# Open Bite Treatment with Combined Aligners and Myofunctional Appliances: A Case Report
## 2 Case Description and Results  
### Diagnosis and Etiology  
A young adult female, aged 18 years, visited the Orthodontic Clinic, University of L'Aquila in December 2018; her chief complaint was regarding a lack of tooth overlap and the non-coincidence of the upper and lower midlines. Although aware of her malocclusion, the patient reported that she had not undergone any orthodontic treatment previously, because she had always been recommended traditional orthodontic treatments with a fixed multibracket appliance, which was not acceptable to her. The patient had asked for a completely invisible appliance, without metal brackets, and had also refused the use of lingual brackets.  
The patient's medical history was collected, and a complete clinical examination was performed.  
The extra-oral evaluation showed that the profile appeared harmonic although slightly convex. A slight skeletal laterodeviation of the chin was detectable; nevertheless, the anamnesis and the clinical examination revealed sound and healthy temporomandibular joints. The smile analysis showed a wide dental exposure from molar to molar with a slightly increased gingival display, non-coincidence of the dental midlines, and an anterior open bite of 3 millimetres. The upper midline was centred on the facial midline, while the lower midline was shifted to the left by 1.5 millimetres (Figure 1).  
The intraoral analysis showed the presence of all permanent teeth except for the third maxillary and mandibular molars. The patient had a molar and canine class III relationship on the right side and a molar and canine class II relationship on the left side, due to the mandibular laterodeviation. There were 2.2 millimetres of crowding in the upper arch and 1.2 millimetres of crowding in the lower arch; the upper anterior segment was the most crowded, and the pre-treatment cephalometric analysis performed with cephalometric software (Dolphin Imaging System, version 11.9, Canoga Park, Calif) showed a skeletal class I, with an ANB of \(-0.2^{\circ}\) and a WITS of \(-2.0\) mm (Figure 2) (Table 1). Vertical parametersshowed a normodivergent pattern. Dental measurements showed a more forward inclination of the upper (U1-Palatal Plane = 117.2\({}^{\circ}\)) and lower incisors (IMPA = 96.9\({}^{\circ}\)).  
In conclusion, it could be stated that the patient's AOB was a dental open bite. In addition, the lower third molars were impacted and mesio-inclinated.  
\begin{table}
\begin{tabular}{c c c c c c} \hline \hline
**Measurement** & \multicolumn{2}{c}{**Norm**} & \multicolumn{2}{c}{**Pre-Treatment**} & \multicolumn{1}{c}{**Post-Treatment**} & \multicolumn{1}{c}{**Difference**} \\ \hline  & **Mean** & **SD** & & & \\ \hline SNA (\({}^{\circ}\)) & 82.0 & 3.5 & 78.7 & 79.4 & 0.7 \\ \hline SNB (\({}^{\circ}\)) & 80.0 & 3.0 & 78.0 & 79.4 & 1.4 \\ \hline ANB (\({}^{\circ}\)) & 2.0 & 2.4 & 0.7 & 0.0 & \(-\)0.7 \\ \hline Wits Appraisal (mm) & 0.0 & 1.0 & \(-\)1.0 & \(-\)2.2 & 1.2 \\ \hline FMA (\({}^{\circ}\)) & 26.0 & 5.0 & 23.9 & 21.9 & \(-\)2.0 \\ \hline U1-Apo (mm) & 6.0 & 2.2 & 4.9 & 5.0 & 0.1 \\ \hline L1-Apo (mm) & 2.0 & 2.3 & 2.0 & 2.5 & 0.5 \\ \hline U1-PP (\({}^{\circ}\)) & 110.0 & 5.0 & 117.2 & 112.4 & \(-\)4.8 \\ \hline \hline \end{tabular}
\end{table}
Table 1: Cephalometric analysis.  
Figure 1: Pre-treatment facial and intraoral photographs.  
Figure 2: **(A)**: Pre-treatment panoramic. **(B)**: Pre-treatment lateral radiograph.