# Open Bite Treatment with Combined Aligners and Myofunctional Appliances: A Case Report
## 3 Discussion  
Patients with dentofacial malocclusions are disadvantaged in society due to low self-confidence associated with physiological problems [24]. An open bite compromises the social behaviour of the individual in multiple ways, thus influencing the quality of life [6,7]. Consequently, the concern for aesthetics motivates patients with an AOB to seek an orthodontic treatment that is effective while being invisible. Knowledge of the main complaints and expectations of the patient, as well as adequate diagnostic examinations, is important when deciding the ideal treatment plan and achieving a satisfactory result [25]. In the present case, clear aligner treatment was chosen to provide a more comfortable and aesthetic treatment [26], but also because the patient's compliance and attitude towards orthodontic treatment were excellent. Indeed, different studies have revealed that treatment with clear aligners is well supported by patients because of its minimum aesthetic impact [27,28] and that this technique is even preferred over lingual fixed appliances because the latter causes oral dysfunctions like tongue injuries [28]. Despite their advantage in terms of comfort, clear aligners are not as effective as braces in creating adequate occlusal contacts and controlling root torque [29], even if clinical outcomes are usually comparable to the planning of the digital setup in regard to torque movements of the anterior teeth [30]. Figure 10: 15-month follow up intraoral photographs. Figure 9: (**A**): Post-treatment lateral radiograph. (**B**): Post-treatment panoramic. However, even though clear aligners can be a successful alternative to fixed appliances to treat patients with mild to moderate malocclusion [31], more complex movements are less predictable, especially vertical movements [32]. For these reasons, in the present case report clear aligners were combined with different auxiliary appliances (TPA, miniscrews, myofunctional appliances, vertical elastics) to predictably obtain molar intrusion and AOB correction. During treatment, IPR was performed to gain space in both dental arches, taking care to perform the exact amount of IPR planned [33]. This treatment option was presented as a compromise treatment compared to orthognathic surgery. However, there is currently no consensus on whether surgical or non-surgical treatment is the most stable approach to treat AOB in adult patients. Of course, the stability of the orthodontic treatment is influenced by aetiological factors and their persistence over time [34]. Because of the frequency of relapse [35], it is essential to evaluate, beyond immediate post-treatment results, the achievement of long-term stability [36]. Many authors have shown that after a few years there is a return to the original configuration both at the molar level and at the level of the upper and lower incisors, of varying degrees [25]. AOB treatment through molar intrusion using skeletal anchorage in adult patients can be considered quite unstable, since a relapse of up to 30% can be observed for both molars [37]. Therefore, more efficient methods of retention should be kept in the long-term follow-up [37]. For AOB cases, tongue rehabilitation is very important, because tongue thrusting is always associated--even though it is not always an aetiological factor--with this kind of malocclusion [38; 39] and the stability of the orthodontic result is dependent on the persistence or not of aetiological factors [6]. Regarding the use of the elastodontic device, [PERSON] et al. investigated the impact that daily clenching had on occlusal contacts and found that voluntary clenching is an effective training exercise to intensify the vertical effects on posterior teeth and to improve the occlusal contact area and the occlusal sagittal balance in normal subjects [39].