Treatment of an anterior open bite, bimaxillary

protrusion and mesiocclusion by the extraction of

premolars and the use of clear aligners
Xiaosong Xiang,*†‡ Chunlin Wang,§ Xiaohang Guan,*†‡ Lu Wang*†‡ and Song Cang*†‡
Department of orthodontics, Tianjin Stomatological Hospital, Tianjin, China*
School of Medicine, Nankai University, Tianjin, China†
Tianjin Key Laboratory of Oral and Maxillofacial Function Reconstruction, Tianjin, China‡
Department of Orthodontics, Stomatological Hospital, School of Stomatology, Southern Medical University, Guangzhou,
Guangdong, China§

An anterior open bite may be orthodontically treated by either the intrusion of posterior teeth, the extrusion of anterior teeth, or
a combination of both. An improvement in bimaxillary protrusion often involves the extraction of premolars and the retraction of
the anterior teeth. The treatment of mesiocclusion mainly involves the mesial and/or distal movement of the molars. However,
these three types of malocclusions pose significant treatment challenges when using clear aligners. The present case report
describes the treatment of a 24-year-old female patient who presented with the above characteristics, which affected her
confidence, willingness to smile and masticatory function. A four-premolar extraction plan was designed to resolve the problems
using clear aligners as the patient rejected fixed or visible appliances. After 33 months of orthodontic therapy, except for the
counter-clockwise rotation of the mandible and the decrease of facial height, the other objectives established in the pre-treatment
plan were achieved, and the patient was satisfied with the results. The combination of clear aligners and premolar extractions
effectively corrected the skeletal anterior open bite, bimaxillary dentoalveolar protrusion, and mesiocclusion.
(Aust Orthod J 2023; 39: 72 - 85. DOI: 10.2478/aoj-2023-0007)

Received for publication: October, 2022

accepted: January, 2023.

Xiaosong Xiang: xiangxsn@163.com; Chunlin Wang: 1982951887@qq.com; Xiaohang Guan: guanxh2021@163.com;

Lu Wang: sethchow@163.com; Song Cang: cangsong@vip.163.com

Introduction vertical control due to recent appliance design

Introduced in 1999 by Align Technology (Santa
Clara, CA, USA), the Clear Aligner System has
become a popular treatment choice for adult
orthodontic patients who reject traditional visible
appliances. The technique was initially introduced
by Kesling1 and improved by Ponitz2 and others.3
The current clear aligner technique (CAT) is used
to treat malocclusions through a series of sequential
removable trays.4 Earlier studies5–10 have shown
significant limitations of using the clear aligner
to treat complex malocclusions. However, several
clinical case reports using CAT have revealed better
improvements.11,12 Studies initially reported the
development of posterior open bites as a result of
CAT treatment,13,14 and demonstrated no correlation
between measured and planned molar intrusion
in the treatment plan.15,16 Recently, clinicians have
claimed that CAT can effectively treat cases of
anterior open bite, especially those with an increased
mandibular plane angle.17,18
The traditional mechanical orthodontic technologies,
including multiloop edgewise arch wires, straight
wires, and implant anchorage, present many
challenges for patients and clinicians in correcting

72   Australasian Orthodontic Journal Volume 39 No. 1 2023 ☉ Open Access. Published by Sciendo. cc BY 4.0 © 2023 Author(s). This work is licensed under
the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/)
 TREATMENT OF AN ANTERIOR OPEN BITE, BIMAXILLARY PROTRUSION AND MESIOCCLUSION BY THE EXTRACTION OF PREMOLARS
an anterior open bite.19–21 The multiloop edgewise
arch wire is difficult to bend, uncomfortable to wear,
and compromises aesthetics due to anterior vertical
traction. Straight wire technology using reverse-curve
arch wires, combined with anterior vertical traction,
presents the same disadvantages. Micro-implant
technology requires surgery and damages the mucosa
and the alveolar bone. However, since the advent of
CAT, the appliances have gained popularity, given
their advantages over conventional fixed appliances
regarding aesthetics, oral hygiene, patient comfort,
a lighter level of force, shorter chair time,22,23 and
provide a convenient solution for anterior open
bite patients.18 Despite the advantages, CAT is
challenging for orthodontists when extractions are
Figure 1. Pre-treatment extraoral and intraoral photographs.
part of the treatment plan. Therefore, a case of the
successful correction of a skeletal anterior open bite,
bimaxillary dentoalveolar protrusion, mesiocclusion
and other issues through the extraction of four
premolars and the use of clear aligners, is presented.
Diagnosis and aetiology
A 24-year-old female patient presented with a history
of tongue thrust and mouth breathing but without
a history of maxillofacial trauma or a non-nutritive
sucking habit. The diagnostic records revealed
that, based on the E line, the patient had a convex
profile with a long face, a decreased nasolabial angle,
a protrusive lower lip, and a shallow mentolabial
Australasian Orthodontic Journal Volume 39 No. 1 2023   73
XIANG, WANG, GUAN, WANG AND CANG
Figure 2. Initial study models.
sulcus. Further, the patient had incompetent and
protruded lips at rest and in contact but with
mentalis strain upon forcible closure. There was also
a low smile line, and the smile arc was not consonant
with the curvature of the lower lip (Figure 1). An
intraoral examination showed an anterior open bite
with no occlusal contact from the right first premolar
to the left first premolar, a bilateral Class III molar
relationship, and a Class III canine relationship on
the right side but a Class I relationship on the left
side. An analysis of the initial study models revealed
that there was an anterior dental open bite of 6 mm,
a decreased overjet (the overjet and overbite were
measured on digital dental models using 3-shape
software), a 3 mm curve of Spee, a mandibular
midline deviation (1.5 mm to the left), and arch-
length discrepancies of 5 mm in the maxilla and
3 mm in the mandible. The anterior and overall
Bolton ratios were compatible. The maxillary dental
arch was narrow, and the upper and lower arches were
unmatched. A crossbite from the upper left canine
to the second premolar was also noted during the
examination. The maxillary right second molar was
in scissor-bite with the mandibular right second molar
(Figure 2). A cephalometric analysis revealed a skeletal
open bite (SN/GO-GN 48°), an increased mandibular
plane angle, a counter-clockwise rotation of the ANS-
PNS plane (S-N/ANS-PNS 6°), proclination of the
upper incisors (UI/ANS-PNS 129°), an interincisal
angle of 108°, excessive lower anterior facial height and a
short upper anterior facial height (Table I). A computed
tomography scan of the anterior teeth revealed adequate
labial and lingual bone volumes (Figure 3A). In addition,
the initial panoramic radiograph and the radiographic
74   Australasian Orthodontic Journal Volume 39 No. 1 2023
and clinical examinations of the temporomandibular
joints revealed no obvious abnormalities (Figure 4
and 3B). The patient was diagnosed with a Class III
malocclusion (S-N/ANS-PNS 6°) and skeletal open
bite (SN/GO-GN 48°) with an increased mandibular
plane angle, a long face, a convex profile, and lip
incompetence with mentalis strain. There was also
proclination of the upper incisors, a crossbite, scissor-
bite, mild crowding and midline deviation.
Treatment objectives
The primary treatment objectives were (1) partly
closing the anterior open bite by a combination
of retraction and extrusion of the upper incisors;
(2) further closure of the anterior open bite by
intrusion of the posterior maxillary dentition
enabling a subsequent counter-clockwise rotation of
the mandible and a reduction in facial height; (3)
levelling and aligning the upper and lower dentition;
(4) achieving Class I molar and canine relationships
and an ideal overbite and overjet; (5) improving the
facial profile and obtaining natural lip competence
without mentalis and lip strain; (6) expanding the
upper dental arch to improve the aesthetics of the
smile; (7) moving the lower teeth to the right side
to correct the midline deviation using the extraction
space; and (8) correcting the crossbite and the scissor-
bite of the maxillary right second molar.
Treatment alternatives
Given the mild skeletal discrepancy and the strong
opposition of the patient to the orthodontic and
 TREATMENT OF AN ANTERIOR OPEN BITE, BIMAXILLARY PROTRUSION AND MESIOCCLUSION BY THE EXTRACTION OF PREMOLARS

Table I. Pre-treatment and post-treatment cephalometric analysis.

Measurement Mean ± SD Pre-treatment Post-treatment

Sagittal skeletal relations
 S-N-A 82° ± 3.5° 76° 72°
 S-N-PG 80° ± 3.5° 73° 70°
 A-N-PG 2° ± 2.5° 3° 2°
Vertical skeletal relations
 S-N/ANS-PNS 8° ± 3.0° 6° 11°
 S-N/GO-GN 33° ± 2.5° 48° 48°
 ANS-PNS/GO-GN 25° ± 6.0° 32° 27°
Dento-basal relations
 UI/ANS-PNS 110° ± 6.0° 129° 118°
 LI/GO-GN 94° ± 7.0° 91° 82°
  LI/A-PG (mm) 2 ± 2.0 4.4 2.7
Dental relations
  Overjet (mm) 3.5 ± 2.5 2.2 2.6
  Overbite (mm) 2 ± 2.5 -2.8 1.2
  Interincisal angle UI/LI 132° ± 6.0° 108° 133°
A, point A; ANS, anterior nasal spine; GN, gnathion; GO, gonion; LI, lower incisor; N, nasion; PG, pogonion; PNS, posterior nasal spine; PO, porion; S,
sella; SD, standard deviation; UI, upper incisor.

orthognathic surgical treatment program, camouflage
treatment with fixed appliances and TAD skeletal
anchorage was considered. However, the patient again
refused because of aesthetic and comfort concerns.
Finally, clear aligner appliances were chosen.
Maxillary arch expansion and interproximal
reduction (IPR) were additional considerations to
relieve the crowding, develop a rounded arch form,
and co-ordinate the maxillary and mandibular
arches. IPR was also indicated to assist alignment
of the lower arch and a combination of anterior
extrusion and posterior intrusion to manage the
anterior open bite. However, this approach did not
adequately address the patient’s concerns, especially
the bimaxillary dentoalveolar protrusion and

Figure 3. The pre-treatment labial and lingual bone volume of anterior teeth (A) and temporomandibular joint radiograph (B).

Australasian Orthodontic Journal Volume 39 No. 1 2023   75

XIANG, WANG, GUAN, WANG AND CANG
Figure 4. Pre-treatment panoramic radiograph (A) and lateral cephalometric radiograph (B).
mesiocclusion. Therefore, an alternative approach was
selected to correct all of the issues, which involved the
extraction of the maxillary second and mandibular
first premolars, followed by mechanics using clear
aligners, which have gained popularity in the
treatment of an anterior open bite malocclusion.24–27
Treatment progress
Before treatment, polyvinyl siloxane (DGM,
Germany) impressions were taken to develop a
ClinCheck treatment plan (Align Technology,
Santa Clara, CA, USA). The digital plan was used
to determine the number of aligners needed and
the treatment duration and to visualise the required
biomechanics of tooth movement. The treatment
involved three phases:
Initial treatment phase
The treatment commened by extracting the four
premolars. The goals of the initial phase were to
align and level the dental arches, close the extraction
spaces, and close the open bite. In the upper arch,
14, 24, 13, and 23 were retracted, leaving a space at
the mesial area of 13 and 23. The anterior teeth were
aligned, and 8° of lingual root torque was added prior
to en-masse retraction. The teeth 16 and 26 were
moved first, allowing further mesialisation of 17 and
27, until 16 and 26 contacted 14 and 24, respectively.
Optimised retraction attachments were applied to
the upper canines, as well as optimised anchorage
attachments and vertical rectangular attachments on
the upper posterior teeth. An extrusion attachment
76   Australasian Orthodontic Journal Volume 39 No. 1 2023
was designed and placed on the upper right incisor
through an automated process. In the lower arch,
the treatment plan was to retract 33 and 43, thereby
leaving space mesial to 33 and 43 (which improved
aligner grip), adding 10° of lingual root torque before
en-masse retraction of the incisors. The G628 solution
for optimised retraction attachments was used on the
canines and optimised anchorage attachments on
the lower posterior teeth. The patient wore bilateral
Class III, 3.5-ounce elastics, full time throughout the
treatment phase. It was planned to intrude the upper
posterior teeth by approximately 2 mm, extrude
the upper anterior teeth by approximately 1.5 mm,
and finally achieve an overbite of roughly 3 mm. In
addition, it was planned to expand the maxillary arch
in order to co-ordinate the arch forms. Palatal crown
torque of 17 was necessary to achieve a normal buccal
overjet of the right posterior teeth. The pre-treatment
ClinCheck treatment plan is presented in Figure 5.
Fifty sets of Invisalign aligners were designed for the
patient. However, the treatment had to be restarted
due to poor engagement of the 31st aligners. During
the following process, a ‘frog’ pattern of movement
of the lower anterior teeth was designed, while the
other plans remained unchanged. A ‘frog’ pattern
is a staggered staging technique: the canines are
first retracted for 10 stages, together with some
mesialisation of the molars, and then stopped.
Then the incisors are retracted for 10 stages and
then stopped. The canine movement is restarted for
another 10 stages and stopped, followed by further
incisor retraction. This pattern is repeated until the
extraction spaces are closed and the incisors fully
retracted. The aligners were used for 9 months,
 TREATMENT OF AN ANTERIOR OPEN BITE, BIMAXILLARY PROTRUSION AND MESIOCCLUSION BY THE EXTRACTION OF PREMOLARS

Figure 5. Pre-treatment ClinCheck treatment plan (Align Technology, Santa Clara, CA, USA).

Figure 6. Refinement stage: ClinCheck treatment plan (Align Technology, Santa Clara, CA, USA).

changed every 10–14 days during the 3 months of
initial treatment and changed every 7 days thereafter.
The patient was seen at monthly intervals to check
aligner fit, attachment stability, and compliance
without using remote dental monitoring during the
treatment period.
Progress treatment phase
Polyvinyl siloxane (DGM, Germany) impressions
were obtained to assess the progress stage of the
ClinCheck treatment plan and to complete the
unfinished goals of the first phase. The treatment
process continued and followed that established in
the first stage. The open bite correction occurred
during the second phase of 50 aligners.
Refinement phase
The final sets of aligners underwent improvements
to correct the anterior overbite and mild posterior
open bite that developed during treatment. During
refinement, 15 upper and 10 lower aligners were
worn for 9 months and were changed every 14–30

Australasian Orthodontic Journal Volume 39 No. 1 2023   77

XIANG, WANG, GUAN, WANG AND CANG
days. The patient’s overbite decreased by attaching
power ridges and the subsequent intrusion of the
anterior teeth. The posterior open bite was corrected
by placing button cutouts in the maxillary and
mandibular aligners for attaching vertical elastics.
The ClinCheck treatment plan for the refinement
stage is presented in Figure 6. While additional
improvements may have been possible, the patient
was satisfied with the results at the end of this
stage; therefore, the treatment was terminated.
At the outset, it was considered that the difference
in the alignment and position of the anterior teeth
before and after treatment was large, and so Hawley
retainers combined with bonded lingual wires for
retention were provided. However, the patient was
Figure 7. Post-treatment extraoral and intraoral photographs.
78   Australasian Orthodontic Journal Volume 39 No. 1 2023
unable to adapt to these retainers because of her
occupation and socialising, so vacuum-formed and
transparent full-arch wraparound retainers were
supplied to maintain the treatment results.
Treatment results
After 33 months of therapy, the treatment objectives
established in the pre-treatment plan were achieved,
which improved aesthetics and the intercuspation of
teeth (Figures 7 and 8). The treatment retracted and
uprighted the patient’s incisors (Figures 9 and 10),
which improved her lip profile and facial appearance
producing a harmonious straight-type of profile.
The nasolabial and mentolabial angles increased,
 TREATMENT OF AN ANTERIOR OPEN BITE, BIMAXILLARY PROTRUSION AND MESIOCCLUSION BY THE EXTRACTION OF PREMOLARS
and the lips closed naturally without lip or mentalis
strain. The treatment completely closed the open bite,
corrected the overbite and overjet, aligned the upper
and lower dental midlines with the facial midline,
and established Class I molar and canine relationships
(Figure 7). Based on panoramic radiographs
(Figures 4 and 11) and the relative positions of the
teeth before and after treatment, standard root
length, sufficient root parallelism, a tight occlusal
relationship, and adequate posterior anchorage were
maintained. The thickness of the labial and lingual
bone volume over the anterior tooth roots before and
after treatment was within normal limits (Figure 12).
The temporo-mandibular joint radiographs before
and after treatment revealed no significant changes
Figure 8. Final study models.
Figure 9. Two-dimensional (2D) superimposed cephalometric tracings.
(Figures 3 and 12). Unfortunately, the objective of
the counter-clockwise rotation of the mandible to
reduce facial height was not achieved; however, the
pretreatment facial height was preserved.
Discussion
Previous research has suggested that the aetiology
of an anterior open bite is complicated and includes
genetic and environmental factors (i.e., unfavourable
growth patterns and parafunctional habits), which
are difficult to completely differentiate.29,30 Therefore,
an accurate diagnosis and causative determination
are the best guides to establish appropriate
objectives, ideal treatment plans and definitive
Australasian Orthodontic Journal Volume 39 No. 1 2023   79
XIANG, WANG, GUAN, WANG AND CANG
Figure 10. Three-dimensional (3D) superimpositions (pre-treatment and post-treatment). (A) the anterior teeth; (B–D) the posterior teeth.
Figure 11. Post-treatment panoramic radiograph (A) and lateral cephalometric radiograph (B).
corrective procedures31. According to the initial
examinations, the patient was diagnosed with a Class
III malocclusion and mild skeletal open bite with an
increased mandibular plane angle and unmatched
dental arches (Figures 1–4; Table I). Dentoalveolar
or mild skeletal open bite patients generally exhibit
normal craniofacial morphology and skeletal facial
shapes but are characterised by proclined incisors,
insufficiently erupted anterior teeth, and normal or
slightly extruded molars. The anterior open bite is
commonly associated with parafunctional habits.30,32
Orthodontics can treat a dentoalveolar or mild
skeletal open bite to intrude the posterior teeth,
extrude the anterior teeth, or both.33 The required
techniques include the “pendulum effect” (Figure 13)
of the anterior teeth relatively extruding during
retraction; the “fulcrum effect” of the posterior
teeth intruding or mesial migration to eliminate
the occlusal fulcrum and move the occlusal contact
point forward;34 uprighting mesially-tipped posterior
teeth and correcting the occlusal plane inclination,
80   Australasian Orthodontic Journal Volume 39 No. 1 2023
not only to reduce the level of the open bite but also
to provide space for anterior tooth retraction.35 A
counter-clockwise mandibular rotation (Figure 14)
is based on studies12,25 suggesting that significant
molar intrusion, particularly of the maxillary molars,
favours mandibular rotation in a similar fashion to
high-pull headgear.
Contemporary orthodontics emphasises the accurate
control of three-dimensional tooth movement, and
CAT illustrates the advantages of this concept. CAT
has unique features related to three-dimensional
tooth control for patients with anterior open bite
deformities, especially those with an increased
mandibular plane angle.13,36,37 Traditional fixed
appliances tend to extrude the posterior teeth and
increase the mandibular plane angle when inter-
arch elastics are used, especially in non-growing
individuals, which leads to adverse vertical effects and
a worsening of the anterior open bite.36,37 In contrast,
even when Class II and Class III elastics are used,
clear aligners may prevent extrusion or aid in the
 TREATMENT OF AN ANTERIOR OPEN BITE, BIMAXILLARY PROTRUSION AND MESIOCCLUSION BY THE EXTRACTION OF PREMOLARS
intrusion of the posterior teeth due to a “bite-block
effect” of the two layers of the aligners covering the
posterior teeth, combined with the patient’s natural
masticatory intrusive forces.11–13,18,25,38 Additionally,
based on Newton’s third law, the extrusive force
placed on the anterior part of the aligner for anterior
extrusion simultaneously causes a reciprocal intrusive
force on the posterior part of the aligner, which is
favourable for posterior intrusion (Figure 15). Some
researchers24 believe that posterior intrusion using
aligners must be programmed. However, evidence
supporting this opinion is lacking. A recent study5 has
found that the amount of intrusion of the maxillary
mesiobuccal cusps can reach 0.47 mm, while others15
have determined that 0.6 mm is possible.
Besides molar intrusion, CAT can be designed to
extrude the anterior teeth. In the presented patient,
the “pendulum effect” of anterior tooth retraction and
the “fulcrum effect” of posterior tooth intrusion and
advancement were used to correct the anterior open
Figure 12. The post-treatment labial and lingual bone volume of anterior teeth (A) and temporomandibular joint radiograph (B).
Figure 13. The ‘pendulum effect’ of the retraction of the anterior teeth.
bite. The radiographic superimpositions revealed
that the aligners intruded the maxillary and
mandibular molars no more than 1 mm and that
the correction of the anterior open bite was primarily
achieved by anterior tooth extrusion accompanying
a small amount of molar intrusion (Figures 9 and
10). This may cause the mandible to rotate counter-
clockwise. The entire treatment process sequentially
involved an anterior open bite, deep overbite, and
finally, a normal overbite, indicating that the anterior
retraction using CAT can easily lead to extrusion
of the anterior teeth. Therefore, the design of the
ClinCheck plan should reduce the anterior extrusion
to strengthen vertical control. In open bite cases
with a large anterior facial inclination, relative
extrusion may be planned during anterior tooth
retraction, followed by the use of optimised extrusion
attachments to produce absolute extrusion. ‘Absolute
extrusion’ indicates a tooth or a group of teeth
that have been extruded (relative to the alveolar
Australasian Orthodontic Journal Volume 39 No. 1 2023   81
XIANG, WANG, GUAN, WANG AND CANG
bone). The mild posterior open bite may result from
two factors, one of which is the intrusive effect of the
aligners, and the other is the occlusal interference
caused by torque loss of the upper anterior teeth.
The former could be adjusted by vertical traction
or self-adjustment, while the latter requires torque
correction.
Transversely, most open bite deformities have narrow
dental arches. The wrap-around design of the aligners
can effectively widen the dental arches, obtain
appropriate arch forms, and digitally match the width
of the upper and lower arches, which is more accurate
than traditional fixed orthodontics. In the present
case, clear aligners were used to widen the narrow
maxillary dental arch, correct the posterior crossbite
and scissor-bite and establish a normal posterior
overbite and overjet. Correcting a buccal scissor-bite
is difficult using fixed orthodontics. While applying
CAT, the “bite-block effect” of the aligner presented a
significant advantage related to opening the occlusion
and avoiding occlusal interference, thereby facilitating
the palatal movement of 17 and correcting the scissor-
bite occlusal relationship (Figure 5). In addition, the
premise was that the movement of 16 provided space
for the palatal repositioning of 17. Sagittally, in order
to achieve Class I molar relationships, the treatment
plan involved the mesial movement of upper molars
and the retraction of lower anterior teeth. Compared
to traditional orthodontics, the mesial movement of
posterior teeth with clear aligners is more difficult
to perform as the molars tend to tip mesially9.
To counteract the mesial tipping, it is possible to
keep the crown tipped distally, design step-by-step
molar mesial movement, and add attachments. The
treatment with 5° of root movement (for 16 and 26)
towards the extraction space was incorporated at
the start. For every 1 mm of mesialisation of 16, 26,
17, and 27, 2° of mesial root tip was added, thereby
keeping the crowns inclined distally (Figure 16).
Concurrently, a vertical rectangular attachment was
used to assist the long-distance mesial movement
of the molars. To control anchorage and torque, a
stepwise retraction mode and lingual root torque of
the incisors were adopted to facilitate retraction of the
anterior teeth. Simultaneously, the patient used Class
III elastics to reinforce lower posterior anchorage.
Before orthodontic treatment, the patient received lip
training and a tongue crib to stop mouth breathing
and tongue-thrusting habits.11 The clear aligner
has also been reported as a useful device to aid in
82   Australasian Orthodontic Journal Volume 39 No. 1 2023
Figure 14. Counter-clockwise rotation of the mandible.
Figure 15. The extrusive force and intrusive force generated by
­reciprocal anchorage.
modifying habits like tongue-thrusting because the
plastic covers the anterior teeth.14,25,39
Contemporary orthodontics also seeks to improve
facial aesthetics and soft tissue profiles40,41. The
current treatment visibly improved the nasolabial
angle, lip protrusion, and mentolabial angle.
Consistent with previous studies42 describing the
retraction of incisors, the inclination of the protruded
incisors reduced, and the nasolabial angle and upper
lip length increased. Based on Ricketts’ aesthetic
E-line,43 the patient attained better lip retraction
and improved the everted lips.42 A previous study
has revealed that the lower incisor provides support
for the lower lip and that any movement of the
incisor will affect the spatial position of the lip
to some extent.42 In addition, mentolabial sulcus
depth changes coincide with lower lip protrusion
and E-plane changes.44 In the present patient, the
retraction of the lower incisor passively retracted the
lower lip, and the mentolabial sulcus depth became
shallower.
Studies have also shown that the mouth and teeth
are the basis of facial aesthetics.44 The aligner
treatment achieved a perfect smile and co-ordinated
the relationship between the lips and teeth. The
midline of the upper and lower dental arches
matched the midline of the face, and the edges of
the maxillary incisors at rest were close to the lower
lip (Figure 7). According to Machado et al.,45 this
ideal position of the maxillary incisors is associated
with beauty, youth, etc. In addition, an ideal smile
 TREATMENT OF AN ANTERIOR OPEN BITE, BIMAXILLARY PROTRUSION AND MESIOCCLUSION BY THE EXTRACTION OF PREMOLARS
Figure 16. Overcorrection to keep the crowns inclined distally. (A-B) during treatment. (C-D) before treatment.
arc (i.e., maxillary incisal edges slightly contoured
to the lower lip) was achieved for the patient. The
anterior extrusion helped obtain a consonant smile
line, which is rated as more aesthetic,45,46 and dental
expansion improved the substantially reduced buccal
corridors. Additionally, retraction of the incisors
facilitated retraction of the upper and lower lips,
increased exposure of the anterior teeth, and reduced
the inter-labial gap. These changes improved the soft
tissue appearance of the lower third of the face and
substantially improved the patient’s aesthetics and
facial profile.
The ClinCheck plan is a graphic representation of the
forces being applied to the teeth.47 Based on the digital
methods and orthodontic biomechanical principles,
clinicians formulate a desired individualised plan to
achieve three-dimensional controlled and sequential
tooth movement from the beginning to the end of
treatment. In 2012, Align Technology announced
multitooth anterior extrusive attachments for
anterior open bite correction associated with their
G4 innovation. These attachments are placed on
the incisors when the software detects the need for
pure extrusion of 0.5 mm or more.11,16,18 The size and
shape of the attachments are designed directly by
the ClinCheck software based on the biomechanical
request.25 This movement requires ‘grip’, especially
on the central and lateral incisors, which have
smooth surfaces and minimal undercuts.48 In
addition, the intramaxillary and intermaxillary
elastics can be designed in the ClinCheck plan
during the early stages of treatment in patients who
need programmed extrusion.49 No attachments are
required on a posterior tooth to be intruded, whereas
adjacent teeth (functioning as anchorage units)
require attachments. In cases of open bite, directions
for the future development of the software include
simulation of the progressive rotation of the mandible
caused by the molar intrusion, which is similar to the
sagittal occlusal jump in Class II patients.25 More
research is needed on the biomechanical feasibility
and effectiveness of the clear aligner system.50
Summary and conclusions
The present case report demonstrated the successful
clear aligner treatment of an adult patient who
complained of a protrusive profile, an anterior open
bite and inefficient masticatory function. At the
completion of treatment, the patient’s protrusive
profile had improved, and the anterior open bite,
mesiocclusion and other problems were corrected.
The limitation of this study was that it only presents
one case, and the guiding significance of CAT in
patients with these characteristics is therefore limited.
In the future, more in-depth research is necessary to
provide stronger evidence and appropriate guidelines
for clinical CAT decision-making.
Corresponding author
Prof. Song Cang, PhD, Associate Senior Doctor,
Department of orthodontics,
Tianjin Stomatological Hospital,
School of Medicine, Nankai University,
Tianjin 300041, China. Tianjin Key Laboratory
of Oral and Maxillofacial Function Reconstruction,
Tianjin 300041, China. NO.75 Dagu Road, Heping
Australasian Orthodontic Journal Volume 39 No. 1 2023   83
XIANG, WANG, GUAN, WANG AND CANG
District, Tianjin, 300041,
China. Tel: +86-022-59080541
Email: cangsong@vip.163.com
Conflict of interest
The authors declare that there is no conflict of interest.
Declaration of patient consent
The authors certify that they have obtained all
appropriate patient consent forms. The patient
has given her consent for images and other clinical
information to be reported in the journal. The patient
understands that her name and initials will not be
published, and due efforts will be made to conceal
her identity, but anonymity cannot be guaranteed.
Consent for copyright
The authors will transfer all copyright ownership
of the manuscript to the Australasian Orthodontic
Journal in the event the work is published. The author
warrants that the article is entirely original and does
not infringe any copyright or proprietary rights of
any third party. The paper has not been accepted by
other journals and has not been previously published,
including in any product journals, whether in print
or electronic media. The authors confirm that they
have viewed and approved the final version of the
manuscript.
We sign for and accept responsibility for releasing
this material.
Availability of data and material
The datasets used and analyzed during the current
study are available from the corresponding author on
reasonable request.
Funding
This research was supported by the Key Clinical
Specialty of Tianjin Stomatological Hospital [grant
numbers 2018268] and [grant numbers 2013544].
The funding body provided financial support but did
not contribute to designing the study, interpreting
the data and writing the manuscript.
Authors’ contributions
Song Cang designed the study, designed writing
ideas, collected and analyzed the data and revised
the manuscript. Xiaosong Xiang designed the study,
collected and analyzed the data, and drafted the
84   Australasian Orthodontic Journal Volume 39 No. 1 2023
work. Song Cang and Xiaosong Xiang contributed
equally to this work. Chunlin Wang and Xiaohang
Guan analyzed and interpreted the data. Lu Wang
helped to collect the data. All authors read and
approved the final manuscript.
References
1. Kesling HD. Coordinating the predetermined pattern and tooth
positioner with conventional treatment. Am J Orthod Oral Surg
1946;32:285–93.
2. Ponitz RJ. Invisible retainers. Am J Orthod 1971;59:266–72.
3. Sheridan JJ, LeDoux W, McMinn R. Essix retainers: fabrication and
supervision for permanent retention. J Clin Orthod 1993;27:37–45.
4. Hajeer MY, Millett DT, Ayoub AF, Siebert JP. Applications of 3D
imaging in orthodontics: part II. J Orthod 2004;31:154–62.
5. Bollen A-M, Huang G, King G, Hujoel P, Ma T. Activation
time and material stiffness of sequential removable orthodontic
appliances. Part 1: Ability to complete treatment. Am J Orthod
Dentofacial Orthop 2003;124:496–501.
6. Djeu G, Shelton C, Maganzini A. Outcome assessment of
Invisalign and traditional orthodontic treatment compared with
the American Board of Orthodontics objective grading system. Am
J Orthod Dentofacial Orthop 2005;128:292–8; discussion 298.
7. Kau CH, Feinberg KB, Christou T. Effectiveness of Clear Aligners
in Treating Patients with Anterior Open Bite: A Retrospective
Analysis. J Clin Orthod 2017;51:454–60.
8. Venugopal A, Manzano P, Rengalakshmi S. A novel temporary
anchorage device aided sectional mechanics for simultaneous
orthodontic retraction and intrusion. Case Rep Dent 2020;2020:
5213936.
9. Dai FF, Xu TM, Shu G. Comparison of achieved and predicted
tooth movement of maxillary first molars and central incisors:
first premolar extraction treatment with Invisalign. Angle Orthod
2019;89:679–87.
10. Papadimitriou A, Mousoulea S, Gkantidis N, Kloukos D. Clinical
effectiveness of Invisalign® orthodontic treatment: a systematic
review. Prog Orthod 2018;19:37.
11. Garnett BS, Mahood K, Nguyen M, Al-Khateeb A, Liu S, Boyd
R, et al. Cephalometric comparison of adult anterior open bite
treatment using clear aligners and fixed appliances. Angle Orthod
2019;89:3–9.
12. Boyd RL. Esthetic orthodontic treatment using the Invisalign
appliance for moderate to complex malocclusions. J Dent Educ
2008;72:948–67.
13. Boyd RL. Complex orthodontic treatment using a new protocol for
the Invisalign appliance. J Clin Orthod 2007;41:525–47; quiz 523.
14. Schupp W, Haubrich J, Neumann I. Treatment of anterior open
bite with the Invisalign system. J Clin Orthod 2010;44:501–7.
15. Khosravi R, Cohanim B, Hujoel P, Daher S, Neal M, Liu W, et
al. Management of overbite with the Invisalign appliance. Am J
Orthod Dentofacial Orthop 2017;151:691–9; e692.
16. Harris K, Ojima K, Dan C, Upadhyay M, Alshehri A, Kuo
CL, et al. Evaluation of open bite closure using clear aligners: a
retrospective study. Prog Orthod 2020;21:23.
17. Sherwood KH, Burch JG, Thompson WJ. Closing anterior open
bites by intruding molars with titanium miniplate anchorage. Am J
Orthod Dentofacial Orthop 2002;122:593–600.
18. Guarneri MP, Oliverio T, Silvestre I, Lombardo L, Siciliani
G. Open bite treatment using clear aligners. Angle Orthod
2013;83:913–9.
19. Endo T, Kojima K, Kobayashi Y, Shimooka S. Cephalometric
evaluation of anterior open-bite nonextraction treatment, using
multiloop edgewise archwire therapy. Odontology 2006;94:51–8.
 TREATMENT OF AN ANTERIOR OPEN BITE, BIMAXILLARY PROTRUSION AND MESIOCCLUSION BY THE EXTRACTION OF PREMOLARS
20. Küçükkeleş N, Acar A, Demirkaya AA, Evrenol B, Enacar A.
Cephalometric evaluation of open bite treatment with NiTi arch
wires and anterior elastics. Am J Orthod Dentofacial Orthop
1999;116:555–62.
21. Cambiano AO, Janson G, Lorenzoni DC, Garib DG, Dávalos
DT. Nonsurgical treatment and stability of an adult with a severe
anterior open-bite malocclusion. J Orthod Sci 2018;7:2.
22. Turpin DL. Assessment of perceived orthodontic appliance
attractiveness. Am J Orthod Dentofacial Orthop 2008;133:S8.
23. Jeremiah HG, Bister D, Newton JT. Social perceptions of adults
wearing orthodontic appliances: a cross-sectional study. Eur J
Orthod 2011;33:476–82.
24. Moshiri S, Araujo EA, McCray JF, Thiesen G, Kim KB. Cephalometric
evaluation of adult anterior open bite non-extraction treatment with
Invisalign. Dental Press J Orthod 2017;22:30–8.
25. Giancotti A, Garino F, Mampieri G. Use of clear aligners in open bite
cases: an unexpected treatment option. J Orthod 2017;44:114–25.
26. d’Apuzzo F, Perillo L, Carrico CK, Castroflorio T, Grassia V,
Lindauer SJ, et al. Clear aligner treatment: different perspectives
between orthodontists and general dentists. Prog Orthod
2019;20:10.
27. Li Y, Deng S, Mei L, Li Z, Zhang X, Yang C, et al. Prevalence
and severity of apical root resorption during orthodontic treatment
with clear aligners and fixed appliances: a cone beam computed
tomography study. Prog Orthod 2020;21:1.
28. Lie Ken Jie RKP. Treating bimaxillary protrusion and crowding
with the invisalign g6 first premolar extraction solution and
invisalign aligners. APOS Trends Orthod 2018;8:219–24.
29. Fujiki T, Inoue M, Miyawaki S, Nagasaki T, Tanimoto K, Takano-
Yamamoto T. Relationship between maxillofacial morphology and
deglutitive tongue movement in patients with anterior open bite.
Am J Orthod Dentofac Orthop 2004;125:160–7.
30. Rijpstra C, Lisson JA. Etiology of anterior open bite: a review. J
Orofac Orthop 2016;77:281–6.
31. Matsumoto MA, Romano FL, Ferreira JT, Valério RA. Open bite:
diagnosis, treatment and stability. Braz Dent J 2012;23:768–78.
32. Subtelny JD, Sakuda M. Open-bite: diagnosis and treatment. Am J
Orthod 1964;50:337–58.
33. Reichert I, Figel P, Winchester L. Orthodontic treatment of
anterior open bite: a review article--is surgery always necessary?
Oral Maxillofac Surg 2014;18:271–7.
34. Turkkahraman H, Sarioglu M. Are temporary anchorage devices
truly effective in the treatment of skeletal open bites? Eur J Dent
2016;10:447–53.
35. Janson G, Laranjeira V, Rizzo M, Garib D. Posterior tooth
angulations in patients with anterior open bite and normal
occlusion. Am J Orthod Dentofacial Orthop 2016;150:71–7.
36. Arat M, Iseri H. Orthodontic and orthopaedic approach in the
treatment of skeletal open bite. Eur J Orthod 1992;14:207–15.
37. Ryan MJ, Schneider BJ, BeGole EA, Muhl ZF. Opening rotations
of the mandible during and after treatment. Am J Orthod
Dentofacial Orthop 1998;114:142–9.
38. Melsen B, McNamara JA Jr, Hoenie DC. The effect of bite-blocks
with and without repelling magnets studied histomorphometrically
in the rhesus monkey (Macaca mulatta). Am J Orthod Dentofacial
Orthop 1995;108:500–9.
39. Dayan W, Aliaga-Del Castillo A, Janson G. Open-bite treatment with
aligners and selective posterior intrusion. J Clin Orthod 2019;53:53–4.
40. Golshah A, Serenjianeh AM, Imani MM. Smile attractiveness
of Persian women after orthodontic treatment. Am J Orthod
Dentofacial Orthop 2020;158:75–83.
41. Bhatia S, Jayan B, Chopra SS. Effect of retraction of anterior
teeth on pharyngeal airway and hyoid bone position in Class I
bimaxillary dentoalveolar protrusion. Med J Armed Forces India
2016;72:17–23.
42. Alqahtani ND, Alshammari R, Almoammar K, Almosa N, Almahdy
A, Albarakati SF. Post-orthodontic cephalometric variations in
bimaxillary protrusion cases managed by premolar extraction—a
retrospective study. Niger J Clin Pract 2019;22:1530–8.
43. Lecocq G, Truong Tan Trung L. Smile esthetics: calculated beauty?
Int Orthod 2014;12:149–70.
44. Durgekar SG, Nagaraj K, Naik V. The ideal smile and its
orthodontic implications. World J Orthod 2010;11:211–20.
45. Arroyo Cruz G, Orozco Varo A, Montes Luna F, Jiménez-
Castellanos E. Esthetic assessment of celebrity smiles. J Prosthet
Dent 2021;125:146–50.
46. Machado AW. 10 commandments of smile esthetics. Dental Press J
Orthod 2014;19:136–57.
47. Krishnan V. The insider’s guide to Invisalign® Treatment (2017).
Journal of the World Federation of Orthodontists; 2017.
48. Glaser BJ. Insider’s guide to Invisalign treatment: a step-by-
step guide to assist you with your ClinCheck treatment plans
Sacramento, CA: 3L Publishing; 2017.
49. Park JH, Kim TW. Open-bite treatment utilizing clear removable
appliances with intermaxillary and intramaxillary elastics. World J
Orthod 2009;10:130–4.
50. Malik OH, McMullin A, Waring DT. Invisible orthodontics part 1:
Invisalign. Dent Update 2013;40:203–4; 207-210, 213-205.
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