progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52

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Clinical contribution

A new type of modified Essix Retainer for anterior open

bite retention

Fakir Uzdil a , Mustafa Kayalioglu b,∗ , Egemen Kendi c , M. Serdar Toroglu d

a DDS, Research Assistant, Department of Orthodontics, Faculty of Dentistry, University of Cukurova, Adana, Turkey
b DDS, PhD, Lecturer and Clinical Instructor, Department of Orthodontics, Faculty of Dentistry, University of Cukurova,
Adana, Turkey
c DDS, PhD, Private Practice, Department of Orthodontics, Faculty of Dentistry, University of Cukurova, Adana, Turkey
d DDS, PhD, Associate Professor, Department of Orthodontics, Faculty of Dentistry, University of Cukurova, Adana, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: The most problematic malocclusion type to retain is anterior open bite although many clas-
Received 20 December 2007 sical retention appliances are known. The difficulty of maintaining the occlusion arises from
Accepted 20 November 2009 the lack of control over the tongue behavior and posture in open bite cases. In the current
article, a 2 year follow-up of 2 open-bite patients who were retained with a new type of
Keywords: retention appliance, successfully, were presented.
Open bite © 2010 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.
Retention
Essix

blocks, elastic modules, magnets, reverse curve arch wires

1. Introduction
The anterior open bite malocclusion is considered one of
the most challenging problems in orthodontics to treat and
maintain successfully. Although a geat deal of attention has
been devoted over the years to the correct diagnosis, suc-
cessful treatment and long term retention of open bites,
there is still controversy for the etiology, lack of agree-
ment over the treatment protocols, and a high percentage of
relapse.
Many treatment modalities have been proposed for the
treatment of anterior open bite malocclusions1 : high pull
headgears for inhibiting maxillary growth, chin cups for lim-
iting and redirecting mandibular growth, vertical elastics
for extruding anterior segments, functional appliances, bite
or multi loop arch wires with vertical elastics, temporary
anchorage devices for intruding posterior teeth,2 orthognathic
surgery and finally cribs and spurs for moderating tongue
behavior.3
Efficiency of open bite treatment through changing the
rest posture of tongue, whether with a crib or a spur, is still
a controversy. While Subtelny and Sakuda4 found no clo-
sure of open bite in eight patients treated for six months
with crib therapy, Epker and Fish5 stated that the crib ther-
apy is only effective in class I growing patients with good
facial balance. Justus6 reported effective closure of the bite
with crib therapy when worn for one year. Huang et al.7 also
reported encouraging results and high percentage of stability
with an average of 5 years post-treatment, even in non growing
patients.

∗
Corresponding author. Department of Orthodontics, Faculty of Dentistry, Cukurova University, Adana, 01330, Turkey.
E-mail address: mkayalioglu@cu.edu.tr (M. Kayalioglu).
1723-7785/$ – see front matter © 2010 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.
doi:10.1016/j.pio.2010.04.009
46 progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
Although not as widely used as tongue cribs, sharp spurs
have been described in the orthodontic literature since 1927.
First to mention spurs for open bite management through
modifying tongue rest posture is Rogers8 in 1927. Parker9
demonstrated dramatic open bite closure using sharp spurs
soldered to the central incisor bands. Justus3 presented suc-
cessfully treated cases and good long term stability with sharp
spurs.
Justus3,6 argues that the neurophysiologic basis of the spur
therapy, unlike the cribs that passively keeps the tongue in
a certain position, is quite different, and is based on condi-
tioned reflexes. The movement and the rest position of the
tongue that has been elicited repetitively by successive stimuli
of sharp spurs, may, after a period of time, be evoked with-
out the need of conditioning stimuli to the tongue. Thus the
tongue “learns” to stay in its place rather than being confined
in it as is the case with a crib. Justus3 also believes that the
pressure applied to the crib by the tongue, unlike the spurs,
might cause molars to move forward and cause or increase a
class II situation.
The real success of any treatment is measured with long
term stability. Lopez and Gavito10 reported that more than one
Fig. 1 – Intraoral and extraoral photographs of ‘Patient I’ before treatment. a) Right. b) Left. c) Facial photograph with smiling.
third of the patients treated with conventionally orthodontic
appliances relapsed more than three millimeters. The studies
of Dension et al.,11 Haymond et al.,12 and Hoppenreijis et al.13
unfortunately dismisses the belief that the surgical correction
is the ultimate solution for open bites. Data from the study of
Denison et al.11 suggested that the relapse caused mainly by
dentoalveolar changes, not skeletal changes. That alone indi-
cates the importance of maintaining dental correction with
retention. Denison et al.11 also suggests that the differences in
treatment response might be contributed to the musculature.
The authors proposed that the tongue posture may have been
the etiology of the open bite and that it might have been the
reason why these patients had their open bites to relapse.11
Anyhow, open bite cases are still considered the most prob-
lematic to retain, and uncertainty of the bite to stay stable is
still one of the chief problems clinicians face when finishing
such case.
In this article, we are presenting 2 year follow-up of 2 open-
bite patients who were retained successfully, with a modified,
spur-implanted Essix retainer (Raintree Essix, Inc., 1071 S. Jeff
Davis Parkway, New Orleans, LA 70125) after the conventional
and non-surgical orthodontic treatment.
 progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52 47

Fig. 2 – Intraoral and extraoral photographs of ‘Patient I’ at the end of the treatment. a) Frontal. b) Right. c) Left. d) Frontal
with spurs. e) Facial photograph with smiling.

Fig. 3 – Intraoral and extraoral photographs of ‘Patient I’ two years post-treatment. a) Frontal. b) Right. c) Left. d) Facial
photograph with smiling.
48 progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52

2. Case history

2.1. Patient I

P.B. was referred to our clinic due to inadequate incisor display

while smiling and an anterior open bite malocclusion when
she was 16 years old. Clinical and radiographic examination
revealed that the patient had a dental and skeletal class I rela-
tionship, a moderately increased lower face height, normal
upper and lower incisor inclinations, and an abnormal tongue
posture (Fig. 1). The treatment plan was non-extraction, extru-
sion of anterior segments with straight wires on a 0.018 Roth
bracket system and anterior box elastic wear. After establish-
ing a class I molar and canine relationship with adequate
bite and incisor display while smiling, anterior box elastic
use ceased, but the bite re-opened after a month. The ante-
rior box elastics were re-applied for another 2 months. When
the correct dental and aesthetic relation established again,
the patient asked for the treatment to be stopped despite the
warnings about the stability of the treatment. The total treat-
ment time was 18 months and for the retention, modified Essix
retainers with spurs were fabricated and applied (Fig. 2). The
patient was instructed to wear the retainer full-time for the
first year except for eating and drinking and only at nights
(sleeping hours) for the following 12 months. She was moving
to another city and could not to travel for the routine reviews. Fig. 4 – Superimposition of the post-treatment (regular line)
When the patient was able to come for her recall appointment and the 2 years post-retention (dashed line)
after 2 years post-treatment, lateral cephalometrics had been cephalometrics.

Fig. 5 – Intraoral and extraoral photographs of ‘Patient II’ before treatment. a) Frontal. b) Right. c) Left. d) Facial photograph
with smiling.
 progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52 49

Fig. 6 – Intraoral and extraoral photographs of ‘Patient II’ at the end of the treatment. a) Frontal. b) Right. c) Left. d) Frontal
with spurs. e) Facial photograph with smiling.

Fig. 7 – Intraoral and extraoral photographs of ‘Patient II’ two years post-treatment. a) Frontal. b) Right. c) Left. d) Facial
photograph with smiling.
50 progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
obtained. Post treatment and two years follow up superim-
position revealed no significant change in the dentoalveolar
structures (Figg. 3 and 4).
2.2. Patient II
E.S. was referred to our clinic with the chief complaint of
mild anterior crowding of the lower and upper arches. In the
clinical and radiological examination of the 21-years old girl,
dental and skeletal class I relationship, moderately increased
lower face height, normally inclined upper and lower incisors
with an open bite malocclusion, inadequate incisor display
while smiling was observed (Fig. 5). Non-extraction with an
0.018 Alpern bracket system and anterior box elastics to close
the bite was the treatment plan. After the leveling and align-
ing phase of treatment, anterior box elastics were used for 3
months and the correct incisal overlap established. The same
problem as the previous patient occurred when the use of box
elastics ceased; the bite reopened. Box elastics were re-applied
and when the overbite was reestablished the patient asked
for her treatment to be finished. Since she was marrying, she
didn’t want braces after her wedding. Again the patient was
warned about the risk of relapse, and a modified Essix retainer
with spurs was fabricated (Fig. 6). The total treatment time was
16 months. The patient was instructed to wear the retainer as
mentioned in the first case. When the patient was reevalu-
ated 2 years after treatment, cephalometric superimposition
revealed that the occlusion was stable (Figg. 7 and 8).
Fig. 8 – Superimposition of the post-treatment (regular line)
and the 2 years post-retention (dashed line)
cephalometrics.
The author(s) declare that the work has been realized in
agreement with the Helsinki Declaration principles and that
the Informed Consent has been achieved from all the partici-
pants involved in the study.
3. Fabrication of the spur-implanted Essix
Retainers
Following debonding and polishing procedures, upper and
lower impressions were taken. Before the fabrication of Essix
plate on the upper cast, a small amount of dental stone was
added near the incisive papilla region in order to create space
for insertion and securing of the wire. C type Essix plates
(0.40 ) were fabricated over the casts and trimmed. A 0.9 mm
stainless steel laboratory wire is bent in “U” shape with a small
helix at the base for retention. The wire is heated and inserted
to the space created on the lingual side of incisors. The hot
wire easily punctures, and when cooled, sticks to the Essix
plate. A small amount of self-curing acrylic is applied to fill
the rest of the space in order to keep the wire firmly in place.
The spurs are sharpened and polished accordingly after the
curing of the acrylic (Fig. 9).
4. Discussion
Whatever the treatment modality is, stability and retention
are the main concern for any open bite patients. The studies of
Justus3 and Huang et al.7 suggest that when the function or the
posture of the tongue is addressed with the help of intraoral
spurs and cribs, improved long-term stability can be achieved
in both growing and non-growing patients.
Open bite retention, especially in patients with higher
relapse tendency, can be carried out by active retention, which
includes use of high pull headgear to upper molars during
retention, an appliance with bite blocks between posterior
teeth (an open bite activator or bionator), a tooth positioner,14
or a crib integrated Hawley.15 Bonded retainers extended
through posterior teeth, can also be used. A headgear during
retention might be difficult for the patient to tolerate, longer
bonded retainers are both hard to place and maintain and
unfortunately not so much effective for controlling vertical
relapse. A positioner can maintain the overbite even improve
it through mild force applied to the posterior segments. But
positioners require considerable amount of laboratory fabrica-
tion time, and therefore very expensive.14 Moreover, because
of their bulk, patients often have difficulty wearing a posi-
tioner and also, positioners do not retain incisor irregularities
and rotations as well as standard retainers.14
Essix retention appliances are widely used since their
introduction in 1993.16 The researches suggest that the Essix
appliances are as effective retention appliances as Hawleys
and bonded retainers.15,17 Over the time Essix appliances not
only used as retainers but also reported to be useful for many
other applications.15
The new modified appliance has primarily two feature tar-
geted especially for maintaining the over bite: (1) the slight
thickness of the appliance over the posterior teeth creates a
bite block effect and (2) the implanted spurs act as a tongue
posture moderator. Justus3 stated that if the patient did not
 progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52 51

Fig. 9 – Fabrication of spur-implanted Essix retainer. a) Upper cast. b) Bump on the lingual side of incisors. c) U shaped wire.
d) Essix plate for the upper cast. e) Insertion of the wire. f) Addition of self-curing acrylic. g) Retainer after polishing.

have spurs during treatment, a spur incorporated retention
appliance might not be successful because he argues that the
spurs works only if they are worn full time and its not likely for
a removable retainer to be worn full time. With a well informed
patient about the risks of relapse, the higher esthetic accept-
ability and comfort of an Essix appliance might be the answer
for those concerns about cooperation.
The duration of the spur treatment is another concern.
Haryet et al.,18 in a 3 years follow up study about thumb suck-
ing, found 91% success rate when cemented spurs used for 10
months compared to 64% when the appliance used for only 3
months. Justus3 suggests the spurs to remain at least 6 months
after a proper over bite relation is achieved. Both patients pre-
sented in our report instructed to wear their modified retainers
full time for 12 months and only at nights for the following 12
months, which according to Justus more than enough.
Ceasing the open bite mechanic during the end of treat-
ment while the patient still have brackets is always a sensible
approach to have an insight about the relapse tendency.
Patients presented in the report had their open bites relapsed
when they cease using anterior box elastics. Both patients in
the current report wanted to remove their appliances, due
to personal reasons, before any overcorrection or any other
means to keep bite stable is made, when they believe they
have acceptable over bite, despite having history of consider-
able relapse and despite being strongly advised to continue
treatment, and warned about the risks of relapse.
A positioner for night time together with bonded lin-
gual retainers was the first retention modality offered to the
patients. Because they both refused to use the positioners for
their bulk, new appliance was designed. The modified Essix
retainer is very easy to fabricate and aesthetically very pleas-
ant and acceptable for the patient. Although the appliance
seems very uncomfortable, even torturous in the first instance,
the patients were unlikely to report any complaints after the
first few days. Almost certainly, after some point, the patient
subconsciously places the tongue away from the sharp edges
and does hardly feel any discomfort.
It was well known that the classical retention appliances,
methods and limitations were in keeping with the stable
52 progress in orthodontics 1 1 ( 2 0 1 0 ) 45–52
occlusion in open bite patients. As is the case with all case
reports, two patients are by no means sufficient to confirm a
sound scientific basis. But, especially the stability attained in
these two patients who both had a high relapse tendency, at
least gives us some insights about the possibilities with the
new type of Essix retention appliance.
5. Conclusions
The present findings provide evidence that modified Essix
retainers with spurs are effective in maintaining the overbite
after the openbite closure.
Conflict of interest
The authors have reported no conflicts of interest.
Riassunto
La malocclusione nella quale è più difficile operare una contenzione
efficace è il morso aperto anteriore, nonostante siano disponi-
bili numerosi apparecchi di ritenzione. La difficoltà di stabilizzare
l’occlusione deriva dalla mancanza di controllo sul comportamento e
sulla postura della lingua nei casi con morso aperto. Nel presente stu-
dio viene presentato un follow-up di 2 anni su due pazienti con morso
aperto nei quali è stata fatta contenzione con un nuovo dispositivo
di ritenzione.
Résumé
Le type de malocclusion le plus difficile à avoir stable pendant la
contention est l’openbite antérieure bien que beaucoup d’appareils
classiques de contention soient connus. La difficulté de maintenir
l’occlusion résulte de l’absence de contrôle du comportement et de
la posture de la langue. Dans l’article courant, on present des con-
trols à 2 ans de patients avec une retention nouvelle après traitement
d’openbite.
Resumen
El tipo de maloclusión más complicado de mantener, es la mordida
abierta anterior aunque si se conocen muchos aparatos de retención
clásica. La dificultad de mantener la oclusión es causada la falta de
control sobre el comportamiento de la lengua y la postura en los casos
de mordida abierta. En este articulo se presenta un nuevo retenedor,
con buenos resultados.
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