CONTINUING EDUCATION ARTICLE

Cephalometric evaluation of open bite treatment with NiTi arch

wires and anterior elastics

Nazan Küçükkeles,, DDS, PhD,a Ahu Acar, DDS, PhD,b Arzu A. Demirkaya, DDS,c Berna Evrenol,
DDS,c and Ayhan Enacar, DDS, PhDd
Istanbul and Ankara, Turkey

The aim of this study was to evaluate cephalometrically the effects of open bite treatment with NiTi arch
wires and anterior elastics. The study group comprised of 17 patients who displayed a high angle skeletal
pattern, along with an anterior open bite. After initial leveling, 0.016 × 0.022 inch upper accentuated-curve
and lower reverse-curve arch wires were placed, with anterior elastics applied in the canine regions.
Cephalometric assessment was carried out on lateral head films taken at the beginning of treatment and on
average 2.8 months after open bite closure was obtained. The results of this study indicated that open bite
closure had been 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.
Lateral cephalograms obtained from 10 patients who had been available after 1 year postretention were
used to evaluate relapse changes. During the follow-up period, 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. (Am J Orthod Dentofacial Orthop 1999;116:555-62)

Treatment of a malocclusion characterized nique include correction of the inclination of the

by open bite can be a difficult task for the orthodontist
because such a malocclusion develops as a result of the
interplay of many different etiologic factors.1-3 Skeletal
open bite cases are usually characterized by an increase
in the vertical growth of the maxillary posterior den-
toalveolar segments.3,4 As intrusion of posterior teeth
becomes more difficult with older age, mechanical
treatment options are limited in adult patients. Orthog-
nathic surgery is indicated in adult patients with severe
open bite and unesthetic facial proportions. For the
treatment of borderline cases, and those individuals
who are reluctant to undergo surgery, the search for
effective treatment modalities continues.
One of the methods available for the treatment of
open bite is the multiloop edgewise arch wire tech-
nique developed by Kim.5 This technique involves the
use of multiloop gable bend arch wires with vertical
elastics in the canine regions. The goals of this tech-
aAssociate professor, Department of Orthodontics, Marmara University, Faculty
of Dentistry, Istanbul.
bAssistant professor, Department of Orthodontics, Marmara University, Faculty
of Dentistry, Istanbul.
cResearch Assistant, Department of Orthodontics, Marmara University, Faculty
of Dentistry, Istanbul.
dProfessor, Department of Orthodontics, Hacettepe University, Faculty of Den-
tistry, Ankara.
Reprint requests to: Dr Ahu Acar, Marmara Üniversitesi, Dis, Hekimliǧi Fakül-
tesi, Ortodonti Anabilim Dalı, Büyükçiftlik Sok. No: 6 Nis,antas,ı İstanbul 80200
Türkiye; e-mail, erverdi@turk.net
Copyright © 1999 by the American Association of Orthodontists.
0889-5406/99/$8.00 + 0 8/1/97248
occlusal planes, alignment of the maxillary incisors
relative to the lip line, and uprighting of the axial incli-
nations of the posterior teeth. Using this technique,
Goto et al6 and Sato7 reported successful treatment
outcomes.
Enacar et al8 modified Kim’s5 technique by using
0.016 × 0.022 inch upper accentuated-curve and lower
reverse-curve nickel titanium arch wires instead of
multiloop gable bend arch wires, with the intermaxil-
lary elastics applied in the canine regions. They sug-
gested that upper accentuated-curve and lower reverse-
curve nickel titanium arch wires were simpler and
more hygienic compared to multiloop arch wires, they
reduced chairtime, and did not irritate the soft tissues.
Enacar et al8 reported that their results were similar to
those obtained by the multiloop edgewise arch wire
system.
The aim of the present study was to evaluate the
changes in dentofacial structures of open bite patients
treated with upper accentuated-curve and lower reverse-
curve NiTi arch wires and intermaxillary elastics.
SUBJECTS AND METHODS
The sample consisted of 17 patients (12 females
and 5 males). Mean ages for females and males were
19.5 years and 19 years, respectively. All of the cases
presented with a high angle skeletal pattern (SN-Go-
Me > 37°) and an anterior open bite that ranged
between 2 and 11 mm with the average being 4.05
555
556 Küçükkeles, et al
A
B tics were continued to be worn. Average treatment
Fig 1. A, Intrusive effect of upper accentuated-curve and
lower reverse-curve NiTi arch wires on anterior teeth. B,
Intrusive force and uprighting moment is created in pos-
terior teeth.
mm. Skeletal relationship in the sagittal direction was
Class I, and the dental relationship was Class I or mild
Class II.
Treatment Procedure
After the placement of bands and 0.018 inch slot
brackets, treatment was initiated with 0.0175 inch
coaxial arch wires. The leveling phase was continued
with 0.016 inch round stainless steel arch wires. After
leveling was finished, 0.016 × 0.022 inch upper accen-
tuated-curve and lower reverse-curve nickel titanium
arch wires were placed. The biomechanical basis of the
appliances is shown in Fig 1. When used without ante-
rior elastics, upper accentuated-curve and lower
American Journal of Orthodontics and Dentofacial Orthopedics
November 1999
Fig 2. Intrusive effect of arch wires is counteracted by
elastics applied in canine regions.
reverse-curve arch wires create an intrusive effect on
the upper and lower incisors. With the addition of ver-
tical elastics in the canine regions, the intrusive forces
that act on the anterior region are canceled, while
those that act on the posterior teeth are allowed. The
intrusive force of the wires on the anterior teeth was
counteracted with two 3⁄16 inch, 6 oz elastics placed
between upper and lower canines on both sides. The
patients were instructed to renew their elastics once a
day (Fig 2).
Once the open bite in the canine region was elimi-
nated, the elastics were applied in box form until 3
months after incisal overlap was fully achieved. After
removal of the NiTi arch wires, 0.017 × 0.022 inch
stainless steel arch wires were inserted and kept in
place for a period of 3 months, during which box elas-
time with fixed appliances was 16 months. After
debonding, positioners were inserted for 3 months,
followed by Hawley retainers which were worn for 6
months (Figs 3-5).
Cephalometric evaluation of the treatment changes
was conducted on lateral cephalograms from 17
patients, taken at the beginning and on average 2.8
months after an overbite of 1 to 2 mm was obtained
(Figs 6-8). Follow-up changes were assessed on lateral
cephalograms obtained from 10 patients who were
available at our clinic at the end of 1 year postretention
period.
Twenty randomly selected cephalograms were
retraced 1 week after the original tracing session. The
error between duplicate determinations was assessed
using Dahlberg’s9 formula. The error ranged between
0.13 and 0.76 mm for the linear measurements and
0.17° and 0.87° for the angular measurements. The
coefficient of reliability exceeded 90% for all the mea-
surements.10
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 116, Number 5
Fig 3. Pretreatment extraoral and intraoral photographs.
The statistical package NCSS (Number Cruncher
Statistical System) was used for statistical evaluation of
the data. Cephalometric changes from pretreatment to
posttreatment films and from posttreatment to postre-
tention films were evaluated by paired t test.
RESULTS
Posttreatment cephalometric changes attained with
this treatment are shown in Tables I and II.
Skeletal Changes
The two skeletal parameters that were altered sig-
nificantly at the end of therapy were N-Me and ANS-
Me. N-Me increased by 2.29 mm (P < .01) and ANS-
ME by 2.50 mm (P < .001).
Dental Changes
Upper incisors were both uprighted and extruded as
shown by the 6.41° decrease in U1-PP (P < .01) and
3.15 mm increase in U1-PP (mm) (P < .001). The
upper first molar was extruded by 1.11 mm (P < .01).
Küçükkeles, et al 557
L1-MP (mm), L4-MP (mm), and L6-MP (mm)
parameters increased by 3.35 mm (P < .001), 2.59 mm
(P < .001), and 1.39 mm (P < .01), respectively, indi-
cating extrusion of lower incisors, first premolars and
first molars. In addition, the lower first molar was
uprighted by 8.35° (P < .001).
There was a 1.79 mm decrease in overjet (P < .05),
and a 5.37 mm increase in overbite (P < .001).
SN-FOP decreased by 2.09° (P < .01) and FOP/MP
increased by 2.38° (P < .001).
Skeletal Changes at the End of 1 Year Follow-up
Period (Table III)
N-Me and ANS-Me increased by 2.20 mm and 2.30
mm, respectively. The rest of the skeletal parameters
showed no significant change.
Dental Changes at the End of 1 Year Follow-up
Period (Table IV)
Upper first molar and lower first molar were
extruded by 1.05 mm and 1.70 mm, respectively (P <
558 Küçükkeles, et al
Fig 4. Posttreatment extraoral and intraoral photographs.
.05, P < .01). Upper first premolar and lower first pre-
molar were extruded by 1.40 mm and 1.85 mm, respec-
tively (P < .01). Overbite decreased by 1.25 mm (P <
.01). The rest of the dental parameters, including the
parameters related to occlusal plane and upper and
lower incisors showed no significant alteration.
DISCUSSION
The results of this study indicated that bite closure
had been achieved to a great extent by extrusion of the
lower incisors and uprighting of the upper incisors.
Elastics, which were applied to prevent incisor intru-
sion as a result of NiTi arch wires, caused extrusion and
uprighting of the incisors. The 3.15 mm extrusion mea-
sured in the upper incisors was in part due to the
change in the relative distance of the incisor tip to the
palatal plane that took place as the central incisor was
being uprighted.
Although the configuration of the arch wires in
the molar region forced the molars to be both
intruded and uprighted, no molar intrusion took
place. Instead, the molars were extruded while being
American Journal of Orthodontics and Dentofacial Orthopedics
November 1999
uprighted. Extrusion of molars is an undesirable
treatment effect in the group of patients that formed
our study sample. However, the amount of molar
extrusion in the present study was minimal (1 mm),
and it may have been related to the selection of
mesiobuccal cusp tip of the first molar as a landmark
for linear measurements. Mesiobuccal cusps of both
upper and lower first molars were elevated as a result
of the uprighting movement caused by the upper
accentuated-curve and lower reverse-curve arch
wires. Extrusion of lower premolars and uprighting
of lower molars have led to rotation of the functional
occlusal plane in a counterclockwise direction, thus
decreasing its steepness. The increase in N-Me and
ANS-Me could be attributed to this 1 mm extrusion
of upper and lower first molars, which may have
caused slight clockwise rotation of the mandible.
However, this change was not reflected in mandibu-
lar plane angle, which stayed stable throughout treat-
ment. Extrusion of lower incisors, increase in over-
bite, and uprighting of upper incisors were in
accordance with the findings of Goto et al 6 and
American Journal of Orthodontics and Dentofacial Orthopedics Küçükkeles, et al 559
Volume 116, Number 5

Fig 5. Photographs of patient after 1 year follow-up period.

Enacar et al.8 Furthermore, uprighting of teeth in the

buccal segments and the alteration of the occlusal
plane to SN angle were in agreement with the reports
of Enacar et al 8 On the other hand, Goto et al 6
reported an increase in SNB angle and a decrease in
ANB and mandibular plane angles, while in the pre-
sent study no significant difference was noted regard-
ing these parameters. Although Goto et al 6 and
Enacar et al 8 reported significant lower incisor
uprighting, lower incisors were uprighted by 1.26° in
the present study, a difference that was not found sta-
tistically significant.
The uprighting and relative extrusion of the upper
incisors during treatment could increase the maxillary
gingival display of the patients when smiling. Thus, it
is of utmost importance to exclude those individuals
who already show a “gummy smile” at the beginning of
the treatment.
The effects of this treatment method were similar to
those of the multiloop edgewise arch wire system in Fig 6. Skeletal measurements: (1) SN-MP, (2) SN-PP, (3)
that the inclination of the occlusal plane was corrected, SNA, (4) SNB, (5) ANB, (6) SN-Pg, (7) N-Me, (8) ANS-Me.
560 Küçükkeles, et al American Journal of Orthodontics and Dentofacial Orthopedics
November 1999

Fig 7. Dental measurements: (1) SN-functional occlusal

plane (FOP), (2) mandibular plane (MP)-FOP, (3) U1-palatal
Fig 8. Superimposition of pretreatment and posttreat-
plane (PP), (4) U1-PP (mm), (5) U4-PP (mm), (6) U6-PP, (7)
ment lateral cephalograms.
U6-PP (mm), (8) L1-MP, (9) L1-MP (mm), (10) L4-MP (mm),
(11) L6-MP, (12) L6-MP (mm), (13) overjet, (14) overbite.

Table I. Comparison of pretreatment and posttreatment skeletal measurements (N = 17)

Pretreatment Posttreatment
Mean SD Mean SD Difference SD P

SN-MP 40.47 5.81 40.73 5.78 0.26 1.28 NS

SN-PP 8.44 3.57 7.97 3.69 –0.47 1.75 NS
N-Me 127.94 6.95 130.23 6.53 2.29 3.27 **
ANS-Me 75.02 6.47 77.52 5.51 2.50 2.41 ***
SNA 78.91 3.74 78.97 3.29 0.06 1.49 NS
SNB 76.26 3.30 76.11 3.37 –0.15 1.37 NS
ANB 2.64 2.42 2.85 2.28 0.21 1.13 NS
SN-Pg 77.14 3.49 77.05 3.36 –0.09 1.09 NS

NS, Not significant.

**P < .01.
***P < .001.

open bite was corrected by extrusion of the lower
incisors and uprighting of the upper incisors, and axial
inclinations of the posterior teeth were uprighted.
Working with upper accentuated-curve and lower
reverse-curve NiTi arch wires was less time consuming
compared with multiloop arch wires. The patients did
not have any difficulty in maintaining their oral
hygiene, and there was no complaint about oral soft tis-
sue irritations.
Stability of treatment effects is probably the most
important criterion when deciding on a treatment method
for open bite correction. Posterior mandibular rotation
resulting from growth after treatment11 or extrusion of
posterior teeth during treatment12 has been reported as an
important factor for open bite relapse. Cephalometric
evaluation of 10 patients at the end of 1 year postretention
has shown that although upper and lower incisor positions
and the inclination of functional occlusal plane had been
maintained, there was a decrease in overbite that was due
to extrusion of upper and lower first molars. Total anterior
and lower anterior face heights were increased, again as a
result of upper and lower molar extrusion.
Relapse into anterior open bite can occur by
depression of the incisors and/or elongation of the
American Journal of Orthodontics and Dentofacial Orthopedics Küçükkeles, et al 561
Volume 116, Number 5

Table II. Comparison of pretreatment and posttreatment dental measurements (N = 17)

Pretreatment Posttreatment
Mean SD Mean SD Difference SD P

SN-FOP 21.38 5.25 19.29 4.69 –2.09 2.34 **

MP-FOP 18.85 3.75 21.23 3.29 2.38 2.26 ***
1-PP 116.50 5.25 110.09 8.07 –6.41 8.88 **
1-PP (mm) 30.23 2.60 33.38 3.07 3.15 3.14 ***
4-PP (mm) 29.82 3.02 30.52 2.30 0.70 1.67 NS
6-PP 101.58 8.17 102.97 4.21 1.39 8.32 NS
6-PP (mm) 26.44 2.29 27.55 1.85 1.11 1.62 **
1-MP 87.76 7.02 86.50 7.35 –1.26 8.54 NS
1-MP (mm) 41.82 3.13 45.17 3.61 3.35 2.15 ***
4-MP (mm) 37.85 3.26 40.44 2.86 2.59 2.55 ***
6-MP 99.94 4.19 108.29 9.76 8.35 8.25 ***
6-MP (mm) 33.14 2.89 34.52 2.79 1.38 1.66 **
Overjet 4.64 3.11 2.85 1.04 –1.79 3.55 *
Overbite –4.05 2.92 1.32 1.11 5.37 2.67 ***

NS, Not significant.

*P < .05.
**P < .01.
***P < .001.

Table III. Comparison of posttreatment and postretention skeletal measurements (N = 10)

Pretreatment Postretention
Mean SD Mean SD Difference SD P

SN-MP 38.50 4.90 38.90 5.40 0.40 1.07 NS

SN-PP 6.80 3.18 6.95 2.75 0.15 1.56 NS
N-Me 129.90 6.69 132.1 6.20 2.20 1.87 **
ANS-Me 78.30 5.16 80.60 5.03 2.30 2.58 *
SNA 79.05 3.29 78.40 3.79 –0.65 1.02 NS
SNB 77.20 2.76 76.45 3.05 –0.75 1.20 NS
ANB 1.85 1.76 1.95 1.55 0.10 0.84 NS
SN-Pg 78.35 2.77 77.75 2.82 –0.60 1.07 NS

NS, Not significant.

*P < .05.
**P < .01.

Table IV. Comparison of posttreatment and postretention dental measurements (N = 10)

Pretreatment Postretention
Mean SD Mean SD Difference SD P

SN-FOP 17.50 3.77 17.25 3.85 –0.25 2.40 NS

MP-FOP 20.75 3.50 21.50 4.27 0.75 2.30 NS
1-PP 111.40 8.29 112.95 6.99 1.55 6.80 NS
1-PP (mm) 34.05 2.20 34.40 2.91 0.35 2.43 NS
4-PP (mm) 31.00 1.45 32.40 2.07 1.40 1.26 **
6-PP 103.40 4.06 101.80 5.73 –1.60 5.55 NS
6-PP (mm) 28.20 1.22 29.25 1.85 1.05 1.30 *
1-MP 87.45 7.15 86.90 5.23 –0.55 5.16 NS
1-MP (mm) 45.45 4.47 46.10 3.02 0.65 2.81 NS
4-MP(mm) 40.35 3.41 42.20 3.48 1.85 1.82 **
6-MP 107.45 10.17 103.20 3.85 –4.25 9.15 NS
6-MP(mm) 34.55 3.41 36.25 3.12 1.70 1.65 **
Overjet 2.60 0.56 3.50 1.15 0.90 1.57 NS
Overbite 1.75 1.16 0.50 1.76 –1.25 1.03 **

NS, Not significant.

*P < .05.
**P < .01.
562 Küçükkeles, et al American Journal of Orthodontics and Dentofacial Orthopedics
November 1999

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of eruption of the posterior teeth.
CONCLUSIONS
Treatment changes obtained by using NiTi arch
wires and anterior elastics were similar to those
reported to be achieved by multiloop edgewise arch
wire technique. Although long-term follow-up studies
are yet to be done, ease of application and patient com-
fort provided by this newer method can make it an alter-
native for multiloop edgewise arch wire technique.
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