Tongue - Cause and Correction of Anterior Open Bite Malocclusion
A Arif Yezdani*1 and Jabeen Fathima2
1Department of Orthodontics and Dentofacial Orthopaedics, Sree Balaji Dental College and Hospital, India
2Yezdani Dental and Orthodontic Center, India
Submission: February 10, 2017; Published: March 24, 2017
*Corresponding author: Arif Yezdani, MDS, FWFO, Professor & Director, Dept. of Orthodontics and Dentofacial Orthopaedics, Bharath University, Sree Balaji Dental College and Hospital, Narayanapuram, Pallikaranai, Chennai-600100, India, Email: firstname.lastname@example.org
How to cite this article: A Arif Yezdani, Jabeen F. Tongue - Cause and Correction of Anterior Open Bite Malocclusion. Adv Dent & Oral Health. 2017; 4(3):555636. DOI: 10.19080/ADOH.2017.04.555636
Objective: To evaluate the efficiency of a low lying transpalatal arch along with fixed appliance therapy in the correction of an anterior open bite malocclusion with an orthognathic maxilla and a mildly prognathic mandible with bi-maxillary dento-alveolar protrusion and forward tongue posture.
Methods: Treatment involved strap-up of a pre-adjusted edgewise appliance, Roth’s prescription (0.022 X 0.028 - inch slot), with a low lying transpalatal arch 4mm away from the palatal mucosa, and a non-extraction approach. The case was assessed at start of orthodontic treatment (T1), and end of orthodontic treatment (T2).
Results: At T2, the anterior open bite was corrected and the canines were treated to a class I relation. The proclined maxillary incisors as also the proclined and imbricated mandibular incisors were corrected.
Conclusion: Anterior open bite malocclusion with forward tongue posture was effectively corrected with the use of a low lying transpalatal arch using the forces of the tongue during deglutition and mastication. The proclination of maxillary incisors and proclination and imbrication of mandibular incisors were corrected with the fixed appliance therapy.
Dentofacial morphology is inadvertently influenced by the tongue and that tongue thrusting or forward tongue posture can affect the stomatognathic function and can cause open bite malocclusion [1-3]. Tongue pressure ranges from 41 to 709g/cm2 according to Winders  and that constant tongue thrust or forward tongue posture can cause proclination of maxillary and mandibular anterior teeth and /or anterior open bite. Posterior open bite too can be a sequelae of lateral tongue thrust. The role of the tongue and the trans palatal arch (TPA) has been well documented in the literature. The TPA is designed with a loop in its middle portion such that it traverses the entire contour of the palatal mucous membrane. It facilitates anchorage and stabilization of molar, correction of molar rotation, molar intrusion [5,6], molar expansion [7-9] and molar distalization . It has been reported that the tongue during deglutition and mastication inadvertently encourages molar intrusion . Animal studies have shown that TPA can control vertical growth . Finite element analysis studies too suggest that TPA increases molar displacement and controls molar rotation . This case report reiterates the fact that though the tongue could have been the causative factor of the
anterior open bite its action on the fabricated TPA in vivo had been reined in to correct what it had caused, namely the anterior open bite.
A 29 year old male presented with forward placement of the maxillary and mandibular incisors, and anterior open bite with forward tongue posture. Extra oral assessment: The patient had a leptoprosopic face, mildly concave profile, mild anterior divergence, incompetent lips, clinical high mandibular plane angle,
with no signs of temporo mandibular joint dysfunction (Figure 1a-
1c). Intra oral assessment: Oral hygiene was satisfactory.
The maxillary arch was U-shaped with severely proclined
maxillary incisors. The mandibular arch was also U-shaped
with proclination and imbrication of mandibular incisors.
Anterior open bite with forward tongue posture was observed.
The maxillary and mandibular dental midlines and the skeletal
midlines coincided with each other. On both sides the molar
relation and canine relation was Class III (Figure 1d-1h).
Radiographic assessment: The panoramic radiograph
confirmed the presence of all permanent teeth with the exception
of missing maxillary and mandibular third molars on the right side
and horizontally impacted mandibular third molar on the left side
with normal alveolar bone levels. Cephalometric analysis revealed
a mild skeletal Class III pattern, with a nearly orthognathic maxilla
and a mildly prognathic mandible, with a high mandibular plane
angle and severely proclined maxillary and mandibular incisors
The main treatment objectives were to improve smile
esthetics, soft tissue profile, lip competence and speech. Since the
maxilla was orthognathic and the mandible mildly prognathic,
and the anterior open bite was dentoalveolar in nature greater
emphasis was laid for the correction of the anterior open bite and
the retraining of the forward posture of the tongue as also the
increased proclination of the maxillary incisors and proclined and
imbricated mandibular incisors. A non extraction approach was
Micro implants placed palatally between first and second
maxillary molars could have been used to intrude the maxillary
molars to correct the anterior open bite. However, an attempt
was made to correct the anterior open bite with a low lying TPA
with retraining of the forward posture of the tongue with lingual
buttons bonded to the palatal surfaces of the maxillary incisors
along with Roth’s pre adjusted edgewise appliance therapy.
Pre adjusted edgewise brackets (Roth prescription,0.022 x
0.028-inch slot) were bonded, complete with a low lying trans
palatal arch made of 0.9 mm stainless steel arch wire, positioned
4 mm away from the palatal surface (Figure 2). Aligning and
levelling was done with 0.014 inch nickel titanium wires (Figure
3). It was subsequently upgraded to 0.016x0.022 inch stainless
steel arch wires and finished with 0.017x0.025 inch stainless steel
arch wires. Lingual bondable buttons were bonded to the palatal surfaces of the maxillary incisors to retrain the tongue and posture
it in its normal position.
The patient showed remarkable improvement in the correction
of the anterior open bite achieved to a great extent by the low lying
transpalatal arch which caused molar intrusion during every act
of mastication and deglutition. The proclined maxillary incisors
and the proclined and imbricated mandibular incisors were
corrected and a class I canine relationship was achieved with the
fixed appliance therapy. A pleasing soft tissue profile was achieved
Anterior open bite results due to the combined influence of
skeletal, dental, habitual and functional factors. Molar intrusion
to correct the anterior open bite can be achieved by high–
pull headgear and TPA but their effectiveness has not been
demonstrated in clinical studies [14-16]. Microimplants have
been understood to bring about absolute intrusion  and its use
with modified TPA has also been reported in the literature .
De-Berardinis et al.  used a vertical holding appliance (VHA)
which was a modified TPA made by the addition of an acrylic plate
which was significant in reducing the percentage of lower anterior
vertical face height.
This case validates the evidence-based use of a low lying TPA.
Tongue pressure increased when the loop was positioned distally
and that maximum pressure was obtained when the loop was
placed at the middle of the palatal mucous membrane between the
first and second maxillary molars. It has been opined that bolus or
fluid is swept backward down the pharynx as the tongue activity
is like a wave along its dorsum [20,21].
The TPA interferes with tongue motion around the area of
maxillary second molars during the act when the tongue moves
upward and backwards toward the hard palate. Chiba et al. 
in a study to measure the tongue pressure exerted on the loop
of TPA during deglutition and the influence of the distance of
the loop from the palatal mucosa opined that maximum tongue
pressure was observed when the loop was 6mm from the palatal
mucosa but for practical applications 4mm was observed to be
sufficient. Kaifan Xu et al.  in another study also opined that
increasing the distance of the pads away from the mucosa leads
to augmentation of tongue force. In the case presented the loop of
the TPA was kept 4mm away from the palatal mucosa and effective
intrusion of the maxillary molars was observed.
Molar intrusion is deemed to be an efficient treatment for an
open bite and is effective for anteriorly rotating the mandible to
improve the facial profile, especially in hyperdivergent patients
as has been observed in various cases that had been reported.
Kincaid  reported that the average frequency of deglutition per
day was 1600 times. Therefore, it seems appropriate to conclude
that the tongue can deliver orthodontic forces with considerable
frequency to correct the anterior open bite which could be further
augmented with the use of anterior open bite elastics with fixed
appliance therapy as had been observed in the case treated. The
bonded palatal lingual buttons were effective in the training of the
faulty posture of the tongue. The patients’ muscle strength and
morphology of the tongue during deglutition also plays a very vital
role in the treatment prognosis.
TPA with a loop 4mm from the palatal mucosa was effective
in the intrusion of the maxillary molars and the subsequent
autorotation of the mandible that occurred was found to be
the reason for the correction of the anterior open bite. Tongue
forces against the TPA during mastication and deglutition could
be reined in to correct the anterior open bite malocclusion with
finishing and detailing of the teeth concomittantly corrected with
fixed appliance therapy.