Download Long-term stability of anterior open bite correction in mixed dentition

D. Celli, A. Manente*, A. De Carlo*, R. Deli
Department of Orthodontics,
Catholic University of the Sacred Heart Rome, Italy
*Private practice in Pescara, Italy.
e-mail: [email protected]
Long-term stability
of anterior open bite
correction in mixed
dentition with a new
treatment protocol
abstract
Background The treatment of choice for skeletal open
bite is orthognathic surgery combined with pre and postsurgicalorthodontics; however relapse can be observed
and alternative solutions are sought to avoid surgery
whenever possible. A case is reported showing an
original treatment protocol in order to obtain aesthetic,
functional and stable results.
Case report A 10.2 year old boy with anterior open bite
was treated with a Hyrax type rapid maxillary expander
on the maxilla (one month )and a lingual arch in the lower
jaw; then, grinding of deciduous molars was performed, a
lingual grid was positioned and a myofunctional treatment
(exercises) was started. The subsequent treatment phase
was achieved with a lip bumper and fixed straight wire
appliances on both arches. After 24 months of active
treatment, retainers were used to maintain the good
results achieved, which were unchanged at the long term
controls, 3 and 7 years after treatment.
Keywords Occlusal grinding; Open bite; Rapid
maxillary expansion.
Introduction
An anterior open bite is a definite lack of contact, in
the vertical direction, between the incisal edges of the
maxillary and mandibular anterior teeth [Subtelny and
Sakuda, 1964]. Several theories have been proposed
about the aetiology of open bite, including genetics,
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altered growth patterns, sucking finger habits, oral
breathing, labial interposition, enlarged lymphatic tissue,
tongue’s thrust and posture [Ferguson, 1995; Ngan and
Fields, 1997]. The term “skeletal” open bite is used when
the malocclusion is associated to specific morphologic
and functional characteristics, such as clockwise rotation
of the mandible, short posterior facial height [Arvystas,
1977; Cangialosi, 1984], increased mandibular anterior
facial height plane [Graber et al., 1985], downward
rotation of the posterior portion of the palatal plane,
counterclockwise rotation of the anterior maxilla [Nahoum,
1975], marked antegonial notching [Bell, 1971], and large
mandibular plane and gonial angles [English, 2002]. In
adult patients with skeletal open bite the treatment of
choice is orthognathic surgery combined with pre- and
post-surgery orthodontics [Proffit et al., 2000]. However
a significant relapse can also be observed with this kind of
treatment and many alternative solutions were sought to
avoid surgery when possible. These are mainly based on a
dentoalveolar compensatory mechanism and may consist
of dentoalveolar changes and correction of oral bad
habits [Mestrovic et al., 2000]. When this kind of path is
chosen, control of the vertical dimension by avoiding the
extrusion of both maxillary and mandibular molars is the
key to success. To this purpose several treatment means
can be used, such as high-pull head-gear [Firouz et al.,
1992], chin cups [Pearson, 1986], multiloop edgewise
archwire (MEAW) appliances [Kim, 1987], bite blocks
[Kiliaridis, 1990], rapid molar intruders (RMI) [Carano
and Machata, 2002] miniplates [Sherwood et al., 2002],
and occlusal grinding [Janson et al., 2008].
The aim of the present case report was to describe
the effects during mixed dentition of deciduous teeth
grinding combined with the contemporary control of
permanent molars eruption using a maxillary expansion
appliance and palatal grid to block the action of tongue
muscles on dentoalveolar remodeling.
Case report
A 10.2-year-old male patient presented to the
observation to correct the anterior open bite, complaining
about a previous orthodontic treatment. The diagnostic
and therapeutic steps adopted were the following.
• Collection of diagnostic records: extra-oral
and intra-oral photographs, plaster models,
orthopantomography, cephalometric analysis on
lateral cephalograms [Celli and Deli, 2006].
• Malocclusion correction with: RME appliance,
mandibular lingual arch, grinding of deciduous
molars, lingual grid, myofunctional exercises, lip
bumper and fixed straight wire appliance.
• Collection of the final diagnostic records: extraoral and intraoral photographs, plaster models,
orthopantomography, cephalometric tracing on
lateral cephalogram.
• Re-evaluation 3 years after completion of treatment:
European Journal of Paediatric Dentistry vol. 15/2-2014
A new treatment protocol for open bite correction
FIG. 1 Pretreatment lateral
cephalogram.
FIG. 2-6 Pretreatment facial
and intraoral photographs.
extra-oral and intra-oral photographs, plaster
models, orthopantomography, cephalometric tracing
on lateral cephalogram.
• Further re-evaluation 7 years after completion of
treatment: extra-oral and intra-oral photographs.
Cephalometric analysis
All lateral cephalograms were taken at pre-treatment
(T0), immediately post-treatment (T1) and three years
after completion of treatment (T2). The cephalometric
tracings were digitised by the authors, using TopCeph®
Apple® software analysis.
FIG. 7 Pretreatment
orthopantomography.
Diagnosis and treatment plan
The initial examination of this 10.2 year old male
patient revealed a severe open bite malocclusion, mouth
breathing, muscle deficit, lip incompetence at rest and
neutro-occlusion (Fig. 1−6). The patient’s long-standing
tongue-thrust habit had contributed to the development
of an anterior open bite of 5 mm and an overjet of 10
mm. The patient maintained good oral hygiene and
showed no evidence of periodontal disease. Radiographic
exams were prescribed: ortopantomography and lateral
cephalogram (Fig. 1, 7). Cephalometric tracing revealed a
Class III skeletal relationship and a vertical growth pattern.
Treatment objectives were to correct the anterior open
bite and achieve ideal overbite and overjet, to correct
the transversal discrepancy of the two dental arches
increasing the space for the permanent teeth, and to
achieve a Class I dental and skeletal relationship.
A Hyrax type rapid maxillary expander (RME) was
applied on the maxillary permanent first molars. The
device was positioned more occlusal in order to be
in contact with the tongue. This procedure allows the
tongue’s pressure to control the extrusion of the upper
molars. The active arms of the appliance were extended
to the canines, embracing them, and had cannulas which
European Journal of Paediatric Dentistry vol. 15/2-2014
FIG. 8 Occlusal
griding on the
deciduous molars.
permitted the insertion of a lingual grid at the end of
the activation period. A mandibular lingual arch was
applied to the lower first molars during the initial phase
of interceptive orthodontics with the objective to reduce
their normal eruption and control the vertical dimension.
Subsequently, a lip bumper was used to increase the
lower arch length and to procline the mandibular incisors
exploiting the functional activity of the tongue and
lips on teeth. During the RME treatment, the occlusal
surfaces of lower and upper deciduous molars were
grounded with a diamond bur (Fig. 8), to anticipate and
adjust the contemporary eruption of the permanent first
molars, and thus, the vertical dimension. Expansion was
completed in one month. Reduction of the open bite
could be attributed also to the lingual grid positioned after
rapid maxillary expansion (Fig. 9), which prevented the
wrong lower tongue posture, and allowed subsequently
the setting up of an oral seal during deglutition. After
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Celli D. et al.
FIG. 9 The lingual grid after rapid
maxillary expansion.
FIG. 10 Strategic brackets positioning with
straight wire appliance.
FIG. 11 Alignment with fixed straight wire
appliance.
FIG. 12-16 Facial and intraoral photographs at the end of treatment.
the first phase of treatment, the patient was instructed
to myofunctional therapy in order to correct the wrong
position of the tongue at rest and the atypical deglutition.
Treatment progress
After the discontinuation phase, maxillary and
mandibular arches were bonded with a Straightwire
022” appliance (STEP®, Leone, Florence, Italy) with
strategic brackets positioning to close the anterior open
bite. The first molars were banded, and a .016” Nickel
Titanium (Ni-Ti) archwire was placed for initial alignment
(Fig. 10, 11).
Over the following 7 months, the archwires were
stepped up to .019” x .025” Ni-Ti, .020” Australian
Stainless Steel (SS), .019” x .025” SS. The case was
finished with a sectional arch wire .019” x .025” SS on
the maxillary arch and a .016” Ni-Ti on the lower arch
in combination with intermaxillary elastics which were
worn to maintain and consolidate the correction.
Results
After 24 months of active treatment, the brackets
were debonded, and a fixed retainer was placed on
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the lower anterior arch, while a wraparound removable
retainer was made for the upper dental arch.
Post-treatment facial and intraoral photographs
showed good aesthetic and functional results (Fig.
12-16). Occlusal results and root angulations were
acceptable (Fig. 17, 18), the overjet was adequate.
Three years after treatment completion the patient
maintained a good occlusion and no malocclusion relapse
was observed (Fig. 19, 20). The orthopantomography
and the lateral cephalogram revealed a good
maintenance of the results and a harmonious dentoskeletal development (Fig. 21).
The superimpositions of records before, after treatment
and at 3 years of follow up showed an advancement of
A-point and an ANS increase (Fig. 22), and all the others
cephalometric values were corrected.
Seven years after completion of treatment the
patient underwent clinical evaluations, extraoral and
intraoral photographs to assess results and the good
stability over time in terms of aesthetics, function and
absence of relapse (Fig. 23, 24). Radiographs were not
taken, because the authors did not considered them as
essentials seven years after completion of treatment.
Discussion
The main objective of dentoskeletal open bite
treatment is mandible counterclockwise rotation, which it
is obtained by molars intrusion or control of eruption. The
orthodontic treatment of patients with hyperdivergent
skeletal phenotype should be performed early, when
they show good compliance at 7−8 years of age [English,
2002]. These were the reasons that led us to start the
treatment of this patient during the mixed dentition and
European Journal of Paediatric Dentistry vol. 15/2-2014
A new treatment protocol for open bite correction
FIG.17, 18 Orthopantomograph and ateral cephalogram at the
end of treatment.
to control molar extrusion as much as possible.
In the literature many options are described for the
early open bite treatment: device to avoid thumb’s
interposition; palatal expansion; palatal bars and/or
mandibular lingual arches to reduce posterior extrusion;
high pull; chin cups; deciduous canines extraction and
sometimes premolars extraction to allow extrusion and
back-tilt of incisors; posterior bite-plates; myofunctional
therapy; adenoidectomy and tonsillectomy [McLaughlin
et al., 2001].
Some authors suggested different combinations of
therapeutic protocols: Fränkel’s function regulator (FR4) appliance combined with myofunctional exercises
[Erbay et al., 1995]; removable appliances with lingual
FIG. 19-20 Facial
and intraoral
photographs
three years after
the completion of
treatment.
FIG. 21 Lateral
cephalogram
three years after
the completion of
treatment.
FIG. 22 Cephalometric tracings with superimposition, before the treatment (black), at the end of treatment (red), three years after the
completion of treatment (green). FIG. 23-24 Facial and intraoral photographs seven years after the completion of treatment.
grid and high pull chin cup [Quintao et al., 2006]; splints
with magnets [Kiliaridis et al., 1990]. However, the
majority of these therapeutic protocols require a good
compliance by patients and/or have side effects.
In the case reported the authors used a treatment
protocol for the correction of open bite composed of a
combination of fixed appliance and a progressive vertical
reduction (selective grinding) of the deciduous first and
second molars that required minimal patient’s compliance.
In the early treatment this innovative therapeutic
protocol employs a rapid maxillary expander with lingual
European Journal of Paediatric Dentistry vol. 15/2-2014
grid, a mandibular lingual arch on the first permanent
molars and first and second deciduous molars progressive
vertical reduction. The rapid maxillary expander is
positioned more occlusally in order to take advantage
of the tongue pressure and therefore control molar
extrusion, while its lingual grid has the goal to redirect
and stabilise tongue’s posture. Rapid maxillary expansion
is sometimes criticised in open bite malocclusions
since it increases vertical dimension and mandibular
post-rotation. However these side effects, which are
temporary and reversible, should not prevent its use
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Celli D. et al.
in open bite patients [Bishara and Staley, 1987]. Even
though a slight relapse occurs after appliance removal in
the long term, particularly in the intercanine width [Gruel
et al., 2010], the palatal expansion can be considered
stable. This could be mainly due to three factors: young
age of the patients, which led to a good orthopaedic
result; prolonged retention period, which permitted
complete closure of the palatine suture, and correction
of the tongue position within the arches following an
increase in upper arch diameter [Gracco et al., 2010].
Since anterior tongue rest position plays an important
aetiologic role in the relapse of anterior open-bite, lingual
grid and myofunctional therapy were also adopted. The
effectiveness of the lingual grid has been repeatedly
reported in the literature. Its effect changes depending on
several parameters, such as length of grid used, patient’s
age, skeletal class of malocclusion, appliance design. The
lingual grid usually causes changes in the anterior tongue
rest position, which in turn permits the correct eruption
of incisors [Smithpeter and Covell, 2010].
In this case, a mandibular fixed lingual arch was chosen
because of its ability to control the vertical development
of the mandibular molars [Villalobos et al., 2000]. The
authors did not consider the use of high pull imperative,
because it requires a good compliance by the patient and
it is not indicated in Class III malocclusions. Moreover, this
way the eruption control on upper molars is performed
quickly and comfortably. The same rationale applies for
the chin cup, which could be less effective or not indicated
[Lentini-Oliveira et al., 2007]. The authors decided to carry
out occlusal adjustments only on the deciduous molars.
Grinding is an aggressive and irreversible procedure for
the dental tissues, but the progressive vertical reduction
on deciduous molars can be considered a transitional
and minimally invasive procedure. Selective grinding, to
be effective, should be performed during the period of
eruption of maxillary and mandibular permanent teeth.
In the case reported a loss of occlusal contact between
the upper and lower molars resulted and the deciduous
teeth were grounded so that a physical contact of the
antagonist permanent molars was established.
Early treatment of open bite should allow for
compensatory craniofacial growth and reduce the need
for a second stage of treatment that might involve teeth
extractions or orthognathic surgery [Ng et al., 2008].
It was interesting and relevant that the simultaneous
presenceof wide overjet disappeared and a natural
harmony to the face of the subject was achieved.
Furthermore the good results in terms of facial
aesthetics and absence of malocclusion relapse 7 years
after completion of treatment were probably due to the
contention systems adopted: wraparound removable
retainer for the upper dental arch and fixed retainer for
the lower anterior dental arch. When incorrect tongue
posture is associated with malocclusion, habit correction
should be achieved to assist in treatment and improve
stability [Celli et al., 2007].
162
Conclusion
The presented therapeutic protocol gives good results in
terms of malocclusion correction, dentofacial aesthetics, no
relapse of malocclusion and stability 7 years after completion
of treatment. Selective grinding of deciduous teeth permits
to obtain fast therapeutic results with minimally invasive and
transitional effects for the dental tissues. Its effect, coupled
with rapid palatal expansion, mandibular lingual arch, lingual
grid and myofunctional exercises, allows bite closure, which
is followed and completed by fixed Straightwire appliances.
Any functional deficiencies or bad oral habits should be
detected and corrected at the end of treatment to ensure
long-term stability.
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