mandibular plane
angle.
- David A. AJO 1996.

Cephalometric evaluation;
Lateral ceph with sufficient exposure to
evaluate the soft tissue.
Reference lines;
I , V , M , O .

Criteria for evaluation;
- The greatest possible area of tongue should
be above reference line.
- The base line is independent of skeletal
structures.
- The tongue should not change with
position of the mandible.

Menstrual data through template;

Template evaluation;

2) Posture of tongue;
The posture is evaluated for various open
bite tendencies.
It can be flat/arched, protracted/retracted,
narrow/long.

ANTERIOR POSTURE;

LATERAL POSTURE;

STRUCTURE OF TONGUE;
In infancy the extrinsic suspensory
muscles attach the tongue to various
osseous structures largely resposible for
gross movements in horrizontal plane.
- It has the property of elasticity &
contractility ----- tongue thrust.
Acts through all / none law.

FUNCTION OF TONGUE;
DEGLUTATION

According to moyers;
Depend on the characteristic;
1) Infantile swallow ---- 12 - 18 mnths.
2) Mature swallow ----2 - 4 yrs

INFANTILE SWALLOW;

Central furrow & gum pads.

MATURE SWALLLOW;

SHALLOW TONGUE;

Do tongue thrust cause open bite ?
Pressure on teeth by swallow - 1 secs
Individual swallow – 800/dy - & few in sleep.
Total 1000/dy

Treatment;
- habit breaking appliance.
- muscle exercise through elastics.
Defect in posture;
Defect in size;
- Glossectomy..
- surgical correction.

Glossectomy;
Pseudo macroglossia True macroglossia
Procedures;
- Midline wedge resection with base in
the anterior tongue.
- Midline elliptical excision.
- Marginal excision.
- “Keyhole” or combined technique.

Keyhole technique;
Midline elliptical incision
Anterior wedge resection
- AJO -96www.indiandentalacademy.com

SEQUENCE OF PROCEDURES;
STAGE I :
GLOSSECTOMY
ORTHOGNATHIC
SURGERY
- Psychological approach.
- No IMF
- No air way obstruction.

STAGE 2 :
ORTHOGNATHIC
SURGERY.
GLOSSECTOMY
- If occlusal stability is a concern.

STAGE 3 :
COMBINED
- Both the procedures combined together at a
same surgical stage.

MOUTH BREATHING;
Definition;
It is defined as the the pattern of
breathing totally / partially through oral
cavity due to anatomical / functional
variations.

Classify;
a) Obstructive.
b) Habitual.
c) Anatomical.

ETIOLOGY;
Mouth breathing primarily has effect on
- posture of jaws.
- Position of tongue
- posture of head.
Altered equilibrium
Tooth position
Growth

Mouth breathing
Mandible lowered Tilted head lowered tongue
LFH Change of 5 degree
cranio vertebral
angle
Mandible rotated
Open bite Obstruction relievedwww.indiandentalacademy.com

Mandible lowered;
Ant; open bite.

Change in cranio vertebral angle;

Physiological variations;
All humans are some mouth breathers.
Average breathing air flow ------ 20 – 25/L/mnt
Partial mouth breathing --------- 40 – 45 L/mnt
Transitional stage ----------- 80 -
Mintz S, Shepard RJ.

Pathological variations;
It becomes a habit when the breathing
persists even when the obstruction is
removed.
Opposing principles;
Total nasal obstruction
Increased LFH
Battgel J BJO - 1996www.indiandentalacademy.com

Clinical features;
Malocclusion associated with the mouth
breathing.
Long face syndrome/classical adenoid facies;

DIAGNOSIS;
- Nasal obstruction.
- Adenoids.
- hyoid triangle analysis.

NASAL OBSTRUCTION
- AJO 1998

Choanal atresia & treacher collins syndrome in
infants ----- tracheostomywww.indiandentalacademy.com

How much obstruction has to occur for effect on
growth ?
- It depends on location of the obstruction.
- nasal function
Anterior
Middle portion
posterior

Methods in assessing the nasal obstruction.
- Cross sectional area.
- Peak nasal air flow
- Nasal resistance.
- Respiratory mode (oral/nasal air flow ratio)
-AJO 1998

Rhinomanometric studies;
Study of air flow with flow meters, and
pressure gauges.
Cleft lip and palate patients increase tendency of
mouth breathing ?
- AJO 1998
Posterior nasal obstruction by
pharyngeal flaps. www.indiandentalacademy.com

ADENOIDS;
Enlargement of adenoids relation to mouth
breathing. www.indiandentalacademy.com

Hyoid bone position;
- AJO 1984.
In 1981 Bibby and Preston.
Hyoid bone is not fixed to a space by any
bony articulations.
Hyoid bone is determined by muscles and
ligaments attached to structures above and
below it.

- It is influenced by the tongue posture and
mandibular position.
it signifies

TREATMENT;
- Removal of the cause.
- Interception of the habit.
- Rapid maxillary expansion.
- orthodontic + surgery

Nasal obstruction; - AJO 1998
- vertically repositioning of maxilla
predictably reduce the nasal resistance.
Not nasal air flow
The highest correlation between these
parameters are 0.24 %---- 0.74%
Breathing mode is behavioral determined than
structurally determination

Adenoids;
- Adenoidectomy.
- AJO -94
Ten yr old

No change in breathing pattern;

Rapid maxillary expansion;
For maxillary deficiency
Increase nasal air flow
Reduction in nasal resistance was frequently
measured.
Rhinometric studies;
No change in breathing mode.

DIAGNOSIS;
Early detection of symptoms is
recommended, so that treatment can be
provided in time whatever the cause may
be.
- Subtenly, AO 1954
- Ricketts, AO 1968

How to decide for open bite ?
It is the ability to recognize vertical growth
in routine treatment mechanics.
Commonly clinicians evaluate
Mandibular plane for open bite.

DIAGNOSIS;
- SKELETAL OPEN BITE
- DENTAL OPEN BITE.
- ANTERIOR OPEN BITE.
- POSTERIOR OPEN BITE.

Skeletal open bite;

Posterior open bite;
- Failure of posterior tooth to erupt fully
in occlusion producing lateral open bite.
Mechanical interference.
Disturbance of eruption
mechanism.

GROWTH PATTERN ;
Its purpose was to assess skeletal factors
associated with development of vertical
facial disproportions.
Horrizontal facial planes tends to be
steeper and more divergent with lower
facial height.

Steeper planes;

1) Mandibular plane;
Favoured --- Nanda.
Not favoured --- Skiller/Bjork.
2) Gonial angle;
3) Palatal plane;
4) Occlusal plane;
5) Cranial base;
Larger cranial base and corresponding positional
deviations of mandible associated with open
bite.
Enlow -
Posterior dips
Steeper
Angle. Bjork –no
change

CEPHALOMETRIC EVALUATION;
There are six specific cephalometric
angular measurements for identifying the
vertical dysplasia.

1) SN --- (ANS – PNS);

2) SN --- MANDIBULAR PLANE;

3) GONIAL ANGLE;
Resultant uprighting of the ramus.www.indiandentalacademy.com

4) PALATOMANDIBULAR ANGLE;
Bimler used this angle for describing facial types.www.indiandentalacademy.com

5) SN --- OCCLUSAL PLANE;

6) CRANIAL BASE ANGLE;

LINEAR PARAMETERS;
GROUP 1;
PFH/AFH ----- Sum of angle
-Jarabak
GROUP 2;
UFH/LFH
Average --- 0.810
Open bite ---0.686

OBJECTIVE OF OPEN BITE;
- AO 1998
1) Creating sufficient overlap with molar relation;
Incisal overlap
0.5 --- 4.0 mm
Average – 2.8mm
- Kim 1974

Central incisor relative to lip line;

The dentition is placed in proper three
dimensional perspective to ensure stability.
- Antero – posterior aspect.
- Vertical aspect.
- Transverse aspect.

Axial inclination; ------ open bite

Axial inclination ----- deep bite.

Eliminate Blocks:
In order to eliminate blocks the molar
are distally tipped.
Extraction ( 1/2/3) molar Non extraction

TREATMENT;
It depends on etiology and location
- Dento alveolar open bite.
- skeletal open bite.
TIMING OF TREATMENT;
Not too early not too late

TREATMENT DURING PRIMARY
DENTITION;
Dental open bite;
- Habits ---- after 3 yrs.
Screening therapy.
Skeletal open bite;
- Habit control secondary.
- Growth modification not indicated

TREATMENT ON EARLY MIXED
DENTITION;
Dento alveolar open bite;
- Screening therapy
- Behavior modification.

Screening appliances;
Vestibular screen ------------ digit sucking
Vestibular screen ------ Its modifications.
Tongue crib ------ tongue thrust.
Posterior tongue crib -------- lateral tongue thrust
Activator ----------- Tongue thrust and finger
sucking ( work as a interceptor).

BEHAVIOR MODIFICATION;
COUNSELLING;
A straight forward discussion with the
child during eruption of permanent
incisors.
REWARD;
For not engaging in the habit.

REMINDER;
For the child who wants to quit.

QUAD HELIX;
Maxillary lingual arch with crib;

OPEN BITE IN LATE MIXED DENTITION;
Skeletal parameters;
- Major diagnostic criteria is either,
“ KEY “
maxilla mandibleor both
Palatal plane Ramus

GROWTH MODIFICATION;
It varies depends on horrizontal/vertical growth;

High pull head gear to molars;

High pull head gear with maxillary splint;

Bite blocks with functional appliance;

Head gear with functional appliance and
bite blocks;

Functional appliance;
Head gear with activator

Bite registration;

TREATMENT IN ADULT;
Correction of vertical relation
maxilla mandible
Vertical
excess anterior posterior
excesswww.indiandentalacademy.com

Maxillary excess;
Le Forte I
Reduce the nasal
septum

Anterior open bite;
Anterior segment is moved more than posterior

Posterior open bite;
Segmental osteotomywww.indiandentalacademy.com

Mandibular surgery;
Surgery in the ramal part is done only to the
secondary aspect to the maxillary osteotomy
for the auto rotation of the mandible.
Advancement genioplasty

GENIOPLASTY;
Long face pts has excess
eruption of lower anterior
which is flared and unstable
Poor chin balance
Bony cut is given upward and forward angulated
to advance it. www.indiandentalacademy.com

PRE – SURGICAL ORTHODONTICS;
allignment
levelling
Antero posterior incisor position

LEVELLING;
MAY OR MAY NOT BE DONE;
- Depend on facial type.
Stabilizing arch wire;
18 slot ------- 17 x 25
22 slot ------ 21 x 25

POST SURGICAL ORTHODONTICS;
Until stabilizing arch wire is removed
the teeth are held in tight position.
- four weeks Light vertical elastics

RETENTION
Removable Appliance with high
pull head gear www.indiandentalacademy.com

Appliance with the bite
block.

Force Amplified Retention
1997 JCO Sheridan
Low profile lingual caplin
hooks
Canine to canine
intra oral elastics.www.indiandentalacademy.com

Conclusion;

THANK U

Open bite sem [recovered]

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Open bite sem [recovered]