A d u l t anterior open bite L. Galletto, DDS, J. Urbanlak, DDS, and J. Daniel Subtelny, DDS, MS Rochester, N.Y.
T h e treatment o f patients with anterior open bite has proved to be one o f the more challenging aspects o f orthodontics. A m o n g the etiologic factors in an open bite are (1) a morpholgenetic abnormality resuiting in a disturbance o f skeletal development, (2) an expression o f muscle growth and muscle function, and (3) a malplacement or displacement o f anterior teeth. ~ Successful orthodontic therapy necessitates a careful appraisal o f the etiologic factors, an accurate determination o f where the skeletal and dental abnormality exists, an accurate appraisal o f the individual growth pattern, and, finally, the development o f an individualized treatment plan to address these factors. The following report demonstrates a nonsurgical approach to the treatment o f an adult open bite case.
vertical growth, with the patient demonstrating 13 of the 13 open bite characteristics reported by Subtelny and Sakuda.' The upper and lower incisors were proclined and supererupted relative to their respective skeletal bases and were positioned well ahead of the skeletal profile. Both the maxillary and the mandibular molars demonstrated excessive vertical alveolar development. The dental casts (Fig. 3, A-E) demonstrated a Class I molar relationship, fight and left, with 2 nun of overjet and 2.5 mm of anterior open bite. The maxillary left first premolar and the mandibular left second premolar were absent at the initial examination. All third molars had been previously extracted. The maxillary and the mandibular dental midlines were located to the left of the skeletal midline by 3 and 4 mm, respectively.
CASE REPORT
The patient asked to be treated nonsurgically if possible. The primary objective of the treatment was to close the antefior open bite by molar intrusion, allowing the mandible to be repositioned upward and forward. Treatment was also aimed at the reduction of the maxillary and mandibular dental protrusion, midline correction, and alignment of teeth. Arch length necessary to reduce the maxillary and mandibular dental protrusion and to correct the midlines was gained through extraction of the upper right second premolar and the lower fight second premolar and through the upfighting of mesially tipped molars adjacent to the sites of the previously extracted upper left first premolar and lower left second premolar. Treatment was initiated in the mandibular arch. In coordination with arch wire therapy, a maxillary bite block was fabricated, exceeding posterior freeway space to upright and intrude the mandibular right and left first and second molars. The right and left first premolars were retracted with reciprocal
The patient, a white woman 19 years 3 months of age, came to the Eastman Dental Center for orthodontic therapy (Fig. 1). The patient exhibited a dolichocephalic facial type with upturned nares and mentalis activity secondary to lip strain to achieve oral closure. Her profile was characterized as retrognathic convex with an associated increased lower anterior face height. The lips were incompetent at rest, while the lower lip was everted, forming a deep sublabial furrow. There was an obtuse nasolabial angle attributable to the small upturned nose. Cephalometrically (Fig. 2), there was a retrognathie convex skeletal profile. The mandible was retruded in relation to the forehead, and the maxilla was well related. The lower anterior face height was increased, with a steep mandibular plane and Y axis. Mandibular form was suggestive of past 8•4•11655
Progress of treatment
Fig. 1. Pretreatment facial photo0raphs. 522
Volume97 Number 6
Case report
M.I~°
NA-FH
86
SNA
77
12-23-75
NPg-FH
71
SNB
GoGn-FH 40 ,~Y-axis
o/~
71
Fig. 2. Initial lateral cephalometric headplate tracing.
Fig. 3. A through E. Initial record dental casts.
523
524
Am. J. Orthod. Dentofac. Orthop. June 1990
Galletto, Urbaniak, and Subteiny
5
.lt
7/~
"
Fig. 4. Lower appliance therapy: reciprocal coil to retract first premolar teeth. Fig. 5. High-pull headgear in conjunction with mandibular bite-block. Fig. 6. Nance transpalatal bar with palatal button. Fig. 7. A through C. Intraoral retention photographs.
push coils (Fig. 4). After premolar retraction was completed, treatment was initiated in the maxillary arch. To intrude and upright the maxillary molars, a high-pull headgear in conjunction with a mandibular bite block was used (Fig. 5). Extraction of the maxillary right first premolar allowed correction of the maxillary midline and reduced dental protrusion. After molar intrusion was completed, use of the highpull headgear was discontinued. A Nance transpalatal bar with palatal button was placed to maintain and control the vertical
and anteroposterior position of the second molars (Fig. 6). Canine retraction was completed with a reciprocal open coil. Incisor retraction was completed with closing loop mechanics after removal of the Nance holding appliance. Since vertical control is an important factor in retention of an open bite case characterized by excessive dental alveolar development, a gnathologic tooth positioner was placed. Retention was initiated with 10 days of full-time wear followed by nighttime wear only.
Case rep'ort 525
Volume 97 Number 6
Fig, 8. A through E. Retention record dental casts.
[ I
l
Fig. 9. A through C. Retention facial photographs.
526
Am. J. Orthod. Dentofac. Orthop. June 1990
Galletto, Urbaniak, and Subteiny
M°R°
'75 INITIAL RECORDS '80 RETENTION
~'
Fig. 10. Superimposition of lateral cephalometric tracings, initial and retention records.
Treatment results The anterior open bite was eliminated through upward and forward mandibularrotation secondary to molar intrusion. Previously tipped molars were uprighted to a normal position in the dental arch. The posterior extractions allowed the case to be finished with a solid Class I molar and canine relationship and ideal overjet and overbite (Figs. 7, A-C and 8, A-E). With regard to the profile consideration, lip strain on closure appeared to be reduced (Fig. 9, A-C). The oral tissues appeared to be healthy, with no areas of decalcification or periodontal inflammation. The retention intraoral photographs show the resulting occlusion. The maxillary right and left second molars were not in solid occlusion at the time of retention. The retention lateral headfilm demonstrated an increase in the facial angle by 3° and a reduction in the Y axis and mandibular plane angle by 3° and 4 °, respectively, resulting in a reduction in the lower anterior face height (Fig. 10). Denture relationships were also significantly influenced. The retention cephalogram demonstrated a more normal interincisal angle. The incisal edge of the maxillary incisor was reduced 5 mm to the skeletal profile (A Pog), while the lower incisor was retroclined 2.5 mm to the skeletal profile; this reduced the dental protrusion. Superimposition of the maxilla and mandible demontrasted significant changes in the maxillary and mandibular incisors and molars. The maxillary too-
lar was tipped back and intruded by 2 mm, while the mandibular molar was intruded by 1.5 mm.
CONCLUSION We have presented a case in which an adult skeletal open bite was treated nonsurgically. The use of posterior occlusal bite blocks in conjunction with high-pull headgear and arch wire mechanics aided in reduction of the lower anterior face height through molar intrusion and upward and forward rotation of the mandible. The treatment resulted in an esthetic, functional, and stable occlusion, along with an improved facial profile. We express our sincere gratitude to the orthodontic residents of the Eastman Dental Center who participated in the treatment of this case.
REFERENCE 1. SubtelnyJD, .Sakuda M. Open bite diagnosisand treatment. AM J ORTHOD 1964;50:337-58. Reprint requests to:
Dr. L. Galletto c/o Dr. Bruce Goldin Eastman Dental Center 625 Elmwood Ave. Rochester, NY 14620
T h e treatment o f patients with anterior open bite has proved to be one o f the more challenging aspects o f orthodontics. A m o n g the etiologic factors in an open bite are (1) a morpholgenetic abnormality resuiting in a disturbance o f skeletal development, (2) an expression o f muscle growth and muscle function, and (3) a malplacement or displacement o f anterior teeth. ~ Successful orthodontic therapy necessitates a careful appraisal o f the etiologic factors, an accurate determination o f where the skeletal and dental abnormality exists, an accurate appraisal o f the individual growth pattern, and, finally, the development o f an individualized treatment plan to address these factors. The following report demonstrates a nonsurgical approach to the treatment o f an adult open bite case.
vertical growth, with the patient demonstrating 13 of the 13 open bite characteristics reported by Subtelny and Sakuda.' The upper and lower incisors were proclined and supererupted relative to their respective skeletal bases and were positioned well ahead of the skeletal profile. Both the maxillary and the mandibular molars demonstrated excessive vertical alveolar development. The dental casts (Fig. 3, A-E) demonstrated a Class I molar relationship, fight and left, with 2 nun of overjet and 2.5 mm of anterior open bite. The maxillary left first premolar and the mandibular left second premolar were absent at the initial examination. All third molars had been previously extracted. The maxillary and the mandibular dental midlines were located to the left of the skeletal midline by 3 and 4 mm, respectively.
CASE REPORT
The patient asked to be treated nonsurgically if possible. The primary objective of the treatment was to close the antefior open bite by molar intrusion, allowing the mandible to be repositioned upward and forward. Treatment was also aimed at the reduction of the maxillary and mandibular dental protrusion, midline correction, and alignment of teeth. Arch length necessary to reduce the maxillary and mandibular dental protrusion and to correct the midlines was gained through extraction of the upper right second premolar and the lower fight second premolar and through the upfighting of mesially tipped molars adjacent to the sites of the previously extracted upper left first premolar and lower left second premolar. Treatment was initiated in the mandibular arch. In coordination with arch wire therapy, a maxillary bite block was fabricated, exceeding posterior freeway space to upright and intrude the mandibular right and left first and second molars. The right and left first premolars were retracted with reciprocal
The patient, a white woman 19 years 3 months of age, came to the Eastman Dental Center for orthodontic therapy (Fig. 1). The patient exhibited a dolichocephalic facial type with upturned nares and mentalis activity secondary to lip strain to achieve oral closure. Her profile was characterized as retrognathic convex with an associated increased lower anterior face height. The lips were incompetent at rest, while the lower lip was everted, forming a deep sublabial furrow. There was an obtuse nasolabial angle attributable to the small upturned nose. Cephalometrically (Fig. 2), there was a retrognathie convex skeletal profile. The mandible was retruded in relation to the forehead, and the maxilla was well related. The lower anterior face height was increased, with a steep mandibular plane and Y axis. Mandibular form was suggestive of past 8•4•11655
Progress of treatment
Fig. 1. Pretreatment facial photo0raphs. 522
Volume97 Number 6
Case report
M.I~°
NA-FH
86
SNA
77
12-23-75
NPg-FH
71
SNB
GoGn-FH 40 ,~Y-axis
o/~
71
Fig. 2. Initial lateral cephalometric headplate tracing.
Fig. 3. A through E. Initial record dental casts.
523
524
Am. J. Orthod. Dentofac. Orthop. June 1990
Galletto, Urbaniak, and Subteiny
5
.lt
7/~
"
Fig. 4. Lower appliance therapy: reciprocal coil to retract first premolar teeth. Fig. 5. High-pull headgear in conjunction with mandibular bite-block. Fig. 6. Nance transpalatal bar with palatal button. Fig. 7. A through C. Intraoral retention photographs.
push coils (Fig. 4). After premolar retraction was completed, treatment was initiated in the maxillary arch. To intrude and upright the maxillary molars, a high-pull headgear in conjunction with a mandibular bite block was used (Fig. 5). Extraction of the maxillary right first premolar allowed correction of the maxillary midline and reduced dental protrusion. After molar intrusion was completed, use of the highpull headgear was discontinued. A Nance transpalatal bar with palatal button was placed to maintain and control the vertical
and anteroposterior position of the second molars (Fig. 6). Canine retraction was completed with a reciprocal open coil. Incisor retraction was completed with closing loop mechanics after removal of the Nance holding appliance. Since vertical control is an important factor in retention of an open bite case characterized by excessive dental alveolar development, a gnathologic tooth positioner was placed. Retention was initiated with 10 days of full-time wear followed by nighttime wear only.
Case rep'ort 525
Volume 97 Number 6
Fig, 8. A through E. Retention record dental casts.
[ I
l
Fig. 9. A through C. Retention facial photographs.
526
Am. J. Orthod. Dentofac. Orthop. June 1990
Galletto, Urbaniak, and Subteiny
M°R°
'75 INITIAL RECORDS '80 RETENTION
~'
Fig. 10. Superimposition of lateral cephalometric tracings, initial and retention records.
Treatment results The anterior open bite was eliminated through upward and forward mandibularrotation secondary to molar intrusion. Previously tipped molars were uprighted to a normal position in the dental arch. The posterior extractions allowed the case to be finished with a solid Class I molar and canine relationship and ideal overjet and overbite (Figs. 7, A-C and 8, A-E). With regard to the profile consideration, lip strain on closure appeared to be reduced (Fig. 9, A-C). The oral tissues appeared to be healthy, with no areas of decalcification or periodontal inflammation. The retention intraoral photographs show the resulting occlusion. The maxillary right and left second molars were not in solid occlusion at the time of retention. The retention lateral headfilm demonstrated an increase in the facial angle by 3° and a reduction in the Y axis and mandibular plane angle by 3° and 4 °, respectively, resulting in a reduction in the lower anterior face height (Fig. 10). Denture relationships were also significantly influenced. The retention cephalogram demonstrated a more normal interincisal angle. The incisal edge of the maxillary incisor was reduced 5 mm to the skeletal profile (A Pog), while the lower incisor was retroclined 2.5 mm to the skeletal profile; this reduced the dental protrusion. Superimposition of the maxilla and mandible demontrasted significant changes in the maxillary and mandibular incisors and molars. The maxillary too-
lar was tipped back and intruded by 2 mm, while the mandibular molar was intruded by 1.5 mm.
CONCLUSION We have presented a case in which an adult skeletal open bite was treated nonsurgically. The use of posterior occlusal bite blocks in conjunction with high-pull headgear and arch wire mechanics aided in reduction of the lower anterior face height through molar intrusion and upward and forward rotation of the mandible. The treatment resulted in an esthetic, functional, and stable occlusion, along with an improved facial profile. We express our sincere gratitude to the orthodontic residents of the Eastman Dental Center who participated in the treatment of this case.
REFERENCE 1. SubtelnyJD, .Sakuda M. Open bite diagnosisand treatment. AM J ORTHOD 1964;50:337-58. Reprint requests to:
Dr. L. Galletto c/o Dr. Bruce Goldin Eastman Dental Center 625 Elmwood Ave. Rochester, NY 14620
