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CASE REPORT

Nonsurgical treatment of an adult with an open


bite and large lower anterior facial height with
edgewise appliances and temporary anchorage
devices
Tadao Fukui,a Hiroyuki Kano,b and Isao Saitoc
Niigata and Minamiuonuma City, Niigata, Japan

A woman was referred to the orthodontic clinic for treatment. She was diagnosed with a skeletal Class II malocclusion, a steep mandibular plane, and an anterior open bite. Conventional orthodontic treatment was considered to correct the maxillary protrusion and anterior open bite, but the patient also requested improvement of
her facial esthetics. We therefore decided that nonsurgical treatment consisting of 4 premolar extractions combined with temporary anchorage devices was indicated. Satisfactory improvement of the overjet and overbite,
and proper functional occlusion were obtained, resulting in a Class I molar relationship. Active treatment was
completed in 2 years 10 months, and the result remained stable at 2 years 6 months after debonding. (Am J
Orthod Dentofacial Orthop 2016;149:889-98)

rthodontists often encounter various types of


open-bite malocclusions in adult patients.
Open-bite malocclusion can be corrected by conventional orthodontic methods, orthodontic treatment
combined with temporary anchorage devices (TADs), or
orthognathic surgery. Recently, TADs have been developed and are indicated for various orthodontic conditions.1,2 The major applications of TADs in orthodontic
treatment are intrusion or distal movement of the
molars. The morphologic characteristics of open bite
are a steep mandibular plane, thin and long
morphology of the mandibular symphysis, and
increased anterior facial height. Orthodontic treatment
combined with TADs, as well as surgical orthodontic
treatment, might improve facial esthetics without
increasing the anterior facial height.
a
Assistant professor, Division of Orthodontics, Graduate School of Medical and
Dental Sciences, Niigata University, Niigata, Japan.
b
Oral surgeon, Yukiguni Yamato Hospital, Minamiuonuma City, Niigata, Japan.
c
Professor and chair, Division of Orthodontics, Graduate School of Medical and
Dental Sciences, Niigata University, Niigata, Japan.
All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conicts of Interest, and none were reported.
Address correspondence to: Tadao Fukui, Division of Orthodontics, Graduate
School of Medical and Dental Sciences, Niigata University, 2-5274 Gakko-cho,
CHou-ku, Niigata 951-8514, Japan; e-mail, fukui@dent.niigata-u.ac.jp.
Submitted, February 2015; revised and accepted, July 2015.
0889-5406/$36.00
Copyright 2016 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.07.043

In this case report, we demonstrate a nonsurgical orthodontic treatment of an adult with a skeletal Class II
anterior open bite and a large Frankfort-mandibular
plane angle (FMA). Since the patient desired improvement of her facial esthetics along with a suitable occlusion by undergoing orthodontic treatment alone,
nonsurgical treatment combined with TADs was applied.
DIAGNOSIS AND ETIOLOGY

The patient was a 28-year-old Japanese woman with


an anterior open bite and crowding. She was in good
health and had no contraindications for dental treatment. No facial asymmetry was evident in the frontal
view of the face. She had a convex facial prole with
increased anterior lower facial height and upper lip protrusion with incompetent lips (Fig 1). She had an anterior
open bite and anterior crowding in both arches. The
molar relationship was Angle Class II subdivision on
the right. Overjet and overbite were 12.5 and
0.5 mm, respectively. Both arches were narrow in the
molar regions (Fig 2). The cephalometric analysis
showed a skeletal Class II malocclusion (ANB, 7.0 )
with a long face, and the morphology of the mandibular
symphysis was thin and long. The maxillary and mandibular incisors had a lingual inclination (maxillary central
incisor to SN, 92.5 ) and an incisor-mandibular
plane angle (IMPA) of 82.0 (Table). The patient was
889

Fukui, Kano, and Saito

890

Fig 1. Pretreatment facial and intraoral photographs.

Fig 2. Pretreatment dental casts.

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Table. Cephalometric measurements at pretreatment,

posttreatment, and postretention


Measurement
Pretreatment Posttreatment Postretention
Angular ( )
SNA
76.0
76.0
76.0
SNB
69.0
70.0
70.0
ANB
7.0
6.0
6.0
Facial angle
74.0
76.0
76.0
Convexity
18.5
17.0
17.5
FMA
54.0
53.0
53.5
Y-axis
76.0
75.5
76.0
Gonial angle
148.0
148.0
148.5
Occlusal plane
19.5
20.0
20.0
to Frankfort
horizontal
U1-SN
92.5
93.0
92.0
IMPA
82.0
74.0
73.5
FMIA
44.0
53.0
53.0
Interincisal angle
122.5
129.0
131.0
Linear (mm)
Overjet
3.0
2.0
2.0
Overbite
0.5
2.0
2.0
U-1 to A-P pog
11.0
9.0
9.0
L-1 to A-P pog
9.0
6.0
6.0
N-ANS
56.0
56.0
56.0
ANS-Ne
79.0
78.0
78.0

diagnosed with a skeletal Class II malocclusion with a


steep mandibular plane, anterior open bite, and crowding. She had a history of treatment for temporomandibular joint disorder, but the pretreatment panoramic
radiograph showed no bony change of the condylar
heads bilaterally (Fig 3).
TREATMENT OBJECTIVES

The patient desired improvement of not only her occlusion but also her facial appearance. The main objectives of treatment were to correct the anterior open bite,
achieve a suitable functional occlusion, and improve her
facial esthetics with a competent lip seal.
TREATMENT ALTERNATIVES

Two treatment options were considered for this patient: (1) surgical orthodontic treatment, which could
improve both occlusion and facial appearance, was the
primary treatment plan of choice; or (2) nonsurgical orthodontic treatment with extraction of the maxillary rst
premolars and mandibular second premolars combined
with TADs for the maxilla and mandible was considered
as an alternative to orthognathic surgery.
These alternatives were discussed with the patient.
TADs would be used to intrude the maxillary and
mandibular molars, resulting in a change in facial
appearance. Since the patient refused surgical

891

orthodontic treatment, conventional orthodontic treatment with TADs was adopted.


The predicted treatment outcome was explained to
the patient, and informed consent was obtained.
TREATMENT PROGRESS

The 0.018 3 0.025-in standard edgewise appliances


were placed in both dental arches. After leveling with a
series of stainless steel round wires, power chains were
placed between the canine or premolar and the rst
molar with stainless steel round wires (0.016 in) to distalize the mandibular canines and premolars. After
4 months of active treatment, plate-type TADs were
placed bilaterally at the zygomatic arch and molar regions of the mandible to provide absolute anchorage
for intruding the bimaxillary molars. To distalize the
maxillary canines and intrude the maxillary molars,
power chains were placed between the canines and the
TADs with stainless steel round wires with an increased
curve of Spee (0.016 in). Similarly, to intrude the
mandibular molars, power chains were placed between
the archwires of the molar region and the TADs of the
mandible (Fig 4, A). The 0.018 3 0.025-in rectangular
wires with vertical closing loops for the maxilla were
used to move the maxillary incisors lingually under the
condition of reinforced anchorage using TADs with
maintenance of suitable torque. The 0.017 3 0.025-in
rectangular wires with vertical closing loops were used
to move the mandibular incisors lingually (Fig 4, B). After establishment of a Class I molar relationship,
0.018 3 0.025-in and 0.017 3 0.025-in ideal archwires
for the maxilla and mandible, respectively, were used to
obtain adequate interdigitation.
The active treatment time was 2 years 10 months. After removal of the edgewise appliances, bonded retainers
with exible spiral wires between the premolars for the
maxilla and the mandible were placed. The occlusal relationship was maintained to a large extent 2.5 years after
retention. Continuation of the xed retainers was
planned in accordance with the patient's wishes.
TREATMENT RESULTS

Upper lip protrusion and mentalis muscle tension


were improved with achievement of a competent lip
seal. In addition, the lower anterior facial height became
slightly shorter. Her prole was changed from a convex
type with receding soft tissue menton to almost the
straight type. The anterior open bite was completely corrected, with Class I molar and canine relationships. There
was no gingival recession after the orthodontic treatment (Fig 5). A functional occlusion was obtained with
canine protection (Fig 6). The posttreatment panoramic

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Fig 3. Pretreatment records: lateral cephalogram, cephalometric tracing, and panoramic radiograph.

Fig 4. Intraoral photographs during active treatment: A, After 4 months of treatment. In the maxillary
arch, to distalize the canines and intrude the molars, power chains were placed between the canines
and the TADs with stainless steel round wire with an increased curve of Spee, for inhibition of the
remarkable lingual inclination of the maxillary incisors. In the mandibular arch, to intrude the mandibular
molars, power chains were placed between the archwire of the molar region and the TADs. B, After
18 months of treatment. The 0.018 3 0.025-in rectangular wires with vertical closing loops were placed
to move the maxillary incisors lingually with maintenance of adequate torque under the condition of reinforced anchorage using TADs in the maxillary arch. The 0.017 3 0.025-in rectangular wires with vertical closing loops were used to move the mandibular molar mesially.

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Fig 5. Posttreatment facial and intraoral photographs.

Fig 6. Posttreatment dental casts.

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Fig 7. Posttreatment records: lateral cephalogram, cephalometric tracing, and panoramic radiograph.

radiograph showed suitable root paralleling and no root


resorption (Fig 7). In the cephalometric superimposition
from pretreatment and posttreatment, the maxillary incisors showed bodily lingual movement with an increase
in the maxillary central incisor to SN angle of 0.5 and no
extrusion, and the mandibular incisors exhibited lingual
inclination with a decrease in the IMPA of 8.0 and a
slight depression. The maxillary molars were inhibited
from mesial movement, and the mandibular molars
were moved mesially. This effectively contributed to
the attainment of a Class I molar relationship. A slight
intrusion of the maxillary and mandibular molars yielded
a slight counterclockwise rotation of the mandible with a
decrease in FMA of 1.0 (Fig 8, Table).
After 2 years 6 months of retention, an acceptable
occlusion and facial prole were maintained
(Figs 9-11). In the cephalometric superimposition from
posttreatment and postretention, the maxillary incisors
showed a slight lingual inclination with a decrease of
the maxillary central incisor to SN angle of 0.5 , and

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the mandibular incisors also had a slight lingual


inclination with a decrease of the IMPA of 0.5 . There
was little change in the position of the maxillary and
mandibular rst molars (Fig 12, Table).
DISCUSSION

To correct an unsuitable occlusion and improve the


facial appearance for our patient, a surgical orthodontic
procedure might have been the best treatment option.
Surgical orthodontic treatment can drastically improve
both the occlusion and the facial appearance. Since
the patient had a history of a temporomandibular joint
disorder and skeletal Class II, the surgical orthodontic
procedure including mandibular advancement might
have increased the likelihood of recurrence of the joint
disorder, including progressive condylar resorption.3
Also, the patient refused surgical orthodontic treatment,
so the decision was made to perform nonsurgical orthodontic treatment using TADs.

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Fig 8. Superimposed cephalometric tracings: A, Sella-nasion at sella for overall change with treatment; B, palatal plane at ANS for maxillary change; C, mandibular plane at mention for mandibular
change. Solid line, Pretreatment; dashed line, posttreatment.

In conventional orthodontic treatment without


TADs, vertical control of the molars and retraction of
both maxillary and mandibular incisors were often performed using high-pull headgear combined with Class
III elastics to correct an anterior open bite.4 Mesial
movement of the molars with extraction of the second
premolars might facilitate reduction of the vertical
dimension and induce forward rotation of the mandible;
this would contribute to correction of the anterior open
bite.5
Since Umemori et al1 and Kanomi2 reported on the
development of an orthodontic treatment system for
open-bite malocclusion using a titanium miniplate or
miniscrew to serve as strategic anchorage, several reports
have suggested that skeletal open bite can be corrected
using TADs.1,2,6-9 These reports showed the intrusion of
the molars in both arches with TADs, resulting in
counterclockwise rotation of the mandible and bite
improvement.
In severe open-bite cases, molar intrusion with TADs
is followed by forward rotation of the mandible; this
leads to anterosuperior movement of the soft tissue menton. Although our patient had a steep mandible with an

FMA of 54.0 , a slight intrusion of the molars was enough


to achieve a suitable treatment outcome because the
open bite was mild, with overbite of 0.5 mm.
The counterclockwise rotation of the mandible was
also slight. Therefore, not only counterclockwise rotation of the mandible because of the intrusion of the molars in both arches with TADs, but also lingual retraction
of the anterior teeth probably contributed to correction
of the open bite and improvement of the soft tissue prole.
In terms of posttreatment stability, the relapse rate of
molar intrusion has been reported to be approximately
20% to 30%.10-12 It is often difcult to obtain a stable
occlusion after correction of an open bite. In this case,
a slight intrusion and mesial movement of the maxillary
rst molar may reduce the likelihood of relapse. The
cephalometric superimposition showed little relapse of
the intruded maxillary rst molars, so that an
acceptable occlusion and facial prole were maintained
even at 2 years 6 months after retention. Based on the
recent concept for long-term retention, the placement
of a exible spiral wire bonded retainer between the premolars in both arches was continued for a long time.13

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Fig 9. Postretention facial and intraoral photographs.

Fig 10. Postretention dental casts.

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Fig 11. Postretention records: lateral cephalogram, cephalometric tracing, and panoramic radiograph.

Fig 12. Superimposed cephalometric tracings: A, sella-nasion at sella for overall change during retention; B, palatal plane at ANS for maxillary change; C, mandibular plane at menton for
mandibular change. Solid line, Posttreatment; dashed line, postretention.

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CONCLUSIONS

Orthodontic treatment of an adult with an open


bite and a steep mandibular plane was performed.
The combination of premolar extractions and TADs
proved to be effective for the treatment of this patient
with a large lower anterior facial height. Proper intrusion of the molars and precise anterior retraction obtained by nonsurgical treatment with TADs seem
to have contributed to the stability of the nal
occlusion.
REFERENCES
1. Umemori M, Sugawara J, Mitani H, Nagasaka H, Kawamura H.
Skeletal anchorage system for open bite correction. Am J Orthod
Dentofacial Orthop 1999;115:166-74.
2. Kanomi R. Mini-implant for orthodontic anchorage. J. Clin Orthod
1997;31:763-7.
3. Kobayashi T, Izumi N, Kojima T, Sakagami N, Saito I, Saito C. Progressive condylar resorption after mandibular advancement. Br J
Oral Maxillofac Surg 2012;50:176-80.
4. Saito I, Yamaki M, Hanada K. Nonsurgical treatment of adult open
bite using edgewise appliance combined with high-pull headgear
and Class III elastics. Angle Orthod 2005;75:277-83.
5. Tanaka E, Iwabe T, Kawai N, Nishi M, Dalla-Bona D, Hasegawa T,
et al. An adult case of skeletal open bite with a large lower anterior
facial height. Angle Orthod 2005;75:465-71.

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6. Kuroda S, Kuroda Y, Tomita Y, Tanaka E. Long-term stability of


conservative orthodontic treatment in a patient with rheumatoid
arthritis and severe condylar resorption. Am J Orthod Dentofacial
Orthop 2012;141:352-62.
7. Choi KJ, Choi JH, Lee SY, Ferguson DJ, Kyung SH. Facial improvement after molar intrusion with miniscrew anchorage. J Clin Orthod 2007;41:273-80.
8. Kravitz ND, Kusnoto B. Posterior impaction with orthodontic miniscrew for openbite closure and improvement of facial prole.
World J Orthod 2007;8:157-66.
9. Watanabe N, Fukui T, Saito I. Orthodontic treatment combined
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99-104.
10. Sugawara J, Baik UB, Umemori M, Takahashi I, Nagasaka H,
Kawamura H, et al. Treatment and posttreatment dentoalveolar
changes following intrusion of mandibular molars with application of skeletal anchorage system (SAS) for open bite correction. Int J Adult Orthod Orthognath Surg 2002;17:243-53.
11. Park HS, Kwon OW, Sung JH. Nonextraction treatment of an open
bite with microscrew implants anchorage. Am J Orthod Dentofacial Orthop 2006;130:391-402.
12. Baek MS, Choi YJ, Yu HS, Lee KJ, Kwak J, Park YC. Long-term
stability of anterior open bite treatment by intrusion of maxillary
posterior teeth. Am J Orthod Dentofacial Orthop 2010;138:
396.e1-9.
13. Booth FA, Edelman JM, Proft WR. Twenty-year follow-up of patients with permanently bonded mandibular canine-to-canine retainers. Am J Orthod Dentofacial Orthop 2008;133:70-6.

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