34

.., 7 1 ..-.. 2547

Orthodontic treatment of the dental

openbite in an adult : A case report
Supranee Tawinburanuwong *, Wanwisa Limpanichkul**
Abstract

Case report of an adult Thai male aged 18 years 2 months who complained about ineffective chewing
of food. The patient was diagnosed to have a 4 mms of anterior dental openbite on skeletal Class I with normal
mandibular plane and palatal plane angles. Treatment was orthodontics alone with non-extraction. The main
mechanics used to close the anterior openbite, were by the conventional aligning and leveling by straight wires,
intruding step bends for posterior teeth, and MEAW technique. The result showed that MEAW was an effective
method to correct the openbite within a short period; however, the appliance was difficult to clean. The treatment
was complete after 11 2 years with positive overbite of 3.5 mms and acceptable occlusion. The patient was happy
with his new appearance and function.

Key words: Orthodontic treatment/ Dental openbite/ Adult/ Non-extraction/ MEAW technique

Introduction

Openbite malocclusion is considered to be one of

the most difficult problems to treat.1 The causes of openbite
are multifactorial, which can develop from genetic and/or
environmental factors.2 Openbite is generally classified in
two categories: skeletal and dental. The diagnosis is
important due to the different treatment approaches. Generally,
a dental openbite can be treated with orthodontics alone,
while a true skeletal openbite requires a combination of
orthodontics and surgery.3

Characteristics of the openbite malocclusion

The dental openbite is an openbite without facial

disfigurement. It is associated with some or all of the
following characteristics1,3-7: Normal craniofacial pattern
Proclined incisors
Undererupted anterior teeth
Normal or slightly excessive molar height

Mesial inclination of posterior dentition

Failure of eruption of teeth with no known
etiology
Divergent upper and lower occlusal planes
No gummy smile
No vertical maxillary excess
Thumb and finger sucking habits
Tongue thrusting habit
Without remarkable cephalometric findings
The skeletal openbite is an openbite with a divergence
of the sagittal skeletal planes. It is associated with one or
more of the following characteristics1,3-8: Steep mandibular plane angle
Increased gonial angle
Short mandibular ramus
Downward rotation of the posterior part of the
maxilla or palatal plane tipped up anteriorly
Increased lower anterior facial height
Decreased upper anterior facial height

* Lecturer, Department of Orthodontics, Faculty of Dentistry, Khon Kaen University

** Graduate student, Master of Science in Orthodontics, Department of Orthodontics, Faculty of Dentistry, Khon Kaen University

KDJ. Vol.7 No.1 January - June, 2004

Increased anterior and decreased posterior facial

heights
Increased flexure of the cranial base (Na-S-Ba)
Steep anterior cranial base
Shorter nasion-basion distance
Small mandibular body and ramus
Retrognathic mandible

Cephalometric analysis of the openbite malocclusion

Cephalometric analysis is useful to distinguish
between the dental problem and the skeletal problem, and to
specify the abnormal parts.
The common cephalometric analysis for the
openbite malocclusion is as follows4,8,9: Sagittal angles
Mandibular plane to palatal plane (MP-PP)
SN-MP
Occlusal plane to mandibular plane (OC-MP)
SN-PP
Gonial angle
Y-axis angle, facial axis angle
Vertical ratios
Posterior facial height to anterior facial height
(PFH:AFH)
Upper anterior facial height to lower anterior
facial height (UAFH:LAFH)
Vertical maxillary excess: root apices of the
upper first molar and the upper central incisor to
palatal plane
Anteroposterior dyspalsia indicator (APDI),
Overbite depth indicator (ODI)

Treatment strategy

The proper differentiation of the etiology of the

openbite malocclusion in an individual patient is very
important because it is used to determine the appropriate
treatment method and the plan for retention.3,10

35

The treatment strategy can be divided into 3

periods of dental development10: 1. Primary dentition
Generally, it is not recommended to treat in this
period because most cases involve habits and self-correct
after stopping parafunctional habits. Control of the abnormal
habits should be advised for the patient and the parents.
2. Mixed dentition
2.1 Habit control
The tongue crib is an appliance that has been
widely used for stopping thumb sucking and other habits
that produce and maintain anterior openbite.10,11
2.2 Lip seal and swallowing exercises
The underlying goal is to establish normal neuromuscular function. The patient is instructed to keep the lips
together at all times.5 Swallowing without thrusting the tip
of the tongue towards the upper or lower incisors is
suggested before treatment and continues during retention.10
2.3 Growth modification to control vertical growth and
posterior dentoalveolar development
The objective is to control vertical growth and
retard eruption of posterior teeth.
The common treatment approaches are high pull headgear12,
Frankel IV regulator, bionator/activator, active vertical
corrector (AVC), posterior bite blocks, vertical pull chin
cups.5
3. Permanent dentition
Treatment approaches in this period can be divided into
4 categories as follows: 3.1 Habit control, lip seal and swallowing exercises
3.2 Growth modification to control vertical growth and
posterior dentoalveolar development (in early
permanent dentition period)
3.3 Orthodontic camouflage (only orthodontics)
3.4 Orthognathic surgery (a combination of orthodontics
and surgery)
As mentioned, a dental openbite can be treated with
orthodontics alone while, generally, a true skeletal openbite
requires a combination of orthodontics and surgery.3

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.., 7 1 ..-.. 2547

Orthodontic camouflage
Several papers have suggested extraction and
retraction for correcting the dental openbite in adult patients.
Proclined upper and lower anterior teeth will be retracted
following extractions to reduce both overjet and openbite,
and elongate the anterior teeth by a drawbridge effect.2,3,13
Generally, the most posterior teeth, such as, second molars,
are recommended to be extracted because this allows
forward rotation of the mandible. On occasions, extraction
of premolars is considered in crowding and /or protruded
anterior teeth.2 Kim4 introduced the Multiloop Edgewise
Arch Wire (MEAW) to correct the openbite malocclusion.
This technique uses a combination of multiloops in bootshape on 0.016x0.022 inch stainless steel archwires in 0.018
inch slot edgewise brackets, and short, heavy anterior 3/16
inch, 6 oz elastic. The vertical loop segment serves as a break
between the teeth, lowers the load/deflection rate, and
provides horizontal control. The horizontal loop further
reduces the load/deflection rate and provides vertical control.
The prepared maxillary MEAW arch should show a marked
sweep curve, and the mandibular arch has a marked reverse
curve of Spee. Before the preparation of MEAW, the teeth
must be well aligned. It has been advocated as a resource to
treat cases of severe openbite without surgical intervention
by retraction and extrusion of the anterior teeth combined
with uprighting and intruding the posterior teeth, and altering
the occlusal planes. The treatment changes with the MEAW
technique minimally affect the skeletal pattern; they occur
mainly in the dentoalveolar region by increasing the upper
and lower anterior dentoalveolar heights. One of the objectives of this technique is the proper vertical positioning of
the incisal edges of upper incisors relative to resting lip line
at or near 4 mm as measured cephalometrically, so that it is
not useful for patients who have adequate or excessive
dentoalveolar height before treatment.1,3,4 The result from
this technique has proven to be very stable.1
Recently, so-called modified MEAW, or upper
accentuated-curve and lower reverse-curve NiTi archwires
combined with intermaxillary elastics, was introduced by
Enacar et al14 as an alternative technique for correcting the

openbite problem. The treatment results in a sample of mean

age 19 years reported by Kucukkeles et al15 using this
modified technique indicated that the openbite closure was
achieved mainly by extrusion of the lower incisors and
uprighting of the upper incisors. The functional occlusal
plane was leveled by extrusion of lower premolars and
uprighting of lower molars. During a one-year follow-up
period, the position of the upper and lower incisors and the
inclination of the occlusal plane were maintained.
However, extrusion of upper and lower molar teeth resulted
in a reduction in overbite. Kuckkeles et al stated that
vertical growth and eruption of posterior teeth may
continue until late teen years or early twenties, making the
openbite tendency quite difficult to control. Thus, retention
in openbite patients should be long term and involve strict
control of eruption of the posterior teeth.15 Furthermore, in
the same year, 1996, Miyajima and lizuka7 also reported an
alternative technique for correcting Class III openbite
malocclusion with the Kims philosophy but employing Tip
Edge brackets. The maxillary dentition was stabilized, while
a NiTi archwire with a reversed curve of Spee was used in
the mandibular arch, combined with short Class III elastics
between upper first premolars and lower canines. This
combination was found to be very easy to manipulate and
achieved a good result in a short period of time.7
Most openbite malocclusions show some aspects
of both dental and skeletal problems. The treatment
principles for skeletal openbite by orthodontic camouflage
are to intrude posterior teeth, maintain or create a curve of
Spee, minimize conventional use of Class II and Class III
elastics, and minimize using anterior vertical elastics.3 There
are several methods to intrude posterior teeth: 1). high pull
headgear2, 2). skeletal anchorage such as a titanium
miniplate temporarily placed implant 16,173). MEAW
technique4, 4). posterior biteblocks3,18,19, 5). functional
appliances such as the functional regulator appliance (FR
4)20 or an openbite bionator/activator3,21, 6). active vertical
corrector22, 7). vertical pull chin cup23, and 8). the rapid molar
intruder which is a modification of the Jasper Jumper24
Recently, Aras stated that the extraction of teeth could

KDJ. Vol.7 No.1 January - June, 2004

reduce a steep mandibular plane, which improves a longfaced patient. However, extraction patterns and the age of
patients must be considered. Aras found that in the deceleration period of jaw growth, extraction of the second
premolars or the first molars led to a closing rotation of the
mandible in skeletal anterior openbite extending to the
posterior teeth.25 Although, there are several orthodontic
approaches that may be used to correct the skeletal openbite
problem as mentioned, it has been known that the more
severe the skeletal pattern, the more likely surgery will be
required.3,5
Orthognathic surgery
The guidelines for coordinating orthodontics and
surgery for the openbite malocclusion is the same as for any
other surgical-orthodontic treatment.26 Surgical procedures
often involve a bimaxillary approach with Lefort 1
posterior maxillary impaction. Segmental maxillary and/or
mandibular osteotomies are likely to be employed. During
the presurgical orthodontics, the objective should be to level
within but not across the segments, to maintain or create
appropriate root separation at the osteotomy sites, and to
avoid cross elastics to move the teeth in the direction of the
surgical correction. Postsurgically, the orthodontic finishing
is no different from that of any other orthognathic surgery
patient.26

Retention

The importance of retention is to enhance stability,

especially eliminating the cause of the openbite.3,27 The
stability is the most important criterion in deciding the
treatment method for openbite malocclusion. Active extrusion of anterior teeth is generally not advisable.28 However,
the study of Beckmann and Segner29 showed that active
extrusion may be possible, but it should not exceed the
vertical growth of the lower face. Elongation of the lower
incisors is more preferable to upper incisor elongation
because it results in better esthetics and stability.30 It has
been found that retrusion of the maxillary incisors during
treatment leads to a more stable overbite during the
retention period.29 The cant of individual occlusal planes
must be corrected and the teeth must be uprighted in

37

relation to the bisecting occlusal plane for ensuring stability and function.4
Relapse of openbite is mostly the result of elongation of the posterior teeth, particularly the upper molars,
without any evidence of intrusion of incisors. Controlling
eruption of the upper molars, therefore, is the key to
retention in openbite malocclusion. Wearing high-pull
headgear to the upper molars at night time, in conjunction
with a standard removable retainer is one effective and comfortable way for the patient to control openbite relapse.31
Other alternative approaches are: 1). placing retainers with
occlusal coverage to prevent further molar eruption3, and
2). wearing conventional maxillary and mandibular retainers
at daytime, and wearing a functional appliance with bite
blocks (an openbite bionator) at night time.31 Prolonged
retention is advisable and necessary in most cases of openbite
treatment; however, generally, patients do not use retainers
as recommended.3
Case report
Case history
A Thai man, 18 years and 2 months, was accepted
in the Orthodontic Department, Khon Kaen University in
2001 with a chief complaint of ineffective chewing of food
because of an anterior openbite, and wanting to have
orthodontic treatment. He had no relevant medical history
and had no previous history of orthodontic treatment. He
mainly breathed through his nose. Speech was normal. He
had a tongue thrust swallowing pattern. From history
taking, he had a habit of clenching teeth on the left side
more than on the right side. Nobody in his family had
similar conditions.
Clinical examination
Extra-oral assessment (Figure 1): He had an asymmetrical mesofacial type, the left side being slightly bigger
than the right side. Lips were competent at rest with normal
position of upper and lower lips. The upper incisal edges
were at the same level as the lip line. On smiling, his upper
lip rested below the gingival margin of upper incisors around
2 mms. The chin point deviated to the left 5 mms. He had

38

.., 7 1 ..-.. 2547

normal lower anterior facial height relative to upper

anterior facial height. He had normal profile convexity. The
nasolabial angle, mentolabial fold and mandibular plane were

normal. His mandible deviated to the left 2 mms while

opening and closing without any symptoms.

Figure 1 : Pre-treatment extra-oral facial photographs

Figure 2 : Pre-treatment intra-oral photographs

Intra-oral assessment (Figure 2): His periodontal

tissues appeared healthy. Frenum and palate were normal
but the tongue was slightly large indicated by the tooth marks
at the lateral sides of the tongue. The upper dental midline
was at the center while the lower dental midline deviated to
the left 1.5 mms. There was a maxillary incisor cant upward
from #12 to #22. The curve of Spee was 1 mm on both
sides. Canine relationships were Class II on both sides; molar
relationship was Class I on the right hand side, and Class II

on the left hand side. Overjet was 4 mms. Openbite was 4

mms between all upper and lower incisors. Crossbite showed
between #23/33. There was scissor bite of #17/47. The only
occluding teeth were the second molars. Premolar relationships were cusp-to-cusp for #14/44, #24/34, #25/35, and a
posterior openbite between #15/45, #16/26, and #26/36
around 2-3 mms. The upper first molars were slight intruded
compared with the upper functional occlusal plane, and the
lower first molars were also quite intruded comparing to

KDJ. Vol.7 No.1 January - June, 2004

the lower functional occlusal plane. There was no CR-CO

discrepancy. The canines and upper incisors showed small
and tapered shape.
Model analysis
The maxillary arch form was symmetrical tapered
while the mandibulary arch form was symmetrical and
ovoid. The upper anterior teeth had 3.5 mms spacing and
the lower anterior teeth had 5 mms spacing. Boltons analysis
indicated 2 mms anterior mandibular excess and 1 mm
posterior mandibular excess.
Radiographic examination
A panoramic radiograph showed that all teeth were
present with all the third molar crown formations complete.
The crowns of the upper third molars were smaller than
normal. The crowns of the lower third molars appeared to
be impacted against the distal cervical margins of the lower
second molars. There were no supernumerary teeth. The
crown-root ratios were normal with good alveolar bone
levels, no bone pathology, and mandibular condyles, nasal
floor and maxillary sinuses appeared normal (Figure 3).

Figure 4 : Pre-treatment postero-anterior tracing

Figure 5 : Pre-treatment lateral cephalometric tracing

incisors.

Figure 3 : Pre-treatment panoramic radiograph

A postero-anterior radiograph showed 5 mms

deviation of the chin point to the left hand side. The left
side of face was slightly bigger than the right side (Figure 4).
A cephalometric radiograph showed that he had
a Class I Skeletal relationship with orthognathic maxilla and
orthognathic mandible. The mandibular plane angle, palatal
plane angle, and functional occlusal planes were normal.
The upper and lower incisors were protruded and proclined.
The soft tissue profile showed normal convexity with long
upper lip with strain (Figure 5).

39

Treatment objectives
1. To retrude and retrocline the upper and lower

2. To correct the cant of the upper incisors downward by extruding them.

3. To align and level the functional occlusal plane
in each arch.
4. To intrude all second molars.
5. To close all spacing.
6. To obtain a normal overbite and overjet.
7. To achieve a Class I molar and canine
relationships.
8. To correct the dental midline.
9. To correct crossbite of #23/33 and scissor bite
of #17/47
10. To correct Bolton discrepancy by restoration
upper anterior teeth and/or stripping lower anterior teeth
11. To accept a slightly asymmetrical face due to
the patient was satisfied with this appearance, and did not
want any surgical procedure.

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Treatment plan
This case had the dental openbite problem, and
the profile was acceptable so that orthodontics only was
decided. The treatment was decided to be non-extraction
(except for all third molars) because of the spacing problem
and the small anterior teeth. The lower third molars also
needed surgical removal because their space would be
useful for aligning and leveling the lower second molars.
The unerupted upper third molars were to be observed with
later removal. Maximum anchorage by banding all second
molars early, was suggested to close all spacing from the
anterior, and to reduce proclined and protruded upper and
lower incisors. The full fixed appliance 0.022x0.028 inch
Roth prescription was used. It was decided to use the
multiloop edgewise archwire (MEAW) technique to correct this openbite problem by extrusion of upper and lower
anterior teeth combined with intrusion of the second
molars. The patient was taught to change the adaptive tongue
thrusting swallowing to be the normal swallowing before
starting the treatment. Wraparound retainers with labial and
buccal acrylic straps were decided for retention in the upper
and lower arches.

Treatment

The treatment started in December, 2001 with

0.012 inch continuous stainless steel archwires (Wilcock
Premium Plus) for aligning and leveling. All the second
molars were banded one month after the first visit. At around
5 months of aligning and leveling stage (Figure 6), the
patient had 2 mms anterior openbite, 3 mms overjet and
occluded only on all the second molars, so 0.016 inch
continuous stainless steel archwires (Wilcock Premium Plus)
with step bends on all the second molars were used to try to
intrude them.
After using the intrusion bends for 2 1 2 months,
the anterior openbite was 1 mm and overjet was 2 mms with
spacing remaining in upper and lower anterior teeth. The
premolars and molars occluded in cusp-to-cusp contact
points. MEAW was then prepared using 0.017x0.025 inch
stainless steel archwires with anterior intermaxillary
elastics (3/16 inch, 4.5 oz double on each side) at the first
loops, and combined with power chain from #7-7 simultaneously in all four arch quadrants (Figure 7).

Figure 6 : After aligning and leveling with conventional straight wires

KDJ. Vol.7 No.1 January - June, 2004

41

Figure 7 : Start using MEAW technique

Figure 8 : After using MEAW technique 3 months

After 3 months of using MEAW (Figure 8), there

was 3 mms of positive overbite and overjet was 2 mms.
Consequently, 0.016x0.022 inch continuous stainless steel
archwires with intrusive step bends on all the second
molars combined with power chain as before were used
instead of the MEAW for detailed finishing, and to close all
remaining spacing. Some bends to correct angulations of
teeth were applied on these archwires later on for another 4
months.
The last archwires were 0.014 inch continuous
stainless steel archwires (Wilcock Premium Plus) with
intruded step bends on all the second molars combined with

zig-zag short Class II elastic 3/8 inch, light force both sides
to get good interdigitation. An anterior box elastic 1 2 inch,
3.5 oz was used to maintain the positive overbite (Figure
9). After 1 1 2 months, overbite was 3.5 mms, overjet was 2
mms with slight Class II canine relationships and Class I
molar relationships. The Bolton discrepancies were not
corrected because the patient did not want to build up the
small and tapered crowns of the upper anterior teeth. The
appliance was taken off in May (Figure 11), 2003, because
the patient satisfied with his occlusion and appearance, and
he wanted to terminate the treatment before moving to
Bangkok. Upper and lower wraparound retainers with

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.., 7 1 ..-.. 2547

Figure 9 : Stage of finishing with 0.014 inch Australian archwire combined with zig-zag short Class II elastics

Figure 10 : Panoramic radiograph before appliance removal

Figure 11 : Post-treatment intra-oral photographs

KDJ. Vol.7 No.1 January - June, 2004

labial and buccal acrylic straps were used for retention

(Figure 12). The patient was advised to wear the retainers
full time for one year, then night-time use might be
sufficient; however, he was also advised to continue to wear
them at night time for as long as he could. He was asked to
come back for follow-up check during his vacation.

Conclusion

Treatment time was 1 1 2 years. The patient had

competent lips without lip strain (Figure 13). He had a

43

normal adult swallowing pattern. Upper incisor edges to lip

line was changed from 0 mm to 2 mms. When smiling, the
upper lip rested at the level of the cervical margins of the
upper incisors. The upper dental midline was correct, but
the lower dental midline had shifted to the right 0.5 mm.
Overbite was 3.5 mms, and overjet was 2 mms with slight
Class II canine relationships and Class I molar relationships.
After three months follow-up, the occlusion was still the
same (Figure 14).

Figure 12 : Wraparound retainers with acrylic straps after appliance removal

Figure 13 : Post-treatment extra-oral photographs

Figure 14 : After three month retention: intra-oral photographs

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.., 7 1 ..-.. 2547

Discussion

The treatment result was satisfactory within the

short treatment time. The result was slightly compromised
in that there was not full interdigitation of the posterior teeth
and the canine relationships were not full Class I, which
were because of Bolton discrepancies as mentioned and the
small and tapered crowns of the upper anterior teeth. Bolton
discrepancies were not corrected because the patient did not
want to build up the upper anterior teeth that probably prone
to break, and he requested termination of treatment earlier
than the operator intended. However, it was an acceptable
occlusion and the patient was happy with his appearance
and improved function.
Cephalometric radiograph superimpositions comparing before and after treatment (Figure 15) showed that
the openbite problems were corrected by: 1). the anterior
part of palatal plane rotating downward, 2). the upper
incisors extruded and tipped backward, 3). the lower
incisors slightly extruded and slightly tipped backward, and
4). the upper and lower first molars extruded, the lower
premolars were slightly upright, while the position of the
upper and lower second molars were the same as the
original both in antero-posterior and vertical direction. As
mentioned before, extrusion is not advisable for openbite
correction because of the relapse tendency. However, this

case had normal functional occlusal planes and only the first
molars showed intrusive position at the beginning compared
to other teeth, so that the slight extrusion of the first molars
was possible in this case. The superimpositions showed that
the second molars were not intruded even with the intrusive
step bends and MEAW technique. This result supported the
previous knowledge that the molars are difficult to intrude.
In this case, the main treatment mechanics used to close the
openbite were the conventional aligning and leveling by
straight archwires and MEAW technique. The scissor bite
of #17/47 was corrected by constricting the upper arch form
in the posterior region combined with buccal root torque
bend of #17 and lingual root torque bend of #47 with the
MEAW archwires.
It was decided to use the MEAW technique
because the patient had a dental openbite problem, with the
upper incisors intruded relative to the lip line. The main
purpose for using this technique in this patient was to
extrude the anterior teeth, correct the cant of the maxillary
incisors by extruding them, and intrude, tip and torque all
second molars simultaneously with the low load/deflection
archwires. The result showed that MEAW can close the
openbite more quickly than other methods observed from
the duration of reducing the openbite. However, it was
difficult to keep clean.

Figure 15 : Lateral cephalometric superimpositions between pre-treatment and post-treatment; A: maxillary superimpositions,
B: mandibular superimpositions, C: overall face superimpositions

KDJ. Vol.7 No.1 January - June, 2004

Table 1 : The cephalometric analysis before and after treatment

References

Measurement

Thai norm

Start

Finish

16/7/01

19/5/03

Di Paolo, et al.,1983

PP - MP (Go - Gn) (deg)

None

21

19

Bell, et al., 1980

SN - PP (deg)

None

11

13.5

Steiner, 1960

SN - MP (deg)

29 4

32

32.5

Steiner, 1960

SN - OP (deg)

15.7 4.6

18.5

20

Owen, 1986

N ANS : ANS Me (%)

None

43:57

45:55

Jarabak and Fizzell,

U1 - SN (deg)

107 6

111

95

Steiner, 1960

U1 - NA (deg)

21 2

25

11

Steiner, 1960

U1 - NA (mm)

32

-1

Tweed,1954;

L1 - MP (IMPA) (deg)

97 6

105

94

Steiner, 1960

L1 - NB (deg)

30 5

39

29

Steiner, 1960

L1 - NB (mm)

62

Burstone, 1967

Profile angle (deg)

None

164

165

Legan&Burstone,

Nasolabial angle (deg)

None

94

103

Upper lip to E line (mm)

-1 2

-0.5

Lower lip to E line (mm)

1.5 2

1.5

Upper lip strain (mm)

None

1972

Downs, 1956

1980
Jarabak and Fizzell,
1972
Jarabak and Fizzell,
1972
Holdaway, 1983,
1984

45

46

.., 7 1 ..-.. 2547

With the MEAW technique, Kim suggested to

wear the anterior elastics at the first loops of upper and lower
arches to intrude the posterior teeth.4 However, if a midline
shift problem or the canine relationships needs to be
corrected, the direction of wearing anterior elastics might
be modified to attach between the first and the second loops,
which depends on the type of malocclusion. In this case,
the anterior elastics were worn at the first loops as Kim
suggested. The lower dental midline improved from the
original by closing lower anterior spacing but, finally, it
shifted to the contra-lateral side to the right 0.5 mm, which
indicated that it might have been better if anterior elastic
use had been modified as mentioned.
The treatment changes obtained by the modified
MEAW were reported to be similarly to MEAW technique
14,15
but it was not used in this patient despite ease of
application and patient comfort because this technique has
recently started, which lacked of long-term follow-up
studies.
The patient had very good compliance and wore
the elastics as recommended, so the openbite could be
corrected within 1 1 2 years. However, due to the complexity
of appliance, he had generalized mild gingivitis with interdental papilla swelling on lower anterior teeth.
Wraparound retainers with labial and buccal
acrylic straps were used for retention. The acrylic straps were
useful to reinforce controlling the position, angulation and
inclination of teeth. Neither headgear, nor posterior bite
block, was used in this case because the treatment results
showed that the openbite correction was mainly from
retraction and extrusion of anterior teeth combined with
small extrusion of the first molars, not from the intrusion of
the second molars. The upper incisor edges to lip line was
changed from 0 mm to 2 mms and the lower lip rested ahead
them, so that it could prevent the proclination of upper
incisors and simultaneously help to control the relapse of
the anterior openbite.

Summary
There are several treatment approaches to correct
the openbite problem. The importance is to detect the cause
and the abnormal features, so that it leads to the proper
treatment. The patients compliance is one important factor
to achieve successful treatment, especially with the MEAW
technique that requires wearing elastics. Finally, the longterm wearing of appropriate retainers is needed for the
openbite case.

Acknowledgement

The authors would like to express gratitude to Prof.

Keith Godfrey for his advice and help of writing this case
report.

References
1.

Kim HY, Han KU, Lim DD, Serraon MLP. Stability of anterior
openbite correction with multiloop edgewise archwire therapy: a
cephalometric follow-up study. Am J Orthod Dentofac Orthop 2000;
118:43-54.
2. McLaughlin RP, Bennett JC, Trevisi HJ. Arch leveling and overbite
control. In: McLaughlin RP, Bennett JC, Trevisi HJ, editors.
Systemized orthodontic treatment mechanics. Edinburgh: Mosby
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Correspondence author :

Dr.Supranee Tawinburanuwong
Department of Orthodontics,
Faculty of Dentistry, Khon Kaen University,
Khon Kaen, 40002, Thailand
Tel./ Fax : (66) 4320-2863
E-mail : supra_ta@kku.ac.th

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