January 2021 Orthodontics 21

Enhanced CPD DO C

Tarun K Mittal Kulraj Achal, James T Taylor, Jay D Kindelan

Partial Glossectomy as an
adjunct to Orthodontic
Treatment of Anterior
Open Bite Associated with
Macroglossia: A Case Report
Abstract: Orthodontic treatment of an anterior open bite is one of the most challenging malocclusions to treat, especially with respect
to post-treatment stability. Complete diagnosis and targeted treatment is required for successful post treatment stability. In instances
where macroglossia is the primary aetiology, partial glossectomy will greatly improve post treatment stability. The following case report
describes a patient with severe anterior open bite and bimaxillary protrusion secondary to macroglossia. Treatment was successfully
performed with partial glossectomy and straight wire orthodontics. Post-treatment relapse was minimal.
CPD/Clinical Relevance: This article describes a review of the aetiology of anterior open bite and documents one possible treatment option,
when the main aetiology of the malocclusion is of soft tissue origin
Ortho Update 2021; 14: 21–25

The successful treatment of anterior open
bite is dependent on accurate diagnosis
and correction of the aetiology. The
development of anterior openbite (AOB)
is multifactorial in nature and may be due
to dental, skeletal or soft tissue causes or a
combination of these factors.
Dental factors
Incomplete eruption of anterior teeth may
result in an anterior open bite. Should the
patient have potential for further eruptive
change of the incisors, then monitoring
would be prudent. Failure of eruption of
incisors may result from the presence of
supernumerary teeth impeding the eruption
of incisors or as a result of bony replacement
resorption (ankylosis) secondary to dento-
alveolar trauma. Treatment may involve
orthodontic or surgical repositioning, alveolar
distraction in conjunction with orthodontics
or extraction and replacement of the
anterior tooth.1
Digit-sucking habits can cause anterior
open bite development by impeding vertical
eruption of incisors.2,3 Should the habit persist
into adolescence, the posterior teeth may
overerupt into contact – there will then be
little chance of spontaneous improvement of
the AOB, even with cessation of the habit.4
Skeletal factors
Vertical growth patterns can lead to the
development of an anterior open bite,
especially in patients with ‘long-face
syndrome’.5,6 The vertical dimension of growth
is thought to be secondary to constricted
nasal airways and mouth breathing.7 It is
postulated that adenoidectomy at an early
stage may improve nasal airway space and
encourage improvement in growth patterns.8,9
Some recent research has investigated the
effect of rapid maxillary expansion on nasal
airways in the early mixed dentition. Results
of the most recent investigation10 comparing
tooth-borne and tooth- and bone-borne

Tarun K Mittal, BDS, DDS, MFDS RCS(Ed), MOrth RCS(Ed), FDS(Orth) RCS(Ed), Consultant in Orthodontics, Leeds Dental Institute, Leeds, UK. Kulraj Achal,
BDS, MClinDent, MJDF RCS(Eng), IMOrth RCS(Eng), FDS(Orth) RCS(Eng), Consultant in Orthodontics, Castle Hill Hospital, Hull, UK. James T Taylor, BDS,
FDS RCS(Eng), MBBS, FRCS RCS(Eng), FRCS(OMFS) RCS(Eng), Consultant in Oral and Maxillofacial Surgery, York Teaching Hospital, York, UK. Jay D Kindelan
BChD(Hons), FDS(Orth) RCS(Eng), MOrth RCS(Eng), MMedSci(Orth) Consultant In Orthodontics, York Teaching Hospital, York, UK.
email: tarun.mittal@nhs.net
 22 Orthodontics
a bite, difficulty in eating and unsatisfactory
b smiling or at rest. The posterior dentition was
c tongue. Electromyography may be employed,
Figure 1. (a–c) Pre-treatment radiographs and
cephalometric tracing.
expanders found that tooth- and bone-
borne expanders resulted in a mean increase
of 52.7 cm3/s in nasal airflow compared to
tooth-borne expanders alone.10,11 Bone-
borne expansion devices may, therefore,
play a role in increasing nasal airflow in
individuals thought to be affected by a
constricted airway.
Intervention while a patient is still
growing may potentially have an effect on
the pattern and direction of growth, although
long-term results are yet to be consistently
reported. If growth has stopped, the only
successful method of treatment will be
surgical correction of the skeletal pattern with
orthognathic surgery.12
Soft tissue factors
The soft tissues have a significant effect
on the dentition and the development
of the jaws.13–15 A commonly seen trait in
patients with AOB is that of macroglossia
with or without a tongue thrust. This can be
adaptive or endogenous in nature, the former
resolving following correction of the AOB, and
the latter often causing significant relapse
following the end of active treatment.16
While myofunctional appliances and tongue
training may have a role in the correction
of AOB during adolescence,17 treatment
following completion of growth is complex.
The diagnosis of endogenous tongue
thrust can often be made on clinical findings
– symmetrical AOB in the absence of digit
habit, presence of lisp, anterior positioning of
but is of limited additional benefit.18 The
diagnosis of macroglossia could be described
as relative macroglossia when the mandible
is retrognathic or deficient, giving the
appearance of a large tongue although
anatomical size is normal. Alternatively the
clinical diagnosis of true macroglossia is
mostly on the basis of clinical findings,19
particularly a broad or flat tongue, open bite,
Class III malocclusion, accentuated curves
of Spee and Wilson in the upper arch and
reversed curves of Spee and Wilson in the
lower arch, anterior spacing and diastema.
Treatment of endogenous tongue thrust
is disputed. While retraining exercises may be
employed, there may be additional tongue
tissue present as well as subconscious activity.
Partial glossectomy has been proposed as
a possible adjuct to orthodontic treatment
when tongue thrust or macroglossia is the
main aetiology.16
This article presents the treatment of
a 33-year-old woman of African descent
with significant anterior open bite and
macroglossia, who was treated with partial
glossectomy and upper and lower pre-
adjusted edgewise appliances.
Case report
Diagnosis and aetiology
A fit and healthy 33-year-old female, originally
from the Gambia, was referred to the
Orthodontic department at the York Teaching
Hospital by her general dental practitioner.
She complained of an excessive anterior open
January 2021
appearance of her teeth. Periodontal status
was sound with no pocket depth greater
than 3 mm. On clinical examination she
presented a mild Class III skeletal base and
mildly increased vertical proportions.20 There
was bimaxillary proclination with an anterior
open bite of 11 mm and severe spacing in
the upper and lower anterior segments. The
molar relationships were Class I bilaterally,
there was an increased curve of Spee in the
upper arch and reversed curve of Spee in the
lower arch. The upper lip length was normal
at 23 mm, but there was no incisor show on
heavily restored. The lower right third molar
had previously been extracted and there
was radiographic evidence of a small cystic
lesion in the body of the mandible. There
was relative macroglossia and the tongue
was positioned anteriorly, sitting between
the upper and lower teeth (Figure 1a-c). The
main aetiology of the anterior open bite was
thought to be the relative macroglossia and
this was discussed with the patient at length.
Treatment aims
Following review with an oral and
maxillofacial surgeon, the following treatment
aims were agreed:
 Partial glossectomy (Obwegeser
modification);
 Attempt to reduce anterior open bite
using fixed appliances only;
 Maintain Class I molar relationships;
 Permanent retention with
bonded retainers.
Treatment alternatives
Should closure of the anterior open bite not
be possible with orthodontic appliances
only, a segmental anterior maxillary set
down osteotomy, or three-part maxillary
osteotomy would be performed following
orthodontic preparation.
Treatment progress
Treatment began with partial glossectomy
under a general anaesthetic. There was full
thickness resection of the tip of the tongue and
partial thickness resection of the mid dorsum
of the tongue (Figure 2) in conjunction with
some laser ablation to the muscles. Closure
was achieved with resorbable sutures. This
tongue reduction design was chosen to reduce
the length and width of the tongue21 while
minimizing the risk of damage to the lingual
and hypoglossal nerves in the ventral portion
of the tongue. Healing occurred uneventfully,
but an anterior tongue tie (ankoglossia)
developed 8 weeks post-operatively and was
released under local anaesthetic.
Orthodontic treatment progressed using
an 0.022” x 0.028” slot pre-adjusted edgewise
January 2021
a b c
d e f
g h
Figure 3. Diagram of proposed partial
glossectomy. Shaded area indicates removed
tissue – full thickness tip of tongue and partial
thickness mid-dorsum.
system with MBT prescription. The heavily
restored premolars on the left hand side were
not bonded. Following the tongue reduction,
Figure 4. Anterior space closed after 6 months of
active space closure.
the AOB had reduced to 9 mm. Levelling and
alignment was completed using an 0.016”
nickel–titanium (Ni–Ti) archwire, and 8 weeks
later, retraction of the upper and lower labial
segments was started using 0.018” stainless
steel (SS) archwires, with tip back bends,
bypassing the premolars and lacebacks in all
four quadrants. Elastic powerchain was placed
in the anterior segments, and treatment
Orthodontics 23
Figure 2. (a–h) Pre-treatment photographs.
Figure 5. Anterior open-bite closed after
6 weeks of anterior elastics. Intermaxillary
traction was continued to maintain change for
12 more weeks.
progressed with similar mechanics for
6 months with the aim of levelling the arches
and extruding the incisors to improve incisal
show (Figure 3).
Anterior box elastics were worn (1/4”,
3.5 oz) to aid AOB closure for 4 months
(Figure 4). Appliances were debonded
and bonded and removable retainers with
posterior bite blocks (active) were provided
24 Orthodontics January 2021

a b c

d e f

g h

Figure 6. (a–h) Two-year follow up post debond.

AOB reduction has remained relatively stable
following treatment.

immediately. The total orthodontics treatment was felt to be the main aetiology and tongue and was advised to have haematinic
time was 14 months, 18 months including partial glossectomy considerably aided in analysis with her general medical
surgical time. the stability of the orthodontic correction. practitioner. Sensory changes following
Should the anterior open bite not have tongue reduction have been reported,30
Treatment results been fully corrected with orthodontics with changes in the threshold for taste and
The final occlusion was a well inter-digitated alone, a segmental maxillary osteotomy was pain perception in the short term following
Class I with positive overbite. At the 1-year considered; however, this carries significant surgery;31 however, other studies have
review, there had been some relapse of the risks, including devitalization and loss of the found no differences in taste perception
AOB. However, this remained stable at 2 years maxillary segment.27,28 following tongue reduction in patients with
post debond (Figure 5). There had been The cephalometric superimposition Beckwith–Weidermann syndrome.32
two episodes of the upper bonded retainer of pre- and post-treatment radiographs The smile aesthetics and incisor show
debonding from one tooth. At the 2-year (Figure 6) demonstrates that the AOB has have dramatically improved following
review, new removable retainers were provided been closed by tipping and retraction of the orthodontic treatment, and this combined
without bite blocks. upper and lower incisors with minimal mesial with good occlusal result, shows an excellent
movement of the molars. The use of light treatment strategy despite some mild relapse
Discussion forces to close anterior spacing has aided in of the AOB following appliance removal.
The use of surgical tongue reduction in patients prevention of loss of anchorage, especially
with macroglossia,16,19,22–25 endogenous tongue because, following the partial glossectomy, Conclusions
thrust, or those affected with Beckwith– there was a reduction in soft tissue forces This is a case report documenting the
Weidermann syndrome26 has been documented resisting retraction.29 treatment of a significant anterior open
in the past. The predictability of treatment of an The patient has not reported any bite associated with macroglossia.
anterior open bite is reliant on sound diagnosis significant problems following her partial An Obwegeser modification partial
in the first instance and correction of the glossectomy and, apart from the mild anterior glossectomy aided orthodontic treatment
aetiological factor. tongue tie that developed, has had no and contributed to the stability, at least in
In the documented case report, the complications. At the final review, the patient the medium term (2 years post debond), of
tongue, rather than skeletal abnormality, did mention a slight ‘heavy feeling’ in the the post-treatment result.
 January 2021
a 8. Linder-Aronson S. Effects of adenoidectomy on
b tongue reduction. Oral Surg Oral Med Oral Pathol
Figure 7. (a, b) Post-treatment cephalometric
tracing and superimposition.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. Yaqoob O, O’Neill J, Gregg T et al.
Management of unerupted maxillary
incisors. 2016. Available at: https://
www.rcseng.ac.uk/dental-faculties/fds/
publications-guidelines/clinical-guidelines/
(accessed January 2021).
2. Lopes Freire GM, Espasa Suarez de Deza JE,
Rodrigues da Silva IC et al. Non-nutritive
sucking habits and their effects on the
occlusion in the deciduous dentition in
children. Eur J Paediatr Dent 2016; 17:
301–306.
3. Borrie FR, Bearn DR, Innes NP, Iheozor-
Ejiofor Z. Interventions for the cessation
of non-nutritive sucking habits in
children. Cochrane Database Syst
Rev 2015; 3: Cd008694. https://doi.
org/10.1002/14651858.CD008694.pub2.
4. Ng CHT, Wong WKR, Hagg U. Orthodontic
treatment of anterior open bite. Int J
Paediatr Dent 2008; 18: 78–83. https://doi.
org/doi:10.1111/j.1365-263X.2007.00877.x.
5. Nanda SK. Patterns of vertical growth in the
face. Am J Orthod Dentofac Orthop 1988;
93: 103–116.
6. Ellis E, 3rd, McNamara JA, Jr. Components
of adult Class III open-bite malocclusion.
Am J Orthod 1984; 86: 277–290.
7. Harvold EP, Vargervik K, Chierici G. Primate
experiments on oral sensation and dental
malocclusions. Am J Orthod 1973; 63:
494–508.
dentition and nasopharynx. Am J Orthod 1974;
65: 1–15.
9. Linder-Aronson S, Woodside D, Lundströ
A. Mandibular growth direction following
adenoidectomy. Am J Orthod 1986; 89: 273–284.
10. Bazargani F, Magnuson A, Ludwig B. Effects on
nasal airflow and resistance using two different
RME appliances: a randomized controlled trial.
Eur J Orthod 2018; 40: 281–284. https://doi.
org/10.1093/ejo/cjx081.
11. El H, Palomo JM. Three-dimensional evaluation
of upper airway following rapid maxillary
expansion: a CBCT study. Angle Orthod 2014; 84:
265–273. https://doi.org/10.2319/012313-71.1.
12. Bell WH, Creekmore TD, Alexander RG. Surgical
correction of the long face syndrome. Am J
Orthod 1977; 71: 40–67. https://doi.org/https://
doi.org/10.1016/0002-9416(77)90176-2.
13. Turner S, Nattrass C, Sandy JR. The role of soft
tissues in the aetiology of malocclusion. Dent
Update 1997; 24: 209–214.
14. Proffit WR. Equilibrium theory revisited:
factors influencing position of the teeth.
Angle Orthod 1978; 48: 175–186. https://doi.
org/10.1043/0003-3219(1978)048<0175:etrfip
>2.0.co;2.
15. Moss ML, Salentijn L. The primary role of
functional matrices in facial growth. Am J Orthod
1969; 55: 566–577. https://doi.org/http://dx.doi.
org/10.1016/0002-9416(69)90034-7.
16. Hotokezaka H, Matsuo T, Nakagawa M et al.
Severe dental open bite malocclusion with
tongue reduction after orthodontic treatment.
Angle Orthod 2001; 71: 228–236. https://doi.
org/10.1043/0003-3219(2001)071<0228:sdobm
w>2.0.co;2.
17. Cayley AS, Tindall AP, Sampson WJ, Butcher
AR. Electropalatographic and cephalometric
assessment of myofunctional therapy in open-
bite subjects. Aust Orthod J 2000; 16: 23–33.
18. Souza DRd, Semechini TA, Kröll LB, Berzin F.
Oral myofunctional and electromyographic
evaluation of the anterior suprahyoid muscles
and tongue thrust in patients with Class II/1
malocclusion submitted to first premolar
extraction. J Appl Oral Sci 2007; 15: 24–28.
19. Wolford LM, Cottrell DA. Diagnosis of
macroglossia and indications for reduction
glossectomy. Am J Orthod Dentofacial Orthop
1996; 110: 170–177.
20. Beane RA, Reimann G, Phillips C, Tulloch C. A
cephalometric comparison of Black open-bite
subjects and Black normals. Angle Orthod 2003;
73: 294–300. https://doi.org/10.1043/0003-
3219(2003)073<0294:accobo>2.0.co;2.
21. Balaji SM. Reduction glossectomy for large
tongues. Ann Maxillofac Surg 2013; 3: 167–172.
https://doi.org/10.4103/2231-0746.119230.
22. Tanaka OM, Guariza-Filho O, Carlini JL et al.
Glossectomy as an adjunct to correct an open-
bite malocclusion with shortened maxillary
central incisor roots. Am J Orthod Dentofac
Orthodontics 25
Orthoped 2013; 144: 130–140. https://doi.org/
https://doi.org/10.1016/j.ajodo.2012.08.029.
23. Farronato G, Salvadori S, Giannini L, Maspero
C. Congenital macroglossia: surgical and
orthodontic management. Progr Orthod
2012; 13: 92–98. https://doi.org/https://doi.
org/10.1016/j.pio.2011.06.003.
24. Wang J, Goodger NM, Pogrel MA. The role of
Oral Radiol Endod 2003; 95: 269–273. https://doi.
org/10.1067/moe.2003.1.
25. Maisels DO, Knowles CC. Spontaneous
regression of anterior open bite following
treatment of macroglossia. Br J Plast Surg
1979; 32: 309–314. https://doi.org/https://doi.
org/10.1016/0007-1226(79)90087-0.
26. Hikita R, Kobayashi Y, Tsuji M et al. Long-term
orthodontic and surgical treatment and
stability of a patient with Beckwith–Wiedemann
syndrome. Am J Orthod Dentofacial Orthop
2014; 145: 672–684.https://doi.org/10.1016/j.
ajodo.2013.08.019.
27. Lanigan DT, Hey JH, West RA. Aseptic necrosis
following maxillary osteotomies: report of 36
cases. J Oral Maxillofac Surg 1990; 48: 142–156.
https://doi.org/https://doi.org/10.1016/S0278-
2391(10)80202-2.
28. Teemul TA, Perfettini J, Morris DO, Russell JL.
Post-operative avascular necrosis of the maxilla:
a rare complication following orthognathic
surgery. J Surg Case Rep 2017; 2017: rjw240.
https://doi.org/10.1093/jscr/rjw240.
29. Liu ZJ, Shcherbatyy V, Perkins JA. Functional
loads of the tongue and consequences of
volume reduction. J Oral Maxillofac Surg 2008;
66: 1351–1361. https://doi.org/10.1016/j.
joms.2007.11.005.
30. Matsumoto K, Morita K-I, Jinno S, Omura K.
Sensory changes after tongue reduction for
macroglossia. Oral Surg Oral Med Oral Pathol Oral
Radiol 2014; 117: e1–e2. https://doi.org/https://
doi.org/10.1016/j.oooo.2012.02.037.
31. Matsune K, Miyoshi K, Kosaki R et al. Taste
after reduction of the tongue in Beckwith–
Wiedemann syndrome. Br J Oral Maxillofac
Surg 2006; 44: 49–51. https://doi.org/10.1016/j.
bjoms.2005.03.015.
32. Maas SM, Kadouch DJ, Masselink A-CCM, Van
Der Horst CMAM. Taste and speech following
surgical tongue reduction in children
with Beckwith–Wiedemann syndrome. J
Cranio-Maxillofac Surg 2016; 44: 659–663.
https://doi.org/https://doi.org/10.1016/j.
jcms.2016.02.010.