To cite: Sanjeev Kumar
1Sanjeev Kumar Verma, 2Deepika R.S Bais, 3Shubhra Pathak
Verma, Deepika R.S Bais,
Shubhra Pathak
1Professor,2,3Junior Resident
Department of Orthodontics and Dental Anatomy, Dr. Z. A. Dental College, Aligarh Muslim University,
Non-Extraction Approach to
Aligarh, India.
Correct the Open Bite
J Contemp Orthod 2020;4(4):
Introduction: An adult female patient with anterior open bite appears dento- alveolar component
with skeletal class III malocclusion , hyperdivergent growth pattern and tongue thrusting habit.
Objective: Aim of this case report is to show the effect of habit breaking appliance along with
Received on:
the fixed orthodontic treatment in a non- growing Class III patient with dental open bite with
marked improvement in overjet, overbite and profile of the patient.
Accepted on:
Results: The goal of the treatment has been achieved according to patient’s desire and
satisfactory interdigitation.
Source of Support: Nil
Conclusion: The treatment resulted in an aesthetic, functional, and stable occlusion, along with
Conflict of Interest: None
an improved facial profile.
Keywords: Non-extraction
orthodontic, open-bite, non-growing, class III malocclusion.
open bite. Literature and different authors have described
different treatment modalities depending on the severity and age
Now-a-days, many adult patients are seeking orthodontic
of the patient for both dental and skeletal open bites including
treatment as it plays a major boon in modifying and
lingual cribs, myofunctional appliances, wires, fixed appliances,
improving the facial esthetics. One such factor which majorly
elastics, aligners with elastics, surgeries etc.13-14 Mizrahi and
affects the facial esthetics is the vertical overlap of teeth.
Ngan have also emphasized on the removal of etiology as the
According to Profitt, overlap of the incisors where the incisal
major corrective approach. Many studies have found favorable
edges of the lower teeth lie slightly below the cingulum of
results in the treatment of dental open bite using habit breaking
upper incisors is known as overbite, however, if this vertical
appliance and fixed orthodontic treatment.
overlap is not present then the condition is known as Open
bite. The term “open bite” was coined in 1842 by Caravelli.1-2
Aim of this case report is to show the effect of habit breaking
It may be seen in a single tooth or a group of teeth.3 It is
appliance along with the fixed orthodontic treatment in a non-
found more commonly in African and Afro-Caribbean
growing Class III patient with dental open bite with marked
populations4 with overall prevalence ranging from 25% to
improvement in overjet, overbite and profile of the patient.
38%.17% of the patients seeking orthodontic treatment show
up with this problem5-7 which along with the esthetics, poses
problems with anterior and canine guidance, tearing of food,
A female patient aged 18 years presented to the department for
language problems and TMJ disorders.
the initial consultation with the chief complaint of ‘improper
facial esthetics with inability to cut food’. Her medical and
Due to the difficulty in both treatment and bite closure
dental histories were non-significant showing good state of
retention, anterior open bite is considered as a complex
general health with no signs of temporomandibular dysfunction
malocclusion. It develops as a result of interaction of various
and good oral hygiene. In terms of functional activity, she
factors such as skeletal disharmonies, tongue thrust and digit
presented alteration in the tongue position during swallowing
sucking habits, airway obstruction etc.8-11 It can be divided
showing a habit of tongue thrust with dental indentations on both
into 2 categories - Dental open bite, where skeletal pattern
the sides of tongue.
does not contribute to the malocclusion and skeletal open bite,
which is a result of influence of skeletal pattern with
elongated lower third of face.12
Pretreatment extra-oral examination revealed mesocephalic head
Dental open bite is usually seen from canine to canine with
form with mesoprosopic facial pattern, convex profile with
protruded and proclined maxillary anterior due to prolonged
divergent pattern and incompetent lips Fig (1). Smile of the
oral habit and is easier to treat in comparison to the skeletal
patient was symmetric with reduced gingival and incisal display
Journal of Contemporary Orthodontics, Oct-Dec 2020; 4(4):11-15
Verma et al
on smiling showing a low smile line and high smile index.
Lateral view revealed a skeletal Class III hyperdivergent
growth pattern with prognathic mandible.
Her intraoral examination demonstrated a symmetric
shaped maxillary arch with spacing in anteriors and prominent
midline diastema of almost 4mm. Mandibular arch was also
symmetric and
‘U’ shaped with spacing in anteriors and
rotations in premolar region. The molar relation was Angle’s
Class III on right side and Class I on left side with Class I
canine relation bilaterally, reverse overjet of almost 2.5 mm
Figure (3) Pre-treatment radiographs (Lateral Cephalogram and OPG)
and open-bite of 4mm. Midlines were discordant with lower
midline shifted to left by 2mm with gingival recession and
bone loss in relation to
31 and
32 showing marked
proclination in mandibular anteriors. Fig
(2) Swallowing
pattern of the patient showed tongue thrust habit with tip of
tongue touching the anteriors instead of palate and thus
providing a thrust for both proclination and spacing of
Table (1) Cephalometric findings showing Pre-treatment Skeletal Class
III base
Figure (1) Pre-treatment Extraoral photographs
Figure (2) Pre-treatment Intraoral photographs
The panoramic radiograph revealed developed 3rd molars in
all the quadrants with generalized bone loss. Fig (3) Lateral
Cephalogram of the patient showed CVMI-Stage V with
Cephalometric findings showing a skeletal Class III pattern
with ANB of 1.5° and Wits reduced to -6 mm and APP-BPP
reduced to 0mm with prognathic maxilla and mandible Table
(1). Patient had a hyperdivergent growth pattern with
Frankfort -Mandibular plane angle increased to 34° and SN-
MP angle increased to 38°. Gonial angle of the patient was
increased to
135°increased lower facial height. Maxillary
incisors were proclined with a value of U1-NA 6mm/31°
while the mandibular incisors were both protruded and
(2) Cephalometric findings showing hyperdivergent growth
proclined with a value of L1-NB being 10mm/40° and IMPA
pattern and pre-treatment proclined maxillary and mandibular anteriors
increased to 100° Table (2).
flexible round wire and settling elastics Fig (5). A panoramic
radiograph was taken to evaluate the roots and their angulations
Cessation of tongue thrust habit
and after getting satisfactory results the patient was debonded
Achieve Class I molar and canine relationship bilaterally
after a period of 26 months.
Correction of spaced dentition
Correction of reverse overjet
Correction of open bite
Figure (4) Torquing of lower anteriors
Align and level the maxillary and mandibular dental
Correction of protruded lips and to attain optimum soft
tissue relationship
Figure (5) Settling carried out using round wire and settling elastics
At the end of the treatment all the treatment objectives were
Use of fixed orthodontic appliance was planned along with
achieved with a Class I molar and canine relationship bilaterally,
fixed tongue crib to guide the movement of tongue and reduce
overjet of 2mm and overbite of 20% shown in Fig (6) and (7)
its effect on the anteriors. The crib was given from the starting
and patient was highly satisfied with her facial esthetics. Fig (8)
of treatment and was continued throughout. Elastics were
used at the end to attain a proper overbite and occlusion. MBT
and (9) shows extraoral and intraoral comparison of the patients
prescription was planned except for the mandibular anteriors
pre and post- treatment photographs.
as their roots were already prominent due to which standard
After removing the fixed appliance, retainers were given in both
edgewise was used in the lower anterior segment.
the arches with removable Hawley’s retainer with a tongue crib
in the upper arch and a fixed canine-to-canine bonded lingual
retainer in the lower arch and she is been recalled every month
Pre-adjusted straight wire appliance was chosen for treatment
for reevaluation.
in this case except for the lower incisors where standard
edgewise brackets were used due to their root prominence.
MBT appliance with 0.022 × 0.028˝ slot was used. The
treatment started with banding and bonding with a fixed crib
for tongue control that was soldered to the molar bands
followed by leveling and Alignment that was done with a
series of Nickel-Titanium wires followed by stainless steel
wires like
0.016˝ nickel-titanium,
0.018˝ Nickel titanium,
020” Nickel titanium,
0.017×0.025˝ nickel titanium,
0.019×0.025˝ nickel titanium and 0.019×0.025˝ stainless steel
arch wires in a sequence. Once the rotations were corrected,
figure of eight was continuously done so as to consolidate the
space and reduce the proclination of incisors. The open bite
went on reducing due to continuous figure of 8 and use of
Figure (6) Post treatment Extraoral and Intraoral photographs
fixed crib. After proper alignment at 19 x 25 stainless steel
lingual root torquing was started in the mandibular arch in
order to reduce the root prominence. Then at 21 x 25 stainless
steel torquing was done Fig
(4). Due to reduction in
proclination of the lower anteriors and also continuous
torquing, the root recession also got corrected by itself. This
was followed by the use of diagonal elastics for the correction
of midline that was off by almost 1mm. Finally after all the
corrections, finishing & detailing phase was carried out using
Figure (7) Post treatment radiographs (Lateral cephalogram & OPG)
Journal of Contemporary Orthodontics, Oct-Dec 2020;4(4):11-15
Verma et al
giving a fixed palatal crib that helped us in controlling the nature
of tongue. Different studies have shown a positive and effective
result with a palatal crib although the skeletal effects and
stability has been controversial and have varied among
studies.21,22 However, in our case the use of palatal crib in
combination with fixed orthodontic treatment showed great
results. We opted for a non-extraction approach as the arch was
quite wide and the amount of space available in the arch helped
us in getting a positive overjet and overbite with satisfactory
improvement in the profile of the patient. The crib-fixed
treatment combination along with the elastics helped us in
improving the U1- NA from 6mm/31° to 4.5mm/ 25°and L1-NB
from 10mm/40° to 5mm/22°. IMPA got reduced from 100° to
Figure (8) Pre and Post treatment Extraoral comparison
83° and inter-incisal angle improved from 108° to 130°. Also,
upper and lower lip fall were seen that added on to the
improvement in profile.
Till date the results achieved are stable however, in such cases
stability has always been a concern as chances of relapse are
always high due to growth related and etiological characteristics
that are unlikely to change. According to a report by Lopez-
Gavito, more than
35% of anterior open bites treated with
Figure (9) Pre and Post Treatment intraoral comparison
conventional appliances relapsed 3mm or more at 10 years post-
retention.23 However, a good stable occlusion adds on to the
stability in orthodontic cases in our case also we expect it to be
Open bite is considered as one of the most difficult
quite stable over a longer period of time.
malocclusions to manage not only due to the problem in
attaining positive overbite but also due to difficulty in
maintaining the results achieved as there are high chances of
Open bite is a multifactorial problem.There is no best time of
relapse. Hence, 2 factors must essentially be analyzed for its
treatment, functional problems should be treated as soon as
treatment -
objectives of the treatment and stability of the
possible.Treatment objectives must be definitively established,
specific case. Management of skeletal open bite is even more
elimination of etiologic factors and pressure habits should be
difficult as more the severity of open bite in a non-growing
achieved followed by correction of dental and skeletal
patient higher is the chances of surgical approach where the
dysplasia.Open bite problems of skeletal nature in growing
treatment aims at intrusion of maxillary anteriors and
patient require orthopedic intervention. Severe skeletal open bite
counterclockwise rotation of mandible.
in nongrowing patients usually requires treatment with
Several treatment approaches are available for its treatment
orthodontic-surgical procedures. The treatment of open bite
but what more important is to detect the cause and then to
remains a challenge to the clinician, and careful diagnosis and
work towards its removal and malocclusion correction.15-18
timely intervention will improve the success of treating this
malocclusion.Despite the statistically significant relapse of
The patient's compliance is equally important along with the
anterior open bite, clinically significant stability was found in
long-term wearing of appropriate retainers to maintain the
66.7% of the patients, there are many patients who will benefit
beautiful results achieved.
considerably from treatment with only orthodontic appliances.
Depending on the patient’s facial pattern and anatomical
characteristics, interruption of a non-nutritive oral habit
before 5 years of age helps in the natural correction of anterior
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