The Skeletal Open Bite Patient
Following last month’s discussion on molar extrusion in cases with reduced vertical dimension, we will discuss in the following months the problems of skeletal open bite cases with or without an anterior open bite. Hyperdivergent cases are a very special category of malocclusion. Their treatment and prognosis, even with the use of miniscrews for molar intrusion, is not very good. We have to put hyperdivergency in perspective and a good starting point is to discuss the cause of the problem. Genetics is a factor but not the only one. We have to take into consideration also the epigenetic factors that may be present in a young child and that can often persist through adulthood. These factors can be respiratory problems (nasal valve problems, adenoids, etc.), finger sucking, swallowing problems, etc. Trying to solve an hyperdivergency problem without eliminating the cause is prone to failure.
The treatment must involve a team approach with the implication of the dentist, the ENT specialist, the speech therapist, the parents, etc. With our fast track life, we should take special care to evaluate parents and patient cooperation, stressing that with low motivation of the parents, we are prone to failure. Before any treatment of vertical excess with or without an anterior open bite, well-conducted myofunctional reeducation based on a progressive program is a must to eliminate any deformative causes of the problem. We cannot treat orthodontically without first treating the function. Preventive early treatment is praised by some and neglected by others. Who is right? Why choose a passive approach? Orthodontics is probably the only medical profession in which, faced with a pathological problem, it chooses to postpone treatment for many years (RODF 2014;48:117). Many are searching for the miraculous rapid treatment, let me just say that it probably does not exist. The question is: ‘’Are early treatments justified and if fesable at an early age, will it be sufficient and stable. Infantile swallowing, the persistence of bad habits like finger sucking or mouth breathing are dysfunctional situations that will negatively affect the growth of the jaws and the implantation of bad occlusal relationship. It is logical and desirable that we correct the functional environment early in life to reduce the aggravation of these deficits or excess of growth and the deformations already apparent. It serves no purpose to train a child to properly place his tongue on the palate if a finger habit is still present and if the sensorial system has not been educated to allow proper evolution to maturity. Oral screens can help children to develop new sensations and better reference spots (Go back and read the March 2020 blog on that topic) but the airway problems must be solved first.
The treatment steps can become more obvious:
- Identification of the problem(s)
- Make the parents aware of the problems and the long term consequences
- Evaluation of the child-parents motivation and degree of cooperation
- Consultations with the medico-dental team and intervention if needed (ENT)
- Functional reeducation
- Dental intervention if needed (transverse development, functional training with an oral screen and swallowing exercises)
- Follow up and evaluation of the results and discussion with the parents on the long term possiblities.
We all know that we have to create favorable conditions and environments to support nature on its compensation of deficits or excess. Not all clinicians have a desire to manage the functional problems mainly because treatments will probably extend on many years. It is your choice but if you do not want to treat these problems I just suggest that you refer them out. This is your job.
Image 1. Face former
Image 2. ENT
Image 3. Anterior open bite