The 20 Principles of the Alexander Discipline, Volume 3. R.G. "Wick" Alexander
on this third volume. My sons, Chuck and Moody, both orthodontists, provide inspiration to me. My daughter, Shanna, fills my heart with joy and determination. And my wife, Janna, continues to adapt with me in our life journey. Their support is invaluable.
Words cannot express my thanks to Dr Elisa Espinas San Juan—my lectures, publications, and research associate responsible for gathering and collating all the cases, images, and graphics presented in this volume. Elisa has a sixth sense that guides her to the patients’ charts, providing the collection of case histories needed for this volume.
Appreciation is also conveyed to Eliza Jade San Juan, who helped her mother and others as the details of this book unfolded. Jade’s willingness to accept any and all tasks kept our team in motion. It’s often the small things that count, and Jade is proficient with the details.
The entire staff provided support when needed, especially my administrative assistant, Becky Davis. Her tenaciousness proved helpful with completion of the manuscript. She continues to evolve in an ever-changing environment.
A final acknowledgment is extended to orthodontists around the world who are still eager to learn and be challenged by new information. Many of you have years of experience, some of you are recent graduates, and all of you are lifetime students. I hope you learn and apply the message behind this book.
Last, but certainly not least, nothing would be possible without the efforts and cooperation of our patients. Everything is theoretical without a compliant patient. Then, with time, the results are revealed. Theoretical concepts become evidence-based conclusions, as catalogued in the “Room of Truth.” Way to go, patients!
Treatment of Open Bite Malocclusions
“Whatever you can do or dream you can, begin it. Boldness has genius, power, and magic in it!”
— Johann Wolfgang von Goethe
My definition of open bite is an occlusion in which the mandibular incisal edges do not touch the lingual edges of the maxillary incisors. Fortunately, only 4% of the US population has an anterior open bite. They are slightly more common among females than males, and they are four times more common among black people than white people.
There are two types of open bite: skeletal and dental. Skeletal open bite has a high-angle vertical skeletal pattern with flared maxillary and mandibular anterior teeth, while dental open bite has a medium or horizontal skeletal pattern with flared maxillary and mandibular anterior teeth.
Etiology
Issues surrounding the etiology of open bites include whether they are inherited, acquired, or the result of the environment. In my experience, open bites are almost always acquired through muscular and occlusal imbalance. A mouth-breathing 6-year-old puts only small amounts of force on the permanent first molars, allowing them to overerupt, thus increasing the vertical pattern. The greater the vertical pattern, the greater the chances for an open bite to develop. In addition, every open bite patient I have treated has had a tongue thrust. Although control of this abnormal muscular function cannot correct the open bite, it can prevent the open bite from redeveloping after orthodontics.
Initial Examination
Certain muscular problems must be identified and resolved in order to successfully treat open bite malocclusions. During the initial examination, the orthodontist should evaluate for the following:
• Thumb sucking
• Mouth breathing
• Tongue thrust
• Weak occlusal forces
Thumb sucking
In the medical and dental history questionnaire, the parent should be asked if the patient has ever sucked his or her thumb. If the answer is “yes,” then the issue must be thoroughly discussed and a plan formulated. In my opinion, tongue rakes with pointed wires are barbaric. For years I have instead engaged patients in conversation and used reminder therapy to help them break the thumb-sucking habit. We “talk” the thumb out of the mouth instead of forcing it out with metal appliances.
In this conversation, the patient is asked five questions while sitting opposite the orthodontist:
1. “Why do you suck your thumb?” Of course the patient has no answer, so I usually pose a guess such as “because it gives you a warm fuzzy feeling?” This makes the patient feel better, knowing that the doctor understands why.
2. “Do you realize what the thumb is doing to your teeth?” After asking this question, I use a hand mirror to point out how the teeth are in abnormal positions. This is a good time to identify which thumb is the culprit. After asking the child to hold out his or her hands, I ask, “Which thumb is it?” I always make a point then to “separate the deed from the doer” by telling the patient that the thumb is the problem, not the patient: “The thumb is ruining your teeth.”
3. “When do you suck your thumb?” My experience has taught me that when the patient sucks his or her thumb at night only, the success rate for a conversational approach is excellent. However, if the patient has no shame and sucks the thumb around friends, this will be a difficult habit to resolve. It might actually require a thumb rake appliance after all.
4. “When are you going to stop?” Of course the patient cannot or will not answer, so I answer for them. “When you get married?” Of course not. Then I begin to work down the calendar: “In high school? Junior high? Now?” By this point the patient realizes what must be done— and hopefully agrees to stop! I get excited, and we highfive each other. The mother and father get high-fives as well, even if they roll their eyes and respond with “We’ve heard that before.” I encourage them that this time is different and that the child needs their support. But the conversation is not over yet!
5. “For how long will you stop? A week, a month, a year?” I continue this conversation until the patient says “forever” or “the rest of my life.” I get excited again. This time the mother or father gets into the celebration, too! After a commitment is made by the patient to stop, it is all about the positive reinforcement: “Don’t you feel better?”
After this conversation takes place, it is very important to follow through to make sure the patient does not reverse this thinking. In our practice, the patient is instructed to place a Band-Aid on the offending thumb as a “burglar alarm” reminder. A new Band-Aid should be placed every day, and the used Band-Aids should be kept in a ziplock bag. This bag is then brought to the office in 3 weeks. Also, the patient is asked to make and bring a 3-week calendar noting the successful days.
I always make it a point to tell the parents to be supportive and encouraging during these first 3 weeks. I tell them to praise the patient each night for completion of another successful day. The parents might choose to give a special reward or gift at the end of the 3 weeks.
An honest conversation can do wonders to stop a child from continuing a bad habit. And the parents are always grateful.
Mouth breathing
Mouth breathing is the result of a nasal or airway blockage and/or protruding anterior teeth. Volume 2 of this series outlines a test to administer to check for nasal or airway blockage (see page 171). Our goal as orthodontists is to allow the patient’s lips to touch when relaxed and while breathing through the nose.
Tongue thrust
Tongue thrust is a great example of muscular imbalance affecting tooth position. If the tongue functions properly during swallowing, the maxillary intermolar width as well as the anterior incisor overbite and overjet should be normal. If the tongue thrusts through the anterior teeth during swallowing, however, there may be incisor flaring, which could lead to an open bite. A simple tongue thrust diagnosis can be determined during the initial examination. This can be done by