# Open Bite Treatment with Combined Aligners and Myofunctional Appliances: A Case Report
###### Abstract  
This case report describes an 18-year-old female patient with a skeletal class I pattern, mandibular asymmetry, a molar class III on the right side, a molar class II on the left side, and an anterior open bite (AOB). Treatment of AOB is often difficult for orthodontists and a multidisciplinary approach is sometimes required to rehabilitate the correct function and posture of the tongue. In this case the AOB was treated using the Nuvola(r) OP System: a treatment system that combines orthodontic aligners and a myofunctional elastodontic device called Freedom. An upper molar intrusion with miniscrews was performed during the first phase of the treatment programme, and then the aligner treatment began. The Nuvola(r) OP System's aligners are characterized by lingual pins that guide the tongue to the palatal spot position and take advantage of tongue function. The patient was instructed to wear the Freedom device for 30 min a day and to clench every 3 s with closed lips while wearing the aligners. These exercises improve the fitting of the aligners, improve the tongue's posture, and take advantage of the masticatory forces to resolve the malocclusion. The patient was successfully treated, thus demonstrating that the Nuvola(r) OP System is a valid alternative for the treatment of AOB.  
clear aligners; anterior open bite; orthodontics; miniscrew; biomechanics; myofunctional appliances +
Footnote †: journal: Medical  
The introduction of skeletal anchorage simplified the correction of an AOB [14] through the orthodontic intrusion of posterior teeth with titanium mini-plates or monocortical bone screws [7; 14; 15]. Skeletal anchorage promotes the intrusion of molars in their bone support and promotes the counterclockwise rotation of the jaw with the consequent closure of the bite [16].  
On the other hand, the demand for orthodontic treatment with invisible appliances is constantly increasing, and therefore innovations in clear aligner therapy, which allows the resolution of even complex malocclusions, are important. Regarding the AOB, there are some case reports that have shown the successful treatment of patients with this malocclusion using different methods and appliances [17]. In some cases, clear aligners were also used [16], and some authors have shown that they are successful in controlling the vertical dimension in patients with open bite even when associated with a combination of incisor extrusion and molar intrusion, promoting the counterclockwise rotation of the jaw [18] and improving facial aesthetics [16]. According to this evidence, clear aligners can be successfully used in anterior open bite cases where the aetiology is represented by intruded anterior teeth [19; 20]. In the presence of these characteristics, the combination of clear aligners with myofunctional appliances could be beneficial in AOB cases. Indeed, a study showed that clenching exercises may be effective in improving dental contacts, and this could also improve the fit of the aligners, although this has not yet been demonstrated. Moreover, myofunctional appliances showed some positive effects in tongue and labial muscle rehabilitation [5].  
Therefore, taking into account this background, the aim of this article was to present a clinical case showing an AOB treated with a combination of clear aligners and a myofunctional appliance (Nuvola(r) OP System) and to discuss the indications and the clinical results of such a hybrid approach.