CASE REPORT

Anterior open bite with temporomandibular

disorder treated with titanium screw anchorage:
Evaluation of morphological and
functional improvement
Shingo Kuroda,a Yasuyo Sugawara,a Nagato Tamamura,b and Teruko Takano-Yamamotoc
Okayama, Japan

Skeletal anterior open bite is one of the most challenging malocclusions to correct because it is difficult to
establish absolute anchorage for molar intrusion with traditional orthodontic mechanics. In addition, patients
with anterior open bite sometimes have signs and symptoms of temporomandibular disorders (TMD). In this
article, we report the successful treatment of a patient with severe skeletal anterior open bite and TMD; we
used titanium screw anchorage. The patient, a woman, age 19 years 11 months, had an open bite of – 4.0
mm and increased anterior lower facial height. The titanium screws were implanted in the mandible, and
intrusion force was provided with elastic chains for 6 months. After active treatment for 36 months, her
mandibular first molars were intruded about 3.0 mm, and good occlusion was achieved. Her retrognathic
chin and convex profile were improved both by upward rotation of the mandible and advancement
genioplasty with vertical reduction. After treatment, the TMD signs and symptoms were reduced, and
improvements of both function and occlusion were achieved. Molar intrusion with titanium screw anchorage
might be a useful treatment option to improve function, occlusion, and facial esthetics in patients with severe
anterior open bite and TMD. (Am J Orthod Dentofacial Orthop 2007;131:550-60)

S
keletal anterior open bite is one of the most
difficult problems in orthodontic treatment. In an
adult patient, treatment of severe skeletal anterior
open bite consists mainly of surgical repositioning of
both the maxilla and the mandible.1-3 However, some
patients do not wish to undergo surgical treatment
because of its risks.
Recently, we reported on a patient with a severe
skeletal anterior open bite who was treated with molar
intrusion with titanium screws for orthodontic anchor-
age.4 Molar intrusion effectively corrected the anterior
open bite without excessive elongation of the anterior
teeth. In addition, the literature contains several reports
of molar intrusion with miniplates in patients with
anterior open bite.5-8 These reports indicated significant
From the Department of Orthodontics and Dentofacial Orthopedics, Okayama
University Graduate School of Medicine, Dentistry, and Pharmaceutical Sci-
ences, Okayama, Japan.
a
Assistant professor.
b
Graduate student.
c
Professor and chair.
Reprint requests to: Teruko Takano-Yamamoto, Department of Orthodontics
and Dentofacial Orthopedics, Graduate School of Medicine, Dentistry, and
Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-Cho, Okayama
700-8525, Japan; e-mail, t_yamamo@md.okayama-u.ac.jp.
Submitted, February 2005; revised and accepted, June 2005.
0889-5406/$32.00
Copyright © 2007 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.12.001
550
improvement of both facial profile and occlusion by
counterclockwise rotation of mandible after molar in-
trusion with stationary anchorage. However, there have
been few reports describing functional improvement
after the treatment of an anterior open bite with
significant mandibular rotation.
Several reports showed that anterior open bite is a
frequent type of malocclusion in patients with temporo-
mandibular disorders (TMD).9-11 On the contrary, re-
cent epidemiological studies have shown that open-bite
patients often suffer from TMD.12,13 Therefore, there
are some concerns about treating anterior open bite by
molar intrusion, because functional problems can occur
during or after orthodontic treatment.
This case report demonstrates successful treatment
results in both occlusion and function in a patient with
severe anterior open bite treated with titanium screws
for orthodontic anchorage.
DIAGNOSIS AND ETIOLOGY
A young woman, age 19 years 11 months, consulted
the outpatient clinic of our university hospital with a chief
complaint of TMD (Figs 1-4). She had an anterior open
bite in childhood, and it became worse as she matured.
She recalled having signs and symptoms of TMD for 3
years, and complained of spontaneous and dull pain in her
American Journal of Orthodontics and Dentofacial Orthopedics Kuroda et al 551
Volume 131, Number 4

Fig 1. Pretreatment facial and intraoral photographs (age 21 years 11 months).

Fig 2. Pretreatment dental models.

masseter muscles. She had a convex profile and an therapy, muscular pain was reduced, and the interincisal
anterior open bite with – 4.0 mm of overjet. The interin- distance at maximal mouth opening without pain had
cisal distance at maximal mouth opening without pain was increased to 40 mm. Orthodontic treatment was initiated
30 mm. Twenty-four months after manipulation and splint to create a stable occlusion.
552 Kuroda et al American Journal of Orthodontics and Dentofacial Orthopedics
April 2007

Fig 3. Pretreatment records: A, lateral cephalograph; B, lateral cephalometric tracing (solid line)
superimposed with mean profilogram (dotted line); C, panoramic radiograph.

The convex profile was due to a retrognathic
mandible. An acute nasolabial angle, increased lower
facial height, and circumoral muscle strain on lip
closure were observed. Facial asymmetry was observed
with mandibular deviation to the left. A severe anterior
open bite with an overjet of 6.0 mm and an overbite of
– 4.0 mm were observed. Mild crowding was present in
the mandibular incisors. The maxillary left second
premolar was congenitally absent. The maxillary and
mandibular dental midlines almost coincided, but they
were shifted 2.5 mm toward the left of the facial
midline.
When compared with Japanese norms,14 cephalo-
metric analysis showed a skeletal Class II relationship
(ANB angle, 11°) with mandibular retrusion (SNB
angle, 67°) (Table I). The mandibular plane angle was
steep (50.5°), and the gonial angle was normal (128°).
The mandibular body length was within the normal
range, but ramus height was short (43 mm). The
inclinations of the maxillary and mandibular incisors
were almost normal. The mandibular molars were
significantly extruded (26 and 42 mm), and the molar
relationships were Angle Class II on both sides. The
mandible was deviated to the left of the facial midline.
The patient still experienced slight muscular and
temporomandibular joint (TMJ) pain during mandibu-
lar movements and occasional spontaneous pain, al-
though these had decreased with manipulation and
American Journal of Orthodontics and Dentofacial Orthopedics Kuroda et al 553
Volume 131, Number 4

Fig 4. Pretreatment records: A, frontal cephalograph; B, tomogram of right TMJ; C, tomogram of

left TMJ; D, condylar and jaw movement on 6 degrees-of-freedom jaw movement recording system.
C, Condyle; M, molar; I, incisor; R, right side; L, left side.

Table I. Cephalometric summary

Variables Mean SD Preorthodontic treatment Postintrusion Posttreatment

Angles (°)
ANB 2.8 2.44 11.0 9.0 9.0
SNA 80.8 3.61 78.0 78.0 78.0
SNB 77.9 4.54 67.0 69.0 69.0
MP-FH 30.5 3.60 50.5 48.0 48.5
Gonial A 122.1 5.29 128.0 128.0 128.0
U1-FH 112.3 8.26 104.0 104.0 101.0
L1-MP 93.4 6.77 94.0 90.0 88.0
IIA 123.6 10.64 115.0 119.0 123.0
Occlusal P 16.9 4.40 23.0 17.0 18.0
Linear (mm)
S-N 67.9 3.65 69.5 69.5 69.5
N-Me 125.8 5.04 147.0 144.0 136.0
Me/NF 68.6 3.71 84.0 82.0 73.0
Ar-Go 47.3 3.33 43.0 43.0 43.0
Ar-Me 106.6 5.74 107.0 107.0 99.0
Go-Me 71.4 4.14 78.0 78.0 74.0
OJ 3.1 1.07 6.0 4.0 2.0
OB 3.3 1.89 ⫺4.0 0.0 2.0
U1/NF 31.0 2.34 34.0 34.0 34.0
U6/NF 24.6 2.00 26.0 26.0 27.0
L1/MP 44.2 2.68 53.0 54.0 54.0
L6/MP 32.9 2.50 42.0 39.0 39.5

splint therapy. TMJ clicking was detected on both (Gnathohexagraph system, version 1.31, Ono Sokki,
sides. Limitation of condylar movement on the right Kanagawa, Japan) (Fig 4, D). Magnetic resonance
side during opening jaw movement was observed on a imaging of the TMJs demonstrated anterior disc dis-
6 degrees-of-freedom jaw movement recording system placement without reduction. Tomograms of TMJs
554 Kuroda et al
Fig 5. A, Titanium screw; B, panoramic radiograph; C, intraoral photograph, after implantation of
titanium screws.
showed flattening and erosion of both condyles. The
right condyle had an anterior position relative to the
glenoid fossa (Fig 4, B and C). The interincisal distance
at maximal mouth opening without pain was 43 mm.
Occlusal force of 116 N and occlusal contact area of
2.31 mm2 were calculated on an occlusal force record-
ing system (Dental Prescale & Occluzer, Fuji Film,
Tokyo, Japan).
TREATMENT OBJECTIVES
The patient was diagnosed as having an Angle
Class II malocclusion, with a skeletal Class II jaw base
relationship, a skeletal anterior open bite, and a con-
genitally absent maxillary left second premolar. The
treatment objectives were to correct the anterior open
bite and establish an ideal overjet and overbite, to
achieve an acceptable occlusion with a good functional
Class I occlusion, and to correct the retrognathic facial
profile.
Because the mandibular molars were significantly
extruded, we planned to implant titanium screws for
anchorage to intrude these teeth; we expected a coun-
terclockwise rotation of the mandible after molar intru-
sion. We also planned an advancement genioplasty
with vertical reduction to correct the retrognathic pro-
file and to reduce excessive lower facial height.
TREATMENT ALTERNATIVES
Several procedures were explored to achieve ideal
overjet and overbite. Although mandibular advance-
ment with orthognathic surgery is considered an effec-
tive treatment methods, the patient did not want surgery
because it required prolonged hospitalization and
higher medical costs, and it was the most invasive
option. Therefore, we did not want to close the anterior
open bite by extruding the anterior teeth, because the
vertical relationship between the incisors and jaws was
considered acceptable before orthodontic treatment.
Intrusion of the extruded mandibular molars and coun-
American Journal of Orthodontics and Dentofacial Orthopedics
April 2007
terclockwise rotation of the mandible were desirable to
treat the anterior open bite.
TREATMENT PROGRESS
Before starting orthodontic treatment, an occlusal
splint was placed in the maxilla to reduce the symptoms
of TMD. Then, 0.018-in slot preadjusted edgewise
appliances were placed sectionally on both mandibular
molars. After leveling and alignment with nickel-
titanium archwires, 4 titanium screws (diameter, 2.3
mm; length, 11 mm, Keisei Medical Industrial, Tokyo,
Japan) were placed bilaterally into the posterior buccal
alveolar bone of the mandible as previously reported
(Fig 5).4
A mandibular lingual arch was placed between the
first molars to compensate for the buccal crown torque
that would be caused by the intrusive force. Then,
0.016 ⫻ 0.022-in beta-titanium archwires were placed,
and intrusion of the posterior teeth was started. Three
months after implantation of the titanium screws, load-
ing of the intrusion force (150 g) was started with
elastic chains (Fig 6). Six months after the start of
loading, the overbite had increased to 2 mm (Fig 6, D).
The mandible had shifted to the right, and the mandib-
ular dental midline was coincident with the facial
midline. Tomograms of the TMJs (Fig 7) show the right
condylar head in a central position relative to the
glenoid fossa. However, the magnetic resonance image
of the TMJs after mandibular molar intrusion showed
anterior disc displacement without reduction.
The maxillary right first premolar was extracted,
and leveling of the maxillary arch was started. The
maxillary anterior teeth were retracted to reduce the
excessive overjet and to correct the midline deviation.
During the finishing phase, advancement genioplasty
with vertical reduction was performed, and the titanium
screws were removed at the same time. The chin was
moved 5 mm superiorly and 6 mm anteriorly. The
implant screw anchorage remained stable for the dura-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 131, Number 4
Fig 6. Intraoral photographs during treatment: A, start of intrusion; B, 2 months later; C, 4 months
after start of intrusion; D, 6 months after start.
tion of treatment. Afterward, the screws were easily
removed with a screwdriver. After removal of the
edgewise appliances, a tooth positioner was placed to
retain both arches. The total active treatment period
was 36 months.
RESULTS ACHIEVED
The posttreatment records (Figs 8-10) show a dra-
matic change in the facial profile compared with the
pretreatment photographs. The retrognathic chin and
convex profiles were corrected, resulting in a straighter
Kuroda et al 555
profile. The facial proportions were improved, because
of the decrease in lower facial height. The strain in the
circumoral musculature during lip closure disappeared.
Posttreatment cephalometric evaluation showed
counterclockwise rotation of the mandible (Fig 11,
Table I). An Angle Class II molar relationship was
achieved on both sides. Overjet had decreased to 2.0
mm, and the anterior open bite had been corrected. The
dental midlines were coincident with the facial midline.
The mandibular first molars were intruded 3.0 mm.
Neither the maxillary nor the mandibular incisors were
556 Kuroda et al
Fig 7. Progress records at postintrusion: A, frontal cephalograph; B, tomogram of right TMJ; C,
tomogram of left TMJ; D, condylar and jaw movement on 6 degrees-of-freedom jaw movement
recording system. C, Condyle; M, molar; I, incisor; R, right side; L, left side.
extruded (Fig 11). The panoramic radiograph showed
some root resorption on the mandibular right molars.
When we evaluated jaw movements after treatment,
we found that the limitation of condylar movement had
disappeared. Both occlusal force and occlusal contact area
were increased (Table II). Pain or symptoms of TMDs
were significantly reduced, according to a retrospective
questionnaire with a 100-mm visual analog scale (Fig 12).
DISCCUSSION
This patient had a severe skeletal anterior open bite,
excessive lower facial height, chin deficiency, and
TMD. In such a patient, the treatment consists mainly
of surgical repositioning of the maxilla or the mandi-
ble.1-3 Orthognathic surgery in skeletal anterior open
bite provides significant improvement in both occlusion
and facial esthetics. Furthermore, several reports show
that orthodontic/surgical treatment results in improve-
ment in signs and symptoms of TMD.15,16 However,
Aghabeigi et al17 suggested that orthognathic surgery
did not improve TMD in patients with anterior open
bites. In addition, Hoppenreijs et al18 reviewed 259
patients treated for anterior open bites and suggested
that women with severe anterior open bites, high
mandibular plane angles, and low posterior-to-anterior
facial height ratios who underwent bimaxillary osteot-
omies were prone to condylar resorption. In addition,
orthognathic surgery requires surgical invasion with
postoperative discomfort and risks, as well as pro-
American Journal of Orthodontics and Dentofacial Orthopedics
April 2007
longed hospitalization. We had previously reported that
molar intrusion using titanium screws was quite useful
to improve both occlusion and facial esthetics in severe
anterior open bite patients, because significant counter-
clockwise rotation of the mandible had occurred.4 Our
patient did not have any functional problems, although
the mandibular plane was rotated more than 5°. There-
fore, we planned to intrude the elongated mandibular
molars using titanium screws.
The retrognathic profile was significantly improved
by counterclockwise rotation of the mandible and
advancement genioplasty with vertical reduction. The
chin was advanced 6 mm and reduced 5 mm vertically
at pogonion. These procedures decreased the anterior
lower facial height by 10 mm and achieved a functional
adaptation in circumoral musculature. We considered
these procedures less invasive for a patient than a
LeFort I osteotomy for maxillary impaction or a man-
dibular setback osteotomy.
The maxillary and mandibular dental midlines were
coincident, but they were deviated 2 mm to the left
compared with the facial midline before orthodontic
treatment. The congenitally missing left second premo-
lar caused deviation of the maxillary dental midline.
The mandible was also shifted to the left with anterior
dislocation of the right condyle; this was shown on the
TMJ tomogram. As a result of the molar intrusion, the
mandible was rotated counterclockwise and shifted to
the right with condylar repositioning. The condylar
American Journal of Orthodontics and Dentofacial Orthopedics Kuroda et al 557
Volume 131, Number 4

Fig 8. Posttreatment photographs (age 24 years 11 months).

Fig 9. Posttreatment dental models.

558 Kuroda et al
Fig 10. Posttreatment records: A, lateral cephalograph; B, posttreatment frontal cephalograph;
C, panoramic radiograph.
movement posttreatment was smoother than that pre-
treatment, and limitation of mouth opening was re-
duced. In addition, occlusal force was significantly
increased, and the evaluation of signs and symptoms of
TMD with the visual analog scale showed a dramatic
decrease in discomfort after orthodontic treatment.
Thus, we suggest that treatment of skeletal anterior
open bite with molar intrusion not only has a beneficial
effect on esthetic appearance and occlusion, but also
results in functional improvement.
As a result of counterclockwise rotation of the
mandible caused by the intrusion of molars, the condyle
was repositioned, and functional adaptation in circu-
moral musculature could be achieved. We suggest that
physiological adaptation of both condylar position and
circumoral musculature should be important factors in
American Journal of Orthodontics and Dentofacial Orthopedics
April 2007
decreasing the symptoms of TMD. However, it had
been difficult to achieve these skeletal improvements
by traditional orthodontic mechanics.19-21 Therefore,
treatment with titanium screws for molar intrusion
might become a new therapeutic approach for anterior
open-bite patients with TMD.
Intrusion of the teeth was considered a factor
associated with orthodontic-induced root resorp-
tion.22-24 Recently, some reports described the relation-
ships between root resorption and molar intrusion with
skeletal anchorage.25-27 An intrusive force of 150 g was
applied to the molars for 3 to 7 months, and the authors
indicated that slight root resorption was observed in the
apical root cementum. However, the degree of resorp-
tion was not clinically significant. In addition, there was
no root resorption in our previously reported patient
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 131, Number 4
Fig 11. Superimposition of cephalometric tracings be-
fore (solid black line) and after (dotted line) molar
intrusion with sectional arch and at posttreatment
(green line): A, superimposed on sella-nasion plane at
sella; B, superimposed on anterior palatal counter;
C, superimposed on mandibular plane.
Table II.Changes in occlusal force and contact area
through orthodontic treatment
Occlusal Occlusal contact
force (N) area (mm2)
Preorthodontic treatment
(after splint therapy) 116 2.3
Posttreatment 631 13.9
with skeletal anchorage for molar intrusion,4 although
root resorption of the mandibular right molars was
observed in this patient. Dellinger22 reported, in an
animal study, that light forces (50-100 g) provided
optimal intrusion with minimal damage, whereas ex-
cessive intrusion force (300 g) caused severe root
resorption. In addition, Al-Qawasami et al28 implicated
a substantial genetic component in external apical root
resorption during orthodontic treatment. Thus, 150 g of
applied intrusive force might have been excessive for
this patient. We suggest that it is necessary to determine
the amount of intrusion force individually and serially
evaluate the root condition by radiographic examina-
tion during treatment.
Molar intrusion can cause pseudo-pockets or alve-
olar bone loss during and after treatment. Sugawara et
al7 reported no significant changes in crestal bone
heights and clinical crown lengths after molar intrusion
with skeletal anchorage. In addition, they also reported
that pseudo-pockets were not observed around the
intruded molars. In our patient, clinical crown length
Kuroda et al 559
Fig 12. Intensity of symptoms of TMD during treatment
indicated by visual analog scale assessments. T1, Pre-
treatment; T2, after splint therapy (before orthodontic
treatment); T3, posttreatment.
and alveolar bone height were stable, and periodontal
pocket depth was not increased around the mandibular
molars. Melsen et al29 reported in their animal study
that new cementum formation and new collagen attach-
ment were observed after intrusion, and periodontal
pocket depth was not increased if good oral hygiene
was maintained. Our patient had adequate oral hygiene
during orthodontic treatment. Therefore, we believe
that it is important to maintain good oral hygiene during
and after orthodontic tooth intrusion.
It is well known that long-term stability can be
achieved after surgical treatment for anterior open
bites.1-3 In a recent report of long-term stability in
anterior open-bite patients treated with miniplate skel-
etal anchorage, 30% of the amount of molar intrusion
relapsed in the mandible.7 In our previously reported
patient, little relapse was observed 1 year posttreat-
ment, even though the molars in both jaws had been
intruded about 3 mm.4 As a result of a significant
counterclockwise rotation of the mandible caused by
the intrusion of molars, the functional adaptation in
circumoral musculature might be more easily achieved.
We suggest that the functional adaptation in muscula-
ture should be an important key in retention of anterior
open bites. However, the long-term stability after treat-
ment for anterior open bite with skeletal anchorage
remains unknown. It is a topic for future study in
implant orthodontics.
CONCLUSIONS
We treated an adult with severe skeletal anterior
open bite and TMD using titanium screws for skeletal
560 Kuroda et al
anchorage. After treatment, TMD signs and symptoms
were reduced, and both function and occlusion were
improved. Therefore, we suggest that molar intrusion in
a patient with severe anterior open bite and TMD might
be useful to improve function, occlusion, and facial
esthetics.
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