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Revista arbitrada de ciencias de la salud
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https://doi.org/10.62574/wdy48a12
11
Efficacy of orthopaedic and orthodontic treatment of anterior open bite in
mixed dentition
Eficacia de los tratamientos ortopédicos y ortodónticos en mordida abierta
anterior en dentición mixta
María José Berrú-Medina
mjberrum73@est.ucacu.edu.ec
Catholic University of Cuenca, Cuenca, Azuay, Ecuador
https://orcid.org/0000-0002-3371-6115
Cristian Hernán Campoverde-Torres
ccampoverdet@ucacue.edu.ec
Catholic University of Cuenca, Cuenca, Azuay, Ecuador
https://orcid.org/0000-0003-0908-1049
ABSTRACT
Objective: To determine the efficacy of orthopaedic and orthodontic treatments in anterior open bite
in mixed dentition. Method: A systematic review of the literature was conducted in three digital
databases, PubMed, Scopus and Web of Science, based on the PRISMA criteria and answering the
PIO question. Bias analysis was performed using the RoB2 tool. Results: Six non-randomised clinical
trials potentially eligible for inclusion in this study were found that evaluated the effectiveness of
orthopaedic and orthodontic treatments in mixed dentition. Conclusion: 85.83% of cases treated in
mixed dentition with quad helix, palatal grid, bionator, high traction chin cup, rapid maxillary expansion
combined with bite block proved to be effective with statistically significant changes. The results
obtained should be interpreted with caution, as the subject matter is broad and requires further
investigation.
Descriptors: open bite; treatment failure; orthodontics; myofunctional therapy (Source, DeCS).
RESUMEN
Objetivo: Determinar la eficacia de los tratamientos ortopédicos y ortodónticos en mordida abierta
anterior en dentición mixta. Método: se realizó una revisión sistemática de la literatura en 3 bases
digitales como son PubMed, Scopus y Web of science, basándose en los criterios PRISMA y dando
respuesta a la pregunta PIO, el análisis de sesgo se realizó con la herramienta RoB2. Resultados:
se obtuvo 6 ensayos clínicos no aleatorizados potencialmente incluibles en la presente investigación
que lograron evaluar la eficacia de los tratamientos ortopédicos y ortodónticos en dentición mixta.
Conclusión: el 85.83% de los casos tratados en dentición mixta con quad hélix, rejilla palatina,
bionator, mentonera High pull de alta tracción, expansión rápida del maxilar combinada con bite
block, demostraron ser eficientes con cambios significativos estadísticamente, se recomienda tomar
con cautela los resultados obtenidos ya que el tema abordado es amplio y requiere una investigación
profunda.
Descriptores: mordida abierta; insuficiencia del tratamiento; ortodoncia correctiva; terapia
miofuncional. (Fuente, DeCS).
Received: 07/02/2025. Reviewed: 16/02/2025. Approved: 26/02/2025. Published: 18/03/2025.
Original article
.
Sanitas
Revista arbitrada de ciencias de la salud
Vol. 4(1), 11-25, 2025
Eficacia de los tratamientos ortopédicos y ortodónticos en mordida abierta anterior en dentición mixta
Efficacy of orthopedic and orthodontic treatments in anterior open bite in mixed dentitionSystematic
review
María José Berrú-Medina
Cristian Hernán Campoverde-Torres
12
INTRODUCTION
Malocclusions represent a significant oral health problem worldwide. These
alterations in occlusion are highly prevalent and affect a large proportion of the
population, and are a frequent reason for orthodontic consultation. Among the most
common malocclusions are crossbite, overbite and anterior open bite. The latter,
characterised by its obvious clinical presentation, is easily identifiable by oral health
professionals and constitutes between 25% and 38% of orthodontic cases (1).
To begin to address this subject, it is important to understand that anterior open bite
refers to a malocclusion that alters the vertical plane, causing the upper incisors not
to contact or not to fully contact the lower incisors. This definition, based on the one
described by Carabelli from the middle of the last century, although quite accepted,
is not unique, it varies according to the different authors, and since that time,
Defoulon has noted that there are external and internal muscular influences in its
development (2,3). Therefore, in an expected occlusion, the upper incisors should
cover at least 2-3 mm of the antagonist incisors, which is visible to the clinician and
the patient, and also causes them to seek immediate help and treatment (4).
The prevalence of malocclusion in the mixed dentition is 75% caused by several
factors such as: partial eruption of the incisors, abnormal size of the lymphoid tissue,
causing an inadequate position of the tongue, persistence of infantile swallowing and
the presence of oral habits (5). Therefore, malocclusion can affect oral health, affect
feeding, speech and the maintenance of good oral hygiene. Malocclusion can also
influence appearance, decreasing self-confidence and self-esteem (6). It is a
complex dental problem that can be triggered by a variety of circumstances, such as
genetics due to facial growth pattern, environmental factors, sucking habits, tongue
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Vol. 4(1), 11-25, 2025
Eficacia de los tratamientos ortopédicos y ortodónticos en mordida abierta anterior en dentición mixta
Efficacy of orthopedic and orthodontic treatments in anterior open bite in mixed dentitionSystematic
review
María José Berrú-Medina
Cristian Hernán Campoverde-Torres
13
protrusion, mouth breathing, adenoid hypertrophy, syndromes, occlusal and eruptive
forces, dental ankylosis and mandibular postural imbalance.
Additional factors such as the time of initial treatment and the severity of the
malocclusion may also contribute to its persistence, making correction more difficult
to achieve over time (7). A study conducted in Mexico City by Ramirez and
colleagues examined a group of children aged 3-6 years and found a prevalence of
38% (8). Another researcher, Wurgaft, studied a group of 67 patients of both sexes
aged 5 to 19 years, determining a prevalence of 16.3% for anterior open bite, being
more common in children aged 5 to 8 years (9).
On the other hand, Thilander points out that in younger patients, the percentage of
anterior open bite is higher because the occlusion is still developing and adapting to
the anatomical changes of the bone. Also, neurological maturation is occurring in
children, which reduces parafunctional habits, although they may develop such
habits over time. These habits may be related to systemic problems that improve
with development, such as stabilisation of swallowing in adults and reduction in
adenoid size. However, other problems such as allergic rhinitis and tonsillar
hypertrophy do not improve with time (10). While in Bogotá, Colombia, a study was
carried out to identify the percentage of open bite in children and adolescents aged
5-17 years. From a sample of 4724 patients, it was found that 9% presented this
condition, being more frequent in the primary and mixed dentition in its first phase
(10).
Based on the above, we know that anterior open bite causes changes that interfere
with function and affect aesthetics, impacting a significant number of patients,
especially in the primary and mixed dentition. It also has a high recurrence rate, so
it is essential that clinicians are familiar with the orthopaedic and orthodontic
treatment options for this condition. Despite the extensive literature on anterior open
bite, interventions lack sound scientific support. In this regard, there is a need for
Sanitas
Revista arbitrada de ciencias de la salud
Vol. 4(1), 11-25, 2025
Eficacia de los tratamientos ortopédicos y ortodónticos en mordida abierta anterior en dentición mixta
Efficacy of orthopedic and orthodontic treatments in anterior open bite in mixed dentitionSystematic
review
María José Berrú-Medina
Cristian Hernán Campoverde-Torres
14
more research on this topic due to the variety of treatments available and to
determine if there is a connection between open bite, breathing pattern, sleep
disturbance and snoring, especially considering the critical systemic disorders that
could be related.
Therefore, the aim of this systematic review was to evaluate the efficacy of
orthopaedic and orthodontic treatments for anterior open bite in the mixed dentition.
METHOD
Protocol and registration
The following study was registered in the INPLASY system (International Platform
for Registered Protocols for Systematic Reviews and Meta-Analyses) under
registration number INPLASY2024100037 with its DOI
10.37766/inplasy2024.10.0037, and was conducted following the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement
(11).
Selection of studies
The selection of the studies was based on the IOP question: "Are early treatments
of anterior open bite in mixed dentition effective?
Gathering information
In October 2024, the search for information began in the digital databases: PubMed,
Scopus and Web of Science. The information was reviewed by two independent
reviewers, including the assessment of bias. Boolean AND operators were used. The
descriptors used were extracted from the health sciences (DeCS) descriptors: open
bite, treatment failure, corrective orthodontics, myofunctional therapy; and from
MeSH: open bite, treatment failure, orthodontics, myofunctional therapy. The
Sanitas
Revista arbitrada de ciencias de la salud
Vol. 4(1), 11-25, 2025
Eficacia de los tratamientos ortopédicos y ortodónticos en mordida abierta anterior en dentición mixta
Efficacy of orthopedic and orthodontic treatments in anterior open bite in mixed dentitionSystematic
review
María José Berrú-Medina
Cristian Hernán Campoverde-Torres
15
combinations used were: open bite AND treatment failure, open bite AND
myofunctional therapy, open bite AND orthodontics.
Selection criteria
Inclusion criteria:
Non-randomised clinical trials, retrospective studies, systematic review articles and
meta-analyses, articles in English and Spanish, with no time limit, that included a
statistical significance value and a percentage value representing efficacy were
included.
Exclusion criteria:
Randomised clinical trials, literature that did not include statistical significance (p)
value and grey literature were excluded.
Therefore, data were collected on study design, treatment modalities, sample
characteristics, measurement methods, success rate, open bite and divergence
reduction, treatment duration, side effects, costs and stability.
Risk of bias
For data analysis, risk of bias assessment of articles from clinical trials was
performed using the Cochrane clinical trials tool (RoB 2) (Table 2).
Conflict of interest
There was no conflict of interest between the researchers.
Search strategy
The preliminary search for information in the Digital Databases: PubMed, Scopus,
Web of Science, showed a total of results of 2569 articles on anterior open bite, then
duplicate documents were eliminated leaving 240 articles, the search continued with
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Revista arbitrada de ciencias de la salud
Vol. 4(1), 11-25, 2025
Eficacia de los tratamientos ortopédicos y ortodónticos en mordida abierta anterior en dentición mixta
Efficacy of orthopedic and orthodontic treatments in anterior open bite in mixed dentitionSystematic
review
María José Berrú-Medina
Cristian Hernán Campoverde-Torres
16
the addition of the filter of non-randomised clinical trials to obtain the results and
articles that have the value of statistical significance, As for the manual search, 18
articles were obtained, some of which were discarded because they did not
quantitatively measure the efficacy of orthopaedic and orthodontic treatments, others
that did not take mixed dentition into account, giving a final of 6 articles included.
RESULTS
The results were based on the 6 potentially important randomised clinical trials in the
present investigation, taken from the 3 digital databases mentioned above, which
took into account orthopaedic and orthodontic treatments used in the mixed dentition
for the management of anterior open bite, significance, number of participants,
patient age, duration of treatment and the outcomes mentioned by the authors which
are described in the present table. Efficacy will be categorised by the percentage
value given by the authors in their studies.
Table 1. Treatment results in mixed dentition for open bite.
Study
Participants
Age
Treatment
Duration
Results
Significance
Efficiency
(12)
n = 21
8.4
years
Quad-Helix
6 months
Improvement of the
anterior open bite by 4.1
mm, 2 years after
treatment.
Mann-Whitney
U test
(p<0.05).
85%
(13)
n = 41
7-10
years
Palatine grille
6 months
Improvement of the
anterior open bite of 3.84
mm.
Kolmogorov-
Smirnov test
(p<0.05).
76%
(14)
n = 20
8.3
years
Bionator
18
months
Net overbite gain of 1.5
mm, with a total overbite
of 2.7 mm.
Mann-Whitney
U test
(p<0.05).
85%
(15)
n = 19
9.7
years
High pull chin
strap with high
traction
12
months
Cephalometric analysis
performed on a case
group and a control
group 15 months after
treatment, with
improvement of the
overbite by 0.56 mm.
Student's t-
test (p<0.05).
95%
(16)
n = 16
8.1
years
ERM and bite
block
12
months
Evaluation 4 years after
treatment in a case
group and a control
group, with improvement
of the overbite by 1.8 mm
and decrease in facial
divergence (-2.8°).
Kolmogorov-
Smirnov
(p<0.05).
100%
(17)
n = 24
9.1
years
Bionator and
combination
8-12
months
Improvement of the
overbite by 2.2 mm and
(p<0,05).
74%
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Efficacy of orthopedic and orthodontic treatments in anterior open bite in mixed dentitionSystematic
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17
with high-
traction chin
guard
decrease in the
cephalometric parameter
of anterior facial height.
Not recommended in
hyperdivergent patients.
Elaboration: The authors.
Of the 6 articles analysed, 3 were case-control studies, among the treatments used
to treat open bite were; Quad Helix, palatal grid, bionator, High pull high traction chin
rest, rapid maxillary expansion combined with bite block, ages ranged from 7 to 9.7
years.
Of the 6 articles cited in the present investigation, the efficacy of orthopaedic
treatments was evaluated with the measurement and improvement of the overbite in
millimetres, and cephalometric values that were mentioned in the table. When talking
about the improvement of the overbite, a trend of 2.03mm was obtained among all
the studies mentioned.
To answer the IOP question posed in the research "Are early treatments of anterior
open bite in mixed dentition effective?", a percentage improvement value of 85.83%
was obtained, which were extracted from the percentage values given by the
authors.
Table 2. RoB2 risk of bias tool.
Bias in the
randomisation
process
Deviations
from planned
interventions
Missing data
on results
Measuring
the result
Selection of
the reported
result
General bias
Studio 1
(Cozza P.)
●
●
●
●
●
●
Studio 2
(Slaviero)
●
●
●
●
●
●
Study 3
(Defraia E.)
●
●
●
●
●
●
Study 4
(Carvalho
Ferreira. F.)
●
●
●
●
●
●
Studio 5
(Mucedero.
M)
●
●
●
●
●
●
Study 6
(Christopher
S. Freeman.)
●
●
●
●
●
●
Legend:● High risk of bias● Unclear risk of bias● Low risk of bias. Elaboration: Authors.
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Efficacy of orthopedic and orthodontic treatments in anterior open bite in mixed dentitionSystematic
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18
In the risk of bias assessment by the two reviewers, 90% of the articles had a low
risk of bias, which represented five articles, and 10% of the articles had an unclear
risk of bias. Articles with a high risk of bias were excluded prior to the bias
assessment.
Management in the primary dentition
In the primary dentition, anterior open bite has been found to be associated with
dentoalveolar problems in about 95% of cases. When this dental condition is a
consequence of thumb sucking, mouth breathing and unusual swallowing habits, the
treatment approach is mainly "aetiological". The health professional should motivate
the patient to abandon these non-functional oral habits through positive incentives
and reward strategies. Interceptive devices, when necessary, aim to correct the
improper tongue position (18).
Orofacial myofunctional therapy
Orofacial myofunctional therapy consists of a series of exercises designed to re-
educate the muscles of the face and mouth with regard to swallowing, speech and
resting posture. The goal is to modify oral functions and eliminate non-nutritive
sucking habits before the age of 6 years, thus creating a suitable environment for
the eruption of permanent teeth (19).
Management in the mixed dentition
In the prepubertal growth period, children with prolonged sucking habits and
excessive facial height are considered to be at risk of developing an anterior open
bite (16). It has been shown that if this anterior open bite persists during pubertal
growth of the skull and face, it rarely corrects spontaneously and may even worsen
(20). Also, in individuals with a marked vertical skeletal imbalance, there appears to
be an underlying craniofacial pattern from early stages that tends to continue or
intensify.
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Efficacy of orthopedic and orthodontic treatments in anterior open bite in mixed dentitionSystematic
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Cristian Hernán Campoverde-Torres
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Orthodontic treatment to correct open bite in the prepubertal growth stage generates
debate in the specialised literature. Feres pointed out that spontaneous correction is
more complicated and requires more time (21). It is also considered important to
intervene in dysfunctional habits which, if eliminated early, can promote proper
development of the masticatory system (16). Rosa and colleagues emphasised that
most cases of anterior open bite have the potential to correct themselves during the
prepubertal stage and recommended that active correction should not be undertaken
during this period of development (22). In cases where active correction is
suggested, orthodontic appliances are used to adjust vertical growth and manage
tongue position and vertical eruption of molars in growing patients (25). Early
treatment approaches in the mixed dentition include mainly functional appliances,
bracket or fixed appliance techniques, extraoral appliances and bite blocks (23,24).
DISCUSSION
Open bite is a dental malocclusion that can cause oral and health problems such as
difficulty chewing, speech problems, digestive problems, facial muscle pain,
tendency to breathe through the mouth, facial aesthetic alterations and
temporomandibular joint disorders. It is known that in the mixed dentition the
incidence of open bite is higher due to habits acquired during childhood that may
cease during growth (10). After more than 50 years of research, the extensive
literature on early treatment of anterior open bite remains controversial and covers
a wide variety of therapeutic approaches.
In this systematic review it was shown that 85.83% of orthopaedic and myofunctional
treatments treated at an early age are effective, mainly those that treat oral breathing
and parafunctional habits in infants. However, Van Dyck et al. mentioned that in their
study there was no significant improvement when treating patients in mixed dentition
with myofunctional therapy, joint and tongue muscle exercises (25). He agrees with
Feres, who mentions that early correction is more difficult and takes longer, but it is
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Efficacy of orthopedic and orthodontic treatments in anterior open bite in mixed dentitionSystematic
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important to mention that in the 22 articles included in his study, he only considered
subjects with mixed dentition and there was considerable variation in therapeutic
approaches, due to poor quality or insufficient evidence, so he concludes that no
consistent results were found (21).
Treatments such as myofunctional devices, the bite block, Frankel 4, tongue grid,
spurs and the high traction harness in younger subjects are reported to be effective;
however, these results should be taken with caution, as the studies showed
important methodological limitations and did not reach a sufficient level of quality to
draw conclusions, as they were not evaluated in untreated control groups. Phelan
mentions that in his study they only reported an improvement of 75%, in contrast to
the present investigation which was 87.5% (26).
Authors such as Slaverio, Canuto, Nascimento MHA and Cayley mentioned great
occlusal, aesthetic and cephalometric improvements in the treatment of anterior
open bite, but it should be stressed that all these studies were based on the
treatment of parafunctional habits. However, if presented with a patient with a true
skeletal anterior open bite, these treatments would actually be insufficient (13,27-
30). Rosa mentions that no treatment should be performed to correct the minimal
anterior open bite (1-3 mm) in the mixed dentition, as this may be transitional (31).
The correlation between open bite and respiratory disorders can be investigated
together with otolaryngologists or other sleep professionals. In addition to
cephalometric measurements, masticatory, swallowing and respiratory functions,
maxillary and mandibular growth, as well as facial analysis should be assessed to
check the validity of interventions (31). Despite all the results and inferences
mentioned here, further research could still be conducted to confirm several
assumptions. The authors encourage prospective, retrospective and case-control
trials to investigate both the effectiveness and stability of orthopaedic treatments in
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Efficacy of orthopedic and orthodontic treatments in anterior open bite in mixed dentitionSystematic
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Cristian Hernán Campoverde-Torres
21
mixed dentition. Despite great variability and methodological inaccuracies, specific
inferences and directions for future studies were presented.
CONCLUSION
Orthopaedic treatment of anterior open bite in mixed dentition proved to be efficient,
mainly treating parafunctional habits. There are several studies that do not coincide
with the present research as they mention that there is great variability and
methodological inaccuracies in the research, and no articles were found that treated
open bite with orthodontic appliances in mixed dentition.
In the present investigation 85.83% of the cases treated in mixed dentition with quad
Helix, palatal grid, bionator, high pull high traction chin rest, rapid maxillary
expansion combined with bite block proved to be efficient with statistically significant
changes, according to the classification of the authors of the present investigation.
In the systematic reviews studied, it was mentioned that the treatment of choice in
the mixed dentition in the first stage are appliances such as the lingual grid, Frankel
IV, twin blocks, Simoes Network and Klammt. The same studies mentioned that in
the permanent dentition, open bite can be treated if it is due to habit with fixed
orthodontic therapy plus lingual educators, in addition to molar intrusion through
mini-screws, anterior extrusion of incisors, extraction of premolars, or through control
of the occlusal plane in the case of using philosophies such as the MEAW technique.
Despite all the results and inferences mentioned here, further research could still be
conducted to confirm various assumptions, especially retrospective studies,
prospective studies, randomised clinical trials and case-control groups, it is
recommended to take the results obtained with caution as the topic addressed is
broad and requires in-depth research.
FUNDING
Non-monetary
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CONFLICT OF INTEREST
There is no conflict of interest with persons or institutions involved in research.
ACKNOWLEDGEMENTS
To the Postgraduate Academic Unit of the Catholic University of Cuenca.
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Sanitas
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Vol. 4(1), 11-25, 2025
Eficacia de los tratamientos ortopédicos y ortodónticos en mordida abierta anterior en dentición mixta
Efficacy of orthopedic and orthodontic treatments in anterior open bite in mixed dentitionSystematic
review
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Cristian Hernán Campoverde-Torres
24
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Sanitas
Revista arbitrada de ciencias de la salud
Vol. 4(1), 11-25, 2025
Eficacia de los tratamientos ortopédicos y ortodónticos en mordida abierta anterior en dentición mixta
Efficacy of orthopedic and orthodontic treatments in anterior open bite in mixed dentitionSystematic
review
María José Berrú-Medina
Cristian Hernán Campoverde-Torres
25
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