ORIGINAL ARTICLE

Three-dimensional evaluation of
open-bite patients treated with anterior
elastics and curved archwires
€ çu
Buket Erdem and Nazan Ku € kkeleş
Istanbul, Turkey

Introduction: One nonsurgical treatment method for a patient with open bite is to use curved nickel-titanium
arches and anterior elastics. The aim of this study was to investigate the effects of this technique with
cone-beam computed tomography. Methods: Eighteen open-bite patients' treatment records were used for
this retrospective study. The treatment methods were identical for all patients, beginning with the levelling
and alignment of the teeth and the placement of maxillary accentuated and mandibular reverse curved
archwires with anterior elastics. Cone-beam tomography images were taken and analyzed 3 dimensionally.
The paired-samples t test statistical analysis was performed. Results: A-point moved anteriorly (0.33 mm)
and the SN-MP angle increased slightly (1.17
). Maxillary and mandibular incisors were extruded by 2.16 and
1.49 mm, respectively. Overbite increased (4.38 mm). There were no significant changes in the vertical
parameters of the premolars and molars. Conclusions: The open bite was eliminated by retraction and
extrusion of the anterior teeth while maintaining the vertical positions of the molars. (Am J Orthod Dentofacial
Orthop 2018;154:693-701)

W
hen treating a patient with an open bite, the
main concern is to control the vertical
dimension by preventing the extrusion of
both mandibular and maxillary molars.1 It has been
shown that every 1 mm of extrusion of the molars
causes a 2-mm decrease in overbite.2 Furthermore,
studies have reported that 1 to 4 mm of molar extrusion
occur during the first year of any fixed orthodontic
treatment.3,4 Therefore, the effects of the treatment
method on the molars are much more crucial in
open-bite patients.
There have been numerous efforts to develop
treatment methods that intrude or maintain the verti-
cal position of posterior teeth in open-bite patients.5-8
In 1987, Kim9 introduced the multiloop edgewise
archwire (MEAW) technique, which comprises L-
shaped loops between the teeth. According to this
technique, every loop has tip-back bends so that the
Private practice, Istanbul, Turkey.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Buket Erdem, Halaskargazi Mah. Valikonagi Cad.
Nuribey Is Merkezi No:65 D:5 Nisantasi-Sisli, Istanbul, Turkey, 34371; e-mail,
buketerd@gmail.com.
Submitted, November 2017; revised and accepted, January 2018.
0889-5406/$36.00
Ó 2018 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2018.01.021
maxillary archwire has an accentuated curve of Spee,
and the mandibular archwire has a reverse curve of
Spee. With the use of anterior vertical elastics and
these bent wires, clockwise rotation of the maxillary
occlusal plane and counterclockwise rotation of the
mandibular occlusal plane are obtained, and the
open bite is closed.10
Some authors have modified the MEAW technique,
by using accentuated curve of Spee nickel-titanium
(NiTi) archwires for maxillary teeth and reverse curve
of Spee NiTi archwires for mandibular teeth at the
same time with anterior vertical elastics. According to
these reports, the bite closing mechanism and the treat-
ment results were smilar to those of Kim.9 Moreover, it
was stated that elimination of the bends resulted in
better hygiene and was less time-consuming. All of
these above-mentioned studies were conducted with
2-dimensional (2D) cephalometric images. Neverthe-
less, more accurate evaluations of tooth positions are
possible with cone-beam computed tomography
(CBCT) technology.
Therefore, the aim of this study was to assess the ef-
fects of the treatment method comprising maxillary
accentuated curve of Spee and mandibular reverse curve
of Spee NiTi archwires, and anterior vertical elastics, on
skeletal, dental, and soft tissues with CBCT volumetric
images.
693
694
Fig 1. A, Passive curved arches; B, anterior vertical elastics.
MATERIAL AND METHODS
This retrospective study was conducted on the treat-
ment records of 18 open-bite patients, with an average
age of 17.77 years. The study was approved by the ethics
committee of Marmara University in Istanbul, Turkey.
Inclusion criteria for the study were a Class I or a mild
Class II skeletal and dental relationship, all permanent
teeth, mild to moderate open bite, normal or minimally
increased facial height, and 2 consecutive CBCT images
of good quality with adequate landmark visualization
and minimal or no rotation of the head, taken before
and after the specific treatment method. All patients
meeting these criteria were included in the study regard-
less of treatment results. Patients who had undergone
surgically assisted maxillary expansion treatment were
excluded from the study.
All the photography and tomography records were
retrieved from the archives of the Faculty of Dentistry,
Department of Orthodontics, of Marmara University.
The cephalometric images were obtained from CBCTs.
The treatment protocol was identical for all patients;
0.022-in slot MBT metal brackets were used. Both
maxillary and mandibular teeth, including the
second molars, were levelled and aligned starting with
0.014-in NiTi archwires. After levelling, 0.017
3 0.025-in maxillary accentuated curve of Spee and
mandibular reverse curve of Spee NiTi archwires were
placed, and the first CBCT images were taken concur-
rently (T1). To apply the anterior box elastics, surgical
hooks were placed between the central and lateral inci-
sors. Box elastics were applied from the maxillary surgi-
cal hooks and the canine bracket hooks extending to the
mandibular surgical hooks, and the canine bracket hooks
on both sides (Fig 1). The force applied by the elastics
was measured with a gauge at the rest position, and
the forces were calibrated to 100 g per side. The patients
were instructed to wear their elastics full time and renew
them once a day. A patient's treatment records are
shown in Figures 2-4.
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Once ideal overbite was achieved, the patients were in-
structed to use their elastics for another 8 weeks on
0.017 3 0.025-in stainless steel archwires without curves,
and then the second CBCT images were obtained (T2).
The effects of the treatment were investigated on these
3-dimensional (3D) volumetric tomographic images and
the cephalometric images obtained from them. All CBCT
images were taken with the same device (Iluma; 3M IMTEC,
Ardmore, Okla) under standardized settings. All CBCT data
were saved in DICOM format. The DICOM data were trans-
ferred to the MIMICS software (version 18.0; Materialise,
Leuven, Belgium), and 3D images were created.
Nine skeletal, 18 dental, and 3 soft tissue reference
points were marked on each patient's 3D images
(Table I). Reference planes were created as described in
Table II, and linear measurements were made accord-
ingly. Seven skeletal and 6 dental reference points
were marked on the cephalometric images.
Two vertical (RP2-RP4) and 2 horizontal (RP1-RP3)
planes were created to measure horizontal and vertical
movements of the reference points (Table II; Fig 5).
Statistical analysis
Statistical analyses of the study data were made using
SPSS software (version 22; IBM, Armonk, NY). Confor-
mity of the parameters to normal distribution was as-
sessed with the Kolmogorov-Smirnov test, and it was
determined that all parameters had normal distributions.
The paired-samples t test was used for within-group
comparisons of parameters with normal distribution. In
the analysis of method error of parameter measure-
ments, the intraclass correlation coefficient (ICC) was
calculated. A value of P \0.05 was accepted as statisti-
cally significant.
RESULTS
The CBCT images and the cephalometric changes ob-
tained with this treatment mechanism are shown in
Tables III-V.
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Fig 2. Pretreatment extraoral and intraoral photographs.

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696
Fig 3. Treatment progress: A, levelling stage; B, placement of NiTi archwires and hooks; C, after
2 months of elastic usage.
Statistically significant increases were determined
in the RP2-A parameter (P \0.05) and the SN-MP
angle (P \0.01). A-point was repositioned by
0.33 mm anteriorly. The mandibular plane angle
increased by 1.17
. The other skeletal parameters
remained unchanged.
Statistically significant increases were determined in
the soft tissue parameters RP1-Li (P \0.05), RP1-Pog΄
(P \0.05), and RP1-Ls (P \0.01). The upper and lower
lips and soft tissue pogonion moved to lower positions.
Both maxillary and mandibular incisors and ca-
nines were upright and extruded significantly
(P \0.01). However, there were no significant
changes in the vertical parameters of the premolars
and the molars. According to the cephalometric find-
ings, the IMPA and U1-SN parameters decreased by
5.8
(P \0.01) and 5.5
(P \0.01), respectively.
SN-UOP increased by 3.7
(P \0.01), and overbite
increased by 4.4 mm (P \0.01).
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DISCUSSION
In nongrowing patients generally, extrusion of the
posterior teeth accompanies anterior open bite. The ideal
treatment approach is to intrude or inhibit vertical move-
ment of the posterior teeth. One treatment method that
works well for this purpose is the MEAW technique, which
has been proven to be effective for the treatment of open-
bite malocclusions.9 Its bends form the stainless steel
archwires as an accentuated curve of Spee for the maxil-
lary arch and a reverse curve of Spee for the mandibular
arch to correct the open bite.10 By using anterior vertical
elastics with those wires, the intrusion effect of the curved
arches on the anterior teeth is transferred to the posterior
region. Thus, the open bite is closed by uprighting the
posterior teeth, extruding and retracting the anterior
teeth, and changing the maxillary and mandibular
occlusal planes' inclinations toward each other.10 Howev-
er, it has been suggested that this technique requires high
professional skills.11
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Fig 4. Posttreatment extraoral and intraoral photographs.

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698
Table I. Dental reference points used on the 3D
images
Point Definition
U1R Midmost point of maxillary right first incisor's incisal edge
U3R Midmost point of maxillary right canine tip
U3L Midmost point of maxillary left canine tip
U5R Buccal cusp tip of maxillary right second premolar
U5L Buccal cusp tip of maxillary left second premolar
U6R Trifurcation of maxillary right first molar
U6L Trifurcation of maxillary left first molar
U7R Trifurcation of maxillary right second molar
U7L Trifurcation of maxillary left second molar
L1R Midmost point of mandibular right first incisor's incisor edge
L3R Midmost point of mandibular right canine tip
L3L Midmost point of mandibular left canine tip
L5R Buccal cusp tip of mandibular right second premolar
L5L Buccal cusp tip of mandibular left second premolar
L6R Trifurcation of mandibular right first molar
L6L Trifurcation of mandibular left first molar
L7R Trifurcation of mandibular right second molar
L7L Trifurcation of mandibular left second molar
Table II. Planes created on 3D images
Plane Definition
RP1 Frankfort horizontal plane, constituted by right and left
porions and right orbitale
RP2 Vertical to RP1, passing through the right and left porions
RP3 Mandibular plane, constituted by the right and left
gonions and mentons
RP4 Vertical to RP3, passing through the right and left gonions
To make the MEAW technique simpler, more hy-
gienic, and less irritating for the soft tissues, Enacar
et al12 developed an alternative technique, in which rect-
angular NiTi archwires (maxillary accentuated curve of
Spee and mandibular reverse curve of Spee) and anterior
vertical elastics were included. They reported similar
treatment results to those obtained with MEAW.
K€ ukkeleş et al13 also treated a group of open-bite pa-
uç€
tients with this modified technique and reported obvious
extrusion and retraction of the incisors. As for the mo-
lars, there was no consensus in the previous studies
whether these techniques have any vertical control.
However, no studies were conducted with CBCT technol-
ogy, which warrents more accurate evaluation of tooth
positions than the previous 2D measuring techniques.
When the intrusion effect obtained on posterior teeth
is determined, one of the biggest problems on lateral
cephalogram radiographs is superposition of the right
and left landmarks.14 To overcome this problem, Endo
et al15 used oblique cephalograms in their MEAW study,
and so they performed all the measurements on the right
and left sides separately. Also, selecting a reference point
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for determining intrusion effect is crucial. Using the cusp
tips or root apices as reference points could create a false
perception, since their positions are affected by tipping
movements of the teeth. True molar intrusion can only
be determined when the center of resistance of the molar
is used as the reference point.16 Therefore, in this study,
we had the advantage of marking the molars' centers of
resistance (trifurcations) on both sides while we had 3D
images of the patients.
In some studies, to measure vertical dental move-
ments, the palatal plane and mandibular plane have
been used as the reference planes, since they are not
influenced by tooth movements.17 Kim et al,9 Chang
and Moon,18 and Kuo et al19 measured the vertical
movements of the maxillary teeth according to the
palatal plane. In our study, the Frankfort horizontal
plane was used, as demonstrated in some previous
studies evaluating molar movements.15,20,21
We evaluated the patients' skeletal, dental, and soft
tissue changes after the specific treatment method. A
significant skeletal change was the 0.3 mm of forward
movement of A-point, which we believe does not have
clinical importance. This might be explained by the
maxillary incisor root moving forward during retroclina-
tion caused by anterior elastics. Researchers have
demonstrated a statistically significant correlation be-
tween maxillary incisor inclination and the position of
A-point.22,23 When the maxillary incisors are proclined,
A-point repositions posteriorly.22 Contrarily, retroclina-
tion of the maxillary incisors leads to anterior movement
of A-point.23
In this study, the mandible had 1.16
of clockwise
rotation, which does not have clinical value. Perhaps
this rotation was caused by distal uprighting of the
maxillary and mandibular molars, leading to insignifi-
cant amounts of posterior tooth extrusion. This agrees
with the results of Kim et al10 and K€ ukkeleş et al.13 Ri-
uç€
11
beiro et al reported a case in which a vertical chincup
was used for vertical control during the levelling stage
before MEAW application and concluded that the
mandibular plane angle was still increased. Moreover,
Endo et al15 treated 17 open-bite patients with MEAW
and found that the most significant skeletal change
was the downward and backward rotation of the
mandible; this also agrees with our findings.
According to the dental changes observed in this
study, the maxillary and mandibular incisors and ca-
nines were considerably extruded. The maxillary and
mandibular incisors had 2.16 and 1.49 mm of extru-
sion, respectively. Thus, overbite increased by
4.38 mm. Kim et al10 found 4.01 mm of overbite in-
crease, 1.29 mm of extrusion of maxillary incisors,
and 1.86 mm of extrusion of mandibular incisors in
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Fig 5. Reference planes created on 3D images: A, RP1 and RP2 for maxillary structures; B, RP3 and
RP4 for mandibular structures.

0.5 mm.19 In another MEAW study, conducted with ob-

Table III. Comparison of T1 and T2 skeletal and soft
lique cephalograms, it was also found that both right
tissue measurements on 3D images
and left maxillary second and mandibular first molars
T1 T2 Difference were extruded.15
Variable Mean 6 SD Mean 6 SD Mean 6 SD P value
In a recent case report, researchers applied MEAW to
Vertical treat open bite, and both 2D and 3D images were ob-
RP1-A 29.0 6 4.17 29.4 6 4.05 0.39 6 1.81 NS tained to evaluate the treatment outcomes.25 All mea-
RP1-B 71.84 6 6.05 72.2 6 5.92 0.36 6 1.94 NS surements were performed on 2D radiographs, and
RP1-Pog 83.12 6 6.42 83.02 6 6.06 0.1 6 1.45 NS only superimpositions were evaluated 3 dimensionally.
RP1-Li 54.75 6 4.57 55.64 6 4.52 0.89 6 1.39 *
The authors mentioned that cephalometric findings
RP1-Ls 40.19 6 3.65 41.13 6 3.63 0.93 6 0.76 y
RP1-Pog΄ 75.62 6 6.08 76.95 6 5.34 1.33 6 2.52 * showed intrusion of all molars, but as a result of their
Sagittal maxillary regional superimposition, they also mentioned
RP2-A 88.7 6 6.02 89.02 6 6.03 0.33 6 0.63 * maxillary posterior tooth extrusion. We assumed that
RP2-B 83.3 6 6.95 83.02 6 7.23 0.28 6 1.2 NS they might have used mesial cusps of the first molars,
RP2-Pog 84.69 6 6.79 84.61 6 7.17 0.08 6 1.21 NS and their conflicting results may be due to tipping of
RP2-Li 104.32 6 6.54 104.24 6 6.72 0.08 6 0.81 NS
RP2-Ls 105.94 6 6.06 106.19 6 6.25 0.25 6 0.86 NS the molars.
RP2-Pog΄ 96.7 6 6.97 96.77 6 7.04 0.07 6 1.25 NS As for the intrusion of maxillary molars, Kim et al10
Paired-samples t test.
were the only researchers who found a statistically sig-
NS, Not significant. nificant change by MEAW alone, which was 0.66 mm
*P \0.05; yP \0.01. of maxillary molar intrusion. This difference could be a
misleading result of 2D imaging systems as mentioned
above. Since the amount of the intrusion is too small,
nongrowing patients. All other MEAW and modified the probability of a measuring bias, caused by tipping
technique studies support the same conclusion or superposition of the right and left sides, is substantial.
regarding the anterior teeth.11-13,15,19,24 Additionally, different load-deflection rates of the
As demonstrated by our findings, anterior bite MEAW system and the NiTi technique might lead to
closure was obtained with no intrusive effect on the pos- different results. Both NiTi wires and multi-loops on per-
terior teeth but with good vertical control and without machrome stainless steel wires aim to lower the load-
extrusion. K€ ukkeleş et al13 found that the maxillary
uç€ deflection rate. Wires with lower load-deflection rates
first molar and the mandibular first molar were extruded generate light and continious forces that are favorable
by 1.05 and 1.70 mm, respectively. In a MEAW case for tooth movement, whereas higher load-deflection
report, it was stated that all molars were extruded by rates are needed for anchorage.26

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Table IV. Comparison of T1 and T2 dental measure- Table V. Comparison of T1 and T2 skeletal and dental
ments on 3D images measurements on cephalometric images
T1 T2 Difference T1 T2 Difference

Variable Mean 6 SD Mean 6 SD Mean 6 SD P value Variable Mean 6 SD Mean 6 SD Mean 6 SD P value
Vertical SNA 79.94 6 3.86 80.28 6 3.56 0.33 6 1.19 NS
RP1-U7L 32.97 6 3.25 33.37 6 3.37 0.4 6 0.87 NS SNB 76.28 6 2.99 76.44 6 2.96 0.17 6 1.04 NS
RP1-U7R 33.04 6 3.54 33.13 6 3.62 0.09 6 0.89 NS ANB 3.47 6 1.99 3.78 6 2.21 0.31 6 1.3 NS
RP1-U6R 35.67 6 3.74 35.5 6 3.95 0.16 6 0.82 NS SN-MP 38.5 6 4.45 39.67 6 4.55 1.17 6 1.54 *
RP1-U6L 35.91 6 3.22 36.03 6 3.19 0.12 6 0.56 NS SN-PP 7.44 6 3.05 7.83 6 2.68 0.39 6 1.85 NS
RP1-U5R 48.22 6 3.48 48.27 6 3.33 0.06 6 0.97 NS N-ANS 57.91 6 1.83 57.83 6 1.77 0.08 6 0.72 NS
RP1-U5L 48.32 6 3.19 48.21 6 3.36 0.11 6 0.86 NS ANS-Me 70.8 6 6.19 70.89 6 6.11 0.09 6 2.21 NS
RP1-U3L 49.35 6 3.34 50.68 6 3.45 1.33 6 0.76 * IMPA 94.61 6 5.09 88.83 6 5.57 5.78 6 3.51 *
RP1-U3R 49.44 6 3.57 50.63 6 3.54 1.19 6 0.94 * UI-SN 106.78 6 4.73 101.28 6 4.79 5.5 6 4.5 *
RP1-U1R 49.19 6 3.66 51.35 6 3.57 2.16 6 1.37 * SN-UOP 14.39 6 3.4 18.06 6 3.96 3.67 6 3.31 *
RP3-L7L 17.5 6 2.86 17.1 6 2.92 0.4 6 0.84 NS SN-LOP 17.56 6 2.81 17.72 6 2.85 0.17 6 1.29 NS
RP3-L7R 17.46 6 3.57 17.38 6 3.66 0.08 6 1.33 NS Overjet 2.96 6 1.31 3.04 6 0.62 0.08 6 1.37 NS
RP3-L6L 21.45 6 3.69 21.58 6 3.77 0.13 6 0.86 NS Overbıte 2.07 6 1.51 2.31 6 0.59 4.38 6 1.51 NS
RP3-L6R 21.91 6 3.7 22.25 6 3.66 0.34 6 1.37 NS
RP3-L5L 34.31 6 4.28 34.86 6 3.92 0.55 6 1.37 NS Paired-samples t test.
RP3-L5R 35.16 6 3.6 35.37 6 3.78 0.21 6 1.6 NS NS, Not significant.
RP3-L3L 39.15 6 4.3 40.45 6 4.2 1.3 6 0.92 * *P \0.01.
RP3-L3R 39.44 6 3.84 40.79 6 4 1.35 6 1 *
RP3-L1R 40.91 6 4.16 42.4 6 4.1 1.49 6 1.01 *
Sagittal
RP2-U7L 53.17 6 4.64 53.35 6 4.82 0.19 6 0.74 NS the MEAW, this higher rate could have been a factor pre-
RP2-U7R 53.71 6 4.69 53.77 6 4.6 0.06 6 0.86 NS venting molar intrusion in our sample.
RP2-U6R 61.66 6 5.11 62.17 6 5.16 0.51 6 0.6 NS
RP2-U6L 61.47 6 5.75 61.86 6 5.65 0.39 6 0.73 NS
RP2-U5R 71.58 6 6.06 71.49 6 5.86 0.08 6 1.39 NS CONCLUSIONS
RP2-U5L 70.72 6 5.4 70.39 6 5.87 0.33 6 1.23 NS
RP2-U3L 84.65 6 6.18 84.23 6 6.49 0.42 6 1.22 NS 1. Maxillary accentuated curve of Spee and mandib-
RP2-U3R 85.01 6 6.21 84.87 6 6.22 0.14 6 1.24 NS ular reverse curve of Spee NiTi archwires together
RP2-U1R 93.39 6 6.82 92.26 6 6.62 1.14 6 0.8 * with anterior vertical elastics can be used for the
RP4-L7L 24.85 6 5.93 25.58 6 5.42 0.73 6 1.75 NS
RP4-L7R 23.07 6 5.7 23.4 6 5.19 0.33 6 1.6 NS
treatment of open bites successfully.
RP4-L6L 34.74 6 5.26 34.87 6 5.27 0.13 6 1.93 NS 2. The open bite was corrected mainly by retraction
RP4-L6R 33.05 6 5.35 33.31 6 4.88 0.26 6 1.77 NS and extrusion of the anterior teeth (mostly maxil-
RP4-L5L 41.17 6 5.01 40.95 6 5.44 0.21 6 1.58 NS lary) while maintaining the vertical position of the
RP4-L5R 39.3 6 5.13 39.15 6 5.05 0.15 6 1.59 NS molars, thus preventing severe backward rotation
RP4-L3L 52.88 6 5.15 52.69 6 5.76 0.19 6 1.53 NS
RP4-L3R 51.32 6 5.4 51.07 6 5.15 0.25 6 2.05 NS
of the mandible.
RP4-L1R 57.03 6 5.38 56.58 6 5.45 0.44 6 1.75 NS 3. Taking the simplicity of the method and the outcomes
Paired-samples t test.
into account, curved arches and anterior vertical
NS, Not significant. elastics can be considered a practical approach for
*P \0.05. nonextraction treatment of patients with mild to
moderate open bites.

The authors of some studies who measured the entire REFERENCES

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November 2018  Vol 154  Issue 5