A Novel Approach in Treatment of Openbite [PDF]

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A novel approach in treatment of open bite: a case report Article  in  International journal of orthodontics (Milwaukee, Wis.) · June 2013 Source: PubMed



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A Novel Approach in Treatment of Open bite: A case report By Rahman Showkatbakhsh,, DDS; Abdolreza Jamilian DDS and Ziba Mashayekhi DDS



Abstract: This case illustrates the treatment of a 12-year-old boy with an open bite, a slight Class II jaw relationship, Class I molar relationship, and a steep lower occlusal plane. The patient needed a surgical procedure due to the severity of openbite; however the surgery option was rejected. Therefore, he was treated by a Hyrax, fixed tongue appliance, posterior bite plate, reverse chin cup and fixed orthodontics. His second premolars and lower second molars were extracted during treatment. The active treatment lasted for 34 months after which favorable correction of the malocclusion was observed. The SNA angle increased by 4° and the GoGn-Sn decreased by 6°. This patient was treated nonsurgically and favorable profile and occlusion were obtained. Keywords: Open bite; Vertical growth pattern; Nonsurgical treatment; Increased anterior facial height; lip incompetency.



ntroduction The anterior open-bite can be defined as the presence of negative overbite between the incisal edges of the maxillary and mandibular teeth, with the posterior teeth in occlusion.1 Many factors such as heredity, parafunctional habits, mouth breathing, and unfavorable growth pattern can be associated with the establishment of the open bite malocclusion. Various treatment modalities have been proposed for the correction of an anterior open bite. Some of these modalities are extrusion of the anterior teeth by intermaxillary elastics,2 inhibition of molar eruption during growth,3 palatal crib and high-pull therapy,1 bite blocks4 and repelling magnets.5 Another treatment option is the repositioning of both the maxilla and mandible through a surgical correction.6 Recently, miniscrews have been used for open bite closure.7,8 Zygomatic anchorage can also be used for open-bite correction through posterior dentoalveolar intrusion.9 In light of our current knowledge on open bite correction, the aim of this study was to report the nonsurgical treatment of an open bite patient with a slight Class II jaw relationship, Class I molar relationship, and a steep lower occlusal plane. Case History A 12-year-old boy was initially referred to orthodontic department for treatment of openbite. He had no medical problems and there were no signs of temporomandibular joint dysfunction. Clinical examination revealed anterior open bite and lip incompetency. Facially, soft tissues were imbalanced (Figures 1-2). Intraoral examination showed an anterior open bite and Class I relationship of right and left molars (Figures 3-7). In fact the molars were in Class III relationship but they rotated to Class I relationship due to vertical growth pattern of the maxilla. Cephalometric analysis confirmed the patient was a vertical grower (Table 01) (Figures 8-9). IJO  VOL. 24  NO. 1  SPRING 2013



Figures 1-2: Pre-treatment extraoral photo of the patient



Table 01 - Cephalometric analysis Cephalometric Data SNA (°) SNB (°) ANB (°) GoGn-SN (°) 1-SN (°) IMPA (°) Interincisal (°) Y-Axis (°)



Pre-treatment



Post treatment



78 72 6 39 107 92 120 72



82 79 3 33 108 85 135 65



Treatment Objectives The treatment objectives for this patient were to: 1. Correct the openbite. 2. Obtain an ideal overjet and overbite. 3. Obtain lip competency.



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were bonded with 0.22 standard edgewise system for 10 months. After debonding, a posterior bite plate was mounted for 6 months. After removal of posterior bite plane, the patient still had some openbite due to the contacts of second molars. The patient was made aware of two possible treatments namely extraction of the lower second molars and use of miniscrew for intruding them. However, he rejected use of miniscrews; therefore, his lower second molars were extracted after obtaining required informed consent forms. Figures 3-7: Pre-treatment intraoral photo of the patient



Figures 8-9: Pretreatment lateral cephalometric and panoramic image of the patient



Treatment Alternatives Orthognathic surgery at 18 years-of-age was considered as an alternative treatment. However, the patient and his parents refused surgery. Therefore, this case was treated orthodontically. Use of anterior vertical elastics could also be an alternative method; nevertheless, they could have elongated the upper incisors and caused a gummy smile. Use of High pull headgear was another viable method in intrusion of posterior segment. Use of vertical chin cup along with posterior bite plate could enhance the effectiveness of posterior bite plate and be very effective in reduction of openbite. Nevertheless, this patient did not show good compliance in using further bulky extra oral devices and was very reluctant to use them. Treatment Progress A hyrax combined with fixed tongue appliance was mounted in the upper jaw (Figures 10-13). The patient was instructed to open the screw of the hyrax 1/4 of a turn twice a day for two weeks. At the same time a posterior bite plate was mounted in the lower jaw. A reverse chin cup10 was used during the night in order to increase the force used for forward movement of maxilla. The hyrax, tongue appliance, posterior bite plate and reverse chin cup were removed after 18 months. Afterwards, all second premolars were extracted and the teeth 30



Treatment Results Positive overjet and overbite were achieved after 34 months of active treatment and open bite was successfully corrected (Figures 14-20). The post treatment cephalometric radiograph and OPG showed a favorable increase of 4° in the SNA angle and a favorable decrease of 6° in GoGn-Sn angle (Figures 21-22). The superimposition of pre and post treatment cephalometric tracing on the anterior cranial base is shown in Figure 23. Discussion The openbite of a 12-year-old patient who needed surgery was successfully corrected by means of hyrax, tongue appliance, posterior bite plate, reverse chin cup and fixed orthodontics. The patient had maxillary deficiency in three dimensions. Fixed tongue appliance combined with hyrax was mounted in the maxilla to train the tongue to function normally. Due to the patient’s vertical growth pattern, a posterior bite plate was used in the lower jaw to control the vertical growth. A Reverse chin cup was also used during the nights in order to enhance forward movement of the maxilla. After removal of these appliances, second premolars were extracted in order to move first molars mesially and reduce open bite. After debonding and use of posterior bite plate, contact was seen in second molars. This contact could be removed by means of miniscrew as an intrusion device or extraction of lower second molars. Due to rejection of miniscrew the lower second molars were extracted in order to close the bite. Following the extractions, the eruption of upper second molars was controlled by use of posterior bite plate. Orthognathic surgery and numerous appliances such as vertical holding appliance,11 high-pull headgear,12,13 vertical chin cup,14 posterior bite blocks,15 spring-loaded bite block,16 active vertical corrector,17 Fränkel IV regulator,18 mini-implants and miniplates19,20 have been used to treat open bite. Extraction of the first premolars has been accepted by many clinicians in the management of skeletal open bite due to the draw-bridge effect of reducing the inclination of both upper and lower incisors. Molars can also be extracted to remove the wedge which has caused the open bite.21 In addition elastics16 are also used for treatment of this malocclusion. High pull headgear can intrude upper first molars and reduce the open bite. Use of posterior bite plate along with vertical chin cup could exert more pressure on the upper posterior segment which is more effective in reduction of openbite than the single use of posterior bite plate. IJO  VOL. 24  NO. 1  SPRING 2013



Figures 21-22: Posttreatment lateral cephalometric and panoramic image of the patient.



Figure 23: Superimposition of pretreatment (black) and posttreatment (red) cephalometric analysis of the patient, on SN, registered at sella.



Figures10-13: Hyrax in situ



Figures 14-15: Post-treatment extraoral photo of the patient



Generally, clinicians try their best to avoid extraction of permanent teeth especially in horizontal growth pattern patients. However, extraction of permanent teeth in vertical growth pattern patients has proven to be beneficial and can often help in achieving lip seal.22 This case, being a vertical grower and rejecting surgery, use of miniscrew and further extra oral appliances left the clinician with no other choice but to extract permanent teeth. Conclusions: • Positive overjet and overbite were achieved. • Anterior Openbite was successfully corrected. • A surgical case was treated nonsurgically. References 1.



2. 3. 4.



Figures 16-20: Post-treatment intraoral photo of the patient



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5. 6.



Torres F, Almeida RR, de Almeida MR, Almeida-Pedrin RR, Pedrin F, Henriques JF. Anterior open bite treated with a palatal crib and highpull chin cup therapy. A prospective randomized study. Eur J Orthod 2006;28:610-617. Kucukkeles N, Acar A, Demirkaya AA, Evrenol B, Enacar A. Cephalometric evaluation of open bite treatment with NiTi arch wires and anterior elastics. Am J Orthod Dentofacial Orthop 1999;116:555-562. Gurton AU, Akin E, Karacay S. Initial intrusion of the molars in the treatment of anterior open bite malocclusions in growing patients. Angle Orthod 2004;74:454-464. Iscan HN, Sarisoy L. Comparison of the effects of passive posterior bite-blocks with different construction bites on the craniofacial and dentoalveolar structures. Am J Orthod Dentofacial Orthop 1997;112:171178. Dellinger EL. Active vertical corrector treatment--long-term follow-up of anterior open bite treated by the intrusion of posterior teeth. Am J Orthod Dentofacial Orthop 1996;110:145-154. Swinnen K, Politis C, Willems G, De Bruyne I, Fieuws S, Heidbuchel K et al. Skeletal and dento-alveolar stability after surgical-orthodontic treatment of anterior open bite: a retrospective study. Eur J Orthod 2001;23:547-557.



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7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.



Kravitz ND, Kusnoto B. Posterior impaction with orthodontic miniscrews for openbite closure and improvement of facial profile. World J Orthod 2007;8:157-166. Xun C, Zeng X, Wang X. Microscrew anchorage in skeletal anterior openbite treatment. Angle Orthod 2007;77:47-56. Erverdi N, Usumez S, Solak A, Koldas T. Noncompliance open-bite treatment with zygomatic anchorage. Angle Orthod 2007;77:986-990. Showkatbakhsh R, Jamilian A. A novel approach in treatment of maxillary deficiency by reverse chin cup. Int J Orthod Milwaukee 2010;21:27-31. Deberardinis M, Stretesky T, Sinha P, Nanda RS. Evaluation of the vertical holding appliance in treatment of high-angle patients. Am J Orthod Dentofacial Orthop 2000;117:700-705. Watson WG. A computerized appraisal of the high-pull face-bow. Am J Orthod 1972;62:561-579. Ngan P, Wilson S, Florman M, Wei SH. Treatment of Class II open bite in the mixed dentition with a removable functional appliance and headgear. Quintessence Int 1992;23:323-333. Pearson LE. Vertical control in treatment of patients having backwardrotational growth tendencies. Angle Orthod 1978;48:132-140. Ngan P, Fields HW. Open bite: a review of etiology and management. Pediatr Dent 1997;19:91-98. Iscan HN, Akkaya S, Koralp E. The effects of the spring-loaded posterior bite-block on the maxillo-facial morphology. Eur J Orthod 1992;14:54-60. Dellinger EL. A clinical assessment of the Active Vertical Corrector--a nonsurgical alternative for skeletal open bite treatment. Am J Orthod 1986;89:428-436. Frankel R, Frankel C. A functional approach to treatment of skeletal open bite. Am J Orthod 1983;84:54-68. Umemori M, Sugawara J, Mitani H, Nagasaka H, Kawamura H. Skeletal anchorage system for open-bite correction. Am J Orthod Dentofacial Orthop 1999;115:166-174. Park HS, Kwon OW, Sung JH. Nonextraction treatment of an open bite with microscrew implant anchorage. Am J Orthod Dentofacial Orthop 2006;130:391-402. Frankel R, Frankel C. Functional aspects of molar extraction in skeletal open bite. In: Graber LW, Graber TM, editors. Orthodontics, state of the art, essence of the science. St. Louis: Mosby; 1986. p. 184-199. Denny JM, Weiskircher MA, Dorminey JC. Anterior open bite and overjet treated with camouflage therapy. Am J Orthod Dentofacial Orthop 2007;131:670-678.



Professor Rahman Showkatbakhsh finished his post-graduate training in the school of dental and oral surgery, Colombia University, in New York City. He established the first post-graduate program in orthodontics in the school of dentistry, Shahid Beheshti medical sciences university where he currently serves as associate professor and director of Orthognathic surgery fellowship.



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Professor Jamilian is an orthodontic specialist serving now as associate professor of Islamic Azad University in Tehran. He is a fellow of Orthognathic surgery and craniofacial syndromes. His practice is limited to orthodontics. He has lectured in several international congresses and has been a consultant for various journals. You can reach him through [email protected]



Dr. Ziba Mashayekhi is an orthodontic specialist and has finished her post-graduate course in Islamic Azad University in Tehran. Her practice is limited to orthodontics.



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