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(J Ind Orthod Soc 2001 ; 34:130·132)
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Open Bite - "An Open Challenge"
James Sunny P,
BOS· ,
Reena J. Rodrigues.
MOS··,
Ashima Valiathan,
BOS. ~OS . MS···
Open Bite malocclusion is a common clinical entity and has long been recognized as
one of the more difficult problems to treat. Patient selection and Irealmenl principles for
non surgical open bite treatment are discussed.
Kim 3 is found 10 be a better diagnostic criterion for
the presence of skeletal open bile than any other
cephalometric measurements or ratio. Normal owrbite
depth indicator value is 74°± 6.07. A value of 68° or
less indicates skeletal open bite tendency.
Even though the incidence of open bite is ION,
it is high on the clinicians list because of its potential
lor frustration and failure.The frustration stems from
conflicting reports that lead to ambiguity with
indecision. Any clinician's attempt to correct open
bile by following a routine rule book will eventually
lead to relapse, failure or questionable compromise.
The objective of !realment for an anterior open
bite malocclusion should be the creation of an
overlapping relationship. The poSition of maxillary
central incisors relative to the lip line must be al or
near the 4 mm norm as measured. The maxillary
cental incisor edges, therefore should be the guide
for the anterior limit of upper occlusal plane. The lONer
occlusal plane should Ihen follow the upper so that
there is a sufficient overlap between maxillary &
mandibular inciso(s3.
Dental vi s skeletal Open Bite
Open bites are generally skeletal or dental.
Dental open bites are associated with the following
characteristics : normal craniofacial pattern , proclined
incisors , undere rupted anterior teeth , normal or
slightly excessive molar height and thumb or finger
sucking habits .
T he craniofacial characteristics most
consistently associated with the skeletal open bite
are increased mandibular plane angle, increased
gonial angle , long anterior facial height, increased
total facial height, palatal plane tipped up anteriorly
and retrognathic mandible.1. 2
A dental open bite can be treated wi th
orthodontics alone . The true skeletal open bite
requires a coordinated orthodontic and orthognathic
surgical approach to achieve a stable occlusion.
Postgraduate Student, Dept. 01 Or thodontics & DentolaclaJ
Orthopaedics. College 01 Denial Surgery. Manipat . 576 119.
Karnataka.
Most open bites show some aspects of both
dental and skeletal types. The difficulty lies in
distinguishing whether a patient should be classified
as a denial or a skeletal open bite. The importance
of making such a distinction becomes evident when
formulating a treatment plan .
•• ASSL Prolessor, Dept. of Onhodontics & Oenlolacial
O!1hopaedics, College 01 Denial Surgery. Manipal ' 576 119,
Karna taka.
• •• Prolessor and Head. Director of Postgraduale Studies. Depl.
01 O"hQdontics & Denlolaci al O"hopaedics, College 01
Dental Surgery. Manipal . 576 I t9. Karnataka.
The overbile depth indicator (001) proposed by
130
(J Ind Orthod Soc 2001; 34:130-132)
Treatment modalities
Dental Open bite : Orthodontics has tittle
influence on the skeletal frame work, but there is a
great deat of benefit that can be derived from tooth
mOlement in the correction of open bites, particularly
in the nongrowing (adult) patient.
Sarver and Weissman· discussed clinical
results using extraction and retraction for dental open
bite correction . Patients who are candidates for this
type of therapy should meet the following criteria:
1. Proclined maxillary or mandibular Incisors
2. Little or no gingival display on smile
3. Normal craniofacial panern
4. No more than 2 - 3 mm 01 upper incisor exposure
at res!.
Kim Y.H5 proposed the use of multi loop
edgewise arch wire (MEAW) as a resource to treat
cases of dental open bite without the benefit of
surgical intervention. Open bites are corrected by
altering the occlusal plane and distally uprighting the
posterior teeth. A modification of Kim's technique .
using 016 IC 022 upper accentuated curve and lower
reverse curve Nili archwires was used by Enacar
etal'. This therapy not only prevents extrusion of
posterior teeth but actually intrudes them. especially
the lower posterior teeth.
Skeletal Open Bite
There are also a number of recommended
techniques for orthodontic treatment of the patient
with skeletal open bite. II has been postulated that
1mm of intrusive vertical movement of the molars
results in approximately 3 mm of bite closure by
mandibular counterclockwise rotalion 7 •
Functional Appliances: According to Rolf &
Christine Frankel' . the functional concept of
!reatmenl used in general orthopaedics is based on
clinical experience that poor postural behaviour plays
an important causative role in development of open
bite. Therefore the primary therapeutic problem in
Functional orthopaedics is to overcome these
functional disorders .
Some consider the Functional Regulator
Appliance (FRIV) to be mainly effective in changing
dentoalveolar structures. but produces no significant
sketetal changes9. Other studies have shown that
the usual downward and backward rotation of
mandible in patients with skeletal open bite can be
changed by FR - IVTherapy1D.
Activator and Bionator have also been used
for correction of these problems. Stellzig et al l l
131
presented the use of a modified activator - -Elastic
Activator" for open bite correction. By stimulating
orthopaedic gymnastics (Chewing gum effect). the
elastic activator intrudes upper and lower posterior
teeth .
Passive posterior bite Blocks
Th is treatment approach is claimed to be
effective by inhibiting the increase in height of the
buccal dentoalveolar process, thus preventing
downward and backward rotation of mandible. It is
most effective before cessatIon of growth of the jaws.
Removable spring loaded bite blocks are also a
modification of the basic design12.
Magnets
The use of samarium cobalt magnets
embedded in acrylic have been considered superior
to the static bite block appliance. Dellinger 1) has used
an -active vertical corrector" which works as an
energized bite blocks. Energy system is obtained
by the repelling force of samarium cobalt magnets.
Cemented magnets have been on average,
twice as effective as the spring loaded appliance
(3.0 mm improvement in over bite vIs 1.3 mm)12.
Varun Kalra, Burstone & Nanda1• have evaluated the
effects of fi xed magnetic appliance on dentoalveolar
complex . Treatment resulted in increase length of
mandible. intrusion of teeth. upward and forward auto
rotation of mandible and creation of temporary buccal
cross bite caused by shearing forces of repelling
magnets.
Use of magnetic activator device MAD (IV)l~
acts with not only posterior repulsive magnets but
also anterior attractive magnets, thus having the
advantage of guiding the mandible to a midline centric
position .
Extra Oral Forces
The use of high pull headgears , maintains the
vertical position of maxilla and inhibits the eruption
of maxillary posterior teeth . Duration of wear is 14
hours/day with a force greater than 12 ounces per
side.
Another appliance that may be considered is
the verticat pull chin cup. Pearson 16 evaluated 79
patients with excessive vertical dimension and
backward growth rotation tendencies . The chin cup
was effective in reducing the mandibular plane angle
and facial height during treatment.
Implants
Osseointegrated implants have been
successfully used with intrusion mechanics in open
132
Open Bite - "An Open Challenge" ' James Sunny p. Reena J. Rodrigues. Ashima Valialhan
bite malocclusions 10 prevent extrusion of posterior
teeth l 7. Titanium miniplates implanted in the buccal
cortical bone in apical regions of 1st and 2nd molars
have been shown 10 produce as much as 3 to 5 mm
of molar inlrusion ls .
Conclus ion
Although correction 01 an open bile cannol
always be perfectly mai ntained. there are many
patients who will derive considerable benefit from
treatment with only orthodontic appliances. Prudent
selection of palients and adhe rence to sound
orthodontic principles can produce very acceptable
and at times, outstanding treatment results.
References
1. Subtelny J.D .. Sakuda M. Open Bite: Diagnosis and
Treatment. Am . J. Onhod. 1964. 50 : 337·358.
2. Nahoum H.1. Vertical proportions: A guide for
prognosis and treatment in anterior open bite. Am.
J. Orthod. 1977.72: 128 · 146.
3. Kim Y.H . Over bite depth indicator with particular
re ference to anterior open bite. Am . J. Orthod. 1974,
65: 586 · 61l.
4. Sarver PM., Weissman 8.M. Non·surgicaltreatment
of open bite in non·growing patients. Am . J. Orthod.
1995. 108: 651 ·659 .
5. Kim V.H. Anterior open bite and its treatment with
multiloop edgewise arch wire. Angle Orthod. 1987.
57: 290 . 331 .
6. Enacar. Correction of anterior open bite using Niti
wires. J. Clin. Orthod. 1996. 30: 43 - 48.
7. Kuhn R. Control of anterior vertical dimension and
proper selection of extraoral anchorage. Angle
Orthod . 1968.38: 340·349.
8. Rolf Frankel and Christine Frankel. A functional
approach to treatment of skeletal open bite. Am . J.
Orthod. 84: 54 - 68.
9. Haydar B .. Enacar A. Funclional regulatory therapy
in treatment of skeletal open bite. J. Nohow. Univ.
8ch. Dent. 1992,34: 278 - 287.
10. Erbay E.. Ugur T.. Ulgen M. The effects of Frankers
Functional Regulatory Therapy (FR4 ) on the
treatment of Angle class I skeletal anterior open bite
malocclusion. Am , J. Orthod. Dentofacial Ortho. 1995.
108: 9 - 21.
11 . Stellzig. Elastic activator for treatment of open bite.
Br. J. Orthod. 1999.26: 89 - 92.
12. Kuster R.. Ingervall B. The effect of treatment of
skeletal open bite with two types of bite blocks. Eur.
J. Orthod. 1992. 14: 489 - 499.
13. Dellinger E,L. Clinical assessment of active vertical
corrector. A non-surgical alternative for skeletal open
bite treatment. Am. J. Orthocl. 1986.89: 428 - 436.
14. Varun Kalra, Burstone. Nanda. Effects of fixed
magnetic appliance on dentoalveolar complex. Am.
J. Orthod . 1989.95: 467 - 478.
15. Darendeliler, SemaYuksei. Open bite correction with
the magnetic activator device IV. J. Clin. Orthod.
1995.29: 569 · 578.
16. Pearson l.E . Vertical cont rol i n fu lly banded
orthodontic treatment. Angle On hod. 1986. 56 :
205 - 224 .
17. Prosterman B. Prosier man L. Fischer R. The useof
implants for orthodontic correction of an open bile.
Am. J. Orthod. 1995, 107: 245 - 250.
18. Richard A. Beane Jr. Non-surgical Management of
the Anterior Open Bite: A review of options. Seminars
in Orthodontics 1999. 5: 279 -283.
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