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Oral Maxillofac Surg
DOI 10.1007/s10006-013-0430-5
REVIEW ARTICLE
Orthodontic treatment of anterior open bite: a review
article—is surgery always necessary?
Isabelle Reichert & Philipp Figel & Lindsay Winchester
Received: 14 May 2013 /Accepted: 29 July 2013
# Springer-Verlag Berlin Heidelberg 2013
Abstract
Introduction Anterior open bite cases are very difficult to treat
satisfactorily because of their multifactorial aetiology and their
very high relapse rate. Dependent on the origin of the anterior
open bite malocclusion and the patient’s age, there are
several treatment pos sibilities ranging from deterrent
appliances, high-pull headgear, fixed appliances with and
without extractions to orthognathic surgery, and skeletal
anchorage with miniplates or miniscrews.
Methods The gold standard treatment of skeletal anterior
open bite cases is the combined approach of orthodontic
treatment with fixed appliances and orthognathic surgery. In
recent years, temporary anchorage devices (TAD) have been
devel oped to correct anterior open bites orthodontically. With
the introduction of TAD as an effective treatment modality,
orthognathic surgery may be avoidable in selected anterior
open bite cases.
Conclusion This is a relatively new technique and to date
there remains a lack of evidence of long-term stability of
anterior open bite closure with TAD.
Keywords Anterior open bite .TAD .Orthognathic .Skeletal
anchorage . Relapse
I. Reichert (*) : L. Winchester
Orthodontic Department, Queen Victoria Hospital NHS Foundation
Trust, Holtye Road, East Grinstead, West Sussex RH19 3DZ, UK e-
mail: Isabelle.reichert@gmx.de
P. Figel
School of Oral and Dental Sciences, Bristol Dental Hospital and
School, University of Bristol, Lower Maudlin Street, Bristol BS1
2LY, UK
Introduction
The anterior open bite (AOB) malocclusion is one of the most
challenging malocclusions to treat due to the high frequency
of relapse [1–6]. It is defined as no vertical overlap of the
incisors when buccal segment teeth are in occlusion. This
paper aims to review and summarize the different orthodontic
treatment modalities that can be used for the management of
AOB as an alternative to surgery, together with the evidence
for their effectiveness.
The early 1960s to the mid-1970s are called the “era of
tongue thrusts,” because the malocclusion was often thought
to be caused by tongue thrust [6]. Before the 1970s, the
orthodontic treatment mainly consisted of dentoalveolar
changes and/or modification of habits [7].
AOB has a multifactorial aetiology including skeletal, den
tal, respiratory, neurologic, and habitual components [1, 8]. It
can be broadly described as being skeletal or dental in origin
[9].
A high-angle skeletal pattern with increased Frankfort
Mandibular Plane Angle can lead to an AOB when the vertical
component of growth disproportionally exceeds the horizontal
component of growth. Labial tooth eruption cannot compen
sate for the increase in inter-occlusal distance with, in severe
cases, only the posterior molars in occlusion. Patients with
an AOB may have some or all of the following cephalometric
features: pronounced ante-gonial notching, recessive chin,
reduced inter-incisal angle, reduced inter-molar angle, and
increased lower anterior facial height. It is believed that soft
tissues also play a role in AOB. Incompetent lips might lead
to a tongue thrust, to make an oral seal while swallowing,
influencing the dentoalveolar position of the anterior segments
by intruding them. Digit sucking often results in an AOB, by
preventing vertical incisor eruption, with associated posterior
cross bites caused by increased cheek pressure and lowered
tongue position, resulting in narrowing of the arch. Prolonged
mouth breathing due to increased tonsillar or adenoidal
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obstruction may be a contributory factor which can cause
increased vertical growth [8].
The indications for treatment are generally aesthetic and
functional improvement. Patients with a severe AOB often have
difficulties incising food as well as speech problems including
lisps. Closure of an AOB usually helps with eating but there is
only little evidence that it might help with speech [8, 9].
The literature shows a variety of treatment possibilities to
close AOB, depending on respective diagnoses. High-pull
Headgear, chin cups, various types of bite blocks, functional
appliances, fixed appliances with or without extractions, and
multi-loop edgewise archwires are some examples of the
treatment modalities [10].
Difinitive treatment in cases of skeletal aetiology frequent ly
involves a combined approach of orthodontic treatment with
fixed appliances and orthognathic surgery. In the major ity of
cases, the surgery includes a Le Fort I osteotomy with posterior
maxillary impaction or bimaxillary osteotomy [8, 9].
Orthognathic surgery for the management of AOB can be
notoriously unstable. Several studies have compared different
orthognathic treatment to close an AOB and their relapse rates.
In 2000, Proffit et al. found that maxillary impaction was less
prone to relapse (7 % overbite decrease) than two jaw surgery
(12 % overbite decrease) [11].
Teittinen et al. also examined the relapse rate of patients
with previous maxillary impaction only compared with patients
with maxillary impaction and mandibular counterclockwise
rotation to close AOB. All of the patients who had a maxillary
impac tion only showed a positive overbite 3.5 years after
treatment but in three cases with bimaxillary surgery the open
bite re curred. A vertical relapse of the maxilla was noticed in
both groups (one and two jaw surgery); in the bimaxillary group,
the changes were statistically significant [12].
It may also be possible to close an AOB surgically by counter
clockwise rotation of the mandible. This has been considered
by many as unpredictable due to the risk of length ening the
pterygomasserteric sling. Frey et al. noticed greater relapses
when the counter clockwise rotation of the mandible was used
as operation method [13]. Bisase et al. reported that the closure
of AOB by mandibular counter clockwise rotation are at least as
stable as AOB closed by maxillary impaction and recommended
this method in class II cases with retrusive
mandible and chin [5]. Van Sickels reviewed the literature on
closure of AOB with counter clockwise movement of the
mandible, presented three cases with variation of stability, and
concluded that counter clockwise rotation of the mandible should
be used with caution. He noted that larger and more rigid plates
and screws can help to prevent the early stability but there is no
doubt that skeletal AOB are prone to relapse independent of the
applied surgical method [14].
In the last few years, as an alternative to treating a skeletal
AOB by orthognathic surgery, skeletal anchorage devises
Oral Maxillofac Surg
have been developed. Skeletal anchorage is being used for
molar intrusion to correct an AOB [2–4, 15–21].
Deterrent appliances
In young patients where the AOB is related to a digit sucking
habit the open bite closes naturally after stopping the habit.
Passive orthodontic appliances such as the Hayrake appliance
(Fig. 1) can help in stopping thumb-sucking habit and allow
spontaneous improvement.
High-pull headgear
The use of a high-pull headgear (Fig. 2) is a common approach
for the management of AOB treatment, intruding upper mo lars
that are considered to be extruded and therefore causing the
AOB [6]. Some authors also reported some vertical control by
minimizing the clockwise rotation or even resulting in a
counterclockwise rotation of the mandible [22, 23]. It is often
combined with functional and fixed appliances.
Posterior bite blocks
Posterior bite blocks are usually made of acrylic and fit between
the maxillary and mandibular teeth. They can be spring loaded
or provided with magnets and are usually used in the early
treatment of AOB cases. By impeding eruption of the posterior
teeth, this allows an upward and forward auto rotation of the
mandible [9, 24, 25]. Maxillary intrusion splints which cover the
whole of the maxillary dentition are also used with high-pull
headgear in cases where it is intended to intrude the whole of
the maxillary dentition, such as gummy smile cases, which have
a degree of vertical maxillary excess. Iscan et al. conducted a
study in which they compared the effective ness of passive
posterior bite blocks of two different heights (5 and 10 mm), with
an untreated control group of AOB cases. It was revealed that
the downward and backward rotation of the
mandible continued in the control group increasing lower face
height significantly, whereas in the treated groups the mandi ble
rotated upward and forward and produced a positive overbite
[25].
Functional appliances
Removable functional appliances combined with high-pull
headgear can be used in growing patients where the AOB is
associated with a class II malocclusion. This combination helps
to correct the anteroposterior discrepancy while control ling the
vertical dimension [9].
In our practice, we usually use a Clark Twinblock as the
functional appliance of choice combined with high-pull head
gear for the management of AOB with a skeletal II pattern.
This removable functional appliance has two bite blocks,
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Oral Maxillofac Surg

Fig. 1 a An 11-year-old female

patient with a digit sucking
associated AOB. b Patient with
fitted Hayrake appliance
(deterrent appliance). c Occlusal
changes 3 months after wearing
Hayrake appliance

upper and lower, which work together to posture the lower The open bite-bionator is a removable appliance with
jaw forward. In Class II AOB cases where the Twinblock is used poste rior bite blocks to inhibit the extrusion of the posterior teeth.
in combination with high-pull headgear the upper appliance
has an expansion screw to widen the arch and always has
tubes positioned occlusally between premolars and molars to
fit the headgear (Fig. 3).

Fig. 3 a Patient with Clark Twinblock with flying tubes to insert a

Fig. 2 Patient wearing high-pull headgear Headgear. b Patient wearing Clark Twinblock with high-pull headgear
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Acrylic portion extends from the lower lingual part into the upper
region as a lingual shield; the labial bow is positioned at the
height of correct lip closure. Defraia et al. examined 20 patients
with a high angle skeletal relationship treated with the bite
bionator and compared the MPA to a nontreated control group.
The treated group showed a significant smaller palatal plane
mandibular plane angle (ÿ1.9°) and greater overbite (+1.5 mm).
He concludes that early treatment with the open-bite bionator
produces an improvement of intermaxillary divergences [26].
The Fränkel 4 has been advocated in cases where the open
bite occurs partly from faulty postural activity of the orofacial
musculature. It is a removable functional appliance which works
by allowing vertical eruption of upper and lower inci sors and
retraction of the upper incisors. Some authors have established
that the wear of the Frankel can change the man dibular rotation
from downward and backward to upwards and forwards. A
randomized clinical trial conducted by Erbay et al. evaluates
the effects of Fränkel’s function regulator appliance on the
treatment of Angle Class I skeletal AOB malocclusion, with
results indicating that a spontaneous downward and backward
growth direction of the mandible, that were observed in the
control group, could be changed to a upward and forward
direction by Fränkel 4 therapy [27].
Vertical chincup
This appliance is occasionally used in growing patients to try to
reduce excessive vertical growth by redirecting the condy lar
growth, but has fallen out of favour in recent years due to poor
evidence of its efficacy.
In 1978 Pearson treated twenty growing patients with
backward rotational tendencies and AOB by extracting four first
premolars, wearing a vertical pull chin cup for at least 12 hours
a day while waiting for the remaining teeth to erupt.
The AOB were all closed and the mandibular plane angles
reduced an average 3.9° [28].
Torres et al. [29] investigated the dentoalveolar and soft
tissue changes produced by a removable appliance associated
with high-pull chin cup therapy in children with an Angle Class I
AOB. They compared the outcome of patients treated with a
control group and the results showed no significant differences
in the level of molar eruption or in lower anterior face height,
which suggests that the vertical control expected from the chin
cup therapy did not occur [29].
Fixed appliances
AOB can also be closed by using upper and lower fixed
appliances with vertical intermaxillary elastics to extrude the
anterior incisors. In addition to the fixed appliance, a transpalatal
arch and a high pull headgear to intrude the upper molars can
be used. Fixed appliances alone should be used in cases where
the open bite is of dental but not skeletal aetiology.
Oral Maxillofac Surg
Fixed appliances with anterior box-elastics induce the extru
sion of the anterior incisors, which is only helpful when the
incisors are not already extruded by natural compensation [8]
and is often unstable. The additional use of straight-pull Head
gear to distalize the molars is contraindicated as it opens the
bite, by inducing molar extrusion.
Class II or III elastics should be used with caution because
of the undesired side effect of molar extrusion [9]. Schudy
elastics (elastics with an anterior vertical component) however
have been reported as helpful in these cases as they allow an
additional anterior extrusion component of force. The
retroclination of proclined upper and lower incisors closes the
AOB [30].The stability of AOB correction by orthodontic fixed
appliances will depend on the adaptation of the soft tissues to
the new dental arrangement of the teeth. Extractions of
premolars and orthodontic space closure with fixed appli ances
are a possible treatment option of AOB correction. The mesial
movement of the molar teeth can result in a reduction of the
mandibular plane angle with a resultant closure in the AOB and
the incisors can be retracted, resulting in uprighting and relative
extrusion [30] (Fig. 4).
A study by Lopez-Gavito et al. dealt with the stability of open
bite cases treated with fixed appliances, headgear, and elastics.
Cephalometric radiographs of 41 patients with at least 3 mm of
open bite were evaluated at three different points in time,
pretreatment, immediately post-treatment, and 10 years post-
retention. They found that 35 % of the patients had an open bite
of 3 mm or more, whereas 65 % showed relatively stable results
[31].
Another study by Zuroff et al. increased the sample size (64
patients) and differentiated between three groups, based on the
amount of pretreatment overbite. A contact group (incisal
overlap and incisal contact), an overlap group (incisal overlap
and no incisal contact), and the open bite group (no incisal
overlap). At ten years post-retention, 60 % of the open bite
subjects did not have incisor contact. On the other hand, in the
whole sample, the largest vertical relapse was 2.4 mm, and no
one had negative incisor overlap [10].
Fig. 4 Patient wearing fixed appliances and Schudy elastics
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Oral Maxillofac Surg
Multi-loop Edgewise Archwire technique
Kim et al. described the use of the Multi-loop Edgewise Archwire
technique for AOB closure treatment [6]. They used a 16×22
stainless steel edgewise ideal archwire in an edgewise bracket
system, with no prescription for torque, angulation or tip.
Vertical and horizontal control and decreasing the load and
deflection rate were achieved through bending loops into the
archwires. The loops are L-shaped and are positioned between
every interbracket distance distal to the lateral incisors (five
loops in each quadrant). This appliance works by uprighting the
molars and extruding the anterior teeth subsequent to the
alteration of the occlusal plane. Heavy intermaxillary elastics are
used to close the AOB by extruding the anterior segments. The
disadvantage of this technique is that the majority of correction
was realized by the extrusion of the anterior teeth, not by the intrusionbuttress area with the tip exposed and used for intrusive force
The extrusion of anterior teeth is prone to relapse [16].
Temporary anchorage devices
In recent years, titanium miniplates and miniscrews have been
used as skeletal anchors to correct AOB orthodontically (Fig. 5).
The use of skeletal anchorage offers more treatment options for
orthodontists and this has a particular application in the correction
of AOB [32]. Some workers claim that the use of skeletal anchors
can obviate the need for orthognathic surgery in the management
of AOB cases.
The studies of Umemori et al. [33] demonstrated the effec
tive intrusion of mandibular molars by using titanium miniplates
for anchorage. In two severe AOB cases, two tita nium L-shaped
miniplates were fixed on each side at the buccal cortical bone
around the apical regions of the lower first and second molars.
By using elastic threads as orthodontic force, the lower molars
were intruded and open bite was significantly improved. One
month after the fixation of the plates force application was
started. Upper and lower teeth were bonded with a straight wire
fixed appliance. Intrusion was completed after 5 months, and
after 18 months, the fixed appliance and the
Fig. 5 TAD in place (between LL6 and LL7) to intrude molars
miniplates were removed. Class I occlusion was achieved with
a normal overbite and overjet and the mandibular plane angle
declined from 41° to 39.5°and 41.9° to 37.7°, respectively,
mainly due to a decreased posterior vertical dimension. The
lower molars were intruded 3.5 and 5 mm, respectively, and the
occlusal plane was counterclockwise rotated by 4°, 2°, and 3,
1°, respectively. The author concludes that implants as anchor
age to simplify the orthodontic treatment can be successfully
used to intrude the molars in AOB cases. Nevertheless, there is
no evidence in long-term follow-up controlled randomized studies
that confirm these theses.
Erverdi et al. [20] proposed the zygomatic buttress area as
an anchorage site for maxillary molar intrusion and reported the
closure of AOB. In his case report from 2006, an L-shaped
implant was fixed with three bone screws in the zygomatic
of molars.
application. The orthodontic appliance consisted of two acryl ic
bite blocks connected with two palatal arches and wire
attachments on each buccal side, which were used for force
application. The force application commenced 7 days after
implant insertion. Two 9.0-mm NiTi coil springs were placed
bilaterally between the tip of the implant and the outer wire
creating an intrusive force of 400 g. The molars were impacted
3.6 mm and the mandibular plane showed 4.0° of counter
clockwise outer rotation. After the gained intrusion, upper and
lower fixed appliances for alignment of the upper and lower
arches were fitted and the intrusion was maintained with wire
ligation between the implants and the molar tubes throughout
the treatment. The intrusion of 3.6 mm was maintained after the
treatment with fixed appliances, whereas the counterclock wise
rotation relapsed during later stages of the treatment. This was
caused mainly by the progressive extrusion of the lower molar
teeth. A slight posterior open bite Caused by the acrylic bite
blocks was observed when the intrusion appliance was first
removed. The upper molar were fixed to the zygomatic implant
and not free to extrude and therefore the open bite was closed
by the extrusion of the lower molars (occlusal plane angle 14.0°
to 21.0°).This paper shows within the limitation of a single case
report, that zygomatic anchorage can be success fully used for
molar intrusion. Further studies with larger samples and
assessment of long-term stability are required.
Sherwood et al. [2] intruded maxillary molars with miniplate
anchorage described by three case reports. The pa tients were
treated with orthodontic fixed appliances and T shaped miniplates
which were surgically placed between the first and second
molars and fixed with two 5-mm miniscrews
each. Loading began 8 weeks after surgery. Intrusion mechan
ics were continued for 5.5 months until the AOB were closed.
These case reports lack longer-term follow up.
In skeletal AOB cases, in which the aim is to close an AOB
by intruding the posterior teeth, miniplates and miniscrews are
being used and undesirable side effects of extrusion of anterior
teeth avoided.
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Several case reports have shown that, at least in the short
term, in the maxilla or the mandible implanted miniplates aid
intrusion of upper and lower molars up to 3–5 mm while also
achieving counterclockwise rotation of the mandible [2, 33, 34].
This treatment enables the orthodontist to close AOB without
extruding the front teeth, which are prone to relapse and root
resorption [16].
Miniplates are more versatile than screws because they can
be placed where anchorage is needed the most. They have the
virtue of three-dimensional stability because they are held in
place by 3 or more screws. Placing them well away from tooth
roots avoids root injury or avoids interference with root move
ment [2]. Before starting active tooth movement a latency of one
week after insertion is required. The miniplates are usu ally
removed a week before debond [8, 16].
Sugawara et al. examined the amount of relapse after SAS
(sketelal anchorage system) in 9 adult open bite patients who
had been successfully treated. They all had a fixed appliance
combined with SAS to intrude the first and second mandibular
molars bilaterally. Three lateral cephalometric radiographs per
patient have been taken; before the SAS placement (T1), at
debond of fixed appliances (T2) and at 1 year post-debond (T3)
to calculate the amount of intrusion. The average amount of
intrusion was 1.7 mm at the first and 2.8 mm at the second
molar respectively. The average amount of relapse was 0.5 mm
at first and 0.9 mm at second molar respectively.
There was no statistically significant difference between the
changes at T1-T2 and T1-T3. Sugawara et al. concluded that
the average relapse rates were 27.2 % at the first molars and
30.3 % at the second molars. Therefore he suggests an
overcorrection of intrusion [16].
Baek et al. examined the long-term stability of AOB cor
rection by intrusion of the maxillary posterior teeth with miniscrew
implants. 9 Patients with diagnosed AOB were treated with fixed
appliances combined with molar intrusion by miniscrew implants.
Lateral cephalometric radiographs were taken before and after
treatment, 1 and 3 years post treatment. The maxillary first molar
was on average intruded by 2.39 mm and showed a relapse rate
of 23 % at the 3-year follow-up. The authors noticed that 80 %
of the relapse occurred during the first year of retention. An
incisor overbite relapse rate of 17 % with no significant recurrence
between the 1- and 3-year follow-up were noticed. Baek et al.
conclud ed that most relapse occurs during the first year of
retention [35].
Miniplates do however have a number of disadvantages.
There are limited areas for their insertion, they are expensive
and require two surgical procedures for insertion and removal
[36]. Miniscrews on the other hand are used routinely in
orthodontics as skeletal anchorage for tooth movement, are
cheap and easy to use and can often be placed under local
anaesthetic. Some recently published case reports have shown
that teeth can be successfully intruded with miniscrews as
Oral Maxillofac Surg
skeletal anchorage [15, 19, 36]. Miniscrews inserted into the
maxillary posterior buccal bone can be useful for posterior
intrusion and therefore used for AOB closure. Additionally, the
use of miniscrews for intrusion during active growth favours
counterclockwise rotation of the mandible improving the vertical
and anteroposterior discrepancy [19].
Conclusions
The Orthodontist has a number of treatment modalities avail
able for the management of mild to moderate AOB cases.
With the introduction of TAD as an effective treatment mo dality,
orthognathic surgery may be avoidable in selected AOB cases.
This is a relatively new technique and to date there remains a
lack of evidence of long-term stability of AOB closure with TAD.
Several case reports have illustrated the successful use of TAD
in nongrowing skeletal open bite cases that may previously have
been treated with orthognathic sur gery. The treatment of AOB
with skeletal anchorage devices have several advantages
compared with single or bimaxillary jaw surgery providing lower
cost, less invasiveness, and less complicated low morbidity
treatment. Further studies in skel etal anchorage devices need
to be conducted to ascertain the long-term stability and
effectiveness of this method as a treatment in the management
of AOB cases.
Conflict of interest The authors declare that they have no conflict of
interest.
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