Corrective orthodontics- deep bite & open bite

Management of deep bite and open bite (anterior, posterior) has been covered in this presentation. Removable as well as fixed corrective orthodontic treatment options have been mentioned.

1. Corrective orthodontics: deep bite & open bite Presented By: Dr susmita Shah III Mds

2. Contents: Introduction corrective orthodontics Deep Bite Introduction Etiology Clinical Features Management Open Bite Introduction Etiology Clinical Features Management Conclusion Bibliography Sunday, August 1, 2021 2

3. Introduction Centric Occlusion- is that position of the mandibular condyle when the teeth are in maximum intercuspation also called as intercuspal position or convenience position. Centric relation- it is relation of the mandible to the maxilla when the mandibular condyles are in the most superior and retruded position in their glenoid fossa with the articular disc interposed also called as interligamentous position or terminal hinge position . Sunday, August 1, 2021 3

4. 2. Corrective orthodontics Corrective orthodontics is that branch of orthodontics that recognizes the existence of malocclusion and the need for employing certain technical procedure to reduce or eliminate the problem and the attendant sequele . Management of Class II & Class III malocclusions Management of Crossbite Management of Deep Bite Management of Open Bite Cleft Lip & Palate Sunday, August 1, 2021 4 Proffit W. Contemporary Orthodontics. 6 th Edition. Elsvier publication

5. 3. Deep Bite Sunday, August 1, 2021 5

6. a. Introduction Graber has defined deep bite as a condition of excessive overbite, where the vertical measurement between the maxillary and mandibular incisal margins is excessive when the mandible is brought into habitual or centric occlusion . It can be of two types- incomplete overbite, complete overbite It can be calculated as a percentage of the clinical crown height of one of the mandibular central incisors. Sunday, August 1, 2021 6

7. Normal bite: 2-4 mm Measurement Vernier caliper, graduated probe. Sunday, August 1, 2021 7 Proffit W. Contemporary Orthodontics. 6 th Edition. Elsvier publication

8. b. Etiology Anterior deep overbite problems may either result from upward and forward rotation of mandible during growth or from excessive eruption of the incisor teeth,(notably mandibular incisors). Anterior teeth erupt until they make contact, either with opposing teeth, palatal mucosa or resting tongue. Factors contributing to deep overbite can be: Skeletal Dental Soft tissue Sunday, August 1, 2021 8 Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005.

9. Skeletal Forward rotation of the mandible in the direction of mouth closing, is due to increased posterior vertical facial growth. Bjork 1969- seven structural signs on lateral cephalometric radiograph. Forward inclination of condylar head Increased curvature of inferior alveolar canal Absence of antegonial notch Forward inclination of mental symphysis Increased interincisal angle Increased intermolar angle A reduced Anterior lower facial height Sunday, August 1, 2021 9 Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005.

10. Skeletal Considerations Three factors significantly affect outcome of overbite correction Vertical dimension Anteroposterior relationship of maxilla to mandible Younger patients: amount of growth remaining and its direction Sunday, August 1, 2021 10 Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005.

11. Dental Over eruption of mandibular incisors Class II div 1 malocclusion with increased overjet- mandibular incisors erupt until they contact palatal mucosa. In class II div 2- deep overbite is due to retroclination of anterior teeth Deep overbite may be partly due to over erupted maxillary incisor teeth. Sunday, August 1, 2021 11 Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005.

12. Soft Tissue In Class II div 2 malocclusion- High lower lip line which is thought to guide the maxillary & mandibular incisors to erupt in more retroclined position. Short face individuals- increased mentalis muscle activity (Strap like lower lip). Forward resting tongue position and/or adaptive tongue position- overbite may be deep. Sunday, August 1, 2021 12 Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005.

13. c. Clinical Features Horizontal growth patten Reduced anterior facial height Reduced interocclusal clearance Cephalometric evaluation Mandibluar plane, SN plane, FH plane are parallel Sunday, August 1, 2021 13 Millett D, Welbury R. Clinical problem in Orthodontics and Pardiatric dentistry. Elsvier publication.

14. Indications for treatment Primary Dentition- Rarely indicated Early permanent dentition- indicated if it is causing soft tissue trauma, maxillary incisors or labial to mandibular incisors. Deep overbite associated with increased overjet- often cannot be corrected until overbite has been reduced. Sunday, August 1, 2021 14 Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005.

15. Why does a deep bite need to be fixed? Besides looking better, there are four other reasons: Over-erupted lower front teeth tend to wear down more quickly. If a patient is biting into the roof of their mouth, painful sores or ulcers may develop. If a substantial amount of tooth structure has been lost, the orthodontist will need to recreate the space needed for restoration by moving the upper and lower teeth apart (opening the bite). Unraveling the crowding and crookedness that usually accompanies deep bites requires that the deep bite be corrected to allow room to align the crowded teeth. Sunday, August 1, 2021 15 Millett D, Welbury R. Clinical problem in Orthodontics and Pardiatric dentistry. Elsvier publication. American Association of Orthodontics.

16. d. Management Extrusion of Posterior teeth Intrusion of Incisors- Relative Absolute Proclination (flaring) of Labial Segment Sunday, August 1, 2021 16 Factors to be considered Lip relationship Growth factor Vertical facial height Interocclusal space Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005.

17. Appliances and techniques for Deep bite reduction Sunday, August 1, 2021 17

18. ANTERIOR BITE PLANE- commonly used removable appliance (Modified Hawley’s appliance). Sunday, August 1, 2021 18 Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005. Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005.

19. Adams clasp- retention Labial Bow- Counter forward component of force Acrylic base plate Sunday, August 1, 2021 19 Proffit W. Contemporary Orthodontics. 6 th Edition. Elsvier publication

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21. 2. Activator Indications: Class II div 1 malocclusion Class II div 2 malocclusion Class III malocclusion Class I open bite malocclusion Class I deep bite malocclusion Preliminary treatment to improve skeletal jaw relation Post treatment retention Children with lack of vertical development in lower facial height Contraindications: Class I malocclusion with crowding Children with excess lower facial height Lower incisors procumbent Children with nasal stenosis, Chronic allergy Non growing individuals Sunday, August 1, 2021 21 Proffit W. Contemporary Orthodontics. 6 th Edition. Elsvier publication

22. Disadvantages: Patients Co-operation No precise detailing and finishing in occlusion Produce moderate mandibular rotation Bulky and uncomfortable Sunday, August 1, 2021 22 Advantages: Uses existing growth of jaw Minimal oral hygiene problems Long appointment intervals Short duration appointments due to minimal corrections Night time wear No tissue injury Economical Proffit W. Contemporary Orthodontics. 6 th Edition. Elsvier publication

23. Mode of action According to Andersen & Haupl Activator induces musculoskeletal adaptation New patten of mandibular closure Loosely fits in mouth Patient has to move mandible forward Stretching of elevator muscles of mastication Prevents further growth of maxillary dentoalveolar process Condylar backward upward growth Sunday, August 1, 2021 23 Proffit W. Contemporary Orthodontics. 6 th Edition. Elsvier publication

24. Fabrication of activator Sunday, August 1, 2021 24 Proffit W. Contemporary Orthodontics. 6 th Edition. Elsvier publication

25. 3. Fixed Appliance therapy Use of Anchorage Bends Use of Arch wires with Reverse curve of Spee Use of intrusion arches Use of Utility arches Use of fixed anterior bite planes Sunday, August 1, 2021 25 Naini F, Daljit SG, Sharma S, Tredwin C. The Aetiology , Diagnosis & Management of Deep Overbite. Dental Updates. July- August 2006.

26. Sunday, August 1, 2021 26 The use of anchor bends in the tip-edge appliance places an intrusive force on the incisor and canine teeth. Just mesial to 1 st molar bands. Rickets Utility Arch Burstones Intrusion arch Turbo Props Naini F, Daljit SG, Sharma S, Tredwin C. The Aetiology , Diagnosis & Management of Deep Overbite. Dental Updates. July- August 2006.

27. Sunday, August 1, 2021 27 Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005. Millett D, Welbury R. Clinical problem in Orthodontics and Pardiatric dentistry. Elsvier publication.

28. Sunday, August 1, 2021 28 Avicenna J Dent Res. 2018 June;10(2):63-66

29. Sunday, August 1, 2021 29 MANAGEMENT OF ANTERIOR DEEP BITE BY USING DIFFERENT TREATMENT MODALITIES - A REPORT OF THREE DIFFERENT CASES Singh D et al Indian Journal of Comprehensive Dental Care JULY - DEC 2013 • VOL 3 • ISSUE 2

30. Sunday, August 1, 2021 30 Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005. Millett D, Welbury R. Clinical problem in Orthodontics and Pardiatric dentistry. Elsvier publication.

31. A. Introduction In 1842 Caravelli coined the term “open bite” as a distinct classification of malocclusion and can be defined in different manners. Classification ( by Worms, Meskin , and Isaacson in 1971) Simple open bite - From canine to canine, with 4mm or more in centric relation. Compound open bite - From premolar to premolar. Infantile open bite - From molar to molar. Sunday, August 1, 2021 31 4. Open Bite Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005. Millett D, Welbury R. Clinical problem in Orthodontics and Pardiatric dentistry. Elsvier publication.

32. Types of open bite False or Dental open bite: In this bite the teeth are proclined as there is no alteration of the osseous bases but it does not extend beyond the canine. This patient has normal facial morphology, a correct bone relation, a pesudo -bite and dento -alveolar problem Sunday, August 1, 2021 32 True or Skeletal open bite: In this type of open bite the alveolar processes are involved or deformed and dolichofacial characteristics are also seen. This patient present’s hyper-divergency in maxilla, with their lower facial third and vertical dimensions increased Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005. Millett D, Welbury R. Clinical problem in Orthodontics and Pardiatric dentistry. Elsvier publication.

33. Sunday, August 1, 2021 33 S I Bhalaji . Orthodontics the Art & Science. 6 th Edition. Arya Publication2015.

34. According to Moyer’s: Simple open bite:- This type of open bite is confined to the teeth and alveolar process. The main problem regarding this type of open bite is failure of some of the teeth to meet the line of occlusion. Complex open bite :-This type of open bite is caused by primary vertical dysplasia. Complex open bite is frequently associated with Class-I and Class-II malocclusions and occasionally associated with Class III malocclusion. Sunday, August 1, 2021 34

35. According to zone: • Posterior open bite : Posterior open bite is characterized by failure of number of teeth in either or both opposing buccal segments to reach occlusion although there is incisor contact. It is seen rarely and can be because of Tongue interposition Disturbances in eruption ( eg. ankylosis) Primary failure of eruption • Complete open bite Sunday, August 1, 2021 35 Anterior open bite : Anterior open bite from its etiological point of view are divided into two categories: Dental Skeletal The dental anterior open bite results from dental eruption impediment. The skeletal open bite is due to posterior facial growth Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005. Millett D, Welbury R. Clinical problem in Orthodontics and Pardiatric dentistry. Elsvier publication.

36. It is defined as a malocclusion with no contact in the anterior region of the dental arches and the posterior teeth in occlusion (Moyers 1991). The absence of any vertical incisor overlap between the upper and lower incisors. Sunday, August 1, 2021 36 Anterior open bite

37. Classification of anterior open bite Sunday, August 1, 2021 37 Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005. Millett D, Welbury R. Clinical problem in Orthodontics and Pardiatric dentistry. Elsvier publication.

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39. B. Prevalence Anterior open bite (AOB) is widespread among young children, with prevalence ranging from 17% to 18% of children in the mixed dentition [ Kasparaviciene et al., 2014; Tausche et al., 2004; Silvestrini-Biavati , 2016]. When associated with sucking habits, the prevalence increases to 36.3% [ Cozza et al., 2005]. A tendency towards self improvement from the deciduous to the late mixed dentition is expected during pre-pubertal growth [Worms et al., 1971; Phelan et al., 2014], and it is demonstrated that, if AOB persists during the cranio-facial pubertal growth spurt, it hardly ever self-corrects or even worsens [Phelan et al., 2014]. Sunday, August 1, 2021 39 M. Rosa, Quinzi V, G. Marzo. The correction of anterior open bite in the mixed dentition: treatment or over-treatment? European Journal of Paediatric Dentistry vol. 20/1-2019

40. Posterior open bite Posterior open bite can be defined as failure of contact between the posterior teeth when the teeth occlude in centric occlusion. Causes: 1. Mechanical interference with eruption, either before or after tooth emerges from alveolar bone.( ankylosis, trauma, supernumerary teeth, non resorbing deciduous tooth roots/alveolar bone.) 2. Failure of eruptive mechanism of the tooth so that the expected amount of eruption does not occur. Sunday, August 1, 2021 40 Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005. Millett D, Welbury R. Clinical problem in Orthodontics and Pardiatric dentistry. Elsvier publication.

41. C. Etiology Hereditary factors The open-bite anomaly is most often associated with inherited facial growth. Horizontal skeletal dysplasias appear to be inherited thus dysplasias in the vertical plane may also be inherited. Three major theories, in the recent years have attempted to explain determinants of craniofacial growth. • Bone, like other tissues, is the primary determinant of its own growth. • The determinant of skeletal growth is cartilage while bone respond secondarily and passively. • The primary determinant of growth is the soft tissue matrix in which skeletal elements are embedded and both bone and cartilage are secondary follower’s. Sunday, August 1, 2021 41 Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005. Millett D, Welbury R. Clinical problem in Orthodontics and Pardiatric dentistry. Elsvier publication.

42. Non-hereditary factors Subtelny and Sakuda (1964) and Tulley (1969), have stressed the abnormal functional patterns of the tongue, pernicious oral habits (Figure 3), abnormal swallowing patterns (Figure 4) and speech problems, all contributing to, and being part of, the open-bite phenomenon. A malfunction of the tongue can be a contributing cause or the result of an abnormal swallowing behaviour. Sunday, August 1, 2021 42

43. Sunday, August 1, 2021 43 S I Bhalaji . Orthodontics the Art & Science. 6 th Edition. Arya Publication2015.

44. Sunday, August 1, 2021 44 Title Authors Journal LOE Aim Methodology Results Conclusion Association between psychological factors, socio-demographic conditions, oral habits and anterior open bite in five-year-old children Gomesa M C , Nevesa ETB , Perazzob MF , Martinsb C, Paivab S M, Granville- Garciaa A. ACTA ODONTOLOGICA SCANDINAVICA 2018 4 to evaluate association between psychological factors, socio-demographic conditions, oral habits and anterior open bite in five-year-old preschool children. A cross-sectional study was conducted with 764 pairs of children and parents/caregivers in preschools. The parents/caregivers answered questionnaires addressing oral health-related quality of life ( OHRQoL ), sense of coherence, locus of control, oral habits and sociodemographic characteristics. The children answered a self-report questionnaire addressing OHRQoL and were submitted to a clinical examination for the anterior open bite by examiners. Descriptive analysis was conducted, followed by Poisson’s regression analysis. The prevalence of anterior open bite was 15.2%. The following variables remained significantly associated with anterior open bite: pacifier use (PR¼7.09; 95% CI: 4.06–12.39), attending a public preschool (PR¼2.40; 95% CI: 1.68–3.43), digit sucking (PR¼2.15; 95% CI: 1.27–3.62), greater number of residents in the home (PR¼1.67; 95% CI: 1.18–2.36) and impact on OHRQoL according to child’s report (PR¼1.56; 95% CI: 1.11–2.20). Anterior open bite was associated with OHRQoL according to the children’s reports. Moreover, attending a public preschool, a greater number of residents in the home, digit sucking and pacifier sucking were associated with this type of malocclusion.

45. Sunday, August 1, 2021 45 Title Authors Journal LOE Aim Methodology Results Conclusion Breastfeeding and non-nutritive sucking patterns related to the prevalence of anterior open bite in primary dentition Camila Campos, Junior H S, Garib D, Ferreira A C, Ferreira R. J Appl Oral Sci. 011;19(2):161-8 4 the association between breastfeeding and non-nutritive sucking patterns and the prevalence of anterior open bite in primary dentition Infant feeding and non-nutritive sucking were investigated in a 3-6 year-old sample of 1,377 children, from São Paulo city, Brazil. Children were grouped according to breastfeeding duration: G1 – non-breastfed, G2 – shorter than 6 months, G3 – interruption between 6 and 12 months, and G4 – longer than 12 months The prevalence estimates of anterior open bite were: 31.9% (G1), 26.1% (G2), 22.1% (G3), and 6.2% (G4). G1 would have significantly more chances of having anterior open bite compared with G4 Breastfeeding and non-nutritive sucking durations demonstrated opposite effects on the prediction of anterior open bite . Non-breastfed children presented significantly greater chances of having anterior open bite compared with those who were breastfed for periods longer than 12 months

46. Sunday, August 1, 2021 46 Title Authors Journal LOE Aim Methodology Results Conclusion The effect of pacifier sucking on orofacial structures: a systematic literature review Schmid K, Kugler R, Prasad N, Bosch C, Verna C. Progress in Orthodontics (2018) 19:8 2a to find scientific evidence on the effect of pacifier sucking on orofacial structures. A search on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science databases was conducted to find all pertinent articles published from inception until February 2018, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality of the studies was evaluated using the risk of bias judgements in non-randomized studies of interventions (ROBINS-I). Among the 2288 articles found, 17 articles met the selection criteria: seven prospective cohort studies, nine cross-sectional studies, and one randomized clinical trial. Using ROBINS-I, 12 studies were evaluated to have a serious overall risk of bias and five, a moderate one. These studies claimed a strong association between a pacifier sucking habit and the presence of an anterior open bite and posterior crossbite . High level of evidence of the effect of sucking habits on orofacial structures is missing. The available studies show severe or moderate risk of bias; hence, the findings in the literature need to be very carefully evaluated. There is moderate evidence that the use of pacifier is associated with anterior open bite and posterior crossbite, thus affecting the harmonious development of orofacial structures

47. D. Clinical features Increased lower anterior facial height Decreased posterior facial height Steep mandibular plane angle Short upper lip with excessive maxillary incisor exposure Anterior open bite Class II malocclusion/ mandibular deficiency Narrow maxilla Sometimes posterior crossbite Sunday, August 1, 2021 47 Millett D, Welbury R. Clinical problem in Orthodontics and Pardiatric dentistry. Elsvier publication

48. E. Cephalometric features Downward backward rotation of mandible Upward tipping of maxillary skeletal base Excessive eruption of maxillary posterior teeth Excessive eruption of maxillary and mandibular anterior teeth Sunday, August 1, 2021 48 Millett D, Welbury R. Clinical problem in Orthodontics and Pardiatric dentistry. Elsvier publication

49. Sunday, August 1, 2021 49 Nagan P, Henry W. Open bite: a review of etiology and management. American Academoyf Pediatric Dentistry. 1997

50. E. management Sunday, August 1, 2021 50 Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005. Millett D, Welbury R. Clinical problem in Orthodontics and Pardiatric dentistry. Elsvier publication.

51. 1. Removal of cause Thumb Sucking or tongue thrusting habit: Awareness, contract of reward/ punishment, positive reinforcement, Chemical aversion, hand wraps. Removable or fixed appliances- with or without arch expansion Sunday, August 1, 2021 51 Dr Deepika Chari Nanda R. Biomechanic & Esthetic Strategies in Clinical Orthodontic. Page No. 131-176. Elsvier Publication 2005. Millett D, Welbury R. Clinical problem in Orthodontics and Pardiatric dentistry. Elsvier publication.

52. Sunday, August 1, 2021 52 Nagan P, Henry W. Open bite: a review of etiology and management. American Academoyf Pediatric Dentistry. 1997

53. Sunday, August 1, 2021 53 Bahadure R , Thosar N , Jain E, Meena D, Pendor S. Management of Open Bite in Primary Dentition: A Case Report. Journal of Datta Meghe Institute of Medical Sciences University · December 2012. Figure 1: Intraoral photograph showing anterior open bite Figure 2: A modified fixed tongue thrusting habit breaking appliance Figure 3: Intraoral photograph showing modified fixed tongue thrusting habit breaking appliance Figure 4: Follow up after 6 months showing correction of anterior open bite Figure 5: Follow up after 4 years showing normal occlusion

54. 2. Myofunctional Therapy a. Bionator : Developed by Balters 1950s. Similar as activator- but less bulky and more elastic Types: Standard Appliance, Class III Appliance, The Open Bite appliance Sunday, August 1, 2021 54 Graber’s Textbook of Orthodontics Basic Principles & Practices. 4 th Edition. Elsvier Publication

55. Components: Wire Components- palatal arch, vestibular wire Acrylic Components- maxillary plate covers only premolars and molars (distal to 1 st permanent molar) Occlusal surface covered to stabilize appliance Anterior region covered to prevent tongue thrusting Sunday, August 1, 2021 55 Graber’s Textbook of Orthodontics Basic Principles & Practices. 4 th Edition. Elsvier Publication

56. b. Functional Regulators Myofunctional Appliance developed by Prof. Rolf Frankel in Germany. Also called as Frankel appliance, vestibular appliance, oral gymnastic. Two main treatment effects- 1. Muscle function- artificial balancing of environment 2. Removes muscle forces in buccal and labial areas & restrict skeletal growth thereby providing environment which enables skeletal growth. Sunday, August 1, 2021 56 Graber’s Textbook of Orthodontics Basic Principles & Practices. 4 th Edition. Elsvier Publication

57. Mode of action of frankel appliance Sunday, August 1, 2021 57 Graber’s Textbook of Orthodontics Basic Principles & Practices. 4 th Edition. Elsvier Publication

58. Frankel Philosophy Sunday, August 1, 2021 58 Graber’s Textbook of Orthodontics Basic Principles & Practices by Shridhar Premkumar . 4 th Edition. Elsvier Publication

59. Frankel 4 is similar as Frankel 1: difference- it lacks canine loops and protrusion bows Consists of 4 occlusal rests on maxillary 1 st molars and 1 st deciduous molars to prevent tipping of the appliance. 1 st few weeks: 2-4 hours /day (day time) After 3 weeks: 4-6 hours/day (day time) After 3 rd visit (2 months): full time wear. Sunday, August 1, 2021 59 Graber’s Textbook of Orthodontics Basic Principles & Practices. 4 th Edition. Elsvier Publication

60. Sunday, August 1, 2021 60 Oliveira D. et. al. Orthodontic and orthopaedic treatment for anterior open bite in children. Cochrane database systematic review. 2014 sept;24(9).

61. 3. Orthodontic therapy Mild to moderate open bites can be corrected Fixed mechano-therapy Consists of elastics stretched between upper and lower anterior Can be combined with transpalatal arch and high pull headgear (to limit vertical development of maxillary molars.) TPA prevents buccal rolling of molars. Distal movement of teeth with headgear is contraindicated- class II/III malocclusion will lead to worsening of open bite Sunday, August 1, 2021 61 Graber’s Textbook of Orthodontics Basic Principles & Practices by Shridhar Premkumar . 4 th Edition. Elsvier Publication

62. 4. Role of Extractions in open bite Anterior open bite associated with proclined anterior Bimaxillary proclination , Class II malocclusions- retraction of anterior teeth help reducing open bite Extraction of premolars has been accepted by clinicians Sunday, August 1, 2021 62 Graber’s Textbook of Orthodontics Basic Principles & Practices by Shridhar Premkumar . 4 th Edition. Elsvier Publication

63. 5. Extraoral traction High pull headgear prevents vertical eruption of upper molars, limits vertical growth of dento -alveolus: minimize clockwise rotation of mandible. Can be used in conjunction with fixed orthodontic therapy and myofunctional appliances. Sunday, August 1, 2021 63 Graber’s Textbook of Orthodontics Basic Principles & Practices by Shridhar Premkumar . 4 th Edition. Elsvier Publication

64. 6. Surgical correction Skeletal open bites in adults Combination of fixed orthodontics and orthognathic surgeries Surgery may be segmental or whole jaw Treatment should be started after growth has ceased. Sunday, August 1, 2021 64 Graber’s Textbook of Orthodontics Basic Principles & Practices by Shridhar Premkumar . 4 th Edition. Elsvier Publication

65. Retention of anterior open bite Continued vertical growth Eruption of posterior teeth until late teenage Vertical growth of maxilla till last stage of maturation Retention of habit Sunday, August 1, 2021 65 Maxillary removable retainer with attached headgear Retainer with passive posterior bite blocks Graber’s Textbook of Orthodontics Basic Principles & Practices by Shridhar Premkumar . 4 th Edition. Elsvier Publication

66. Sunday, August 1, 2021 66 S I Bhalaji . Orthodontics the Art & Science. 6 th Edition. Arya Publication2015.

67. Sunday, August 1, 2021 67 Title Authors Journal LOE Aim Methodology Results Conclusion Effectiveness of the open bite treatment in growing children and adolescents. A systematic review Feres N F, Abreu G L, Insabralde M I , Almeida R, Flores-Mi C 1a to provide a comprehensive review evaluating the effectiveness of the orthodontic correction of AOB in growing individuals. Search was conducted on PubMed, Embase, Cochrane Library, Web of Science, Scopus, Google Scholar, Scielo , and Lilacs databases. Trials registries were consulted for ongoing trials, and grey literature was also contemplated. The 22 studies included in this review mostly considered mixed dentition subjects, and there was a considerable variation regarding therapeutic approaches. Because of poor-quality and/ or insufficient evidence, consistent results were not found. However, some useful clinical inferences and suggestions for future studies were provided for each therapeutic modality considered here A comprehensive and updated review regarding the effectiveness of the orthodontic therapy on the early correction of dental or skeletal open bite was provided. Despite large variability and methodological inaccuracies, specific inferences and directions for future studies were presented. Even though the methodological quality of the studies has been improving, additional efforts must still be directed to perform better and conclusive studies.

68. Summary Sunday, August 1, 2021 68