ONLINE ONLY

Long-term stability of anterior open-bite

treatment by intrusion of maxillary posterior
teeth
Man-Suk Baek,a Yoon-Jeong Choi,b Hyung-Seog Yu,c Kee-Joon Lee,d Jinny Kwak,a and Young-Chel Parkc
Seoul, Korea

Introduction: Anterior open bite results from the combined influences of skeletal, dental, functional, and
habitual factors. The long-term stability of anterior open bite corrected with absolute anchorage has not
been thoroughly investigated. The purpose of this study was to examine the long-term stability of anterior
open-bite correction with intrusion of the maxillary posterior teeth. Methods: Nine adults with anterior open
bite were treated by intrusion of the maxillary posterior teeth. Lateral cephalographs were taken immediately
before and after treatment, 1 year posttreatment, and 3 years posttreatment to evaluate the postintrusion sta-
bility of the maxillary posterior teeth. Results: On average, the maxillary first molars were intruded by 2.39 mm
(P \0.01) during treatment and erupted by 0.45 mm (P \0.05) at the 3-year follow-up, for a relapse rate of
22.88%. Eighty percent of the total relapse of the intruded maxillary first molars occurred during the first
year of retention. Incisal overbite increased by a mean of 5.56 mm (P \0.001) during treatment and
decreased by a mean of 1.20 mm (P \0.05) by the end of the 3-year follow-up period, for a relapse rate of
17.00%. Incisal overbite significantly relapsed during the first year of retention (P \0.05) but did not exhibit
significant recurrence between the 1-year and 3-year follow-ups. Conclusions: Most relapse occurred during
the first year of retention. Thus, it is reasonable to conclude that the application of an appropriate retention
method during this period clearly enhances the long-term stability of the treatment. (Am J Orthod
Dentofacial Orthop 2010;138:396.e1-396.e9)

A
n anterior open bite is a difficult condition to
treat in orthodontics. The deformity is caused
by combined influences from skeletal, dental,
functional, and habitual factors. Various treatment mo-
dalities have been suggested for treating patients with
anterior open bites, although the condition is typically
treated by the orthodontic extrusion of the anterior teeth
or a combination of orthodontic and orthognathic
surgical treatments in adults.
However, correcting an anterior open bite with ante-
rior extrusion is limited in improving the dentofacial
From the Department of Orthodontics, Oral Science Research Center, Instititute
of Craniofacial Deformity, College of Dentistry, Yonsei University, Seoul,
Korea.
a
Graduate student.
b
Clincial and research assistant professor.
c
Professor.
d
Associate professor.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Supported by the research fund of the 2008 Institute of Craniofacial Deformity,
Oral Science Research Center, BK 21 Project, Yonsei University, Seoul, Korea.
Reprint requests to: Young-Chel Park, Department of Orthodontics, College
of Dentistry, Yonsei University, 134 Sinchon-dong, Seodaemun-gu, Seoul
120-749, Korea; e-mail, ypark@yuhs.ac.
Submitted, December 2009; revised and accepted, May 2010.
0889-5406/$36.00
Copyright Ó 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.04.023
esthetics of a patient with a skeletal open-bite tendency.
As a general rule, for enhancing the facial esthetics of
a patient with a skeletal open bite, the maxillary poste-
rior segments need to be impacted with a surgical
approach. Denison et al1 corrected open bite by
upwardly repositioning the maxilla with LeFort I osteot-
omy and studied the postsurgical stability of patients
with skeletal open bite. At 1 year posttreatment, relapse
significantly increased in facial height, and eruption of
the maxillary molars and overbite significantly de-
creased, resulting in a 21% relapse rate. Proffit et al2
also treated open-bite patients using LeFort I osteotomy
and observed their posttreatment stability over 3 years.
They reported that 7% of the maxilla-only surgery
group and 12% of the 2-jaw surgery group had 2 to
4 mm of overbite reduction.
With the advent of an absolute anchorage, however,
it has become feasible to nonsurgically correct an ante-
rior open bite with orthodontic intrusion of the posterior
teeth and obtain satisfying results. A number of studies
were concomitantly released to introduce treatment
methods with absolute anchorages and their results.
Kuroda et al3 noted that it is simpler to treat an open
bite by intruding the posterior teeth with skeletal an-
chorage than to correct it surgically. Sugawara et al4
also used miniplates to treat patients with anterior
396.e1
396.e2 Baek et al
open bite by intruding the mandibular molars, but they
did not report the long-term stability of the treatment
after their last report of a 30% relapse rate at 1 year post-
treatment. Lee and Park5 used miniscrew implants to
intrude the maxillary molars and reported a 10.36%
relapse rate for the intruded molars and an 18.1%
relapse of overbite at 1 year posttreatment.
Because there has not been a substantial report on
the long-term stability of treating anterior open bite
with absolute anchorage, we evaluated the 3-year post-
treatment stability of anterior open bite in adults treated
by orthodontic intrusion of the posterior teeth with
miniscrew implants.
MATERIAL AND METHODS
Our study participants were selected from the
archives of the Department of Orthodontics, Dental
Hospital of Yonsei University College of Dentistry in
Seoul, Korea. Patients who were treated with miniscrew
implants to intrude the maxillary posterior teeth and fol-
lowed for at least 3 years of the retention period were
selected according to the following criteria: (1) diag-
nosed with incisal open bite (incisor overbite: \–1.0 mm),
(2) high SN-MP angle (.40 ), and (3) skeletal Class
I or Class II discrepancy (anteroposteriorly).
Nine patients (1 man, 8 women) met these criteria
and were included in the study. Three of these patients
had premolar extractions. The mean age at the begin-
ning of treatment was 23.7 years (range, 18.3-31.1
years), and the mean treatment period was 28.8 months
(range, 18-37 months). The mean period during which
the miniscrew implants were applied was 5.4 months
(range, 3-9 months), and the mean retention period
was 41 months (range, 36-51 months). All patients
were given lingual fixed retainers; the extraction
patients applied them between the premolars, and the
nonextraction patients applied them between the
canines. In addition, they were also given the usual
circumferential retainers for retention; the retainers
were applied on both the maxilla and the mandible for
the entire day during the first 6 months after treatment
and only at night after that.
Two methods were used for intrusion of the maxil-
lary molars. The first method was miniscrew implants
placed on the buccal and palatal sides, between the roots
of the maxillary second premolar and first molar, and
between the roots of the maxillary first and second mo-
lars. After a 1 to 2 week period, an intrusive force was
directly applied on the molars with elastomeric chains
(Fig 1, A and B).
The second method was the placement of miniscrew
implants on the buccal side only, between the roots of
American Journal of Orthodontics and Dentofacial Orthopedics
October 2010
the maxillary second premolar and first molar, and be-
tween the roots of the maxillary first and second molars.
Rigid transpalatal arches were placed before applying
an intrusive force to prevent buccal tipping of the teeth
(Fig 1, C and D).
Lateral cephalographs were taken at the Department
of Radiology, Dental Hospital of Yonsei University Col-
lege of Dentistry by using Cranex31 (Soredex Orion
corp, Helsinki, Finland) and stored in digital imaging
and communications in medicine (DICOM) file format
in the picture archiving communication system (PACS;
Infinitt Co, Ltd, Seoul, Korea). The PACS digitizes and
manages radiographic images from individual hospitals.
The cephalometric radiographs taken before the in-
troduction of PACS were scanned by using Diagnostic
Pro Plus (Vidar Systems, Herndon, Va), corrected for
their measurements, and uploaded to the PACS to be in-
cluded in the study.
The cephalographs were taken with conventional ra-
diography at the initial evaluation (T1), after treatment
(T2), 1 year after treatment (T3), and 3 years after treat-
ment (T4). The cephalographs were traced through the
midpoints between the right and left structures, and
the measurements were corrected by considering
a 110% magnification rate. Cephalometric landmarks,
reference planes (Fig 2), and cephalometric variables
(Table I) were selected based on commonly used
analyses.
Statistical analysis
The lateral cephalographs stored in the PACS in
DICOM file format were analyzed by using V-ceph soft-
ware (version 3.5, CyberMed, Seoul, Korea) to measure
the landmarks and reference points.
In an effort to maintain consistency, all cephalomet-
ric measurements and analyses were done by 1 exam-
iner (M.-S.B.). Once a week, a number of reference
points were randomly selected to remeasure and reana-
lyze the dimensions with paired t tests to verify and re-
duce systematic errors.
The Shapiro-Wilks test was used to verify normal
distribution, the paired t test to compare variables at
T1 and T2, 1-way repeated-measures analysis of vari-
ance (ANOVA) to compare the values at T2, T3, and
T4, and the Pearson correlation analysis to examine
their correlations.
RESULTS
The mean measurements for selected cephalometric
variables from the T1 evaluation to T4 are shown in
Tables I and II, and the correlation coefficients between
the variables are presented in Tables III, IV, and V.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 4
Fig 1. Biomechanics for intrusion of maxillary molars by using miniscrew implants. In 1 method, the
miniscrews are placed on the buccal and palatal sides: A, buccal view; B, palatal view. In a second
method, the miniscrews are placed on the buccal sides only, with rigid palatal splints to prevent buc-
cal tipping: C, transverse view; D, palatal view.
In regard to the skeletal changes after treatment, sig-
nificant changes occurred from intrusion of the posterior
teeth. The mean vertical distance between the maxillary
posterior teeth and palatal plane was reduced by 2.39
mm (P \0.01), which in turn decreased the ANB angle
difference by 0.66 (P \0.05), the SN-GoMe angle by
2.03 (P \0.01), and the anterior facial height by 2.53
mm (P \0.01) as pogonion moved forward and upward
and the vertical reference place-pogonion increased by
2.40 mm (P \0.05) (Tables I and II). In the dental
changes, the mean overbite values at T1 and T2 were
–3.91 and 11.65 mm, respectively; there was a mean
bite closure of 5.56 mm (P \0.001).
Among the skeletal changes during retention pe-
riods, the SNPog angle decreased by 0.86 (P \0.05),
the FMA angle increased by 0.69 (P \0.05), and the
vertical reference place-pogonion length decreased by
1.37 mm (P \0.05) by the end of 3 years (T4-T2). How-
ever, at 1 year posttreatment (T3-T2), no significant
skeletal changes were observed other than a 0.46 de-
crease in the SNPog angle (P \0.05). Between the
end of the first year and the third year of retention
(T4-T3), no significant change was observed in any
skeletal parameters.
Baek et al 396.e3
As for dental changes, overbite decreased by an
average of 0.99 mm (P \0.05) during the first year of
retention but did not significantly decrease thereafter.
By T4, overbite decreased by an average of 1.20 mm
(P \0.05). The vertical distance between the maxillary
molars and the palatal plane significantly increased by
0.45 mm (P \0.05) after 3 years (Tables I and II).
The vertical distance between the maxillary anterior
teeth and the palatal plane significantly increased by
0.33 mm (P \0.05) between T4 and T3.
While analyzing the correlations between variables,
we verified that overbite correction was induced by the for-
ward and upward rotation of the mandible after intrusion at
the posterior teeth. The changes after treatment, compared
with before treatment (T2-T1), of the SNPog (P \0.05),
SN-MP (P \0.05), and SNB angles (P \0.05) all were
highly correlated with the change in overbite. The SNPog
angle also was highly correlated with hard-tissue pogonion
(P \0.01), suggesting that the change in the SNPog angle
during treatment was caused by the forward and upward
displacement of pogonion (Table III).
Analyzing the correlations between the severity of
the initial condition and the amount of relapse, we found
no significant correlation between initial overbite,
396.e4 Baek et al
Fig 2. Cephalometric measurements: 1, N-Me: anterior
facial height (AFH); 2, VP-Pog: anteroposterior location
of pogonion; 3, U6-PP: perpendicular distance from
the mesiobuccal cusp of the maxillary first molar to the
palatal plane; 4, U1-PP: perpendicular distance from
the maxillary incisor edge to the palatal plane; 5, OB:
overbite, distance between the incisal edges of the max-
illary and mandibular central incisors, perpendicular to
the horizontal reference plane; 6, OJ: overjet, distance
between the incisal edges of the maxillary and mandib-
ular central incisors, perpendicular to the vertical refer-
ence plane; 7, HP: horizontal reference plane, a line
through nasion rotated 7 clockwise from the sella-
nasion line; 8, VP: vertical reference plane, a line through
sella and perpendicular to the HP.
mandibular plane angle, or lower anterior facial height
and the amount of relapse (Table IV).
The correlation between the extent of the correction
achieved by the treatment and the extent of relapse after
3 years of retention was also examined. The extent of in-
trusion performed on the maxillary posterior teeth did
not highly correlate with the extent of relapse, whereas
the extent of overbite correction showed a significant
correlation with relapse (Table V).
As for relapse rates, 22.88% of the vertical distance
between the maxillary molar and palatal plane and
17.00% of the overbite relapsed after 3 years of reten-
tion (Table VI).
American Journal of Orthodontics and Dentofacial Orthopedics
October 2010
DISCUSSION
Umemori et al6 and Sugawara et al4 reported on pa-
tients with anterior open bite treated by intruding the
mandibular molars with the skeletal anchorage system,
and Sugawara et al4 reported a relapse rate about 30% at
1 year posttreatment. However, those patients with ante-
rior open bite also had skeletal problems that were
mostly caused by an excessive vertical growth tendency
of the maxillary posterior area; it would be a more fun-
damental approach to correct the condition by intruding
the maxillary molars.7 For this reason, we intended to
evaluate the long-term stability of maxillary molar
intrusion treatment of patients with anterior open bite.
Before the study, reference planes from which we
could accurately assess the changes had to be defined.
In many previous studies evaluating the posttreatment
stability of anterior open bite, the direct distance be-
tween the maxillary and mandibular incisors on lateral
cephalographs was measured to quantify the extent of
the overbite. Concerns arose that various examiners
were defining overbite differently and applying differ-
ent methods to measure it; such interexaminer differ-
ences were causing significantly different results.8-10
In more recent studies on anterior open bite, overbite
and overjet values were determined mostly by using
calipers to measure the interincisal distances in
reference to the nasion-menton line. However, when
treating these patients with posterior intrusion, the refer-
ence line was altered because of the accompanying skel-
etal changes and the counterclockwise rotation of the
mandible. Therefore, in this study, we determined new
reference planes in reference to the constant sella-
nasion plane: the horizontal reference plane and vertical
reference plane (Fig 2).
To correct anterior open bite, 2 methods were used
to intrude the maxillary posterior teeth (Fig 1). There
was no significant difference between the 2 methods
in regard to the extent of intrusion achieved.
As the posterior teeth were intruded, concurrent
skeletal changes occurred; counterclockwise rotation
of the mandible occurred toward the closing of the
bite, which in turn induced forward and upward dis-
placement of B-point and pogonion, as well as a reduc-
tion in the ANB difference, the mandibular plane angle,
and the anterior facial height (Table II). In patients with
skeletal Class II tendency, correction to a skeletal Class
I relationship was achieved by the changes. These re-
sults agree with previous studies that found that intru-
sion of the posterior teeth with skeletal anchorage
induced counterclockwise rotation of the mandible
and, as a consequence, corrected the anteroposterior in-
termaxillary relationship.3,4
American Journal of Orthodontics and Dentofacial Orthopedics Baek et al 396.e5
Volume 138, Number 4

Table I. Cephalometric variables before treatment (T1), after treatment (T2), 1 year after treatment (T3), and 3 years
after treatment (T4)
T1 T2 T3 T4

Variable Mean SD Mean SD Mean SD Mean SD

Skeletal
ANB ( ) 4.60 1.28 3.94 1.56 3.94 1.55 4.11 1.67
FMA ( ) 38.26 3.45 35.11 3.88 35.74 4.11 35.80 4.04
SN-GoMe ( ) 45.44 4.11 43.41 4.41 43.68 4.88 43.98 4.76
SNPog ( ) 76.08 3.57 77.18 3.79 76.71 4.10 76.31 4.04
AFH (mm) 133.95 5.55 131.41 6.10 131.86 5.54 132.32 5.87
VP-Pog (mm) 50.10 8.40 52.50 8.54 51.75 9.55 51.13 9.13
Dental
OB (mm) 3.91 1.65 1.65 0.82 0.66 0.79 0.45 1.09
OJ (mm) 7.23 3.68 2.90 0.78 3.36 1.57 3.31 1.49
IMPA ( ) 89.08 3.39 88.42 5.87 88.89 5.31 88.97 5.27
U6-PP (mm) 26.88 1.12 24.50 1.64 24.89 1.69 24.94 1.68
U1-PP (mm) 31.50 2.67 32.56 2.12 32.49 1.91 32.83 2.15
L1-MP (mm) 43.58 2.46 45.17 2.78 44.90 2.58 45.12 2.57

Table II. Mean changes in the cephalometric variables at different time intervals
DT2-T1a DT3-T2b DT4-T3c DT4-T2d

Variable Mean SD Sig Mean SD Sig Mean SD Sig Mean SD Sig

Skeletal
DANB ( ) 0.66 0.79 * 0.00 0.70 NS 0.17 0.71 NS 0.17 0.71 NS
†
DSN-GoMe ( ) 2.03 1.59 0.27 1.14 NS 0.31 1.33 NS 0.57 1.46 NS
†
DSNPog ( ) 1.10 0.94 0.46 0.56 * 0.40 0.72 NS 0.86 0.92 *
†
DFMA ( ) 3.16 1.81 0.64 1.41 NS 0.05 0.86 NS 0.69 0.88 *
†
DAFH (mm) 2.53 1.90 0.44 0.89 NS 0.46 0.80 NS 0.90 1.21 NS
DVP-Pog (mm) 2.40 2.32 * 0.75 1.29 NS 0.62 1.02 NS 1.37 1.59 *
Dental
‡
DOB (mm) 5.56 1.94 0.99 1.05 * 0.21 0.55 NS 1.20 1.44 *
DIMPA ( ) 0.66 7.34 NS 0.47 2.55 NS 0.08 2.05 NS 0.55 2.39 *
†
DU6-PP (mm) 2.39 1.76 0.40 0.59 NS 0.05 0.35 NS 0.45 0.46 *
DU1-PP (mm) 1.05 1.40 * 0.07 0.49 NS 0.33 0.34 * 0.27 0.49 NS
DL1-MP (mm) 1.59 2.10 NS 0.27 0.81 NS 0.22 0.58 NS 0.04 0.58 NS
a
DT2-T1, change from initial evaluation to immediately after treatment; bDT3-T2, change during the first year of retention; cDT4-T3, change after the
first year to the end of 3 years of retention; dDT4-T2, change during the entire 3 years of retention; Sig, significance; NS, not significant.
*P \0.05; †P \0.01; ‡P \0.001.
Negative values represent decreases during treatment; positive values represent increases during treatment.

Although posterior intrusion promotes the necessary
skeletal changes to enhance the patient’s dentofacial es-
thetics, the conventional method of anterior extrusion is
limited to dentoalveolar changes and has fewer effects
on facial appearance. For this reason, one can reason-
ably conclude that the posterior intrusion method is
a more suitable way to nonsurgically correct an anterior
open bite.
In this study, we followed the posttreatment skeletal
changes for 3 years and observed significant relapses for
a number of variables (Table II). After the relapsed
eruption of the maxillary molars, the mandible subse-
quently rotated clockwise toward the open bite,
pogonion rotated downward and backward, and anterior
facial height increased. Surprisingly, we also observed
significant eruption of the maxillary anterior teeth be-
tween the end of the first year and the third year of re-
tention (T4-T3); this consequently deepened the bite.
This eruption compensated for the relapse of the poste-
rior teeth, as well as the overbite and skeletal parame-
ters. Such results are consistent with the study of
Sugawara et al,4 who reported that relapse of intruded
molars does not directly influence the posttreatment
skeletal and overbite changes.
The overall pattern of relapse observed in this study
was similar to that of surgical treatment. Downward
396.e6 Baek et al American Journal of Orthodontics and Dentofacial Orthopedics
October 2010

Table III.Correlation coefficients between cephalomet- Table V. Correlation coefficients between T2-T1 vari-
ric variables (T2-T1) ables and T4-T2 variables
Variable 1 Variable 2 R P Sig (2-tailed) Variable 1 Variable 2
(T2-T1) (T4-T2) R P Sig.(2-tailed)
U6-PP FMA 0.56 0.120 NS
U6-PP OB 0.02 0.963 NS U6-PP U6-PP 0.602 0.086 NS
OB SNPog 0.70 0.036 * OB OB 0.674 0.023 *
OB SN-MP 0.74 0.022 *
T1, before treatment; T2, after treatment; T4, 3 years after treatment;
OB SNB 0.71 0.046 *
‡ R, Pearson correlation coefficient; Sig, significance; NS, not
SNB SNPog 0.97 0.000
significant.
SNB SN-MP 0.79 0.011 *
† *P \0.05.
VP-Pog SNPog 0.84 0.005
VP-Pog SN-MP 0.50 0.175 NS
†
VP-Pog SNB 0.83 0.006
Table VI. Relapse rate of U6-PP and overbite (OB)
T1, before treatment; T2, after treatment; R, Pearson correlation coef-
Relapse rate (%)
ficient; Sig, significance; NS, not significant.
Variable ([T4-T2]/[T2-T1])
*P \0.05; †P \0.01; ‡P \0.001.
U6-PP (mm) 22.88
OB (mm) 17.00
Table IV. Correlation coefficients between pretreatment
measurements (T1) and changes in overbite (OB: U6-PP, Vertical distance between maxillary first molar tip and palatal
plane.
T4-T2)
Variable 1 Variable 2
(T1) (T4-T2) R P Sig (2-tailed) of retention (Table II, Fig 3). A significant amount of
overbite relapse and over 80% of the total relapse of
OB OB 0.448 0.226 NS
the maxillary molars occurred during this first year.
SN-MP OB 0.243 0.529 NS
LAFH OB 0.092 0.815 NS The 2 values showed recurrence, even between the
end of the first year and the third year (T4-T3), but it
LAFH, distance from ANS to Me; T1, before treatment; T2, after treat- was not significant. Taken together, these results suggest
ment; T4, 3 years after treatment; R, Pearson correlation coefficient;
Sig, significance; NS, not significant.
that, if an effective retention method is applied during
the first year of retention, we could prevent the relapse
and significantly improve the long-term stability of
displacement of the posteriornasal spine, eruption of the treatment.
the maxillary molars, and downward and backward ro- Many studies have emphasized the importance of
tation of the mandible resembled the relapse events after proper retention after orthodontic treatment. To achieve
orthognathic surgery.1,2,11 Such events after surgery are good stability, one must pay great attention to the col-
thought to be a physiologic adaptation of adjacent laborative influence of the tongue and the soft tissues
muscles and soft tissues to the altered skeletal around the mouth. Any causative factor should be de-
structures.2,12 tected by meticulous examination of the patient and
As for dental changes before and after treatment, the thoroughly eliminated as part of the treatment; other-
incisal overbite deepened after posterior intrusion as wise, it will counteract the bite closure. Continuously
intended, but we also found a significant amount of monitoring these factors during the retention period is
extrusion on the maxillary anterior teeth during treat- also essential to prevent them from reappearing.1,13-15
ment that aided in deepening the overbite (Table II). Furthermore, having these surrounding structures
Because the amount of overbite correction did not sig- adapt and maintain a functional balance with the
nificantly correlate with posterior intrusion (Table III), reformed skeletal and occlusal relationships is
we confirmed that both posterior intrusion and anterior important in achieving excellent stability.3,16,17 Along
extrusion contributed to the improvement in the anterior these lines, Kondo and Aoba,13 Kondo,14 and Arai and
overbite. In addition, there was no significant difference Kondo15 reported that maintaining myofunctional ther-
between groups treated with and without premolar apy after its application for open-bite correction helps
extractions, in terms of the amounts of extrusion of significantly to enhance the long-term stability of the
maxillary anterior teeth and overbite correction. treatment.
Although the intruded maxillary molars and over- Although one can never overemphasize the impor-
bite significantly relapsed throughout the 3 years of tance of retention after orthodontic treatment, an effec-
retention, most relapse occurred during the first year tive method of retention after intrusion treatment has not
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 4
Fig 3. Changes in the vertical distance between the maxillary first molar tip and the palatal plane
(U6PP) and changes in overbite (OB) during the treatment and retention periods. T1, Before
treatment; T2, after treatment; T3, 1 year after treatment; T4, 3 years after treatment. *P \0.05;
**P \0.01; ***P \0.001.
been introduced. Even in our study, the intruded maxil-
lary molars had significant amounts of relapse during
the entire 3 years of retention. A tooth displaced intru-
sively is much less stable than one displaced either me-
siodistally or rotationally; a reason is that there is really
no effective way to retain an intruded tooth.18-20
Beckmann and Segner21 suggested the use of Hawley
removable appliances to enhance the stability of ortho-
dontic treatments, but they are inadequate for prevent-
ing relapse of intruded posterior teeth.
Although it was not used in this study, we have de-
vised our own retention appliance to solve this problem
and effectively retain intruded molars. The appliance
was designed to be aided by the miniscrew implants
used to intrude the maxillary molars. After we achieved
molar intrusion with these implants, we made sure that
they were well maintained for further use. Then, we fab-
ricated the so-called active retainer, which is a clear
retention appliance with buttons attached to the buccal
side of the maxillary molar positions to provide sites
where they can hook to miniscrew implants with elastics
(Fig 4). This appliance is expected to effectively prevent
the eruption of intruded maxillary molars.
The importance of these results is that they provide
the basis to emphasize the importance of posttreatment
retention, especially during the first year after treatment.
Subsequent studies might further elaborate on this point
by analyzing the relapse patterns in patients treated with
and without retainers during this period.
In analyzing the correlations between cephalometric
variables, we verified that overbite correction was
mainly attained by forward and upward rotation of the
mandible. There was also forward and upward
Baek et al 396.e7
displacement of pogonion as the SN-Pog angle in-
creased during treatment (Table III). There was no sig-
nificant correlation between the amounts of posterior
intrusion and overbite correction, indicating that other
components, such as eruption of the anterior teeth,
also contributed to the deepening bite.
Researchers have attempted to develop indexes to
predict the stability of open-bite treatments by observ-
ing the relationships among such cephalometric vari-
ables. Beckmann and Segner21 reported that patients
with severe open bite and a large mandibular plane an-
gle and anterior facial height tend to have relatively low
posttreatment stability. Janson et al22,23 and de Freitas
et al24 concluded that the severity of pretreatment
conditions greatly affects the stability after extraction
treatment. On the other hand, Lopez-Gavito et al25
asserted that there is not 1 indicator to help predict the
posttreatment stability and reported that no pretreat-
ment value in their study strongly correlated with the
extent of relapse after treatment. Remmers et al10 also
reported that no pretreatment variable can serve as an
indicator of stability and that it is impossible to predict
the success and stability of open-bite treatment before-
hand. The results of our study were consistent with these
reports; initial overbite, mandibular plane angle, ante-
rior facial height, and all other pretreatment values did
not correlate with the extent of relapse on incisal over-
bite (Table IV). However, in regard to the correlation be-
tween overbite change after treatment and overbite
relapse 3 years posttreatment, the results did not agree
with previous reports, including the precedent study
by Lee et al5; only the change in overbite significantly
correlated with the extent of relapse (Table V). This
396.e8 Baek et al
Fig 4. The active retainer: a clear plate with buttons attached on the buccal side to hook to the
miniscrew implants with elastic.
correlation suggests that overbite relapse was propor-
tional to overbite correction achieved during treatment.
Therefore, a practitioner might plan to overcorrect the
overbite because of the estimated relapse of the overbite
correction. This approach would allow the patient to end
up with the targeted correction even after a certain
amount of relapse.
In the study by Lee et al,5 relapse occurred in
10.36% of intruded maxillary molars and 18.10% of
overbites by 1 year posttreatment. These results show
relatively high posttreatment stability compared with
that reported by Sugawara et al,4 whose open-bite
patients were treated with intrusion of the mandibular
molars and experienced relapse in 30% of the intruded
molars. In our study, relapse occurred in 22.88% of
the intruded maxillary molars and 17.00% of overbites
by 3 years posttreatment (Table VI). Inversely, these
relapse rates give success rates of 77.12% for maxillary
molar intrusion and 83.00% for overbite correction.
Comparing these success rates with those of orthog-
nathic surgery of anterior open-bite patients, Denison
et al1 reported a 79% success rate at 3 years posttreat-
ment, Hoppenreijs et al26 reported 81% success at 5
American Journal of Orthodontics and Dentofacial Orthopedics
October 2010
years posttreatment, Lo and Shapiro27 reported 75%
success at 5 years posttreatment, and Proffit et al2 re-
ported 88% success at 5 years posttreatment. Huang9
also asserted that the overall success rate of orthog-
nathic surgery is approximately 75% to 88%. Although
not involving surgery, the success rate from this study
had little disparity from surgical approaches, providing
a strong basis for applying the orthodontic posterior
intrusion method for correcting patients with mild to
moderate skeletal anterior open bite.
Many studies evaluating the stability of anterior
open-bite treatments point out that their studies were
limited by small sample groups, short retention and
follow-up periods, and no control groups. Because our
study also had these limitations, future prospective stud-
ies are expected to further support these results by in-
cluding more patients and longer retention periods,
and by using quantitative methods to assess the treat-
ment results.
CONCLUSIONS
The purpose of this study was to evaluate the long-
term stability of anterior open-bite treatment in adults
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 4
treated by orthodontic intrusion of the maxillary poste-
rior teeth. This evaluation was performed by measuring
the posttreatment changes of selected parameters and
the extent of relapse after more than 3 years. The follow-
ing conclusions can be drawn.
1. Skeletally, counterclockwise rotation of the mandi-
ble occurs after treatment and, in turn, improves
skeletal Class II malocclusion tendencies to skele-
tal Class I.
2. More than 80% of relapse of the intruded maxillary
first molars occurs during the first year of retention.
3. A significant amount of overbite relapse occurs at
the end of the first year of retention, but not between
the end of the first year and the third year.
4. There was no correlation between initial amount of
open bite, mandibular plane angle, or lower anterior
facial height and posttreatment overbite relapse.
However, there was a significant correlation be-
tween the amount of overbite correction achieved
by the treatment and the extent of relapse.
If an appropriate retention method is applied during
the first year, considering the initial skeletal configura-
tion, muscle force, and influence of the tongue and
soft tissues, it would effectively enhance the long-
term stability of anterior open-bite treatment.
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