Vertical Discrepancy

Dr. Tassneem Elagib, MSD

(Orthodontics, Republic of Korea),
B.D.S (Sudan)
Anterior Open
Bite
Introduction
• An open bite is said to exist when there is a lack of vertical
overlap between the maxillary and mandibular teeth.
• In normal circumstances the mandibular dental arch is
contained within the maxillary arch.
• The classification and treatment will depend mainly on the
location, etiology and the extent of the open bite.
• An open bite present in the anterior segment is the most
unesthetic.
CLASSIFICATION OF OPEN
BITE
Based on the location of the open bite, they may be
classified as:
• Anterior open bite
• Posterior open bite.
Based on the dental or skeletal components involved, open
bites can be classified as:
• Skeletal open bite, or
• Dental open bite.
ETIOLOGY OF ANTERIOR OPEN BITE

Habits
• Anterior tongue thrust
• Digit sucking habits
• Mouth breathing
Abnormally increased tongue size
Inherited or acquired, abnormal growth pattern
 Majority of the anterior open bites encountered in day to-
day clinical practice are dental in nature. They are usually
associated with a local cause, which has to be removed for
the correction of the malocclusion
Features of dental anterior open bites
Intraoral features:
1. Open bite limited to the anterior segment, often
asymmetrical.
2. Proclined maxillary and/or mandibular incisors.
3. Spacing between maxillary and/or mandibular anteriors.
4. Narrow maxillary arch is a possibility.
Features of skeletal anterior open bites
Extraoral features:
1. Long face due to increased lower anterior face height
2. Incompetent lips
3. An increased mandibular plane angle
4. An increased gonial angle
5. A short mandible is a possibility
6. The angle formed by the mandibular and maxillary
planes is also increased
Cephalogram and profile photographs of a patient with a skeletal anterior open bite
CORRECTION OF ANTERIOR OPEN BITE
The appliances used for the corrections of anterior open bites
are usually used in conjunction with the habit breaking
appliances used for the elevation of the underlying etiologic
cause.
Spontaneous correction of a mild anterior open Fixed appliances used along with a fixed tongue
bite with the wearing of a removable habit breaking crib for the correction of anterior open bite
appliance
 Box elastics of medium to heavy forces may be used for the
correction of mild to moderate open bites.
 A chin cup with a vertical pull head cap may be used for the
correction of anterior open bites in the pre-adolescent age
group. Skeletal open bites in adults should be treated
surgically after the correction of the existing habit.
Pre-adolescent patient with Patient wearing the chin cup with a
skeletal anterior open bite vertical pull head cap
POSTERIOR OPEN BITE

Posterior open bites are characterized by a lack of contact

between the posterior teeth when the teeth are brought in
occlusion. Posterior open bites are relatively rare and are
caused mainly because of a lateral tongue thrust habit or
submerged/ankylosed posterior teeth.
Posterior open bite caused by a lateral tongue thrust habit
Since lateral tongue thrust is the most frequently encountered etiologic
factor, the use of lateral tongue spikes either fixed or incorporated in a
removable appliance, form the first line of treatment.
Vertical elastics used along with fixed orthodontic appliances can be
used once the lateral tongue thrust habit has been controlled. It has
been noted that, most of the posterior open bites close spontaneously
following the cessation of the tongue thrust habit.
Lateral tongue spicker incorporated in an
acrylic appliance
Oral Habits and Open Bites
• An open bite in a preadolescent child with normal vertical facial
proportions is most likely caused by a habit such as thumb- or finger-
sucking.
• A disproportionately large lower anterior face height with a severe
anterior open bite indicates a skeletal problem (excessive vertical
growth and rotation of the jaws).
• Many of the transitional and habit problems resolve with either time or
cessation of the sucking habit. Open bites that persist until adolescence,
except those related to habits, almost always have a significant skeletal
component. These are termed complex open bites and require advanced
treatment methods
 Effects of Sucking Habits
• During the primary dentition and early mixed dentition years, many
children engage in digit- and pacifier-sucking, with these behaviors being
more prevalent in girls and non-breastfed children. Although it is possible
to deform the alveolus and displace the teeth during the primary dentition
years with a prolonged and intense habit, much of the effect is on
eruption of the permanent anterior teeth.
• The extent to which such a habit affects eruption depends on its frequency
(hours per day) and duration (months or years).
• With frequent and prolonged sucking, maxillary incisors are tipped
facially, mandibular incisors are tipped lingually, and eruption of some
incisors is impeded.
• As long as the habit stops before the eruption of the permanent
incisors, most of the changes resolve spontaneously.
A) to (D) Photos at 1-year intervals of a child who stopped sucking his thumb at the time
of the first photo. Gradual closure of the open bite, without a need for further
intervention, usually occurs in patients with normal facial proportions after habits stop.
Nondental Intervention
• As the time of eruption of the permanent incisors approaches, the
simplest approach to habit therapy is a straightforward discussion
between the child and the dentist that expresses concern and includes an
explanation by the dentist of the problems caused by a prolonged finger
habit.
• This “adult” approach may be enough to terminate the habit during this
first part of the transition to the permanent dentition, but is most
effective with older children.
• Another level of intervention is reminder therapy. This is for the child who
wants to quit but needs help.
An adhesive bandage can be applied over the end of the finger to remind the child not to
suck and to reduce the enjoyment. The bandage should be anchored at its base for
retention with waterproof tape, so that it will stay in place if sucking is still attempted.
• If the reminder approach fails, a reward system can be
implemented that provides a small tangible daily reward for
not engaging in the habit.
• If all these approaches fail and the child really wants to quit,
an elastic bandage loosely wrapped around the elbow
prevents the arm from flexing and the fingers from being
sucked.
Appliance Therapy
• The child who wants to stop can be fitted with a cemented reminder
appliance that impedes sucking

The preferred method is a maxillary arch with an anterior crib device, making
it extremely difficult for the child to place the thumb or other object in the
mouth.
• In about half of the children for whom such a crib is made, thumb-
sucking stops immediately and the anterior open bite usually begins to
close relatively rapidly thereafter.
• The crib device is eventually effective in extinguishing thumb-sucking in
85% to 90% of patients.
• leave the crib in place for 6 months after the habit has apparently been
eliminated.
• Excellent oral hygiene is important.
• An appliance to laterally expand a constricted maxillary arch will be
required, and flared and spaced incisors may need retraction, but the
open bite should require no other treatment in children with good
skeletal proportions.