Open bite malocclusion is one of the most difficult malocclusions to treat. The multiple intervening etiologies and the various skeletal, dento-alveolar, soft tissue and habitual factors contribute to such complexity. It is paramount to combine all the diagnostic information and collate them properly in order to customize the treatment plan for each individual patient. Seeing beyond this anterior gap requires zooming out of it and examining closely the facial features of the patient. The facial type, proportions and the presence of any asymmetry need to be considered. Smile characteristics in the form of smile arc, incisal and gingival show on smiling, the presence of anterior or posterior gumminess and lower incisal show on smiling are crucial for planning and sequencing treatment.
A patient with a reversed smile arc and decreased upper anterior dentoalveolar height reflects a dental open bite that is possibly due to a habit. Such a case would benefit from anterior segment extrusion with control of the habit to close the open biteand improve the smile arc, while maintaining the posterior segment in place. Another patient with a skeletal open bite and over-eruption of maxillary posterior dento-alveolar segments combined with normal incisal show on smiling would be indicated for posterior segments’ intrusion, while maintaining the anterior segments to avoid their inadvertent extrusion, which would compromise the smile. However, the combination of skeletal open bite with decreased incisal show would require combined posterior intrusion and anterior extrusion aiming at open bite correction and enhancement of smile esthetics. In cases where the vertical jaw dysplasia occurs with antero-posterior skeletal discrepancies, especially those of class 3, orthognathic surgical procedures might give better esthetic and functional outcomes.
In a nutshell, diagnosis of anterior open bite might be challenging. The meticulous analysis of the contributing factors for each individual patient is the most guaranteed way for a customized, successful and stable treatment. Clinical and cephalometric findings should be integrated to depict the components that need and need not be treated in order to achievethe best esthetic and functional outcome.