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Anterior open-bite: A cephalometric

analysis and suggested treatment

Henry I. Nahoum, D.D.S.*

New Yorlc, N . Y.

n e of the most difficult a spects of dia gnosis lies in ma king a decision

r ega r din g t h e n a t u r e of t h e con dit ion or syn dr om e u n der con sider a t ion . Th is
con cept u a l difficu lt y is illu st r a t ed by som e r ecen t a r t icles on t h e su bject of
anterior open-bite. I, 2 In t h ese r epor t s, open-bite is considered an adequate
definition of the condition, a nd little considera tion is given to the fa ct tha t
t h is t er m in clu des sever a l skelet a l va r ia n t s t h a t a ll h a ve in com m on a ?zegative
incisal overbite.3
The purpose of this essay is to present a cephalometric assessment of various
types of anterior open-bite malocclusion and to review some concepts that
m a y h elp in u n der st a n din g t h e lim it a t ion s in t h e t r ea t m en t of su ch pa t ien t s.
Many of these concepts are not new and have been ably presented by H ellm a n
Su bteln y a n d associates,5* 6 and Horowitz and Hixon.7
It sh ou ld be em ph a sized t h a t ceph a lom et r ics, a t best , is a descr ipt ive t ech n iqu e wh ich h elps t o define or cla ssify a con dit ion bu t does n ot n ecessa r ily
pr ovide u s wit h t h e in sigh t for t h e su ccessfu l t r ea t m en t of a n a n om a ly.
Review of the literature

Anterior open-bite has been grouped into two broad categories. The first
ca tegory consists of the a cquired or denta l open-bites which do not show a ny
distinguishing craniofacial malformations. The second group consists of patients
with craniofacial dysplasia in addition to the open-bite.
The dental open-bites are believed to result from obstructed eruption of
t h e a n t er ior t eet h (F ig. 1). Ma n y of t h ese sh ow spon t a n eou s r em ission s, a n d
75 t o 80 per cen t h a ve m a r ked im pr ovem en t wit h ou t a n y for m of treatment.8
P r esen t ed befor e t h e Kor t h ea st er n Societ y of Or t h odon t ist s, Nov. 8, 1974.
*Associa t e P r ofessor of Den t ist r y, Colu m bia Un iver sit y Sch ool of Den t a l a n d Or a l


Fi g.


initia te d

The d e ntitio n o f a p a tie nt w ith a ha b itua l a nte rio r o p e n-b ite w hic h w a s p ro b a b ly

b y thum b -suc king . No te


a sym m e tric

o p e ning

c a use d

b y p la c ing


thum b


the rig ht sid e . This typ e o f o p e n-b ite re sp o nd s to ha b it the ra p y.

Fi g . 2 .


Th e d e n t i t i o n o f a p a t i e n t w i t h a t r a n si t i o n a l o p e n - b i t e w i t h a C l a ss II

m a lo c c lusio n a nd

m ild

a nte rio r c ro w d ing . B, The

d e ntitio n o f the

sa m e

p a tie nt a fte r tre a t-

m e n t w i t h c e rv i c a l e x t ra o ra l f o rc e . A l o w e r l i n g u a l a rc h i s i n p l a c e a n d i s b e i n g u se d
t o m a i n t a i n a rc h l e n g t h . Th i s p a t i e n t h a s t h e sk e l e t a l c o n t ig u ra t io n
w ith

c lo se -b ite s.

(Tra c ing s in

Fig .

t h a t i s a sso c i a t e d


Some respond to mvofunctional therapy. Since the vast majority of these

patients are children in the transitional dentition stage, it is conceivable that
the rate of eruption of the anterior teeth had slowed down temporarily (Fig. 2).
Eruption does not occur at a constant rate and may take place in spurts. Consequently, these subjects may be referred to as having transitional or
pseudo open-bites.
The group with the craniofacial malformations have varied characteristics
which continue on into maturity.I( These subjects usuallv have slightly longer
total anterior face height. The palatal plane map br tipped upward anteriorly,
so that the upper anterior face height is shorter and the lower anterior face
height is longer. The posterior face height is usually shorter t,han the norm.

PI L c

Class I


Normal d

Cla ssII

Fig . 3. A, Tra c ing

of a

p a tte rn

(S-N-M e -G o -S]

p a tte rn


no rm a l

sub je c t w ith a

sho w ing

c o ntro l

o c c lusa l

m a tc he d

N o rm a l O p e n Bi t e - - -

d e nto fa c ia l a nte rio r o p e n-b ite . B, Ave ra g e

p o lyg o n

a nd

Ave ra g e

a g a inst

p a la ta l
a ve ra g e

p la ne s.

No rm a l

c o ntro ls.

C la ss II o p e n-b ite


su b ie c t s.

No t e

d if f e re n c e s in S- G O , g o n ia l a n g le , m a n d ib u la r p la n e , f a c e h e ig h t , a n d c a n t o f t h e
o c c lu sa l p la n e s a n d o f t h e p a la t a l p la n e . Su p e rim p o sit io n a lo n g S- N re g ist e re d a t S.

The ratio of the upper anterior fact height to the lower anterior fact> height
serves as one of the diagnostic criteria. (The normal IJFII/LFH ratio is 0.800,
open-bite < 0.700 and closed bite > 0.900.) An obtuse genial angle is seen
with a steep, notched mandibular plane. In addition, there are two distinct
occlusal planes. The maxillary occlusal plant may bc tipped upward ankriorly
in conjunction with the palatal plane, while the mantlibular ocelusal plam is
canted downward. Our studies indicated that dcntoalvcolar height is ctf I( trsf
normal except for the mandibular molar, whkh is significantly shorter.: Thr

5 16


Na h own





at 4-month

















intervals. C, Patients dentition 2 years later. Note persistence of open-

bite. (UFH/LFH is 0.684.)

distance from the SN plal~c t o thtb maxillary incisor is shorter,

would br
in t h o s c ~ s u h , jc & in whom the ]>lIiItaI plane is tipptd UJ ) (Fig. :j).
All open-hitc patients dcmonstratc t.ongue tlrruding during swallowing.
This is the way that the subjcet crctitcs ~JJ oral seal, which is necessary for
tleglutition. In some, particularly those with skeletal v;triations, this map be
a necessity. It is important to cdonsitlcr the size of the tongue ant1 the available
space i n the oropharyns. The s i z e o f the oropharyngeal space influonc~cs t h e
posturing of the tongue as it ptdains to respiration and ckyqlutit,ion.
I n a d d i t i o n , thcrca a r c suhtlr ~~(~~~~(~ttlusc~~lar
cliffcrrnces bct,wcen the t w o
major catcgorics of open-bite. Some cbf tht> patients in that c~rirniofaC.ial malformat i o n s g r o u p , w h o ;lre pcrnicaious
tollgut> thrust,rrs, lack iI ga,g r&:x.* :I IJl
t&s of stercognosis
thcscl p a t i e n t s are unable t o icleutify diffrrrntly s h a p e d
objects with the tongue, and some ot thc3tr subject,s c a n n o t eserut,e alternate
repetitive movements with the tongue (tlvsclieclokokirl~~sis)
. I These conditions
arc probably due to deficient proprioc.t~l)t,ivr
mechanisms. Einally, the exact

e Xpt Y%d,

A n t erior open -bit e 5 1 7

Fig. 5. A, The skeletal configuration that is typical of a subject with a deep-bite. Note
that this patient has a transitional open-bite. (UFH/LFH is 1.017.) B, Same patient 2
years later, after treatment of Class II malocclusion with cervical EOF. Note tendency to

r oles of t h e ext r in sic a n d in t r in sic m u scles of t h e t on gu e a n d t h e leva t or s a n d

depressors of the mandible are not known.16
Ton gu e t h r u st m a y con t r ibu t e t o open -bit e defor m it y. Th is con dit ion is
sometimes associated with tactile hypesthesia and disorders of oral motor
a ct ivit y. It h a s im por t a n t dia gn ost ic a n d t h er a peu t ic im plica t ion s. Th e u n den ia ble con clu sion , t h en , is t h a t open -bit es h a ve a n a t om ic a n d neurologic com ponents.l?
Not a ll of t h ese ch a r a ct er ist ics a r e n ot ed in a ll open -bit e pa t ien t s, bu t
various permutations of some of them are. The most common skeletal deformity
is in the a ngle of the pa la ta l pla ne to the ma ndibula r pla ne. It is of pa ra mount
im por t a n ce t h a t open -bit e su bject s be ca r efu lly exa m in ed in or der t o det er m in e
the exa ct location of the deformity a nd to gain some insight as to the possible
ca use. Should a ll open-bites be trea ted in the sa me wa y, rega rdless of the
va riety? Ca n we hope for sta bility if the ca use is not neutra lized beca use it is
not understood?
Comments on treatment

The treatment of patients with anterior open-bite is difficult and is often

u n su ccessfu l. It r equ ir es good ju dgm en t a n d skill. Tr ea t m en t sh ou h l attempt to
correct the skeletal as well as the dental dysplasia. TJ nfortunately, the means for
a ccomplish in g th ese idea l goa ls a re n ot rea dily a va ila ble, since we a re severely
limited in identifying and in eliminating, or diminishing, the causes of these malfor m a t ion s (t h a t is, gen et ics, gr owt h , n eu r om u scu la r , h a bit u a l, et c.). Su bt eln y
and Sakuda5 cor r ect ly qu est ion t h e fea sibilit y of t r ea t in g a ll open -bit es.
Nea r ly a ll pa t ien t s ca n be t a u gh t t o swa llow wit h ou t t on gu e t h r u st in g on a
volu n t a r y or con sciou s level. H owever , deglu t it ion h a s r eflex a n d in volu n t a r y

.I i,, J. O?.thod.
.Ilrr !, 1 9 i i

5 1 8 Nahounz.


Dec. 13, 1962

---- Mar. 16,


Fig. 6. A, Cephalometric tracing of a patient with skeletal anterior open-bite. B, Tracing of

same patient after 18 months of twin arch treatment and 1 year of retention. C, Beforeand after-treatment tracings superimposed on anatomic cranial landmarks. Note favorable growth of posterior face height in addition to maxillary growth.

com pon en t s wh ich a r e in it ia t ed a n d execu t ed on a su bcon sciou s level.lx Swallowin g occu r s 1,200 t o 1,500 t im es a da y, a n d t h e pa t ien t is n ot a wa r e of t h is
activity.l! Th er e is n o evidence to support the cla im of beneficia l thera peutic
effects of myofunctional therapy in skeletal open-bite patients20-22 (F ig. 4).
Th e dia gn osis of a gr owin g ch ild is different fr om t h a t of a n a du lt . Th e a du lt
pr esen t s u s wit h a fa it a ccom pli. Th er e is n o h ope for im pr ovem en t wit h ou t
treatment. The child presents us with an unusual challenge to make an educated
guess a s to the potentia l for fa vora ble growth. Although genera liza tions ma y be
m a de, it is ext r em ely difficu lt t o m a ke pr ecise pr edict ion s for t h e in dividu a l
pa t ien t . Con sequ en t ly, we a r e u n a ble t o r en der a n a ccu r a t e a ssessm en t of ou r
pa t ien t a n d a va lid pr ogn osis. An illu st r a t ion m a y ser ve t o em ph a size t h e im por t a n ce of t h is con cept . A ch ild wit h t h e skelet a l con figu r a t ion t h a t is t ypica l
of a close-bite will continue to grow a s a close-bite pa tient (Fig. 5). It is unlikely that he will develop a skeletal open-bite. A similar, but opposite, generali-

A n t erior open -bit e 5 1 9



- 7-63
- - - - 6-66

Fig. 7. A, Pa tient with severe open-bite who wa s trea ted with vertica l ela stics. 6, Superimposed

tra cings


indica te

minima l




Cra niofa cia l

ma lforma tion


una ffe c te d.

zation may be made about an open-bite patient (Fig. 4). However, minor
changes in the growth pattern may facilitate treatment, so that a poor prognosis
can become a, favorable one. Apparently, growth makes the difference.
If we think of the first or second molar as a fulcrum, consider what 1 or 2
mm. of additional posterior face height growth would mean to a patient with an
anterior open-bite! Relatively small changes in strategic locations can modify
the subjects position within the spectrum of the deformity (Fig. 6).
In a recent publication, Nemeth and Isaacson reported that orthodontically
treated patients who exhibited anterior open-bite relapse showed greater combined sutural and alveolar growth of the maxilla and alveolar growth of the
mandible than posterior facial height increase. This study indicated that some
open-bite patients continued to have insufficient vertical growth of the posterior
face as the other components continued their normal growth. Conversely, we
may assume that, if the trend reverses itself and there is adequate growth in
posterior face height, an open-bite may close. This is one area where we can
observe structural differences in growing patients who exhibit the anterior
open-bite syndrome. However, it should be stressed that this is not the only site
of deformation.
The patient with a craniofacial malformation should not be treated by elongation of anterior teeth. Dentoalveolar height is finite. Incisors should not be
extruded without restraint. Even if the bite were closed, facial improvement
would be limited except t.hrough
favorable growth or surgical intervention
(Fig. 7).
It is not surprising that orthodontists would look for and readily accept
some method of determining the severity of the overbite-positive or negative.
Such an indicator has been suggested by Kim, who utilizes a combined measurement of the palatal plane angle to FH and the angle of the AB plane to the
mandibular plane. It is referred to as the ODI. Although the use of the palatal

plant as o~c arca of tliscrepunc\- iii opclr-bitts had begun suggestetl

previously, wo
have not bcci~ su~cssful in applying the 0111. Whei~ tlic 0111 was applied to five
a d u l t open-bite suhjccts W~ORC t ratings ;rppcarccl
i n WI p u b l i c a t i o n ou the
J)&tal JhIl(, only one was in the opcwl)itc~ railgt~. Thc~s, in ntl(litiolr to other
JMtiPllb, have lctl us to qucstioli 1hc valitlity oi this intlic%tor
in its prcsrlkt form.
There is no short-cut method for assessing skeletal anterior opcln-bites.
sites of the dysplasia vary and all must bc considcrcd. ITnfortunatcly, m o s t
efforts have been tlirccted t,oward trcatrntwt of the dentition via mechanothcrapy
and myofunctional therapy without c~onsidcration
of anatomic liabilities.
It is natural for orthodontists to lw c9nccrncd with dental ilS& IWt S of opc llbitts and to accept cosmetic improvcmcnt as a welcomcl bonus t,o treatment. The
fact that the facial, neuromuscular, and yharyngcal components are of usual or
greater importance has led us into partnerships with other disciplines. The
surgical correction of anterior open-bites is bring refinctl to the point whcrc we
must consider this modality as a primary mcthotl ot treating this dysplasia,
cvcn though t,he results are not cntircly s t a bl e . The removal of molars and partial
glosscctomy have been rcvivt~d.: These J~rocctlurcs
are I~eing iltltlltl 1 0 various
types of maxillary and mandibular ostcotomy.
Time will tell if tllr benefits tha,t
accrut a r c w o r t h t h e t i m e and effort rspcntled. LKt~rcrtllelcss, we sh0~11d btl
acutely awart of the fact that, we art treating symptoms. This is the reason
that treatment is often haphazard alld unsuccessful.



3. A detailed description of the open-bite subject, with a craniofacial malformation is given in order to diffrrentiate this malocclusion from the acquired
2. The reasons for the failure of various modes of treatment ilr( presented
in the light of neuromuscular and anatomic variations that, are inhcrcnt in these
3. The importance of growth in strategic: sites is emphasized as a determining
factor in successful treatment.
Th e a u t h or gr a t efu lly a ckn owledges t h e su ggest ion s of Kicbolns
I,. H or owit z in t h e pr epa r a t ion of t h is a r t icle.

A. DiSalro and Sidn ey


I. Semetb, R. B., a n d Isaxcson H. J .: Vwtical a n t er ior r ela pse, Ah<. J . ORTH OI). 65: 565-585,
2. Kim , You n g H .: Over bit e tlept,h indicntor, A&f. J . ORTHOD. 65: 586.611, 1974.
3. Na bou m , 11. I., H or owit z, H. I,., a n d Benedicto, E .: Varirt.ies of a n t er ior open -bit e, A&z.
J. ORTHW. 61: 486.492,


4. Hellnmn, M.: Open bit e, IN T. J . OKTHOI).

8: 421, 1931.
5. Subtclny, J . I)., a n d Subtelny, .J . I).: Or a l h a bit s; studiw in for m , fu n ct ion , a n t 1 therapy,
An gle Or t h od. 43: 347-383, 1973.
6. Su bt eln y, .J . U., a n d Sa k u da , M.: Open -bit e; dia gn osis a n d t r ea t m en t , A&f. J. (~RTIIOI).
50: 337-358, 1964.
i . Iforowitz, S. L., a n d H ixon , E . H .: Th e n a t u r e of or t h odon t ic dia gn osis, St . Lou is, 1966,
The (1. V. Mosby Com pa n y.

A nterior



8. Wor m s, F . W., Meskin, L. H ., a n d Isa a cson , R. J .: Open -bit e, AX J . ORTHOD. 59: 589-595,
9. Staub, W. : Malfunction of the tongue, AM. J. ORTHOD. 46: 404-424,
10. Na h ou m , H . I.: Ver t ica l pr opor t ion s a n d t h e pa la t a l pla n e in a n t er ior open -bit e, AM. J .
ORTHOD. 59: 273-282,1971.
11. Lin der -Ar on son , St en : Aden oids : Th eir effect on m ode of br ea t h in g a n d n a sa l a ir flow
a n d t h eir r ela t ion sh ip t o ch a r a ct er ist ics of fa cia l skelet on a n d t h e den t it ion , Aeta Otola r yn gol; Supp 265, 1970.
12. Wh it m a n , C. L.: H a bit s ca n m ea n t r ou ble, AM. J. ORTHOD. 37: 647, 1951.
13. McDon a ld, E . T., a n d Au n gst , L. F .: St u dies in or a l sen sor im ot or fu n ct ion . In Bosm a ,
J . F .: Sym posiu m on or a l sen sa t ion a n d per cept ion , Spr in gfield, Ill., 1967, Ch a r les C
Th om a s P u blish er , Ch a p. 11.
14. Bloom er , H . H a r la n : Or a l m a n ifest a t ion of dysdia dokokin esia wit h or a l a st er iogn osia .
la Bosm a , J . F .: Sym posiu m of or a l sen sa t ion a n d per cept ion , Spr in gfield, Ill., 1967,
Ch a r les C. Th om a s P u blish er , ch a p. 19.
15. Henkin, R. I.: Sen sor y m ech a n ism in fa m ilia l dysa u t on om ia . In Bosm a , J . F .: Sym posiu m
on or a l sen sa t ion a n d per cept ion , Spr in gfield, Ill., 1967, Ch a r les C Th om a s P u blish er
ch a p. 20.
16. Gr a ber , T. M.: Th e t h r ee Ms-Mu scles, m a lfor m a t ion , a n d m a locclu sion , AM. J. ORTHOD.
49: 418-450, 1963.
17. Henkin, R. I., Ch r ist ia n sen , R. L., a n d Bosm a , J . F .: F a cia l h ypopla sia , gr owt h r et a r da t ion , im pa ir m en t of or a l sen sa t ion : A n ew syn dr om e, Secon d Sym posiu m on Or a l Sen sa t ion a n d P er cept ion , Spr in gfield, Ill., 1970, Ch a r les C. Th om a s P u blish er .
18. Gr a ber , T. M.: Or t h odon t ics: P r in ciples a n d pr a ct ice, P h ila delph ia , 1972, W. B. Sa u n der s
Com pa n y, ch a p. 6.
19. Kydd, W. L., a n d N eff, C. W.: F r equ en cy of deglu t it ion of t on gu e t h r u st er s com pa r ed
t o a sa m ple popu la t ion of n or m a l swa llower s, J . Den t . Res. 43: 363, 1964.
20. Ba r r er , II.: Lim it a t ion s in or t h odon t ics, AM. J. ORTHOD. 65: 613-625, 1974.
21. Tully, W. J .: A cr it ica l a ppr a isa l of t on gu e t h r u st in g, AM. J. ORTHOD. 55: 640-649, 1969.
22. Speidel, T. Mich a el, Isa a cson , R. J ., a n d Wor m s, F . W.: Ton gu e t h r u st t h er a py a n d
anterior dental open-bite, AM. J. O RTHOD. 62: 287-295, 1972.
23. Lin es, P . A., a n d St ein h a u ser , E . W.: Dia gn osis a n d t r ea t m en t pla n n in g in su r gica l orthodontictherapy, AM. J. O RTHOD. 66: 378-379, 1974.