How can bite issues be corrected?

Correcting Bite Issues: Evidence-Based Management

Bite issues in children should be managed based on the specific type of malocclusion and patient age, with observation being the primary approach for anterior open bite in young children (particularly when associated with digit-sucking habits), while referral to an orthodontist is indicated for persistent malocclusion after age 6-7, deep bite requiring intervention, or when tooth displacement interferes with occlusion. 1

Initial Assessment and Classification

When evaluating bite problems, determine whether the issue is:

• Trauma-related occlusal interference: Assess if displaced teeth are preventing proper bite closure by asking the child to bite down gently and checking if posterior molars can fully interdigitate 2
• Developmental malocclusion: Anterior open bite, deep bite, or Class II division 2 malocclusion with retroclined upper incisors 1, 3
• Acute displacement: Jaw dislocation, lateral luxation, or alveolar fracture requiring immediate repositioning 2, 4

Management Algorithm by Clinical Scenario

Trauma-Induced Bite Problems

For lateral luxation with occlusal interference:

• Minor displacement: Apply gentle digital apical pressure to reposition the tooth immediately 2
• Ensure the tooth position does not interfere with occlusion by having the child say "cheese" or the letter "e" to visualize whether posterior teeth can fully interdigitate 2
• If the luxated primary tooth is near exfoliation and interfering with the bite, extraction is indicated 2
• Permanent teeth with significant displacement require dental forceps repositioning and flexible splinting for 4 weeks with immediate dental referral 2

For alveolar fractures (multiple teeth moving together):

• Immediate repositioning of the segment and stabilization with a splint is required 2
• Immediate referral to a dentist is mandatory 2

Developmental Anterior Open Bite

Age-based management strategy:

• Under age 6-7: Observation is the primary management, especially when associated with digit-sucking habits, as spontaneous correction frequently occurs during normal dental development 1
• After age 6-7: If open bite persists, obtain orthopantomography (OPT) for evaluation, as permanent tooth buds are not adequately visible before age 6 and radiation exposure cannot be justified earlier 1, 5
• Referral timing: Refer to orthodontist when eruption asymmetry or malocclusion requires treatment, typically in late mixed or permanent dentition 1

Treatment modalities for persistent cases:

• Clear aligners (Invisalign) can achieve 0.4-3.8 mm of bite opening for mild to moderate dentoalveolar open bites, though planned correction often falls short of actual achieved correction, requiring overcorrection or refinements 6, 7
• Optimized extrusion attachments show no superiority over conventional attachments for open bite correction efficacy, though they may shorten treatment time 7
• Skeletal anterior open bites traditionally require combined orthodontic treatment with orthognathic surgery, though temporary anchorage devices (TAD) may avoid surgery in selected cases, though long-term stability data remains limited 8

Deep Bite Correction

Management approach:

• Provide routine dental examinations, appropriate hygiene, restorative care, and orthodontic care when clinically indicated rather than immediately in all cases 1
• Clear aligners can effectively correct mild to moderate dentoalveolar deep bites but show limited efficacy for skeletal cases compared to full-fixed appliances 9
• Accuracy of deep bite correction with clear aligners ranges from 33% to 48.88%, often requiring overcorrection planning or refinements 9

For Class II division 2 malocclusion with deep bite:

• No high-quality evidence exists to recommend specific orthodontic approaches (functional appliances vs. headgear vs. extraction treatment) 3
• Treatment decisions must be made based on clinical judgment in absence of RCT evidence 3

Diagnostic Imaging Guidelines

Timing and modality selection:

• Do not obtain OPT before age 6 unless there are compelling clinical signs requiring urgent evaluation, as permanent tooth buds are inadequately visible and radiation exposure is not justified 1, 5
• After age 6: OPT is indicated for persistent malocclusion, clinical suspicion of impacted teeth, supernumerary teeth, or tooth agenesis 1, 5
• Periapical intraoral X-ray is the imaging technique of choice for localized dento-alveolar trauma, providing sufficient information for treatment planning in most cases 2
• CBCT should be reserved for cases where 2D imaging is insufficient, particularly for suspected root fractures, alveolar bone fractures, or complex tooth luxation, following ALARA principles with reduced FOV 2

Critical Pitfalls to Avoid

• Never replant an avulsed primary tooth, as this risks damage to the underlying permanent tooth germ 2
• Avoid premature radiographic imaging before age 6 for malocclusion evaluation, as radiation exposure is rarely justified 1, 5
• Do not use OPT for localized dental trauma, as it has lower spatial resolution than intraoral X-ray and requires longer exposure time leading to movement artifacts in young children 2
• Screen for child abuse in children younger than 5 years with trauma affecting lips, gingiva, tongue, palate, and severe tooth injury 2, 4

Immediate Referral Indications

Refer immediately to dentist for:

• Tooth displacement interfering with bite/occlusion 2, 4
• Inability to close jaw properly 2, 4
• Multiple teeth moving together as a segment (alveolar fracture) 2, 4
• Severe extrusive injuries (>3 mm) requiring extraction 2
• Jaw dislocation or luxation 4