Journal of ISSN: 2373-4345JDHODT

Dental Health, Oral Disorders & Therapy
Case Report
Volume 4 Issue 4 - 2016
The Fallacy of Tongue Thrust and Non-Surgical Treatment of a Severe Anterior Open Bite
Anthony D Viazis1, Evangelos Viazis2 and Tom C Pagonis3*
1Orthodontist, Private Practice, Dallas, Texas, USA
2Private Practice, Athens, Greece
3Department of Restorative Dentistry and Biomaterials Sciences, Harvard School of Dental Medicine, Boston, MA, USA
Received: February 07, 2016 | Published: April 20, 2016
*Corresponding author: Tom C Pagonis, Department of Restorative Dentistry and Biomaterials Sciences, Harvard School of Dental Medicine, 188 Longwood Avenue, Boston, MA 02115, USA, Telephone: + 1 617-432-5846; Fax: + 1617-432-0901; Email:
Citation: Viazis AD, Viazis E, Pagonis TC (2016) The Fallacy of Tongue Thrust and Non-Surgical Treatment of a Severe Anterior Open Bite. J Dent Health Oral Disord Ther 4(4): 00120. 10.15406/jdhodt.2016.04.00120

Abstract

Introduction: The causal relation between tongue thrust swallowing or habit and development of anterior open bite continues to be made in clinical orthodontics yet studies suggest a lack of evidence to support a cause and effect. Treatment continues to be directed towards closing the anterior open bite frequently with surgical intervention to reposition the maxilla and mandible. This case report illustrates a highly successful non-surgical orthodontic treatment without extractions.

Case report: After seeking treatment options since the age of 12 and undergoing several unsuccessful attempts to close her anterior open bite, the patient who is a dentist presents at the age of 33 and successfully completes non-extraction orthodontic treatment in 15 months. Post treatment results show a dramatic closure of the anterior open bite and proper intercuspation of teeth with a proper over jet and overbite relation. A stable occlusion without an anterior overbite relapse is maintained at a two-year recall visit.

Conclusion: Tongue thrust swallowing as a cause of an anterior open bite appears more a fallacy than a direct cause. This case report illustrates the potential of non-extraction orthodontic therapy with a system of braces that utilizes light forces and moves the tooth roots toward their final position from the onset of treatment in a short of amount of time from weeks to months.

Keywords: Anterior open bite; Tongue thrust; Non-extraction orthodontic treatment

Introduction

The anterior open bite remains one of the most challenging cases to treat in orthodontics. It is characterized by a negative overbite or lack of a proper overbite relation of maxillary and mandibular incisors with posterior teeth in occlusion. The prevalence of an anterior open bite varies with age and among ethic groups and ranges from 1 to 11.5% [1-3]. The etiology of open bite remains uncertain [4,5] with numerous theories of development that include tongue function, digital habits, heredity and unfavorable patterns of growth [6]. In addition, some studies suggest a correlation between a weakened musculature and a long face anterior bite pattern [7]. One of the most debated theories of open bite development particularly in the classic literature and with a reported wide variation in prevalence is tongue thrust swallowing [8-10]. Tongue thrust is considered a normal physiological manifestation of suckling and also occurs in transitional dentition but typically disappears with the establishment of a normal anterior overbite [10]. The tongue thrust diagnosis is still prevalent and treatment is directed towards closure of the associated anterior open bite frequently with surgical intervention to reposition the maxilla and mandible with adjunctive treatment involving tongue reeducation [11,12]. Other treatment modalities include the use of micro implant anchorage complemented by genioplasty along with multiple jaw surgeries with dental implants for cases with missing teeth [13,14]. Classic non-surgical interventions which include extraction therapy or multi-brackets with fixed habit correcting appliances and high-pull therapy often result in marginal skeletal and occlusal improvements [15- 18]. Advances in mechano therapy, orthodontic diagnosis and treatment concepts have nearly eliminated the need for surgical intervention and multiple tooth extractions for correction of an anterior open bite. Viazis et. al. [19] has proposed new diagnostic terms of orthodontosis and orthodontitis as a replacement to the widely used, arbitrary and scientifically unverified Angle classifications of I, II and III. The central paradigm of these new diagnostic terms is based on the theory that malpostioned teeth and the clinical manifestation of an anterior open bite represent unfinished tooth eruption. This system of braces known as Fastbraces® simplifies the diagnostic and treatment process significantly. The treatment is based on the non-extraction mechanically aided continuation of eruption by mimicking the lighter natural forces of tooth eruption. The following case report illustrates the successful long term treatment outcome of a severe anterior open bite and challenges the diagnosis of tongue thrust as its cause.

Case Report

The patient is a 33-year old female dentist who presents to the treating co-author’s private practice in Athens, Greece with a chief complaint of an open bite and poor posterior occlusion (Figure 1). As a 12-year old child growing up in Serbia, the patient accompanied by her parents first presented to the private family dentist for evaluation and treatment. She was diagnosed with a skeletal open bite secondary to a “tongue thrust problem” which her dentist described as continuous suckling. She was given a series of removable habit correcting appliances which she used as instructed but tapered herself off in about a year because treatment was ineffective. Several years passed before the patient returned to a public dentist (state run health and dental care) for treatment at the age of 19 where she was given removable orthodontic/orthopedic appliances followed by application of brackets prior to surgical orthodontic treatment. Once again her anterior open bite was attributed to tongue thrust. Because of the uncertain outcome and difficulty associated with the surgical orthodontic procedure as described by her dentist and surgeon she decided not to pursue treatment and brackets were removed. Shortly thereafter she started dental school where she was seen by a professor in the department of orthodontics. She was told that surgical orthodontics was the only viable treatment option but was once again cautioned of the difficulty and uncertain outcome of the procedure. She once again decided to forgo surgery and all orthodontic treatment for several years.

Figure 1(A): Pre-treatment facial and intra-oral frontal view photographs.
Figure 1(B): Pre-treatment intra-oral occlusal view photographs.

Treatment objective

On examination the patient has a mesoprosopic face with an anterior open bite of 8 mm with end to end occlusal contacts of first molars and stable second molar occlusion. After review of pretreatment panoramic and lateral cephalogram radiographs the patient was treatment planned for non-surgical, non-extraction orthodontic treatment to eliminate the anterior open bite and correct associated malocclusion by utilizing the bracket system, Fastbraces ® (Figure 2).

Figure 2: Pre-treatment lateral cephalogram and panoramic radiographs.

Treatment progress

Treatment took 15 months with appointments scheduled approximately on a monthly basis. Brackets were initially placed on the four maxillary incisors for patient comfort for one month. At the second appointment brackets were placed on all remaining maxillary teeth including the properly occluding second molars. This set up provided appropriate force and adequate torque for both the maxillary first molars and all premolar roots to upright and aligns the maxillary arch by inducing alveolar bone growth in order to provide proper occlusion with opposing mandibular teeth. At the third visit and three months into treatment, brackets were placed on the mandibular teeth with elastics to close the anterior bite. The treating co-author notes that treatment time could have been substantially less had the patient diligently complied with the use of elastics.

Treatment results

Clinical results along with photographs and radiographs comparing pre and post treatment show dramatic closure of the anterior open bite, a stable occlusion with alignment of roots in a treatment time of 15 months (Figure 3 & 4). Overjet and overbite was measured at 2 mm and normal intercuspation of teeth was achieved. At a two-year follow-up visit the patient maintained stable occlusion, proper overjet/overbite relation without relapse of an open bite (Figure 5).

Figure 3A: Post-treatment facial and intra-oral frontal view photographs.
Figure 3B: Post-treatment intra-oral occlusal view photographs.
Figure 4: Post-treatment lateral cephalogram and panoramic radiographs.
Figure 5: Two-year post-treatment follow-up, intra-oral frontal view.

Discussion

Tongue thrust swallowing and development of an anterior open bite have been and continue to be associated yet the relationship between the two remains unclear. There is evidence to suggest that an anterior tongue position may prevent anterior teeth eruption but that tongue thrust swallowing is an adaptive mechanism to an open bite in order to maintain an anterior seal rather than it’s cause [10,20]. The main treatment objective with this clinical presentation should be to close the anterior open bite thereby correcting the functional tongue thrust.

There are limitations with traditional orthodontic systems which greatly influence treatment planning towards a combination of mechanotherapy and surgical orthodontics for a severe anterior open bite. Many patients wish to forgo the risks and possible complications of surgical treatment and opt for a non surgical solution which is more difficult especially for long term stability and retention [20]. Most often traditional orthodontic therapy in these cases will require dental extractions and high-pull headgear to aid in bite closure [17-19] and intrusion of maxillary molars, respectively [21]. Complicating matters is the adherence to Angle’s arbitrary diagnostic classifications of Class I, II and III which compels the clinician to change mandibular position and functional occlusion in order to achieve a morphologic occlusion that conforms to the arbitrary ideal of Class I [22-23]. In 2014, Viazis et al. [19] introduced biologically based orthodontic diagnostic terms after a multi year observational study of completed cases with an overwhelming majority treated non-extraction. Orthodontosis is defined as the non-inflammatory deficiency of alveolar bone in the horizontal dimension caused by the displaced root(s) of the tooth, typically palatally or lingually. Orthodontitis is defined as associated excess soft tissue manifestation and chronic manifestation. In effect the hard tissue bony hypoplasia (Orthodontosis) and soft tissue manifestation (Orthodontitis) associated with malpositioned roots represent unfinished eruption. The utilization of the orthodontic system, Fastbraces® is designed to decrease orthodontic forces by increasing wire flexibility and simultaneously moving the roots towards their final position from the beginning of treatment by allowing immediate torque from the onset [19]. This new technology of orthodontic tooth movement contemplates that light forces possibility stimulate bone remodeling around displaced roots therefore eliminating the need for extraction therapy.

Conclusion

Tongue thrust swallowing as a cause of an anterior open bite appears more a fallacy. The authors believe that an anterior open bite represents unfinished tooth eruption rather than a consequence of tongue thrust swallowing. This case report illustrates the potential of non-extraction orthodontic therapy with a system of braces that utilizes light forces thereby facilitating the continuation of eruption while inducing alveolar bone remodeling and development in shorter treatment times.

References

  1. Profit WR, Fields HW, Moray LJ (1998) Prevalence of malocclusion and orthodontic treatment need in the United States: Estimates from the NHANES III survey. Int J Adult Orthodon Orthognath Surg 13(2): 97-106.
  2. Woon KC, Thong YL, Abdul Kadir R (1989) Permanent dentition occlusion in Chinese, Indian and Malay groups in Malaysia. Aust Orthod J 11(1): 45-48.
  3. Thilander B, Pena L, Infante C, Parada SS, de Mayorga C (2001) Prevalence of malocclusion and orthodontic treatment need in children and adolescents in Bogota, Colombia. An epidemiological study related to different stages of dental development. European Journal of Orthodontics 23(6): 153-167. 

  4. Pae EK, Kuhlberg A, Nanda R (1997) Role of pharyngeal length in patients with a lack of overbite. American Journal of Orthodontics and Dentofacial Orthopedics 112(2): 179-186.
  5. Ngan P, Fields HW (1997) Open bite: a review of etiology and management. Pediatric Dentistry 19(2): 91-98.
  6. Alexander CD (1999) Open bite, dental alveolar protrusion, Class I malocclusion: a successful treatment result. Am J Orthod Dentofacial Orthop 116(5): 494-500.
  7. Profit WR, Fields HW (1983) Occlusal forces in normal- and long-face children. J Dent Res 62(5): 571-574.
  8. Andrianopoulos MV, Hanson ML (1987) Tongue-thrust and the stability of over jet correction. Angle Orthod 57(2): 121-135.
  9. Xu K, Zeng J, Xu, T (2016) Effect of an intraoral appliance on tongue pressure measured by force exerted during swallowing. Am J Orthod Dentofacial Orthop 149(1): 55-61.
  10. Cayley AS, Tindall AP, Sampson WJ, Butcher AR (2000) Electropalatography and cephalometric assessment of tongue function in open bite and non-open bite subjects. European Journal of Orthodontics 22(5): 463-474.
  11. Garrett J, Araujo E, Baker C (2016) Open-bite treatment with vertical control and tongue reeducation. Am J Orthod Dentofacial Orthop 149(2): 269-276.
  12. Nielsen IL (1991) Vertical malocclusions: etiology, development, diagnosis and some aspects of treatment. Angle Orthod 61(4): 247-260.
  13. Xu A, Hu Z, Wang X, Shen G (2014) Severe anterior open bite with mandibular retrusion treated with multiloop edgewise archwires and microimplant anchorage complemented by genioplasty. Am J Orthod Dentofacial Orthop 146(5): 655-664.
  14. Jung MH, Baik UB, Ahn SJ (2013) Treatment of anterior open bite and multiple missing teeth with lingual fixed appliances, double jaw surgery, and dental implants. Am J Orthod Dentofacial Orthop 143(4 suppl): S125-S136.
  15. Alexander CD (1999) Open bite, dental alveolar protrusion, class I malocclusion: a successful treatment result. Am J Orthod Dentofacial Orthop 116(5): 494-500.
  16. Smith GA (1996) Treatment of an adult with a severe anterior open bite and mutilated malocclusion without orthognathic surgery. Am J Orthod Dentofacial Orthop 110(6): 682-687.
  17. Ren Y (2007) Treating anterior open bite. EBD 8(3): 5-6.
  18. Baek MS, Choi YJ, Yu HS, Lee KJ, Kwak J, et al. (2010) Long-term stability of anterior open-bite treatment by intrusion of maxillary posterior teeth. Am J Orthod Dentofacial Orthop 138(4): 396-399.
  19. Viazis AD, Viazis E, Pagonis TC (2014) The concept of a new dental disease: orthodontosis and orthodontitis. J Dental Health Oral Disord Therapy 1(5).
  20. Hiller ME (2002) Nonsurgical correction of class II open bite malocclusion in an adult patient. Am J Orthod Dentofacial Orothop 122: 210-216.
  21. Lindsey CA, English JD (2003) Orthodontic treatment and masticatory muscle exercises to correct a class I open bite in an adult patient. Am J Orthod Dentofacial Orthop 124(1): 91-98.
  22. Pearson L (1991) Treatment of a severe open bite excessive vertical pattern with an eclectic non-surgical approach. Angle Orthod 61(1): 71-76.
  23. Rinchuse DJ (1989) Ambiguities of Angle’s classification. Angle Orthod 59(4): 295-298.
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