International Journal of Orthodontic Rehabilitation

: 2019  |  Volume : 10  |  Issue : 4  |  Page : 147--151

Open bites in a Saudi Arabian subpopulation presenting for orthodontic treatment: A retrospective study from Najran province

Bandar Alyami1, Ramat Oyebunmi Braimah2, Salem Almoammar3, Mahmoud Omar Ibrahim4,  
1 Department of Preventive Dentistry, Faculty of Dentistry, Najran University, Najran, Saudi Arabia
2 Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Center, New Medical City, Najran, Abha, Saudi Arabia
3 Department of Pediatric Dentistry and Orthodontics, College of Dentistry, King Khaled University, Abha, Saudi Arabia
4 Department of Orthodontics, Dalma Specialist Clinics, Najran, Saudi Arabia

Correspondence Address:
Dr. Bandar Alyami
Department of Preventive Dentistry, Faculty of Dentistry, Najran University, P.O. Box 1988, Najran
Saudi Arabia


Background: Open bite (OB) is a vertical malocclusion and is considered the most challenging malocclusion to manage. The aim of this study was to find out the prevalence and describe the pattern of OB among patients presenting for orthodontic treatment. Materials and Methods: Three hundred and twenty-six male and female patients who were presenting for orthodontic treatment of dental malocclusion were retrospectively reviewed. They were screened with cephalometric X-rays. Demographics and type of OBs were retrieved. Data were stored and analyzed using IBM SPSS Statistics for IOS Version 25 (Armonk, NY, USA: IBM Corp). Results: Of the 326 cases who presented for the management of different types of malocclusion, 78 (23.9%) had OB. There were 23 (29.5%) males and 55 (70.5%) females with an M: F ratio of 1:2.4. Age ranged from 9 to 40 years with mean ± standard deviation (19.5 ± 6.9). Most of the patients (33, 42.4%) were cases of anterior OB (AOB), 20 (25.6%) were cases of posterior OB (POB), while 25 (32.0%) cases were combined OB (COB). Bulk of the patients had Class I molar relationship (42, 53.8%). Six (7.7%) patients reported being involved in oral habits. Conclusion: A high prevalence of 42.4% of AOB, 25.6% of POB, and 32.0% for COB was reported. A population-based study is required in Najran province among preschool and early school children.

How to cite this article:
Alyami B, Braimah RO, Almoammar S, Ibrahim MO. Open bites in a Saudi Arabian subpopulation presenting for orthodontic treatment: A retrospective study from Najran province.Int J Orthod Rehabil 2019;10:147-151

How to cite this URL:
Alyami B, Braimah RO, Almoammar S, Ibrahim MO. Open bites in a Saudi Arabian subpopulation presenting for orthodontic treatment: A retrospective study from Najran province. Int J Orthod Rehabil [serial online] 2019 [cited 2020 Sep 22 ];10:147-151
Available from:

Full Text


The term open bite (OB) was first coined by Careveli in 1842.[1] OB is a vertical malocclusion and considered the most challenging managing orthodontically because of the high risk of relapse. It can be anterior OB (AOB) or posterior OB (POB). AOB when there is no contact between the anterior teeth (canine to canine) and POB when no contact between the posterior teeth (premolar to molar). However, when OB extends from anterior to posterior teeth, then it is referred to as combined OB or complex OB (COB).[2] OB may occur with Class I, Class II, or Class III skeletal pattern.[3] Numerous etiological factors are involved in this category of malocclusion which includes digit sucking habits, tongue-thrusting, mouth breathing, adenoid hypertrophy, syndromes, occlusal and facial growth pattern, eruptive forces, and dental ankylosis.[4],[5] Other factors such as severity and time of initial treatment can make OB rectification and stability more challenging.[6] Difficulty in incising food is the main complaint of these groups of patients. Other symptoms include masticatory, speech, and esthetic problems.[7] The esthetic problems are contributed by the adenoid facies or long face syndrome together with incompetence lips and nonexistence of overbite.[8] OB can be managed by removing the cause, which allows the teeth to close normally without any intervention, or by orthodontic forces.

AOB was reported to be present in about 25%–38% of the orthodontically treated patients.[9] In the United States, it is estimated to occur in 0.6% of the population. There are racial variations in the prevalence of OB; it was reported to be 16% among Blacks and 4% in White population.[1] In the Arab countries, a study from Oman has reported a prevalence of AOB to be 2.2%,[10] while in the Kuwaitis, the prevalence of AOB was reported to be 3.4%.[11] In Saudi Arabian population, prevalence studies from northern region (AOB [7.7%[12]], POB [0.6%[12]], OB [11.1%[13] and 4.6%[14]]) and southern region (AOB 6.1%[15] and 7.2%[16]) have also been documented.

To the best of our knowledge, literature search did not reveal any study on the prevalence of OB in this part of Saudi Arabia. The aim of this current study, therefore, is to report the prevalence of OB in a Saudi Arabian subpopulation that is presenting for orthodontic treatment and to describe its pattern.

 Materials and Methods

After obtaining ethical approval from the Ethics and Research Committee of Dalma Clinics, Najran region of Saudi Arabia, 326 male and female patients were retrospectively reviewed. All patients who presented for orthodontic management of malocclusion were screened both clinically and radiographically (Cephalometric, Carestream Dosimetry of the 9500 3D Cone Beam System, Carestream Dental LLC, 3625, Cumberland Blvd. Ste. 700, Atlanta, GA 30339) for malocclusion patterns. Incomplete data were excluded from the study.

Demographics were retrieved and whether AOB, POB, or COB was present or not. Based on severity of OB, when vertical separation between the teeth either anterior or posterior is within 0–2 mm, then it is recorded as moderate OB, and when it is within 3–4 mm, then its severe OB, while it is extreme OB when greater than 4 mm.[17]

Data were analyzed using IBM SPSS Statistics for IOS Version 25 (Armonk, NY: IBM Corp) and the results were presented as simple frequencies and descriptive statistics. Pearson's Chi-square was used to evaluate the association and level of significance among categorical variables such as age group of patients, gender, and type of OB, with P ≤ 0.05 considered as statistically significant.


Of the 326 cases who presented for the management of different types of malocclusion, 78 (23.9%) had OB. There were 23 (29.5%) males and 55 (70.5%) females with an M: F ratio of 1:2.4. Patients' age ranged from 9 to 40 years with mean ± standard deviation (19.5 ± 6.9). Among the 78 cases of OB, most of the patients (33, 42.4%) were cases of AOB, 20 (25.6%) were cases of POB, while 25 (32.0%) cases were COB with no significant difference [Table 1] and [Figure 1]. Majority of the cases of OB were observed in the age group 11–20 years (47, 60.2%) although this did not attain statistical significance [Table 2]. When types of OB were compared with molar relationship seen the patients, bulk of the patients had Class I molar relationship (42, 53.8%) that was not significant. This was followed by Class III molar relationship (28, 35.9%). Class II molar relationship had the least number of patients with OBs (8, 10.3%) [Table 3].{Table 1}{Figure 1}{Table 2}{Table 3}

With respect to oral habits, only 6 (7.7%) patients reported being involved in oral habits in all cases. Within the AOB group (n = 33), thumb sucking was reported in 3 (9.1%) patients, in the POB group (n = 20), 1 (5.0%) patient reported tongue-thrusting, while in the COB group (n = 25), 2 (8.0%) patients reported tongue-thrusting.

Of the 33 cases of AOB, 10 (30.3%) cases were mild, 21 (63.6%) were moderate, and 2 (6.1%) were severe. In the POB, 9 (45.0%) were mild, 10 (50.0%) were moderate, while only 1 (5.0%) case was severe [Figure 2]. Patients with COB had 11 (44.0%) mild cases, 12 (48.0%) moderate cases, and 2 (8.0%) severe cases [Figure 2].{Figure 2}


OB is a malocclusion in the vertical axis and involves both AOB and POB. Orthodontically, OB malocclusion is considered one of the most difficult conditions to treat because of the multifactorial etiological factors ranging from genetic and/or environmental.[18],[19],[20],[21] Generally, OB can be classified into two: skeletal and dental OBs.[3] While dental OB often caused by nonnutritive pacifiers can be managed by orthodontic mechanics,[22] skeletal OB usually caused by genetic and environmental factors that facilitate vertical growth in the molar region without compensatory growth at the condyle or the ramus may require both surgical and orthodontic treatment because of its severity.[3] Established environmental factors include digit sucking,[3],[4] enlarged adenoids with mouth breathing,[23] and tongue-trusting.[7]

There is huge variation in the epidemiological data on the prevalence of OB worldwide. It has been reported to range from 6.2% to 50.0%.[24] This wide variation has also been reported within the same region and country.[25],[26],[27] The current study has reported a prevalence of 42.4% for AOB [Figure 3], 25.6% for POB [Figure 4], and 32.0% for COB [Figure 5], which is in tandem with the literature. On the contrary, lower prevalence rates have been reported in Saudi Arabian studies [12],[13],[16],[28] and other Arab communities.[10],[11] Customary, regional, and socioeconomic variations of each municipality have been considered the most probable explanation for the diverse prevalence rates of AOB.[3],[24],[29] In a recent Brazilian population-based study, multivariate analysis revealed that preschool children living in southern part of Brazil had an increased probability of 1.8 more times of having AOB and posterior crossbite as compared to other regions of the country.[24] This situation can be explained by diverse cultural habits that may expose the child to risk factors associated with AOB.[24],[27] Examples of such habits include breastfeeding time, variations in nonnutritive sucking habits, and type of diet.[18],[30]{Figure 3}{Figure 4}{Figure 5}

The current study showed a female predilection for OB. This finding is in agreement with several studies reporting a female predilection.[31],[32],[33] On the contrary, higher male predilection of ratio 4:1 has been reported among Yemeni adults [34] and Sudanese University students.[35] Variations in the prevalence of AOB among genders can be partially attributed to the fact that parents in Islamic communities are more concerned about the appearance of girls than boys and try to observe, prevent, and treat all kinds of the abnormalities, concerning the teeth and face that can affect the smile of their daughters at early age.[35]

Studies have reported age variations in the incidence of AOB.[3],[36] In the United Kingdom, for example, the incidence of 2%–4% was identified in the children.[36] This incidence drops between 9 and 13 years as a result of normal occlusal development, stoppage of oral habits, reduction in size of adenoids, and the establishment of full adult swallowing pattern.[36] After 13 years of age, the incidence spikes again probably as a consequence of late vertical growth or continuation and/or noncessation of oral habits.[37] In the current study, higher frequency of AOB was observed in the age group of 11–20 years, which coincides with the age group where spikes in the incidence of AOB have been reported.[36],[37] To our surprise, this condition persisted into adulthood (21–40 years) where 37.2% of the total number of patients investigated was reported. This trend showed that probably oral habits persisted or there exists some genetic background that may need further investigation in the Najran province of Saudi Arabia. From the current study, only 6 (7.7%) patients (n = 78) reported oral habits of thumb sucking and thumb-trusting. This low incidence of oral habits suggests that probably, a genetic background may be responsible for the etiology of OB in Najran patients presenting for orthodontic treatment. Another possibility of the low reported oral habits is that these patients were already adults and might have forgotten they practiced such habits when they were young. Tongue-thrusting has been described as an endogenous habit or adaptive behavior [3] to prevent food/water/saliva from leaking from anterior part of the mouth during swallowing.[38] Literature has also documented that thumb sucking for >6 h a day and most importantly during the night will result in a severe AOB.[3] This is because the digit acts as an impediment to the erupting incisors while permitting over eruption of the molars, resulting in OB.[3] Population-based study on oral habits and nonnutritive pacifiers among preschool and early schoolchildren in Najran province will unravel this mystery since strong association between oral habits and OB has been established hitherto.[18],[39]

In terms of severity of OB, most studies have reported moderate OB as the most common type, while severe types were described to be rare.[17] This study has validated this position as most of the cases were moderate types in the AOB, POB, and COB cases. COB has been described as OB extending from anterior region to the molars.[2]


This current study has reported a prevalence of 42.4% for AOB, 25.6% for POB, and 32.0% for COB in patients presenting for orthodontic treatment, which is in tandem with the literature. Very low number of patients (7.7%) reported having engaged in oral habits. We postulated a genetic background of OB in Najran province, or rather, probably, most patients did not remember the oral habits they were engaged in when young. To unravel this unknown, a population-based study on oral habits and nonnutritive pacifiers is required in Najran province among preschool and early school children. Such data are important for the strategic planning of government programs targeted at prevention, interception, and treatment of OB.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Proffit WR, White RP Jr. Who needs surgical-orthodontic treatment? Int J Adult Orthodon Orthognath Surg 1990;5:81-9.
2Wajid MA, Chandra P, Kulshrestha R, Singh K, Rastogi R, Umale V, et al. Open bite malocclusion: An overview. J Oral Health Craniofac Sci 2018;3:11-20.
3Agbaje HO, Osiatuma VI, Fadeju AD, Kolawole KA, Otuyemi OD. Anterior open bite: A review of epidemiology, aetiology and management. West Afr J Orthod 2012;1:5-12.
4Burford D, Noar JH. The causes, diagnosis and treatment of anterior open bite. Dent Update 2003;30:235-41.
5Onyeaso CO, Sote EO. Prevalence of oral habits in 563 nigerian preschool children age 3-5 years. Niger Postgrad Med J 2001;8:193-5.
6Matsumoto MA, Romano FL, Ferreira JT, Valério RA. Open bite: Diagnosis, treatment and stability. Braz Dent J 2012;23:768-78.
7Maciel CT, Leite IC. [Etiological aspects of anterior open bite and its implications to the oral functions]. Pro Fono 2005;17:293-302.
8Salguero AE, Valverde AS. Correction of an skeletal anterior open bite with mini-screws and a modified bite block. Rev Mex Ortod 2017;5:102-10.
9Espeland L, Dowling PA, Mobarak KA, Stenvik A. Three-year stability of open-bite correction by 1-piece maxillary osteotomy. Am J Orthod Dentofacial Orthop 2008;134:60-6.
10Al Jadidi L, Sabrish S, Shivamurthy PG, Senguttuvan V. The prevalence of malocclusion and orthodontic treatment need in Omani adolescent population. J Orthodont Sci 2018;7:21-7.
11Behbehani F, Artun J, Al-Jame B, Kerosuo H. Prevalence and severity of malocclusion in adolescent Kuwaitis. Med Princ Pract 2005;14:390-5.
12Alajlan SS, Alsaleh MK, Alshammari AF, Alharbi SM, Alshammari AK, Alshammari RR, et al. The prevalence of malocclusion and orthodontic treatment need of school children in northern Saudi Arabia. J Orthod Sci 2019;8:10.
13Rashid IM, Alshammari DS, Al Zubaidi S, Alshammari NS, Alenezi AS, Siddiqui AA, et al. Prevalence of malocclusion among the Saudi population in Ha'il city of Saudi Arabia. Can J Dent 2019;1:1-8.
14Gudipaneni RK, Aldahmeshi RF, Patil SR, Alam MK. The prevalence of malocclusion and the need for orthodontic treatment among adolescents in the northern border region of Saudi Arabia: An epidemiological study. BMC Oral Health 2018;18:16.
15Asiry MA, Al Shahrani I. Prevalence of malocclusion among school children of Southern Saudi Arabia. J Orthodont Sci 2019;8:2-6.
16Meer Z, Sadatullah S, Wahab MA, Mustafa AB, Odusanya SA, Razak PA, et al. Prevalence of malocclusion and its common traits in Saudi males of Aseer region. J Dent Res Rev 2016;6:99-102.
17Mizrahi EA. Review of anterior bite. Br J Orthod 1978;5:21027.
18Góis EG, Vale MP, Paiva SM, Abreu MH, Serra-Negra JM, Pordeus IA, et al. Incidence of malocclusion between primary and mixed dentitions among Brazilian children. A 5-year longitudinal study. Angle Orthod 2012;82:495-500.
19Katz CR, Rosenblatt A, Gondim PP. Nonnutritive sucking habits in Brazilian children: Effects on deciduous dentition and relationship with facial morphology. Am J Orthod Dentofacial Orthop 2004;126:53-7.
20Janson G, Valarelli FP, Beltrão RT, de Freitas MR, Henriques JF. Stability of anterior open-bite extraction and nonextraction treatment in the permanent dentition. Am J Orthod Dentofacial Orthop 2006;129:768-74.
21Artese A, Drummond S, do Nascimento JM, Artese F. Criteria for diagnosing and treating anterior open bite with stability. Dental Press J Orthod 2011;16:136-61.
22Lentini-Oliveira D, Carvalho FR, Qingsong Y, Junjie L, Saconato H, Machado MA, et al. Orthodontic and orthopaedic treatment for anterior open bite in children. Cochrane Database Syst Rev 2007;2:CD005515.
23Urzal V, Braga AC, Ferreira AP. The prevalence of anterior open bite in Portuguese children during deciduous and mixed dentition correlations for a prevention strategy. Int Orthod 2013;11:93-103.
24Machado DB, Brizon VS, Ambrosano GM, Madureira DF, Gomes VE, de Oliveira AC, et al. Factors associated with the prevalence of anterior open bite among preschool children: A population-based study in Brazil. Dental Press J Orthod 2014;19:103-9.
25Carvalho AC, Paiva SM, Scarpelli AC, Viegas CM, Ferreira FM, Pordeus IA, et al. Prevalence of malocclusion in primary dentition in a population-based sample of Brazilian preschool children. Eur J Paediatr Dent 2011;12:107-11.
26Dimberg L, Lennartsson B, Söderfeldt B, Bondemark L. Malocclusions in children at 3 and 7 years of age: A longitudinal study. Eur J Orthod 2013;35:131-7.
27Peres KG, De Oliveira Latorre Mdo R, Sheiham A, Peres MA, Victora CG, Barros FC, et al. Social and biological early life influences on the prevalence of open bite in Brazilian 6-year-olds. Int J Paediatr Dent 2007;17:41-9.
28Al-Emaran S, Wisth PJ, Boe OE. Prevalence of malocclusion and need for orthodontic treatment in Saudi Arabia. Comm Dent Oral Epidermiol 1990;18:253-5.
29Otuyemi OD, Noar JH. Anterior open bite: A review. Saudi Dent J 1997;9:149-57.
30Tomita NE, Bijella VT, Franco LJ. The relationship between oral habits and malocclusion in preschool children. Rev Saúde Pública 2000;34:299-303.
31Hosseini N, Talezade S, Yassaie S, Moradi Z. Prevalence of open bite malocclusion among 11-12 years old school children in Yazd, Iran. Iran J Ortho 2015;9:4845-50.
32Shivakumar KM, Chandu GN, Reddy S, Shafiulla MD. Prevalence of malocclusion and orthodontic treatment among middle and high school children of Davangere city, India by using dental aesthetic index. J Indian Soc Pedod Prevent Dent 2009;27:211-18.
33Kassis A, Serhal JB, Nassif BN. Malocclusion in Lebanese orthodontic patients: An epidemiologic and analytic study: An observational retrospective study. IAJD 2010;1:34-43.
34Daeir AA, Abuaffan AH. Prevalence of open bite among Yemeni adults. Al-Azahar J Dent Sci 2015;17:125-9.
35Hassan DS, Abuaffan AH. Prevalence of anterior open bite among sample of Sudanese University students. Enz Eng 2016;5:143-6.
36Mouatt RB. Children's dental health in the United Kingdom 1983 a review. Health Bull (Edinb) 1986;44:283-5.
37Cozza P, Mucedero M, Baccetti T, Franchi L. Early orthodontic treatment of skeletal open-bite malocclusion: A systematic review. Angle Orthod 2005;75:707-13.
38Noar J, Portnoy S. Dental status of children in a primary and secondary school in rural Zambia. Int Dent J 1991;41:142-8.
39Vasconcelos FM, Massoni AC, Heimer MV, Ferreira AM, Katz CR, Rosenblatt A, et al. Non-nutritive sucking habits, anterior open bite and associated factors in Brazilian children aged 30-59 months. Braz Dent J 2011;22:140-5.