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Innovative technique for correction of open bite - A case report
R Siddhartha1, Shetty Suhani Sudhakar2, Kripal Rai3, Shreyas Rai4, Shivprasad Rai5
1 Department of Orthodontics, Srinivas Institute of Dental Sciences, Mangalore, Karnataka, India
2 Consultant Orthodontist, Bangalore, Karnataka, India
3 Department of Public Health Dentistry, Srinivas Institute of Dental Sciences, Mangalore, Karnataka, India
4 Department of Conservative Dentistry, Srinivas Institute of Dental Sciences, Mangalore, Karnataka, India
5 Department of Orthodontics, Manipal College of Dental Sciences, Mangalore, Karnataka, India
|Date of Submission||25-Mar-2021|
|Date of Decision||07-Jul-2021|
|Date of Acceptance||30-Sep-2022|
|Date of Web Publication||28-Nov-2022|
Shetty Suhani Sudhakar,
Department of Orthodontics, Srinivas Institute of Dental Sciences, Mukka, Mangalore - 574 146, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Anterior open bite is defined as a condition in which upper incisor crowns fail to overlap the incisal third of the lower incisor crowns when the mandible is brought into full occlusion. The diagnosis, treatment, and successful retention of treated open-bite malocclusion continue to be a constant subject of discussion and study, contributing to the frustrations of clinicians. Various modalities have been used for the correction of open bite for the different age groups. In adult cases, an open bite can be corrected either by anterior extrusion or posterior intrusion, or a combination of both. Kim had described a method of using multiloop edgewise archwire for posterior intrusion. Here is a case report in which an innovative method is described which is a modification of Kim's method which is simpler, less time-consuming to place, hygienic, and they do not irritate the soft tissue. The bite closing mechanism and the treatment results are similar to Kim's method.
Keywords: Box elastic, open bite, posterior intrusion, reverse curve NiTi, skeletal open bite
| Introduction|| |
Anterior open bite is defined as a condition in which upper incisor crowns fail to overlap the incisal third of the lower incisor crowns when the mandible is brought into full occlusion. Within the limits of this definition, the degree or severity of malocclusion may vary from a mild edge-to-edge relationship of the incisor teeth to a severe and handicapping malocclusion.
The diagnosis, treatment, and successful retention of treated open-bite malocclusion continue to be a constant subject of discussion and study, contributing to the frustrations of clinicians. Studies related to the etiology, incidence, classification, characteristics, and treatment of this dysplasia have implicated many potential etiologic factors, including unfavorable growth patterns,,,, digit-sucking habits,,,,,,, heredity,, lymphatic tissue,,,, tongue and orofacial muscle activity, orofacial functional matrices, mental retardation, and imbalances between jaw posture, occlusal and eruptive force, and head position.
Treatment of open bite is complicated by the difficulty of differentiating among many possible dentoalveolar and skeletal etiologic factors, depending on the patient's growth pattern. Cephalometric measurements such as the mandibular plane angle, upper-to-lower facial-height ratio, and anterior-to-posterior facial height ratio have been used to identify vertical discrepancies, but these measurements do not always predict the treatment response and stability of an open-bite malocclusion., The overbite depth indicator (ODI) proposed by Kim can be helpful in determining the skeletal pattern. ODI is the arithmetic sum of the angle of the AB plane to the mandibular plane and the angle of the palatal plane to Frankfort horizontal. The norm is 74° ± 6.07°; a value of 68° or less indicates a skeletal open-bite tendency.
An open bite will sometimes correct spontaneously after the elimination of detrimental habits in the early mixed dentition. Some of the treatment modalities are interceptive orthodontics treatment using removable Hawley appliance with screening device and habit breaker, tongue crib followed by phase II treatment, Haas appliance which is followed by Hawley retainer with tongue guard for stability (retention) after which phase II treatment follows, fixed orthodontic therapy with anterior elastics, and orthognathic surgery. A successful nonsurgical treatment for an adolescent female presented with Angle Class III malocclusion, excessive lower facial height, and the anterior open bite has been reported in previous studies. The patient refused the orthosurgical treatment modality and another option was suggested using multiloop edgewise archwire (MEAW) in association with a chin cup to correct the divergence of occlusal planes and molar relationship, without a major change in the patient's profile.
Whatever form of treatment is chosen, goals should include correcting the inclination of the occlusal planes, aligning the maxillary incisors relative to the lip line, and uprighting the axial inclinations of the posterior teeth. This article presents a modification of the McLaughin, Bennett, Travesi (MBT) technique, using 0.017 × 0.025 reverse curves NiTi archwire in the upper and lower arch and posterior box elastics.
The appliance is a modification of the MEAW technique introduced by Charles Tweed. The multiple loops were replaced by the reverse curve of Spee in the lower arch and the exaggerated curve of Spee in the upper arch. Enacar et al. gave a modification by placing a reverse curve in both arches along with very heavy Class II elastics. In our study, we have used a 17 × 25 reverse curve NiTi archwire with posterior box elastic. The posterior box was given in the Class II pattern.
| Case Report|| |
A 23-year-old female came to the department with the chief complaint of forwardly placed upper front teeth. The patient cited esthetics as the main reason for desiring orthodontic treatment. The patient had no relevant dental or medical history. Siblings and parents of the patient did not have similar malocclusion, confirming that there was no hereditary component responsible for the patient's malocclusion. Patient's written consent was taken before starting the treatment.
On extraoral examination, she had a mesocephalic, mesoprosopic face, a convex profile, anterior divergence, and incompetent lips. The patient displayed a nonconsonant smile arc and upturned nose in profile view. There was no history of respiratory problems. On functional examination, it was found that the patient has a tongue-thrusting habit. Intraoral examination revealed an anterior open bite of 6 mm with Angle's Class I molar relation bilaterally. The intraoral examination also showed upper and lower anterior spacing [Figure 1].
Tongue size was normal as no lateral indentations were present on the lateral aspect of the tongue. The cephalometric tracing confirmed that the patient had a moderate Class II skeletal pattern with an ANB value of 4°. The patient had an average growth pattern and proclined maxillary and mandibular incisors. Cephalometric analysis for orthognathic surgery (COGs) dental analysis revealed intrusion of incisors and extrusion of posterior teeth confirming diverging maxillary and mandibular occlusal planes.
The objectives of the treatment were to eliminate the tongue-trusting habit and redefine perioral muscular function, close the open bite by correcting the inclinations of the maxillary and mandibular occlusal planes, correct the axial inclinations of the anterior teeth and improve facial appearance and labial balance.
Nonextraction treatment plan was decided for the patient. The patient was advised to perform tongue exercises to correct the tongue-thrusting habit. An innovative technique was decided upon which was a modification of the Enacar method of open-bite correction [Figure 2].
Preadjusted 0.022 slot mechanotherapy was used and initial wires were used for alignment. After alignment, 17 × 25 reverse NiTi was placed in the upper and lower jaw. Heavy Class II elastic was used in Enacar modification which was replaced in our case by box elastic placed in a Class II manner. About 3/16-inch box elastics were used which provided 4 oz force which was replicated from Kim's method. [Figure 3] depicts the occlusion status after the appliance removal. The total treatment time was 18 months. Posttreatment photographs have been shown in [Figure 4]. Pre- and postcephalometric changes are shown in [Table 1]. For retention, a removable Hawley appliance was placed in the upper arch and fixed lingual retainers were given in the lower arch as shown in [Figure 5]. As the patient responded well to the tongue exercise and once the bite was closed the tongue-thrusting habit stopped which meant that the patient had a secondary type of tongue thrusting. Thus, a tongue crib was not included during the treatment and retention. An open-bite bionator was given to the patient for nightwear.
| Discussion|| |
Cangialosi suggested that most patients with anterior open bite have skeletal and dentoalveolar features contributing to the malocclusion. The distinction between skeletal and dental open-bite malocclusion is a practical matter because there should be different approaches for each condition to obtain an effective and stable treatment result. Various therapeutic modalities have been proposed for the treatment of anterior open-bite malocclusion in both growing and nongrowing patients, depending on the treatment objectives. Conventional orthodontic-orthopedic treatment has been directed at inhibiting vertical maxillary growth with headgear, retarding mandibular growth with chin cups, and extruding anterior teeth with vertical elastics., Some other methods that have been used include tongue-crib therapy for habit control, posterior bite-blocks, posterior magnets, magnetic active vertical correctors, and functional appliances.
MEAW therapy for anterior open-bite malocclusion has been demonstrated to be effective in the treatment of this malocclusion. Kim et al. evaluating its long-term stability found no significant relapses in a 2-year follow-up. This mechanism was able to retract and extrude the anterior teeth and to upright the posterior teeth., It is a good option for orthodontic treatment of skeletal open bite, although the technique has little or no effect on the skeletal pattern.
In Kim's method, a precisely formed MEAW is used to obtain all objectives of open-bite correction. Originally 0.016 × 0.025” stainless steel (SS) wire was used on a double edgewise bracket with a 0.018 slot. In the current case report, we have used 0.017 × 0.015” reverse NiTi wire on 0.022 MBT prescription as it is widely used. In Kim's method, 3/16 inch heavy elastics were placed in opposing posterior teeth with the force of 50 g when the jaw is closed. This was replicated in our study using box elastics with the Class II vector of the force applying a force of 50 g.
The MEAW system advocated by Kim extrudes the anterior teeth while uprighting the posterior teeth. This leads to individual uprighting of the posterior segment. Its loops of SS wire, placed in every interdental area, have the same effect as the more resilient nickel titanium archwire used in our technique. Upper accentuated-curve and lower reverse-curve wires are used because they are simpler, less time-consuming to place, and more hygienic, and they do not irritate the soft tissue. The bite closing mechanism and the treatment results in our case were similar to those of Kim.,
Stability is the most important criterion for selecting a method of treatment and retention of open-bite malocclusions. The articles presenting the MEAW system showed only one case that was stable for at least 2 years after treatment. This would traditionally have been treated surgically due to the severity of their skeletal problems. Our method of orthodontic treatment was successful in correcting the open bites without greatly affecting the patient's facial proportions. This is one such appliance which could act as an aid to an orthodontist in the treatment of open bite.
| Conclusion|| |
Open-bite correction be it skeletal or dental in origin is difficult to treat and can be challenging for any orthodontist. Hence, this is one such mechanic which could act as an aid to an orthodontist in the treatment of open-bite malocclusion.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mizrahi E. A review of anterior open bite. Br J Orthod 1978;5:21-7.
Subtelny JE, Sakuda M. Open-bite: Diagnosis and treatment. Am J Orthod 1964;50:337-58.
Schudy FF. The rotation of the mandible resulting from growth: Its implications in orthodontic treatment. Angle Orthod 1965;35:36-50.
Garino GB. Open bite: Clinical considerations. Odontostomatol Implantoprotesi 1976;2:29-32.
Richardson A. Facial growth and the prognosis for anterior open-bite. A longitudinal study. Trans Eur Orthod Soc 1971;1:149-57.
Swinehart EW. A clinical study of open-bite. Am J Orthod Oral Surg 1942;28:18-3.
Gershater MM. The proper perspective of open bite. Angle Orthod 1972;42:263-72.
Justus R. Treatment of anterior open bite; A cephalometric and clinical study. ADM 1976;33:17-40.
Atkinson SR. “Open-bite” malocclusion. Am J Orthod 1966;52:877-86.
Linder-Aronson S. Adenoids. Their effect on mode of breathing and nasal airflow and their relationship to characteristics of the facial skeleton and the denition. A biometric, rhino-manometric and cephalometro-radiographic study on children with and without adenoids. Acta Otolaryngol Suppl 1970;265:1-132.
Lowe AA. Correlations between orofacial muscle activity and craniofacial morphology in a sample of control and anterior open-bite subjects. Am J Orthod 1980;78:89-98.
Sassouni V. A classification of skeletal facial types. Am J Orthod 1969;55:109-23.
Proffit WR. Equilibrium theory revisited: Factors influencing position of the teeth. Angle Orthod 1978;48:175-86.
Nielsen IL. Vertical malocclusions: Etiology, development, diagnosis and some aspects of treatment. Angle Orthod 1991;61:247-60.
Katsaros C, Berg R. Anterior open bite malocclusion: A follow-up study of orthodontic treatment effects. Eur J Orthod 1993;15:273-80.
Dung DJ, Smith RJ. Cephalometric and clinical diagnoses of open bite tendency. Am J Orthod Dentofacial Orthop 1988;94:484-90.
Kim YH. Overbite depth indicator with particular reference to anterior open-bite. Am J Orthod 1974;65:586-611.
Al Hamadi W, Saleh F, Kaddouha M. Orthodontic treatment timing and modalities in anterior open bite: Case series study. Open Dent J 2017;11:581-94.
Ribeiro GL, Regis S Jr., da Cunha Tde M, Sabatoski MA, Guariza-Filho O, Tanaka OM. Multiloop edgewise archwire in the treatment of a patient with an anterior open bite and a long face. Am J Orthod Dentofacial Orthop 2010;138:89-95.
Enacar A, Ugur T, Toroglu S. A method for correction of open bite. J Clin Orthod 1996;30:43-8.
Cangialosi TJ. Skeletal morphologic features of anterior open bite. Am J Orthod 1984;85:28-36.
Beane RA Jr. Nonsurgical management of the anterior open bite: A review of the options. Semin Orthod 1999;5:275-83.
Sabri R. Nonsurgical correction of a skeletal class II, division 1, malocclusion with bilateral crossbite and anterior open bite. Am J Orthod Dentofacial Orthop 1998;114:189-94.
Lopez-Gavito G, Wallen TR, Little RM, Joondeph DR. Anterior open-bite malocclusion: A longitudinal 10-year postretention evaluation of orthodontically treated patients. Am J Orthod 1985;87:175-86.
Kim YH, Han UK, Lim DD, Serraon ML. Stability of anterior openbite correction with multiloop edgewise archwire therapy: A cephalometric follow-up study. Am J Orthod Dentofacial Orthop 2000;118:43-54.
Kim YH. Anterior openbite and its treatment with multiloop edgewise archwire. Angle Orthod 1987;57:290-321.
Erdem B, Küçükkeleş N. Three-dimensional evaluation of open-bite patients treated with anterior elastics and curved archwires. Am J Orthod Dentofacial Orthop 2018;154:693-701.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]