Mohammed Aslam

2 nd year P G student
Department of orthodontics
1
 Introduction
Classification
Etiology
Diagnosis
BIOMECHANICS
Management
Orthodontic
Surgical
Retention and Relapse
References

2
 Definition: Open bite is the failure of a tooth
or teeth to meet their antagonist in the
opposite arch.

Open bite is a condition of malocclusion

wherein there is an overlap between the
maxillary and mandibular dentition.

3
 Open bite creates significant problems such
as
Difficulty in speech (dysphonia)
TMJ disorders
Functional imbalance
Bad aesthetics
Alteration of incisior guidance
Reduction of normal functional activity

4
 Increase in the lower facial height
Clockwise rotation of the

mandible
Extrusion of molars

5
 Open bite is classified :
On the basis of region involved as
Anterior Open Bite
Posterior Open Bite
On the basis of etiological factors as
Skeletal Open Bite
Dental Open Bite
On the basis of Molar Relationship as
Class I Open Bite
Class II
Class III

6
 On the basis of clinical evaluation as
Simple (occurs between the incisors)
Complex (extends from premolars or deciduous
molars from one side to the other)
Compound/Infantile open bite (completely open
including the molars)
Iatrogenic Open Bite (consequence of orthodontic
or surgical therapy)

7
 Can be classified in to
Epigenetic
Environmental
OR
Disturbances in the eruption of teeth or alveolar
growth (ankylosed teeth)
Mechanical interference with eruption and alveolar
growth (thumb or digit sucking)
Vertical skeletal dysplasias

8
 Posture, morphology and size of the tongue
Skeletal growth patterns of the maxilla and

the mandible
The vertical relationship of the jaw bases

9
 Abnormal function
Thumb or digit sucking habit
Tongue thrusting habit
Improper respiration
Mouth breathing

10
 Thumb or digit sucking habit
This is one of the most common habits seen in
children.
The habit is quite reversible till the age of 3or4
Beyond this age, this habit becomes the cause of
many malocclusions.
Causes of the habit
Sigmund Freud- emotional security derived from the
oral phase of psychological development of first 3
years of life

11
 Tongue thrust habit
Infantile / visceral swallowing is the physiological
basis for the neonate/infant to create a proper lip
seal during suckling. When the deciduous teeth
erupt, the pattern of swallowing changes to
adult/mature swallow. If the visceral swallow
persists after the 4th year of life, the habit is called
retained infantile swallow or tongue thrust.

12
 Sean and Wise (1950) stated that digit sucking led to
thumb sucking
Benjamins theory- the basis of thumb sucking is
found in the physiological rooting reflex of infancy
where the infant reflexively sucks the nipple of the
breast, a teat of a feeding bottle, or a finger.
Psychological labilty- thumb sucking is a sign of lack
of parental love or fundamental psychological
insecurity.
Learned behaviour: children learn the habit from
siblings or toddler friends.

13
 Etiology of tongue thrust
Genetic factors
Learned behaviour
Maturational factors
Mechanical restrictions
Macroglossia
Constrictive dental abscess
Adenoid hypertrophy
Neurological disturbances
hyposensitive palate
Moderate motor disability
Psychogenic factors

14
 Classification of tongue thrust activity
(Bohr & Holt):
Tongue thrust without deformation
Tongue thrust causing anterior deformation
Anterior / Simple Open Bite
Tongue thrust causing buccal segment
deformation with a posterior open bite (lateral
tongue thrust)
Combine tongue thrust causing both anterior
and posterior open bite (complex open bite)

15
 Mouth breathing habit
The mode of respiration influences the posture of
the jaws, the tongue and to a lesser extent, the
head. Hence mouth breathing can result in altered
jaw and tongue posture thereby altering the oro-
facial equilibrium leading to malocclusion.

16
 Classification of mouth breathers
Obstructive
Complete or partial obstruction of the nasal passage
Habitual
Unconsciously performed act whereby breathing
occurs despite removal of obstruction
Anatomic
Lip morphology does not permit complete closure of
the mouth

17
 Clinical features of mouth breathers
Long and narrow face
Narrow nose and nasal passage
Short and flaccid upper lip
Contracted maxillary arch
Flaring of incisors
Anterior marginal gingivitis

18
 Clinical
Pseudo-open bite (overjet and overbite < 1mm)
Simple open bite (open bite >1mm)
Complex open bite (open bite extending from
deciduous molars on one side together)
Compound or infantile open bite (completely open
including molars)
Iatrogenic open bite (consequence of orthodontic or
surgical treatment)

19
 Cephalometric
Dento-alveolar open bite ( depends on the extent
of eruption of the teeth)
Vertical growth pattern
protrusion of upper anterior, lingual inclination of lower
incisors
Horizontal growth pattern
upward and forward tipping of the maxillary base

20
 Skeletal open bite
Excessive anterior facial height but decreased
posterior facial height
Mandibular base
Usually normal
Antegonial arching
Ramus is short
Increased bony angle
Growth pattern is vertical
21
 Maxillary base
Upward tipping of the forward end of the
maxillary base
Downward tipping of the posterior end of
the maxillary base
Increased total anterior facial height with
no difference in the cranial base
In skeletal open bite the anterior teeth are
either normally erupted or over erupted
In dento-alveolar open bite the anterior
teeth are under erupted due to certain
interferences (certain habits)

22
An extrusion arch (in blue) tied
to a rigid anterior segment
creates a one-couple force
system that generates a single
force (F) anteriorly (in green).
The moments (M) generated
(in blue) are counteracted by
another set of moments (in
red) using elastics (yellow) as
shown. This example is
assuming that the center of
resistance of the posterior
segment is between the roots of
the premolars

Anterior elastics

23
A case report based on
Figure illustrating the
application of elastics and
an extrusion arch in the
successful management of
an open-bite
malocclusion.
Note how the judicious
application of elastics in
combination with the
extrusion arch results in
the
correction of the open
bite
and also provides the
necessary overcorrection
for
long-term retention

24
Management is based on etiology and
localization of malocclusion
Management in dento-alveolar open bite
Habit control and elimination of abnormal
perioral muscle function
Management in skeletal open bite
During active growth phase
Redirection of growth
After active growth phase
Extraction and orthodontics or orthognathic surgery

25
 Management in combined dento-alveolar
and skeletal open bite
Combined therapeutic approach is needed to
achieve optimum results

26
 The timing of treatment and determination of
growth pattern are crucial. Based on type of
dentition, the management can be divided
into
Management in deciduous dentition
Management in mixed dentition
Management in permanent dentition

27
 Management in deciduous dentition
Dento-alveolar
Tongue crib, oral screen, reminder appliance,
activator, etc.
Open bite is usually corrected as soon as the habit is
broken
Skeletal
Phase I
Extra-oral orthopaedic appliances (chin cap)
Phase II
Habit control

28
 Management of mixed dentition
Dento-alveolar
Early mixed dentition
Screening appliances and habit breaking appliances
Late mixed dentition
Multi-attachment fixed appliances
Extended retention phase
Swallowing exercises
Skeletal
Management depends on severity of malocclusion and
possibility of a DA compensation

29
 Skeletal
The inclination of the maxillary base plays a vital role in
the management. If the jaw bases are divergent, the
prognosis is poor.
If the maxillary base is tipped downward and forward,
functional appliance therapy may be successful.
If the jaw bases are divergent, fixed appliance therapy is
indicated
In severe cases, orthognathic surgery with impaction of
buccal segments is performed.
If the lip sealing ability is disturbed, surgical resection of
the mentalis muscle is performed to reduce the golf
ball chin effect.
Schili insists on surgery after eruption of lower canines
to enhance stability

30
 Combined dento-alveolar and skeletal
Elimination of abnormal perioral function
Screening and habit breaking appliances, serial
extraction, activators, etc.
Improvement of the skeletal relationship
Fixed appliances or orthognathic surgery (severe)

31
 Management in permanent dentition
Multi-attachment, fixed mechano-therapy
Screening appliances
Screening appliances with active extrusive force on
incisors (tongue crib with active labial bow)
Repelling and attracting magnets
Functional appliances can be used in the retention
phase to prevent over eruption in the posterior
segments

32
 Management of open bite can be majorly
classified as:
Orthodontic correction
Surgical correction
Combination of orthodontic and
surgical correction

33
Correction oral habits: Tongue thrust
(Neuromuscular re-education), Thumb
sucking, Mouth breathing

34
 Habit breaking appliances
Tongue crib
Reminder appliance
Vestibular screen
Others
Myofunctional appliances
Activator
Bionator
FR-IV
Twin Block
Jasper jumper

35
 Multiloop edge wise arch wire technique
Tip edge technique
Headgears
Elastics
Magnets
Implants
Posterior bite blocks
TCA
SAS

36
 Anterior maxillary and mandibular subapical
osteotomy
Koles modification of subapical osteotomy
Sagittal split ramus osteotomy
LeFort I osteotomy
Adjunctive surgical procedures
The V excision
The Keyhole procedure
Deep Lingual Frenectomy
Genioplasty
TMJ considerations

37
 Habit breaking appliances
Tongue crib
Anterior open bite
A palatal acrylic plate with a horseshoe shaped wire crib and
labial bow
Crib placed 3 to 4 mm lingual to upper incisors or at gingival
1/3.
Posterior open bite
The crib is placed 2-3 mm away from the teeth
Fixed tongue cribs are also used.
Reminder appliances
An acrylic plate in which a bead or a wire mesh is
embedded
Reminds the patient not to go back to the habit

38
 Patients with tongue
thrusting can be treated
effectively in the same
manner as that used for
patients who suck on a
thumb or finger
,although different
appliances, such as the
habit appliance with
lingual spurs or cribs ,
have been suggested, In
one
study, immediately after
crib placement the tip
of the tongue was
positioned posteriorly
during all stages of
deglutition.
This altered tongue
posture aided in the
correction of an anterior
open bite through an
Tongue spurs
increase in overbite of
3.6-m

39
 Vestibular screen
An acrylic shield extending vertically from the
upper labial fold to the lower labial fold and
horizontally from the distal margin of the last
erupted molar on one side to that on the other
Edge to edge bite registered
Achieves proper lip seal, thereby creating a
somatic swallow pattern
Worn at night and 2 to 3 hours during daytime
Lip exercises along with the appliance
Modifications
Vesitbular screen with breathing holes
Vestibular screen with tongue crib
40
 Other methods
Psychological approach
Parent counselling
Patient counselling and motivation
Dunlops Beta hypothesis
Chemical approach
Bitter tasting or foul smelling preparation placed on
the thumb or digit

41
 Myofunctional appliances
Activator
Used to correct anterior open bite.
Increases salivary secretion, swallowing activity,
muscle contraction and amount of intermittent
forced applied to the tooth..
Forward positioning of the mandible not necessary
Open bite correct by selective trimming
Intrusion of molars achieved by loading the cusps
Extrusion of incisors achieved by loading the
lingual surfaces above the area of greatest
concavity and also with the labial bow above the
area of greatest convexity.

42
 To close the V between
Upper and lower dental arches
By depressing the posterior
Maxillary segments with the
Activator in a manner analogous
to that of orthognathic surgery

43
44
 Activator

A modification, the Elastic Activator similar to

Stockfishs kinetor was used in the treatment
of anterior open bite by A. Stellzig et.al in
1999.
The intermaxillary acrylic of the lateral occlusive
zones is replaced by elastic rubber tubes
Intrusion of both upper and lower posterior teeth
by orthopaedic gymnastics
45
 The Bionator

The open bite bionator inhibits abnormal posture

and function of the tongue.
Construction bite is as low as possible
The palatal part moves the tongue into a more
posterior position
The labial bow run between the incisal edges of
the upper and lower incisors at the height of
correct lip closure to achieve a competent lip seal
Reduced bulk and full time wear are the
advantages
The labial bows lateral extensions have a
screening effect.

46
 FR-IV

The FR IV is used in the treatment of skeletal

open bite and maxillary protrusion
It has two buccal shields, two lower lip guards,
an upper labial wire, and four occlusal rests.
The occlusal rests prevent eruption of the
posterior teeth.
Lip-seal exercises should be advocated along
with FR-IV.
Modifications:
FR-IV with chin cap.
FR-IV with a tongue crib. 47
 Twin Block

Consists of simple upper and lower bite blocks

that engage on occlusal incline planes and
modify them effectively
Contact between occlusal bite blocks and
posterior teeth should be maintained to
prevent eruption of the posterior teeth
Modifications
Headgear tubes can be attached and high pull traction
can be applied to a modified face bow (concorde) for
intrusion of molars
Vertical elastics (Mills)
Repelling rare earth magnets
Palatal spinner can be added to the upper appliance

48
 Jasper jumper

Robert G. Cash in 1987 used

Jasper jumper to treat open bite
The Jasper jumper was used to
distalize and intrude maxillary
molars

49
 Young H. Kim in 1987 used the MEAW technique
to correct anterior open bite
This is one of the most effective treatment
modalities for anterior open bite malocclusions
The MEAW technique lowers the load deflection
rate and allows the tooth to move independently

50
 It uses double edgewise brackets with 0.018
inch slots with an auxiliary vertical slot
Archwire used is 0.016 x 0.022 inch
rectangular SS wire and there are five loops on
either side
Vertical loop components are centered at
interproximal areas and the horizontal loop
components are directed mesially.
Wire used is 2 times more than normal and
hence a tenfold reduction in the load
deflection rate.

51
 The curve and reverse curve of Spee in both
archwires worsen the open bite and this is
counteracted by using anterior vertical elastics
full time
The completed archwire is treated to about 900
deg F. to increase resiliency and stiffness
Extraction of second and third molars offers a
feasible therapeutic situation by eliminating the
dynamic blocking effect and also cortical bone

52
53
Typical tip back bends of 3-5 degrees are given on each teeth
Elastics are placed between the loops that lie mesial to
opposing cuspids
Recommended elastic size is 3/16inch heavy,with a force
approximately 50 grams when the jaw is closed

54
 Haruo Takayama et al, in 1990 used double
key-hole archwire loops in the posterior
region in open-bite with Turners syndrome.

Ahyanenacar et al, in 1996 used 0.016 x

0.022 Niti wires instead of SS wires along
with heavy inter maxillary elastics in the
canine region.

55
 Kesling in 1986 designed the Tip-edge
brackets which are dynamic and upright
teeth easily and automatically with or
without intermaxillary elastics.
No loops are required for uprighting.
Anteriorly placed class III elastics with Tip-
edge brackets were used to correct anterior
open-bite.
Kims philosophy + Tip-edge brackets
produced stable results in a very short
period of time.
56
Headgears have been used to correct open-
bite by molar intrusion.
Galletto in 1990, used posterior bite blocks
in conjunction with high-pull headgear and
archwire mechanics to correct adult anterior
open-bite.
Roberto Martina et al in 1990, used a
cervical pull J-hook type headgear attached
at the anterior part of the archwire.
Allison et al in 1994, used a cervical pull
headgear and a lower utility archwire in
growing patients.
57
 Center of resistance in midfacial complex
1,Alveolar process
2,Maxilla

58
 Direction of forces passes behind both
alveolar and skeletal centers of
resistance,producing clockwise rotation of
maxila and maxillary dentition

59
Direction of forces passes between alveolar and
skeletal centers of resistance,producing clockwise
rotation of maxilla and counter clockwise rotation
of maxillary dentition

60
 Direction of force passes above both alveolar
and skeletal centers of resistance,producing
counterclockwise rotation of maxilla and
maxillary dentition

61
Dentoalveolar comparative study between removable and
fixed cribs,associated to chincup,in anterior open bite
treatment
Fernando cesar,Renato rodrigues,J Appl Oral Sc,july14,2011

Chincup with the force vector directed to the condyle

62
 David Gehring et al in 1998, used a high
pull headgear with vertical elastics to treat
class II div.1 cases with anterior open-bite.
Roy Sabri in 1998, used used a high pull
headgear with class II & vertical elastics, to
treat class II div.1 cases with anterior open-
bite.
Smith& Alexander in 1999, used a cervical
pull headgear, Cl.II & Ant. Box elastics, and
gingivally placed brackets to correct Cl.II
div.1 sub-division right open-bite.

63
64
Class II orientation

Class III orientation

65
For mild open-bite malocclusions (1 to 3 mm),
placing step bends and meticulous bracket
positioning
can help reduce the open bite
without any significant side effects. In this patient,
the anterior brackets were placed more gingivally
as compared to the
posterior brackets, to aid in correction of the open
bite

66
 Aids in the improvement of class I cuspid
intercuspation and increasing the overbite
relationship anteriorly by closing open bites
in the range of 0.5mm to 1.5mm
They extend from upper cuspid to lower

cuspid and first bicuspid teeth

67
 Intermaxillary elastics from the posterior
teeth have a vertical force vector which
extrudes these teeth and can further open the
posterior vertical dimension
Class II elastics from molar to molar should

not be utilised untill these teeth are well

anchored in buccal cortical bone
If class II or classIII elastics are required,they

should be attached to premolars rather than

molars

68
 Since the introduction of rare earth magnets
such as Samarium Cobalt by Becker in 1970,
their use in the field of Orthodontics has
become increasingly popular.
Eugene Dellinger in 1986 was the first to use
them to correct anterior open-bite in his Active
Vertical Corrector. The AVC consists of upper &
lower bite blocks with Samarium Cobalt
magnets in stainless steel cases embedded in
them. The method of action is reciprocal
intrusion of the maxillary & mandibular
posterior teeth leading to the autorotation of
the mandible, closure of the open-bite &
reduction of lower anterior facial height.

69
 Kalra & Burstone in 1989 introduced a fixed
magnetic appliance which consisted of
upper & lower acrylic splints with Samarium
Cobalt magnets in SS cases in the repelling
mode, in open-bite cases.
Killiardis used magnets in bite-blocks in the
correction of open-bite.
Noar,Shell & Hunt used Neodymium-Iron-
Boron magnets with an acrylic coating in
treating ant. Open-bite.

70
 Ali Darendeliler in 1995 used the MAD IV
(Magnetic Activator Device IV ) to correct
anterior open-bite.
The MAD IV consists of anterior attracting &
posterior repelling magnets. It consists of
removable upper & lower acrylic plates, each
containing 3 cylindrical Neodymium magnets
coated with stainless steel. The attracting
force of the anterior magnets is 300gm & the
repelling force of the posterior magnets is
also 300gm.

71
In the mixed & permanent dentition, the
plates are retained mechanically but, in the
late mixed dentition, mod. Adams clasps &
Torquing springs give added retention.
MAD IV a: used in cases where the max. ant.
Segment is vertically overdeveloped.
MAD IV b: used when an additional extrusive
effect is required in the max. ant. region.
MAD IV c: used when only anterior extrusion
is needed.

72
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 Beth Prosterman et al. In 1995 has described
the use of implants for correction of open
bite.
He concluded that since osseo integrated
titanium implants show remarkable resilience
to pressure they can prevent extrusion of
mandibular post. teeth thereby preventing
increase in ant. facial height
He advocated the use of implants in
conjunction with fixed appliances to correct
ant. open bite.

76
77
 Viazis in 1993 described the Thumb sucking /
tongue thrusting / tongue posturing
correction appliances.
The TCA consists of a palatal wire that is
inserted in the upper lingual molar sheaths &
carries over to the lower incisors ending 1-2
mm. above the labial surface.
The TCA prevents the habits by blocking the
tongue from the ant. teeth.
The TCA should be worn for atleast 3 months.

78
79
 The skeletal anchorage system was developed
by umemori and Sugawara
Appliance design:consist of titanium

miniplates,which are stabilised in the maxilla

or mandible using screws
The earlier of these miniplates where the

conventional surgical miniplates,which are

used by oral surgeons for rigid fixation

80
 The recent versions of these miniplates have
been modified for attaching orthodontic
elastomeric or coil springs
Different designs of miniplates are available

and this fact offers some versatility in placing

the implants in different sites

81
 The Lshaped miniplates have been the most
commonly used ones,while the Tshaped
ones have been proposed for usage while
intruding anterior teeth
The screws used for fixing the miniplates are

usually 2-2.5mm in diameter

82
 Titanium miniplates were implanted after LA
with intravenous sedation
First,a mucoperiosteal incision was made at

the buccal vestibule directly under first or

second molar
The mucoperiosteal flap was then elevated

and surface of cortical bone at apical region

of the molar was exposed

83
 An Lshaped miniplate was adjusted to fit the
contour of each cortical bone surface and was
fixed by bone screws of length 5 or
7mm,with the long arm exposed to oral cavity
from the incised wound

84
 The implant was placed such that it did not interfer with
mandibular movement.

All of the miniplates were transfixed at the region of the buccal

vestibule.

Loading was done after wound is healed.

85
 The implant was placed such that it doesnt
interfere with mandibular movement
All of the miniplates were transfixed at the

region of the buccal vestibule

Loading was done after wound is healed

86
 The shape of miniplate can be adjusted to the
type of tooth movement.i.e,intrusion of
molars,incisors etc and based on thickness of
patients bone
Position of miniplate can be adjusted during

treatment

87
It can be placed without destroying the teeth or bone
The anchor plates are monocortically placed at the
piriform opening rim, the zygomatic buttresses, and
any regions of the mandibular cortical bone.

The anchor plates work as the onplant and the screws

function as the implant, SAS enables the rigid
anchorage that results from the osseointegration
effects in both the anchor plates and screws All
portions of the anchor plates and screws are placed
outside the maxillary and mandibular dentition, so
the SAS does not interfere with tooth movement

88
Intusion of lower molar for correction of open bite.
Intrusion of the lower molars was achieved with the
application of elastic orthodontic force on the SAS ,
Lingual crown torque was applied to the lower
molars with Burstones precision lingual arch to
avoid buccal flaring during intrusion .

89
A)L-shaped miniplate for intrusion of molars
B) L-shaped for distal movement of molars
C) Y-shaped intrusion and distalizaton of maxillary molars
D) Straight miniplate for intrusion of molars

90
 Advantages of SAS :
No serious side effects.
Simplified treatment mechanics.
Shortened treatment period.
Minimum discomfort.
Control of the level of occlusal plane.

91
 Hulliten in 1849, was the first to surgically
correct an ant. open bite.( Ant. Mand. Sub-
apical Osteotomy ).
Cohn-stock in 1921, introduced Ant. Max.

Osteotomy which was modified by

Wassmund, Wunderer & Cupor.
Schuchardt introduced Post. Max.

Osteotomy as a two-stage procedure which

was modified to a single-stage procedure
by Kufner.

92
 Limberg in 1925, introduced Closed Sub-condylar
& Open oblique Osteotomy.

The present-day surgical techniques to correct

open bite involves, Max. surgery for ant. extrusion
& post. intrusion, and Mand. surgery to elevate the
incisor segment. The choice of the appropriate
surgical technique requires careful diagnostic
evaluation.

93
 INDICATIONS FOR MAXILLARY ASO
A small open bite with minimal tooth exposure,
lip incompetance , good naso-labial angle &
adequate lower ant.facial height.
An unaesthetic edentulous appearance due to
concealed maxillary incisors.

94
 INDICATIONS FOR MAND. ASO
Ant. open bite due to reverse curve in the
mandibular arch.
Transverse max.-mand. harmony & good
aesthetic balance between upper lip & max. ant.
teeth.

After surgery the max. & mand. Ant.

Segment are immobilised for 5-6 weeks. Relapse
potential is very minimal.

95
 INDICATIONS
Mandibular prognathism with ant. open bite.
Severe reverse curve.
Excessive chin height.
Functional post. occlusion.
Satisfactory lip-tooth relationship & no
transverse deficiency in maxilla.
The principle disadvantage here
relates unpredictable soft tissue profile changes
& chin height changes.
96
 This surgery can be performed in both extraction &
non-extraction cases.
It is indicated in open-bite cases with severe mand.
deficiency or prognathism.
It is usually done along with maxillary osteotomy to
minimize relapse.
If performed separately, posterior overcorrection with
an interocclusal splint, supra-hyoid myotomy and
cervical collar should be considered to prevent relapse.

97
This surgery is indicated in open-bite cases with:
High & constricted palatal vault.
Lip incompetence.
High mand. plane angle.
Increased distance between the palatal root apices

& the nasal floor.

98
 If the inferior turbinates are interfering with the
repositioning of the maxilla, they are trimed with a
Mayo scissors (Adjunctive Inferior Turbinectomy ).
Stabilization of the maxilla is done with trans-

osseous 26-guage wire sutures.

If there are bony defects after surgery, bone grafts

from the Iliac crest or Hyroxyapatite crystals are

used to bridge them.

99
1.Horizontal incision:through
mucoperiosteum in the anterior
region,extending from premolar
to premolar
2.Soft tissues of maxilla and
nasal floor are carefully reflected,
3.Osteotomy is performed from
lateral-inferior corner of piriform
aperture ,parallel to the ridge
and posterior to
pterygomaxillary suture.
4.Maxilla is mobilised with
manual pressure and
repositioned inferiorly.

100
5.Bone from ileum is inserted
into the space
6.Mobilised maxilla and grafts are
secured with interosseous sutures at
piriform rims and
zygomaticomaxillary buttress.

10
1
Adjunctive surgical procedures have to be
performed to combat either, a large tongue or
a tongue with abnormal function, which cause
open-bite or even its recurrence.
To correct True, Relative or Functional
Macroglossia, the following procedures are
performed:
The V excision for partial glossectomy.
Keyhole procedure for partial glossectomy.
Deep lingual frenectomy.

102
A V shaped excision is made from the front of
the tongue, lateral to the midline & extending
posteriorly in nearly a straight line,
converging at the midline at about 4mm from
the Circumvallate papillae.The dorsum of the
tongue is closed by layers using 3-0 & 4-0
chromic sutures & the ventral surface is
sutured by one layer.
103
A Keyhole shaped mass of muscle is excised when
the tongue is too large in the molar area and the
ant. fourth is nearly normal.

The ant. incision begins at the tip of the tongue and

extends posteriorly until it reaches the expanded
part of the keyhole begins. The posterior incision
curves laterally and forward and then towards the
midline until it joins the posterior end of the ant.
incision.
104
A mirror image incision is made through its opposite
side.The posterior incision should taper like a
funnel to avoid any injury to the Lingual artery,
nerve, vein, &the Hypoglossal nerve.

After surgery the jaws must be immobilised so that

the mouth has a fixed volume and also act as a
splint. Tongue excercises are advocated after the
14th post-op day.
105
 Deep lingual frenectomy with Z plasty is indicated in
Ankyloglossia or Functional macroglossia where the
tongue does not adapt after ortho. or surgical
treatment.

A linear excision of the mucosal portion of the

thickened frenum is made(care-submandibular duct
opening). The dissection of the fibrosed Genioglossus
extends posteriorly until desired amount of mobility is
achieved. Excercises should be advocated till about 2
months after surgery.
106
 Incision half way the depth of vestibule and
extended to canine region bilaterally.
Periosteum left intact on the inferior border
Line of osteotomy should be 5 mm below canine
root & 10 to 15 mm above the inferior border & 5
mm below the lowest mental foramen

107
 Fragment stabilized by
unicortical or bicortical wires
bone plates
prebent chin plates
lag screws

108
The status of the TMJ is of great importance before
surgery, because the movements associated with
surgery increase pressure in the joint until the
muscles, soft tissues & dento-osseous structures
readapt.

Hence, if pre-existing TMJ disorders are carefully

assesed and appropriately managed, the TMJ is
stable after the surgery is performed.

109
The main etiological factors responsible for relapse after
ortho correction are:
Latent vertical growth of the face.

The role of the tongue.

The main etiological factors responsible for relapse after

surgical correction are:
Mandibular musculature

Incompletely understood biomechanical factors

influencing the Elevator group & Suprahyoid group of

muscles.

110
The success of treatment depends upon the ratio:
Magnitude of improvement

Success = Magnitude of relapse

Wick Alexander stated that retention begins with

Diagnosis & Treatment planning.
Begin with the end in mind should be the
philosophy of treatment.

111
 Upper and lower border wiring of mandible
Steinmann pins to stabilise the maxilla
Skeletal wire fixation(circumzygomatic and

circummandibular wires)
Rigid fixation

112
RETENTION AFTER ORTHODONTIC CORRECTION :
Criteria to begin retention are :

Coincidence of Centric relation& occlusion.

Class I cuspid relation.
Maintenance of mand. cuspid width.
Interincisal angle close to normal.
Normal ant. Overbite & Overjet.
Normal Buccal Overjet.

113
Criteria:
Levelled max. & mand. arches.
All spaces closed & all rotations eliminated.
Roots parallel near extraction sites.
Posterior cusps may or may not be settled.

114
Active retention normally utilizes :
A maxillary wraparound retainer and a
mandibular 3x3 bonded retainer.
A full coverage clear acrylic appliance.
In conjunction with myofunctional therapy,
tongue position excercises are advocated.

115
 John Sheridan in 1997, described the Force
Amplified System for corrected open-bite.It
involves the use of conventional max. & mand.
cuspid to cuspid bonded lingual retainers, low-
profile bonded lingual Caplin hooks and intraoral
elastics. The retainers are bonded to each tooth to
distribute the elastic forces.

116
117
 conclusion
The treatment of open bite remains a challenge
to the clinician, and careful diagnosis and timely
intervention will improve the success of treating
this malocclusion.The recent trend of combining
orthodontic and surgical methods to manage
open bite,which is a multi factorial problem has
been successful.Lets hope this combination
asserts enough stability in the management of
open bite and similar conditions.

118
 REFERENCE
Orthodontics principles and practice,
T.M.Graber,3rd edition,1988
Orthodontics and dentofacial orthopedics,
McNamara and Brudon,1st edition,2001
Biomechanics and Esthetic Stratergies in Clinical
Orthodontics,R Nanda
Clinical biomechanics,seminars in orthodontics
March 2001,vol.7,no.1

119
 Profit WR, Ackerman JLA systematic approach to
orthodontic diagnosis and treatment planning.
Graber TM and Swain : Orthodontic concepts &
techniques
William R. Profit , Raymond P White - In surgical
orthodontic treatment
Applications of orthodontic mini implants;Jong suk
lee
Temporary anchorage devices in orthodontics-
Ravindra nanda
Johan P Reyneke Essentials of orthognathic
surgery

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THANK YOU

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