EJPD 2019 CLINICAL FOCUS

M. Rosa*, V. Quinzi**, G. Marzo**

Paediatric *Insubria University in Varese, Italy

**Department of Life, Health and Environmental Sciences, Postgraduate School of

Orthodontics
Orthodontics, University of L’Aquila, L’Aquila, Italy

e-mail: [email protected]

Part 1: Anterior
open bite in the DOI: 10.23804/ejpd.2019.20.01.15

mixed dentition

Abstract Introduction

Anterior open bite (AOB), or lack of contact of incisors,

The correction of anterior open is one of the most challenging malocclusion to treat. The
bite in the mixed dentition: cause of an anterior open bite is generally multifactorial due
treatment or over-treatment? to a combination of skeletal, dental and soft tissue issues.
Anterior open bite (AOB) is widespread among young
children, with prevalence ranging from 17% to 18% of
Early treatment of the anterior open bite is a common, children in the mixed dentition [Kasparaviciene et al.,
widespread treatment, which involves sometimes multiple 2014; Tausche et al., 2004; Silvestrini-Biavati, 2016]. When
clinical procedures: active orthodontic treatment and associated with sucking habits, the prevalence increases
correction of the dysfunctional habits with a large waste of
to 36.3% [Cozza et al., 2005]. A tendency towards self-
financial and biological costs. Therefore, also considering
improvement from the deciduous to the late mixed dentition
the significant possibility of self-improvement in the pre-
pubertal phase, active early treatment should not aim to is expected during pre-pubertal growth [Worms et al., 1971;
the active correction of the AOB, but only to other aspects Phelan et al., 2014], and it is demonstrated that, if AOB
of the malocclusion and to the interception of dysfunctional persists during the cranio-facial pubertal growth spurt, it
habits. hardly ever self-corrects or even worsens [Phelan et al.,
2014]. Thus, in the one hand, it seems indicated to treat the
AOB early and to intercept the dysfunctional habits that, if
removed early enough, become likely to promote optimal
development of the masticatory system. On the other
hand, if there is a chance that the anterior open bite will
self-correct during growth, all or many of the treatments
proposed during the deciduous and mixed dentition should
be considered as over-treatment.

Literature review

After more than 50 years of investigations, the extensive

literature concerning the early treatment of AOB still is
controversial and covers a wide variety of therapeutic
approaches [Fränkel and Fränkel, 1983; Kiliaridis et al., 1990;
Ngan et al., 1992; Erbay et al., 1995; Sankey et al., 2000;
Almeida, 2005; Pedrin et al., 2006; Defraia et al., 2007;
Giuca et al., 2008; Quinzi et al., 2018; Giuntini et al., 2008;
Doshi and Bhad, 2011; Cerruto et al., 2018]. Retrospective
controlled trials (CT) and CCT studies suggested that the
combination of different treatment modalities is effective,
such as the use of a functional appliance, the bite block,
cribs and the high pull headgear in younger subjects.
The above treatments seem effective for the correction
of dentoalveolar and skeletal open bite. However these
KEYWORDS Anterior open bite; Dysfunctional results must be viewed with caution, because the studies
habits; Orthodontic treatment. showed important methodological limitations and did
not reach a quality level sufficient enough to draw any

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 EJPD 2019 CLINICAL FOCUS: PAEDIATRIC ORTHODONTICS

evidence-based conclusions. AOB with appliances during the mixed dentition is the risk
To the best of our knowledge [Lentini-Oliveira et al., 2014; of overcorrection, coupled with the retention phase that
Pisani et al., 2016; Feres et al., 2017] there are only two follows. The biological cost of retention between the first
systematic reviews that assessed the evidence regarding and the second phase can be very high: it will burn the
the early management of AOB [Erbay et al., 1995; Almeida, compliance of a likely phase two in the permanent dentition
2005]. In addition, treatment protocols aiming to eliminate and it will mask the severity of the open bite.
bad oral habits were only superficially considered in those
reviews, as only 12 had untreated matched subjects as Conclusion
control group and in all untreated AOB groups described in
those articles a spontaneous improvement was observed as The diagnostic criteria for anterior open bite in the mixed
well (a 75% self-correction) [Phelan et al., 2014]. dentition should be standardised and further investigated.
Randomized controlled trials (RCTs) with rigorous
Discussion methodology and a non-treated control group should be
carried on to elucidate not only the treatment modalities,
Diagnosis and the definition of the anterior open bite but also the need for treatment of the AOB during the
in the mixed dentition are the first issues to be discussed. mixed dentition and the pre-pubertal phase.
Indeed one possible explanation for the high prevalence No treatment should be performed to correct minimal
of open-bite from canine to canine at age 7 to 9 is the (1–3 mm) AOB in the mixed dentition. Only some other
incomplete eruption of the incisors. Diagnostic criteria malocclusions should be treated early when needed (i.e.
for anterior open bite in the mixed dentition should be posterior cross bite, mandibular shift etc.) [Rosa, 2012,
standardised. 2016].
The main conclusion of all meta-analyses and literature Before planning for correction of the AOB in the mixed
reviews is that “randomised controlled trials (RCTs) with dentition, other aspects— including tolerability, cost, and
rigorous methodology should be adopted to elucidate patients satisfaction—should be taken into consideration.
the interventions for treating anterior open bites”. RPCT The correlation between open bite and sleep-
are considered among the highest level of investigation, disordered breathing may be investigated together with
but, once again, the few RPCT available did not provided otorhinolaryngologists or other sleep professionals. In
knowledge not previously available from retrospective addition to the cephalometric measurements, masticatory,
studies and CTs. In addition, there is no sense in designing swallowing, respiratory functions, maxillary and mandibular
a PRCT to compare two different treatment modalities growth, as well as facial analysis should be evaluated to test
to correct AOB in the mixed dentition, when there is a the validity of the interventions.
significant probability that the negative overbite will self-
correct during growth in the pre-pubertal phase. The only References
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