Background: Anterior Open Bite (AOB) is a malocclusion condition characterized by the absence of contact between the upper and lower anterior teeth, resulting from oral bad habits for a long time or abnormalities in skeletal patterns. AOB leads a lack of confidence in children because of the difficulty for lip sealing and the unclear pronunciation function. AOB occurs in children and continues into adulthood so it needs to be treated early on at the age of growth and development. One method of treating AOB is Orofacial Myofunctional Therapy (OMT) which is a method to improve the stability of the stomatognatic system by involving the exercise of the facial and neck muscles.

Aim: Literature Review (LR) writing aims to find out the effectiveness of OMT in the case of AOB children, how the treatment is carried out and the problems that occur during OMT.

Mini-Review: OMT increases the activity of the masseter and buccinator muscles, and decreases the contraction of the lip muscles that the lips may seal. OMT is able to increase the ability to hold the tongue to stay in contact with the palate so there is no obstacle to the eruption of the lower insisivus tooth and AOB can be corrected. Results: Orofacial Myofunctional Therapy (OMT) is effective for the correction of a child's Anterior Open Bite (AOB) as a combination therapy with the use of orthodontic tools or myofunctional equipment, especially in children older than 12 years of age and craniofacial deformity has occurred.

Orofacial myofunctional; Child;Growth and development; Anterior open bite

In the era of globalization, the demands and services of orthodontic care for children continue to increase over time. Initially, they focused more on orthodontic curative action against malocclusion in children, but today more demand and services have shifted to prevention and early orthodontic care [1-4]. In the case of orthodontic services for children, it indicates different service patterns; both at the stages of preventive, interceptive, and orthodontic curative services [4]. In fact, the development of orthodontic in children, especially in preventive orthodontics and interception has been in line with government programs in the dental and oral health services in a tiered and integrated manner; however, its implemetation is still a complex problem [4-6]. The current orthodontic care system has delivered satisfactory results, but there are still difficult cases that are proven to be treated. There are still some bad habits that accompany myofunctional in a child, such as finger sucking, posture problems, and tongue placement when swallowing, and abnormal breathing patterns [7] included in the treatment of anterior open bite in children.

Anterior Open Bite is a malocclusion condition that often occurs in children. The prevalence of AOBis 16.52% in children and adolescents aged 2-16 years [8]. The prevalence of primary dentition AOBis 16.9% and mixed dentition is 11.3%. The habits of sucking, tongue thrusting, and oral breathing are the main risk of AOB in the firstborn teeth, in mixed dentition, the habits that often cause AOB are sucking pacifiers, sucking lips, tongue thrusting, and breathing with the mouth [9].

Treatment for AOB correction includes the use of removable, fixed, and functional appliance, which the aims are inhibiting mechanical factors (such as thumb sucking or sticking out the tongue) that cause open bites to continue to exist and limiting excessive vertical growth of the craniofacial skeleton [10-12]. The principle of the use of oral myofunctional therapy devices is highly recommended for use in the growth and development of children. Treatment that begins at the mixed dental stage can increase effectiveness, minimizing the need for orthodontic treatment with permanent tooth extraction ororthognatic surgery has been widely reported [13]. Some publications state that early interceptive treatment in AOB patients with a deviated and persistent swallowing pattern may use Orofacial Myofunctional Therapy(OMT) [14-17]. Other authors also state that the normal oral function is re-established after OMT in patients with myofunctional disorders such as tongue thrusting [18,19].

Although the use of tools is effective in making AOB corrections, including can eliminate oral bad habits, OMT remains a treatment option. This is based on cost efficiency considerations and gives a sense of comfort because it does not use tools in the mouth [20]. OMT can also provide effective results when done during desidui teeth and teeth mixed and become an adjunctive treatment [21,22].

The purpose of writing this literature review is to find out the effectiveness of OMT in the case of AOB children, how the treatment is carried out, and the problems that occur during OMT.

Anterior Open Bite (AOB) is a condition in the oral cavity, characterized by no contact or deficit of normal vertical contact between antagonistic teeth in the arch of the anterior tooth [23-25]. AOB causes a variety of aesthetic and functional changes that interfere with the grip and cutting of food. It also causes problems in articulating certain phonemes. These changes can lead to poor psychosocial conditions. Some clinical problems due to malocclusion are permanent insisivus tooth injury of the upper jaw during growth, periodontal damage, difficulty closing the lips normally, and social influences such as lack of confidence in the child.

Open bites are classified into skeletal open bites and dental open bites. Dental open bites are localized to the anterior teeth and the surrounding soft and hard tissues without showing bone defects in cephalometric radiography, while skeletal open bites exhibit vertical disharmony in cephalometric radiography [27,28].

A number of habits may lead to AOB [29,30] but if the habit is performed only until the period of primary or mixed dentition will not have a negative effect [31,32].AOB can develop in permanent dental periods [33-35].In the age range between 6-8 years, AOB is the dominant type of malocclusion [36].In the early days of mixed dentition, 39.1% of children did not have either contact between the upper and lower insisivus teeth or palatal gingiva, while 4.6% had no incisal overlap [37].

The habit of sucking fingers, nipple milk bottles, and tongue including the habit of tongue thrusting, as well as upper airway obstruction are the main cause of AOB [38-40]. All habits involving obstruction mechanisms can inhibit tooth eruption or allow continuous dental supra-eruption that causes less incisal contact, affect the tongue reducing pressure on the maxillary and can dilate the mandible. An imbalance between the tongue and perioral muscle pressure can lead to a cusp-to-cusp relationship, the mandible is in a clockwise rotational position and contact of the incisive tooth is obstructed. The habit of sucking fingers can cause negative pressure and worsen unwanted forces. However, muscles are thought to have a stronger influence. The habit of placing the tongue by pushing forward when swallowing also plays a role in causing AOB. When AOB is present, the habit of sucking produces pro alveolus that blocks the closure of the lips when swallowing and the placement of the tongue in an abnormal position, especially at rest. Dentalshifts in AOB often occur due to a lack of balance between the strength of the tongue muscle (centrifuge) and the lip and cheek muscles (centripetal). As the balance of muscle strength deteriorates, the shift of the tooth and the alveolus of the tooth causes anterior injury.The loss of balance is caused by a decrease or increase in the strength of muscle components or the result of reduced closure and increased overhang due to poor sucking habits. In Skeletal Anterior Open Bites (SAOB), when the vertical component of facial growth is disproportionately larger than the horizontal component, there is an increase in the angle of the Frankfurt-Mandibular Plane (FMPA). AOB arises from an eruption of labial teeth that cannot compensate for the increase in interoclusal distance. The resulting open bite will usually be symmetrical and, in most extreme situations, only the posterior molars will be in occlusion [43,44].

Orofacial Myofunctional Therapy (OMT) is re-education of muscle function to improve the function of suffocation, tongue, habit of breathing through the mouth and posture of lips, tongue and cheeks at rest [45]. OMT includes cervical and facial muscle exercises for proprioceptive, tone and movement enhancement, [46-50] including exercises that support the tightening and endurance of the mouth muscles [51,52]. OMT re-education trains normal and strong sucking skills, good sanctification using both sides of the jaw, normal swallowing, tongue in a normal position, and nasal breathing with lips in good contact at rest [53].

Journal samples are determined by inclusion criteria, namely children in primary and mixed dentition, with Anterior Open Bite (AOB) or incompetence of the lips closure. Exclusion criterias are review articles and case reports.

Search method

Journal searching uses electronic databases through Pubmed, Science Direct, Wiley Online Libraryportal and manual searching.

Search details

Journal search using keywords: "anterior open bite" AND "myofunctionaltherapy" AND children.

Figure 1: Completedatasearchprocessflowchart.

Table 1: Synthesis Table.

The author collected 106 articles through an electronic database and manual search according to the keywords. The author assessed the title and abstract of the journals resulting from the search. The relevant title and abstract were selected with the result that 28 articles were obtained. The author read the full-text article to determine that the study met the inclusion criteria. Studies that meet inclusion criteria then underwent quality assessment and data extraction. The author reviewed selecting 11 articles that included the synthesis table.

This literature review discusses the effectiveness of Orofacial Myofunctional Therapy (OMT) in Anterior Open Bite (AOB) of children. From the 11 studies, 6 journals stated that correction of AOB can be performed through a combination of OMT with myofunctional appliance, orthodontic appliance and post adenoidectomy treatment. Four journals showed the effectiveness of OMT as a single therapy. One journal showed the use of myofunctional appliances was more effective than OMT in performing AOB corrections.

According to Daglioet. al., 1993 [43] malocclusion (open bite, anterior slit position and cross bite) can occur in neuromuscular disorders. Maloclusion can be treated with a combination of orthodontic use and myofunctional therapy compared to myofunctional therapy alone, by affecting the activity of the tongue muscles compared to the lip muscles, buccinators and facial muscles.

In Skeletal Anterior Open Bite (SAOB), the mandible grows and develops downward and backward. Erbayet. al., 1994 [44] showed that by using FR-4 and lip-seal training tools, the rotation of the mandible forward and upwards resulted in SAOB correction. Lip-seal training can activate and increase muscle tone, that the lips are able to close and mandible is held in the right position. Hong et. al., 2021 [45] show SAOB has an abnormal Orofacial Myofunctional Status (OMS) including distorted swallowing patterns and weak involuntary muscles, related to more than normal facial height and the presence of protrusive insisivus.

AOB may result from Obstructive Sleep Apnea (OSA). OSA causes children to tend to oral breathing that the lip posture is not able to close. The most common therapy is adenoidectomy. Lembrechtset. al., 1999 [46]stated that there was lip closure after 2 months of adenoidectomy and the administration of training instructions to close the lips and breathe with the nose (logopedic).

Smithpeter and Covell 2010 [47] stated that OMT is needed as an additional treatment after the use of orthodontic applaiance to prevent AOB relapsing. OMT is performed before, during and after using the appliance as an orofacial muscle therapy and eliminates oral bad habits.

OMT as a single therapy was performed by Cayley et. al., 2000 [48] and Van Dyck et. al., 2016 [49]. There is a downward trend of AOB and further eruption of upper and lower insisivus teeth after OMT is performed. Schievanoet. al., 1999 [50] showed that OMT can decrease perioral muscle activity so that the lips are able to close. Decreased muscle activity is seen from the clinical picture through electromyography. While Degan and Puppin 2005 [51] stated that eliminating oral bad habits shows a pattern of thickening and posture of the tongue at rest is better. Huang et. al., 2015 [52] showed that eliminating oral bad habits using Non-Orthodontic Intervention (NOI) effectively decreased AOB and reduced overjet. Reduced overjet implies backward movement, or rotation, of upper incisors. Due to the sensation of a foreign body, a stomahesive wafer placed attached to sharp papillae can cause the tip of the tongue to touch that spot, divert the subject from insertion of the thumb or other finger into the mouth, and stop oral bad habits.

Correction of AOB using combination treatments is indicated in neuromuscular disorders, SAOB, OSA and post-use stabilization of orthodontic devices. Effective combination treatment is performed in children up to the age of 18 years. Correction of AOB using a single OMT in children aged <10 years indicates early treatment of AOB in children of growing age is able to prevent maloclusion to reduce the need for orthodontic care in adolescence. The use of myofunctional equipment is considered effective in repairing AOB compared to OMT without tools because the use of an appliance is carried out for a longer duration than OMT and works directly on the orofacial muscle.

OMT has the effectiveness of correction of AOB by increasing the activity of the masseter and buccinator muscles, as well as decreasing the contraction of the lip muscles so that the lips are able to close. OMT is able to increase the ability to hold the tongue to stay in contact with the palate so that there is no obstacle to the eruption of the lower insisvus tooth and AOB can be corrected. AOB children have a wider pattern of tongue surface contact with palate because it involves the posterior and lateral sides of the tongue. In a normal swallowing pattern, only the tip of the tongue touches the palate behind the insisal papillae, while in AOB children the tongue is pushed into the open bite area so that contact occurs to the posterior and lateral parts of the tongue. In addition to AOB correction, OMT also has an effect on eliminating oral bad habits.

Based on these researches, it can be said that Orofacial Myofunctional Therapy (OMT) is effective in correcting a child's Anterior Open Bite (AOB) as an adjunct therapy or combined with the use of orthodontic or myofunctional appliance, especially in children over 12 years of age and craniofacial deformities have occurred. OMT is used as a single therapy when the child is still in the stage of growth and development.

Based on the analysis of literature reviews in related journals, it can be concluded that:

1. Orofacial Myofunctional Therapy (OMT) is effective for increasing facial muscle activity, decreasing perioral muscle contractions and improving tongue posture

2. OMT effectively eliminates bad mouth habits especially in relation to correction of Anterior Open Bite(AOB)

3. The effectiveness of OMT is used as a single therapy to eliminate children's bad habits and correction of AOB, especially while still in the stage of growth and development and there has been no craniofacial deformity

4. The effectiveness of OMT as an adjuvant therapy or combination with orthodontic treatment especially if there has been maloclusion or craniofacial deformity

The author is responsible for the content and writing of the paper. The author has read and approved the final manuscript of this literature review.The study did not receive any special grants from funding agencies in the public, commercial or nonprofit sectors.

The author states that this manuscript has no conflict of interest.

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