THIS WILL AID IN MANAGEMENT OF PATIENTS WITH AOB

1. ENUMERATE THE COMPLICATION OF DIGIT
SUCKING. DISCUSS THE NON-SURGICAL
MANAGEMENT OF ANTERIOR OPEN BITE.
By
Dr Aghimien Osaronse
University of Benin School of Dentistry. Nigeria
20th March, 2014
7 August 2014 1

2. Outline on digit sucking
 Introduction to digit sucking
 Definition
 Etiology andPrevalence
 Clinical phases
 Complications of digit sucking
 considerations
 classification
 hard or soft tissue
 interarch relationship
 digit affected
 others
 consequence of sucking
 Conclusion

7 August 2014 2

3. Introduction
Habit is define as fixed or constant practice
established by frequent repetition(Dorlan 1957).
Sucking is an inherent biological drive observed
in-utero. This can either be nutritive or non
nutritive(O’ Brien, 1996).
According to Larsson the non-nutritive sucking
include those earliest sucking habit adopted by
infants in response to stress and to satisfy their
and need for contact.
7 August 2014 3

4. In-utero
7 August 2014 4

5. Definition
Digit sucking is defined as the placement of the
thumb or one or more fingers in varying depth
into the mouth. It is considered a natural early
childhood developmental habit. This should
be discontinue by age 3-4 years.
7 August 2014 5

6. The commonest digit is the thumb.
Prevalence;
2.1% in 10-15 years old(Isiekwe, 1984)
17% in 4-15 years old (Quashie-Williams et al)
7 August 2014 6

7. ETIOLOGY
Several theories have been postulated as a possible
causes of digit sucking. These include;
 Freudy theory,1905;related it to oral phase of
psychological development
 Benjamin theory 1962;described the rooting reflex
 Sear and wise 1982; oral drive theory due to prolonged
suckling
 Davidson 1967 –Learning theory
Others have related it to; stress, family conflict, lack of
parental love
7 August 2014 7

8. Clinical Phases of digit sucking
This is a clinical classification MOYER 1955
PHASE I:
 Seen within the first 3 years of life
 Normal and sub-clinically significant
 Prophylactic intervention if it persist.
PHASE 11:
 Extend to 3-6/7 years
 This is clinically significant
 Definitive correction is indicated
7 August 2014 8

9. PHASE 111:
• an intractable sucking
• presence of significant problems of
malocclusion exist.
7 August 2014 9

10. 7 August 2014 10

11. Complication of digit sucking
Factors to considered;
1. Intensity
2. Duration
3. Frequency
4. Digit sucked
5. Number of digits
6. Position of digit in the mouth
7. Associated behavior
7 August 2014 11

12. 7 August 2014 12

13. Classification of the complication
1. Base on tissue:
Hard tissue: Skeletal and dental
Soft tissue
2. Base on Interarch relationship
3. Digit affected
4. Others.
7 August 2014 13

14. Skeletal/dental
Proclination of maxillary incisor
Retroclination of mandibular incisors
Increase maxillary arch length
Decrease maxillary arch width
Increase mandibular arch width
High palatal vault
Maxillary anterior crowding
Abnormal resorption of the primary central
incisor
7 August 2014 14

15. Soft tissue
Lip incompetence
Tongue thrusting
Lisping
Low tongue resting position
7 August 2014 15

16. 7 August 2014 16

17. Interarch relationship
Increase overjet
Posterior(buccal) cross bite
Anterior open bite
Temporomandibular dysfunction
Decrease inter-incisal angle
7 August 2014 17

18. 7 August 2014 18

19. digits
 Dishpan
 Ulceration
 Paronychia
7 August 2014 19

20. others
Trichotillomania
Alopecia
Obstructive sleep apnae
Infection
Psychological behavior
7 August 2014 20

21. Consequences
Malocclusion
Speech defect: bi-labial, labio-dental, bi-
dental
TMJ dysfunction
Feeding defect
Dermatological problems
Psychological disorders
7 August 2014 21

22. Conclusion
While digit sucking can be part of normal
response in the early developmental age
attention should be paid to this habit when it
persist as it could lead to detrimental effect on
occlusion, function and psychology of the
individual.
7 August 2014 22

23. Discussion on the non-
surgical management of
anterior open bite[AOB]
7 August 2014 23

24. Outline
Introduction
Definition
Classification
base on hard tissue affected
unilateral or bilateral
symmetrical or asymmetrical
physiological or pathological
simple or complex
7 August 2014 24

25. Etiology
oral habit
abnormal skeletal growth
abnormal tongue size and positioning
physiologic
trauma
mouth breather and causes of mouth breathing
7 August 2014 25

26. Characteristic feature of AOB
dental AOB
skeletal AOB
Understanding the pathophysiology of AOB
physiologic AOB
dental AOB
skeletal AOB
Management of AOB
history
clinical examination
investigation
clinical records
treatment options
7 August 2014 26

27. Aims and objectives of treatment
Treatment modalities
preventive
interceptive non surgical treatment
corrective:
camouflage
orthognatic surgery
adjunctive treatment.
7 August 2014 27

28. Non-surgical treatment option
 Considerations
 Preventive
counseling
reward therapy
habit breakers
 Interceptive
vertical holding appliance
vertical chin cup
active vertical corrector
functional appliance
high pull head gear
 Camouflage
fixed orthodontic appliance with
extraction
elastics; multiloop eadgwise arch wire(MEAW)
mini-implant/miniscrew/micro-screw
7 August 2014 28

29. Introduction
Anterior open bite is one of the most difficult
orthodontic problems also with difficulty
maintaining stability after treatment(Yu-Ching,
2005).
The bite is said to be open when there lack of
anterior vertical overlap. A reduction in such
overlap would amount to an incomplete bite.
7 August 2014 29

30. A prevalence of 2.8%1 was reported among 2-5
year old and thumb sucking was said to be the
major cause. In 2008 a prevalence of 4.1%2
was also reported among other cases of
malocclusion.
(1Ize-Iyamu, Isiekwe 2012; 2Ajayi
2008)
7 August 2014 30

31. Definition
Subtelney and sakuba in 1964 defined it as an
open vertical dimension between the incisal
edges of the maxillary and mandibular teeth.
It has also been defined as a vertical discrepancy
where the upper incisor crown fail to overlap
the incisal third of the lower incisor crown
when the mandible is brought into full
occlusion.
7 August 2014 31

32. classifications
a. base of hard tissue affected
skeletal
dental
b. Base on symmetry
symmetrical
assymetrical
c. unilateral/ bilateral
d. Could either be physiological or pathological
7 August 2014 32

33. 7 August 2014 33

34. Etiology
 Oral habit
digit sucking
tongue thrusting
Mouth breathing
 abnormal skeletal growth pattern
 Abnormal size and function of the tongue
 Traumatic injuries; bilateral condylar fracture,
Le-Fort injuries.
7 August 2014 34

35. Causes of mouth breathing
Deviated septum and other naso–pharyngeal
deformities.
Allergic rhinitis nasal polyps.
Enlarged adenoids or tonsils.
Abnormally short upper lip preventing proper lip
seal.
Obstruction in the bronchial tree or larynx.
Genetically predisposed individuals
Mouth breathing children are breast fed for a
Shorter period of time (Luciana et al. )
7 August 2014 35

36. Characteristic features of AOB
DENTAL AOB
Proclined incisors
Under-erupted incisor
History of oral habit
Narrow maxillary arch(especially with intense
digit sucking habit)
7 August 2014 36

37. Features of skeletal open bite
Extraoral features:
 Long face due to increased lower anterior face height
 Incompetent lips
 An increased mandibular plane angle
 An increased gonia! angle
 Marked antegonial notch
 Maxillary base may be more inferiorly placed (vertical maxillary excess)
 Ratio of upper facial height : total facial height is reduced
 short posterior facial height; PFH:AFH (Jarabak ratio ) less than normal
Intraoral features:
 Mild crowding with upright incisors
 Maxillary, occlusal and palatal planes tilt upwards anteriorly
 Mandibular occlusal plane canted downwards
Gurkeerat Singh, 2007
•
7 August 2014 37

38. Understanding the pathophysiology
Physiologic AOB
this is a natural phenomenon that occur during
the mixed dentition stage. Incomplete
eruption of the maxillary anterior create the
opening in the anterior segment. It should
completely overlap on full eruption
7 August 2014 38

39. Dental AOB
Oral habit especially digit(thumb sucking) has been
reported to be a major cause of AOB(Ize-yamu,
2012).
Habitual position of the digit between the anterior
teeth causes a dis-occlusion of the posterior
segment which causes a supra-eruption of the
molars and infra-occlusion of the anteriors. The
intensity of the habit results in other features;
high narrow palate, procline incisor, spacing etc.
Gurkeerat Singh, 2007
7 August 2014 39

40. Skeletal AOB
1The maxilla grows downward and forward due to
forward growth of the anterior cranial with
contribution from sutural growth. Mandibular
growth is also downward and forward with
backward rotation.
2The growth at the head of the condyle occurs in
an upward and backward direction. This
compensate for the vertical displacement of the
mandible.
1Profitt ; 2Bishara, 20017 August 2014 40

41. Deficiency in the growth of the condyle would
lead to uncompensated mandibular
downward and forward growth.
Bjork in 1969 outline seven(7) features to help
predict abnormal rotation of the mandible
which might lead to an open bite.
7 August 2014 41

42. MANAGEMENT OF ANTERIOR OPEN BITE
7 August 2014 42

43. History
Clinical examination
Investigation
Clinical records
Treatment options
7 August 2014 43

44. History
Age;
 it is a transitional when transiting from the
deciduous to the mixed dentition period.
 habits(frequency, duration, intensity, number of
digit or use of pacifier) have been implicated as a
major cause in younger children while abnormal
skeletal growth becomes more important as a
cause in the adolescent age
Adenotonsilitis common among mouth breathing
children
7 August 2014 44

45. Chief complaint
esthetics; possibility of incompetent lips
function; biting, speech defects
r/o any traumatic injury that can cause pathological
fracture
Medical condition;
obstructive sleep apnae could cause mouth breathing
Arthritic degeneration of the TMJ could alter condylar
growth.
Others include allergies, rhinitis etc.
7 August 2014 45

46. Clinical examination
General examination: a quick general appraisal
should be performed. Examine patient digits if
sucking is suspected.
Extra-examination:
lip: presence of separated lips due to the
proclined incisors
facial profile: long lower anterior face
Skeletal pattern: could be 1,2 or 3.
7 August 2014 46

47. Intra-oral examination:
inspect the extent of the AOB
unilateral or bilateral
symmetrical or asymmetrical
measure the vertical discrepancy
*A typical thumb-sucker has a malocclusion characterized
by an asymmetric anterior open bite due to digit position
and a transverse constriction of the maxillary arch.
(Peter N and Henry w,1997; chui shan teresa et al, 2008)
7 August 2014 47

48. Investigation and diagnostic records
Clinical photograph(intra- and extra-oral) taken
to aid planning and also for medical legal
reasons
Impression for study model;
to assess arch width and amount of space
present
space analysis
Radiograph; dental panoramic radiograph and
lateral cephalometry
7 August 2014 48

49. Lateral cephalometry and OPG
7 August 2014 49

50. Bjork in 1969 identified cephalometric features
of significant abnormal growth rotation of
open bite.
Kim, 1974 also provided information on
behavior of vertical relationships using what
he called Overbite Depth Indicator (ODI).
7 August 2014 50

51. diagnosis
This could either be a dental or skeletal anterior
open or a combination.
Patients with skeletal AOB would present with
discrepancies in their cephalometric values.
7 August 2014 51

52. Aims of treatment
To achieve a vertical overlap
Improve esthetics
Improve function
Maintain a stable results
7 August 2014 52

53. Treatment modalities
In general, four treatment modalities are used
by surgeons and orthodontists in the
treatment of anterior open bite:
1.advice on early problems and observation
2. interceptive treatment
3. camouflage treatment by orthodontics only
4. a combined orthodontic and surgical
approach(CHUI SHAN TERESA , 2008).
The first 3 constitute the non-surgical mode of treatment.
7 August 2014 53

54. NON-SURGICAL TREATMENT
7 August 2014 54

55. Treatment considerations
Age of patient
Presence of habit
Severity of the open bite
Presence of concomitant medical condition
Patient compliance
Esthetic consideration of the appliance
7 August 2014 55

56. A. Counseling
B. Reward
C. Habit breakers; reminder therapy
tongue rake
blue grass
goal post
long sleeves
acrylic thump cap
elbow joint restriction
chemical aversion
adhesive bandage
7 August 2014 56

57. D. Appliance
Functional
Frankel regulator IV
Teuscher activator
Stockfisch avtivator
posterior bite blocks
passive
active(spring loaded/repelling magnet)
Vertical holding appliance
7 August 2014 57

58. Vertical chin cup
Active vertical corrector( Dellinger)
Fixed appliance
extraction
intrusion posterior teeth( TADS,HIGH PULL HEAD GEAR)
MEAW
Extrusion arches
E. Adjunctive treatment
glossectomy
adenotonsillectomy
management of allergy
reduction of fracture
7 August 2014 58

59. COUNSELLING:
Explain about habits ill effects
Show photographs, video
Dunlop hypothesis
Card to score
Discuss with parents
7 August 2014 59

60. REWARD
this is a kind of positive re-enforcement.
the children are encouraged with a gift the day
they do not display the habit
7 August 2014 60

61. HABIT BREAKERS-REMINDER THERAPY:
depends on the habit
 indicated for those who are willing to quit but
the habit has entered a subconscious level;
they involve:
Removable habit breakers
Fixed habit breaker
Chemical approach
7 August 2014 61

62. 7 August 2014 62

63. 7 August 2014 63

64. Bluegrass Appliance
The Bluegrass Appliance is a fixed tongue retraining
device used for
patients with a mixed or permanent dentition. It is an
alternative to the
Rake or Crib design.
7 August 2014 64

65. Tongue crip
The Tongue Crib appliance has a vertical gate
inhibiting the access of the tongue to the
anterior dentition.
7 August 2014 65

66. INTERCEPTIVE
7 August 2014 66

67. Vertical holding appliance:
It is a modified transpalatal arch with an acrylic
pad. It utilizes the tongue pressure to prevent
dentoalveolar development of maxillary
permanent first molars
7 August 2014 67

68. Vertical chin cup
result in a decrease in mandibular plane angle
Anterior rotation due to inhibition of
mandibular posterior dento-alveolar segment
Increase in total anterior facial and lower
anterior facial height.
However there is poor compliance
7 August 2014 68

69. Posterior bite blocks
The blocks(acrylic) are usually set at a slightly
elevated position vertically, so that, the
stretched muscles place an intrusive force on
the posterior teeth, which in turn helps
control eruption and permits an upward and
forward autorotation of the mandible.
Several modifications exist:
application of spring, use of repelling magnets
7 August 2014 69

70. Active vertical corrector(Dellinger)
A modified posterior bite blocks with repelling
magnet incorporated into the acrylic. Has
embedded in it eight opposing field (four per
arch) cobalt samarium magnets
Causes intrusion of the molars, allowing the
mandible to rotate upward and forward.
Compliance is a factor due to the challenge and
duration(4–7 months) of wear.
7 August 2014 70

71. Vertical pull chin cup Posterior bite blocks
7 August 2014 71

72. High pull headgear
7 August 2014 72

73. Functional appliances
Base on the possibility that faulty postural
activity of the oral-facial musculature can also
cause AOB hence, functional appliances
modifying growth. They iclude;
Functional regulator 1V
Teuscher activator
Stockfisch activator
7 August 2014 73

74. Corrective treatment option
7 August 2014 74

75. Camouflage treatment
Some cases of open bite can be corrected by
fixed appliances that cause dental movements
while the skeletal profile and characteristics
are kept unchanged.
This may be accompanied with extractions, use
of elastics, or application of mini-implants or
miniplates.
7 August 2014 75

76. extractions
Extraction of premolars have been advocated due
to the draw-bridge effect of reducing the
inclination of the maxillary and mandibular
incisors.
Pearson (1973) reported that a significant increase
in the lower posterior facial height can occur
during extraction therapy of moderately steep
cases.
Molar extraction have been said to remove the
wedge created by the supra0eruption of the
molars.
7 August 2014 76

77. Here retraction of the incisor results in relative
extrusion of the incisor as it rotate around its
centre of resistance, increasing the bite.
7 August 2014 77

78. Elastics
The multi-loop edgewise arch wire(MEAW) is an
example.
Involves use of multi-loop wire and vertical elastics
on the canine region.
Aim of technique:
Correcting the inclination of the occlusal plane
aligning the maxillary incisors relative to the lip
line
making the axial inclinations of the posterior
teeth upright.
7 August 2014 78

79. Treatment changes occur mainly by a
dentoalveolar compensation mechanism that
causes retraction and extrusion of the anterior
teeth and an upright movement of the
posterior teeth. Thus, the upper and lower
occlusal planes move towards each other.
There is only minimal skeletal changes
7 August 2014 79

80. Temporary anchorage devices
These include
Miniplates
Minisrews
Microscrews
They provide absolute anchorage for intrusion of
the molars
7 August 2014 80

81. Adjunctive treatment
a. Reduction and fixation of fracture injuries
e.g. repair of Le Fort and condylar injuries
b. Alignment of deviated nasal septum
c. Adenotonsillectomy
d. Glossectomy
7 August 2014 81

82. conclusion
Anterior open bite is considered to be one of the
most difficult clinical encounter by
orthodontists. Proper diagnosis and treatment
planning, successful treatment, and retention
have been stressed for the long-term stability
of open bite treatment.
7 August 2014 82

83. Brian Palmer: The Importance of Breastfeeding as it Relates to Total Health,
2002.
Andlaw R.J, Rock W.P. A manual of paediatric Dentistry(4th Edition); Persistent
digit sucking21:176-177
Ize-Iyamu I, Isiekwe MC; Prevalence and factors associated with anterior open
bite in 2 to 5 year old children in Benin city, Nigeria, African Health
Science. Dec 2012; 12(4): 446–451.
Ajayi E. O. Prevalence of Malocclusion Among School Children in Benin City,
Nigeria . Journal of Medicine and Biomedical Research, Vol. 7, No. 1 & 2,
December 2008, pp. 58-65
Gurkeerat Singh. Texbook of Orthodontics (4th Edition,2007). Management of
Open Bite; 54:643-654.
Bishara, Samir E. Textbook Of Orthodontics, 2001. Introduction to growth of
the Face. 4:41-53
7 August 2014 83

84. Yu-Ching W, Ellen Wen; The Nture of Open Bite; Journal Of
Taiwan Association of Orthodontist. 17(2):35-41,2005.
Peter N,Henry W. F. Open bite: a review of etiology and
management. Pediatric Dentistry 19:91-98, 1997.
chui shan teresa et al: Orthodontic treatment of anterior open
bite. International Journal of Paediatric Dentistry 2008; 18:
78–83
Roberto Silva Meza. Practical Application of Overbite Depth
Indicator, Anteroposterior Dysplasia Indicator and Extraction
Index. Orthodontic cyber journal, 2004.
Julio Pedra e Cal-Netoa et al: Severe Anterior Open-Bite
Malocclusion Orthognathic Surgery or Several Years of
Orthodontics? Angle Orthodontist, Vol 76, No 4, 2006
7 August 2014 84

85. Basanta K Shrestha . Orthodontic Treatment of Anterior Dental
Open Bite with Drawbridge Effect: A Case Report. Orthodontic
Journal of Nepal, Vol. 3, No. 1, June 2013
7 August 2014 85