CASE REPORT

The segmented arch approach: A method for

orthodontic treatment of a severe Class III
open-bite malocclusion

Mar
ıa Barrera-Mora,a Jose
Eduardo Espinar-Escalona,a Jose
Mar
ıa Llamas-Carreras,a and



Marıa Belen Ruiz-Navarro b

Seville, Spain

An open bite is a common malocclusion, and it is generally associated with several linked etiologic factors. When
establishing the treatment plan, it is essential to consider every aspect of the various etiologic causes and their
evolution; this will help to correct it. This article reports the case of a girl aged 10.7 years with a skeletal Class III
malocclusion and an open bite. The treatment mechanics were based on compensatory dental changes per-
formed to close the bite and correct the skeletal Class III malocclusion. The patient had a deep maxillary defi-
ciency, and the lower facial third was severely enlarged. In this article, we aimed to describe a simple
mechanical approach that will close the bite through changes in the occlusal plane (segmentation of arches).
It is an extremely simple method that is easily tolerated by the patient. It not only closes the bite effectively
but also helps to correct the unilateral or bilateral lack of occlusal interdigitation between the dental arches. A
Class III patient with an anterior open bite is shown in this article to illustrate the effectiveness of these treatment
mechanics. (Am J Orthod Dentofacial Orthop 2013;143:254-65)

A
n open bite is a deviation in the vertical relation-
ship of the maxillary and mandibular arches,
characterized by lack of contact between oppo-
site dental segments.1 It can be associated with any type
of malocclusion in the sagittal plane (Class I, Class II, or
Class III).
A dental open bite is characterized by a reduction in
the vertical growth of the dentoalveolar process in the af-
fected area, generally associated with an oral habit (pro-
longed pacifier use, finger sucking, or altered swallowing
habits) and a normal or favorable growth pattern. It is
usually accompanied by incisor proclination and a re-
duced interincisal angle, and it generally responds to
myofunctional treatment and mechanotherapy.
On the other hand, a skeletal open bite is due to a hy-
perdivergent phenotype with a vertical growth pattern
that affects both the maxillary and mandibular bony
a
Associate professor, Department of Orthodontics, Faculty of Odontology, Uni-
versity of Seville, Seville, Spain; private practice, Seville, Spain.
b
Postgraduate student, Department of Orthodontics, Faculty of Odontology,
University of Seville, Seville, Spain.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Eduardo Espinar-Escalona, c/Virgen de Lujan, 8, 41011, Sev-
illa, Spain; e-mail, eduardoespinar@arrakis.es.
Submitted, August 2011; revised and accepted, September 2011.
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2011.09.015
254
bases.2 Because of its skeletal component, the orthodon-
tic correction of a skeletal open bite is much more diffi-
cult, and there is no clear limit between what can be
achieved by orthodontic compensation and what inevi-
tably requires orthognathic surgery. Early treatment of
the vertical dysplasia (during the deciduous or mixed
dentition) might reduce the treatment needed in the per-
manent dentition3,4 when surgery is a valid option.5
A logical question regarding this matter is where to
place the limits of the dentoalveolar compensation. To
answer this question, we report a patient with a Class
III open-bite malocclusion and vertical skeletal dysplasia
treated with camouflage orthodontic therapy.
DIAGNOSIS AND ETIOLOGY
The patient was a girl aged 10.7 years with no relevant
medical history or bone or dental pathology in her family
history. The extraoral examination showed a distinct in-
crease of the lower facial third, with slight mandibular
asymmetry and midface deficiency along with a Class
III profile (Fig 1). The intraoral examination showed
a Class III malocclusion with severe maxillary compres-
sion in all 3 planes that caused posterior and anterior
crossbites (both with negative results). In the vertical
plane, there were both anterior and lateral open bites.
The mandibular dental cast (Fig 2) showed that the
deciduous canines were missing, and the incisors were
Espinar-Escalona et al 255

Fig 1. Pretreatment photographs.

Fig 2. Pretreatment dental casts.

American Journal of Orthodontics and Dentofacial Orthopedics February 2013  Vol 143  Issue 2
256
Fig 3. Pretreatment lateral skull radiograph and cephalometric analysis.
Fig 4. Pretreatment panoramic radiograph.
retroclined. The mandibular arch-length discrepancy was
3.7 mm. In the maxillary arch (Fig 3), a transverse defi-
ciency and an arch length deficiency of 3 mm were
noted. Moreover, a molar Class III relationship coexisted
with the anterior and posterior crossbites and the previ-
ously mentioned open bite. The panoramic radiograph
showed the lack of space for the permanent canines,
and the condyles appeared thin and elongated, as nor-
mally seen in patients with vertical growth patterns (Fig 4).
The cephalometric analysis was typical of a skeletal
Class III pattern with a retruded maxilla and retroclined
mandibular incisors (showing that the skeletal malocclu-
sion was worse than it seemed because of the physio-
logic dentoalveolar compensation) in a hyperdivergent
pattern with a significant vertical growth discrepancy.
February 2013  Vol 143  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Espinar-Escalona et al
TREATMENT OBJECTIVES
The proposed treatment consisted of 2 phases: (1)
correction of the crossbite and protraction of the maxilla
with a facemask; and (2) (during the permanent denti-
tion) leveling, alignment, and coordination of the dental
arches, with bite closure and finishing of the occlusion.
This treatment plan reflects the importance of treating
the transverse and sagittal problems during the early
stages and subsequently correcting the open bite
through changes in the occlusal plane in the permanent
dentition with a segmented arch approach.
The treatment plan involved 2 phases that took into
account the eruption times and growth of the patient:
(1) crossbite correction (maxillary disjunction with rapid
palatal expansion) and traction with a facemask for den-
toalveolar mobilization (phase 1); (2) a waiting period
until dental eruption has been completed preceded by
dental alignment; and (3) control of the open bite and
the possibility of its closure (phase 2).
Complete correction of this type of malocclusion by
providing only orthodontic treatment mechanics is espe-
cially difficult because of the underlying skeletal malrela-
tionship. Therefore, the patient would need to undergo
surgery if the response to dental compensation were
not good enough. For this reason, in similar cases, ortho-
dontic treatment seeks to improve some dental esthetic
aspects, whereas the sagittal and transverse skeletal cor-
rections are achieved through orthognathic surgery.
Espinar-Escalona et al
Fig 5. Progress photographs: A and B, end of phase 1; C, fixed appliance; D, arch leveling; E and F,
segmented arch and open-bite closure (overlay).
Class III patients with severe vertical problems are
rather controversial, since all correction approaches,
both sagittal and transversal, can severely worsen the
vertical relationship. On the other hand, all vertical
responses lead to improvements of sagittal Class III ex-
pression. In other words, it is difficult to improve vertical
Class III problems while closing the bite. This depends on
the magnitude of both problems and the way the me-
chanics are managed.
A bite-closure technique with segmented arches was
used in this patient; it allowed us to obtain dentoalveolar
closure thanks to a counterclockwise rotation of the oc-
clusal plane without anterior vertical elastics, which
could have increase the potential for relapse.
TREATMENT ALTERNATIVES
Patients with severe skeletal dysplasia require multi-
ple treatments to solve their various problems. The treat-
ment of patients with a Class III malocclusion is likely to
require orthognathic surgery in adulthood. In other
words, this approach will correct not only the dental
problems, but also the facial and skeletal discrepancies.
Treatment is not complete until the patient’s facial
growth has ceased.
On the other hand, a first phase of treatment with ini-
tial control of the transverse and sagittal dimensions is
American Journal of Orthodontics and Dentofacial Orthopedics
257
considerably effective and useful for these patients. It
improves the patient’s dentofacial appearance, and the
remaining improvements can be achieved in the post-
growth stage through a surgical approach. Therefore, or-
thodontic treatment cannot be fully efficient but can
sometimes help the patient, at least transversely, making
the required surgical treatment less substantial.
A 2-phase treatment plan allows us to assess prog-
ress, and in patients whose response is positive, we can
pursue a dentoalveolar correction. Orthodontic treat-
ment will obviously not solve the skeletal problem, espe-
cially the vertical, since this can only be corrected by
a surgical approach or by using temporary skeletal
anchorage devices. They are a useful alternative when
trying to reduce the anterior vertical dimension.
If there were a loss of the achieved objectives after
growth and dental compensation are over, an orthog-
nathic surgical treatment would be a valid option to re-
solve all problems and to obtain appropriate dentofacial
harmony.
TREATMENT PROGRESS
Initially, a transpalatal arch was used during phase 1
to correct the mesial rotation and the torque of the
molars. Placement of an expander was deferred be-
cause of the early stage of dental development.
February 2013  Vol 143  Issue 2
258
Fig 6. Posttreatment photographs.
Meanwhile, anterior traction was performed with
a facemask for a year.
Second, and as part of phase 1, rapid palatal expan-
sion was achieved with a cemented hyrax appliance
while continuing with the facemask to prevent sagittal
relapse. Once the rapid palatal expansion was finished,
a transpalatal arch was placed for retention. Maxillary
and mandibular brackets were bonded (Fig 5).
Closing the open bite with segmented arches involved
a sequence that started with superelastic wires to align and
level the dental arches. Once coordinated, the archwires
were segmented in 3 sections: 2 sections including the
molars and premolars, and a third section including all 6
anterior teeth. In the maxillary arch, a 0.021 3 0.028-in
or a 0.019 3 0.025-in superelastic wire was used.
Similarly, in the mandibular arch, a 0.020 3 0.020-in
superelastic archwire was used. At this point, triangular
elastics were used to achieve bite closure in the premolar
area and to modify the canting of the occlusal plane.
Once these changes were accomplished, a thermoelastic
0.014-in overlay (piggyback) was placed to obtain an
February 2013  Vol 143  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Espinar-Escalona et al
acceptable overbite. After closing the bite, the treatment
was finished with a regular wire sequence (Fig 5).
TREATMENT RESULTS
A Class III skeletal malocclusion with an open bite is
not simple to treat. In many cases, orthognathic surgery
is the only therapeutic option to correct all dental and
facial aspects. In some patients, achieving dental com-
pensation would solve some important problems associ-
ated with this kind of malocclusion (open bite, dental
Class III, maxillary compression, and so on). Satisfactory
results can be achieved if the orthodontic treatment me-
chanics and management are good and the patient co-
operates effectively. However, the facial pattern will
remain severely dysplasic. Occlusal stability of the gener-
ated dental compensation will only be achieved if the
end of treatment coincides with the end of facial growth.
The final results were satisfactory for this patient (Figs
6-8 and Table). The use of a facemask, attached to the pal-
atal expander, helped to reduce the dental discre-
pancy. Further treatment with segmented archwires and
Espinar-Escalona et al
Fig 7. Posttreatment dental casts.
multibracket therapy for bite closure also produced satis-
factory results. The patient was considerably stable skele-
tally, probably because she had finished her growth.
The retention phase after treating the patient in-
volved the following.
1. In the maxillary arch, a thermoplastic retainer pro-
vided stability during the daytime, especially regard-
ing dental rotations. This splint is highly sensitive
and provides maximum fixation if the patient coop-
erates. It was used during the day for 6 months after
bracket removal. Also, in the maxillary arch, a cir-
cumferential Hawley retainer was used at night to
provide the required lateral stability.
2. In the mandibular arch, a bonded lingual wire was
placed and was to remain for at least 24 months.
The patient's collaboration with these retainers
was essential to provide stability to the orthodontic
treatment.
After questioning her family and studying the levels
of growth hormone, which were deficient, we concluded
that the patient had nearly completed her growth. The
fact that she also had an early menarche caused us not
to expect major changes.
The analysis of existing and new records and super-
impositions 2 years after the end of the treatment
showed a slight decrease of the overbite and a secondary
American Journal of Orthodontics and Dentofacial Orthopedics
259
labial interposition habit (Table). The patient is currently
out of active retention and is wearing only the mandib-
ular lingual wire, which will be removed after 36 months
(Figs 9-11).
DISCUSSION
Overall, the final results can be considered to be sat-
isfactory, exceeding our expectations. This was due
mainly to excellent patient compliance, which allowed
the biomechanical approach to work satisfactorily. The
treatment of a patient like this involves a continuous
diagnostic process in which biomechanical decisions
should be made appropriately. It would be difficult to
treat such a severe sagittal and vertical discrepancy
with dentoalveolar compensation.
The treatment of most of these patients, if under-
taken at early stages, will allow partial improvement of
the sagittal relationship but can sometimes worsen the
vertical dimension. Attention should be paid to crossbite
corrections throughout this stage, since skeletal modifi-
cations can occur. Early treatment usually simplifies any
orthognathic surgical procedures that are required in
adulthood.
During the first stage of treatment, the sagittal cor-
rection was quite efficient as well as the crossbite correc-
tion. Generally, both conditions do not improve the
February 2013  Vol 143  Issue 2
260 Espinar-Escalona et al

Fig 8. Posttreatment lateral skull radiograph, cephalometric analysis, and superimpositions (pretreat-
ment to posttreatment).

Table. Cephalometric analysis

Pretreatment Posttreatment Retention Mean 6 SD
Sagittal skeletal relationships
Maxillary position S-N-A ( ) 7.5 78.1 78.8 82 6 3.5
Mandibular position S-N-Pg ( ) 78.4 78.3 79.7 80 6 3.5
Sagittal jaw A-N-Pg ( ) 0.9 0.1 0.8 2 6 2.5
Vertical skeletal relationships
Maxillary inclination S-N/ANS-PNS ( ) 11.6 12.5 13.1 8 6 3.0
Mandibular inclination S-N/Go-Gn ( ) 44.9 48.1 46.6 33 6 2.5
Vertical jaw ANS-PNS/Go-Gn ( ) 33.3 35.5 33.5 25 6 6.0
Dento-basal relationships
Maxillary incisor inclination 1-ANS-PNS ( ) 107.6 116.0 118.1 110 6 6.0
Mandibular incisor inclination 1-Go-Gn ( ) 71.8 67.4 68.7 94 6 7.0
Mandibular incisor compensation 1-A-Pg (mm) 3.1 2.7 3.3 2 6 2.0
Dental relationships
Overjet (mm) 0.4 3.4 3.1 3.5 6 2.5
Overbite (mm) 2.4 1.3 0.7 2 6 2.5
Interincisal angle 1/1 ( ) 145.0 136.7 136.5 132 6 6.0

February 2013  Vol 143  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Espinar-Escalona et al
Fig 9. Retention photographs.
vertical problem but worsen it. Our aim is generally to
treat these patients with vertical control, restraining
and in some cases intruding the posterior segments by
using an expander with complete occlusal coverage.
However, the severity of this patient’s vertical problem
was considered excessive for this approach.
According to Hwang et al,6 Class III occlusal planes
have a flatter orientation, and the treatment goals for
this type of malocclusion should involve achieving
a steeper occlusal plane. The treatment of a Class III pa-
tient with an open bite will be successful by controlling
the posterior occlusal plane and making it steeper.7
Treatment planning for both sagittal and vertical prob-
lems comes together with changes in the occlusal plane.
These changes should be developed by clockwise modi-
fication of the maxilla and counterclockwise changes in
the mandible, but with a vector of intrusion of the pos-
terior segments.8
The segmented arch approach provides rotation of
the occlusal plane. The maxillary arch rotates indepen-
dently on the lateral sectors, with subsequent leveling
of the anterior segment, as shown in Figure 12.
American Journal of Orthodontics and Dentofacial Orthopedics
261
As the superimpositions show, the closure was estab-
lished by clockwise rotation of the maxilla and counter-
clockwise rotation of the mandible. The elastic vector
affects this correction, and it must remain active in the
second step of anterior leveling.
During phase 1, the occlusal plane decreased as
a consequence of the anterior traction with the face-
mask. The maxillary complex was moved forward and
downward.9 Despite this, the overbite was still main-
tained in phase 2. This shift was clearly established by re-
solving both the sagittal and vertical malocclusions.
The orthodontic treatment was finished after the level-
ing was completed and the recovery of the mandibular
arch segmentation achieved. The procedure must extend
until growth has finished because, in an open bite, either
growth10 or persistent habits11 can eliminate the correc-
tions partially. When possible, it is important to correct
the skeletal alteration after the end of the treatment.
This type of “heroic” treatment is perhaps unpredict-
able. Therefore, patient selection, patient compliance,
and the predicted response to the mechanical treatment
must be judged carefully.10
February 2013  Vol 143  Issue 2
262
Fig 10. Retention dental casts.
The obtained corrections affect the dentoalveolar
relationships, but the patient will continue to have dys-
plasic skeletal development, which can only be solved by
orthognathic surgery.12 Most of this patient's expecta-
tions were met, and surgery was avoided. Only the verti-
cal dimension remained severely impaired and would
need a surgical solution. Options should be discussed
with the patient to determine the final treatment
approach.
The improvements obtained for this patient were due
to a change in the cant of the occlusal plane. The prob-
lem was clearly surgical; therefore, no matter how well
the dentoalveolar situation was corrected, no skeletal
changes were obtained, and the vertical facial pattern
was maintained. Therefore, the lower facial height was
not reduced, since the patient did not undergo surgery.
Subtelny and Sakuda1 stated that patients with a truly
skeletal and severe open bite cannot be corrected by or-
thodontic treatment alone, and orthodontic correction
alone should not be recommended in these surgical sit-
uations.
Since the introduction of temporary skeletal anchor-
age devices (miniplates and miniscrews), better skeletal
outcomes have been demonstrated in the treatment of
these types of malocclusions with dolichofacial patterns,
by overcoming the classic limits of posterior segment in-
trusion. By intruding the posterior segments, the
February 2013  Vol 143  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Espinar-Escalona et al
treatment is more effective, and the patient’s facial es-
thetics improve.13 Treating an open bite by pure intru-
sion would in theory be possible, but there is a lack of
evidence. A literature review by Ng et al14 showed no ev-
idence of real intrusion or, if there is any, it is very little.
Baek et al15 evaluated long-term stability and found that
most of the relapse occurs in the first year—hence the
need to increase the retention period to prevent the re-
lapse.
Occasionally, dental compensation treatments can
relapse significantly over time. Huang16 suggested that
20% of the treated open-bite subjects will lose their
overbite whether they received either treatment—or-
thognathic surgery or orthodontics. Stability is mainly
determined by the presence or absence of growth, func-
tional alterations (habits, tongue interposition), and the
instability of the surgical fragments.17-19 Our patient
had almost finished her growth by the end of treatment.
Determining the appropriate time to start orthodontic
treatment combined with orthognathic surgery is one of
the most controversial aspects regarding stability, since
relapse can also occur after this type of treatment.
Orthognathic surgical treatments have proven to be suc-
cessful in a 15-year follow-up study of LeFort surgical
treatment along with bilateral sagittal osteotomy.20
However, the success rate was low compared with the re-
sults produced by orthodontic treatment alone, and it
Espinar-Escalona et al 263

Fig 11. Retention lateral skull radiograph, cephalometry, and superimpositions (treatment to reten-
tion).

Fig 12. Scheme of the segmented arch mechanics: changes of dental inclinations and occlusal
planes, maxillary and mandibular, to achieve bite closure.

American Journal of Orthodontics and Dentofacial Orthopedics February 2013  Vol 143  Issue 2
264
had aworse long-term stability.21 Other studies have
shown similar results and a similar frequency of relapse,
with clinical stability in only 66.7% of the patients stud-
ied.22 Bondemark et al23 analyzed morphologic stability
and patient satisfaction. They found that most of the re-
lapse occurs during the first 6 months after surgery, and
there can be secondary dentoalveolar compensation.
In a recent meta-analysis, Greenlee et al24 analyzed
the stability parameters of open bites of patients treated
orthodontically or surgically. The average stability values
were 75% in those treated with orthodontics and 82%
for surgical treatment. In our patient, the overbite was
reduced from 2.7 mm before treatment to 1.3 mm af-
ter treatment. Two years after treatment, the overbite
was 0.7 mm. Our patient’s response was similar to the re-
sults of other nonsurgical treatments that varied from
2.5 mm before treatment to 1.3 mm after treatment,
with a relapse to an 0.8-mm overbite after 3.2 years.
The patient had some vertical relapse, possibly
caused by the tongue's interposition at rest, which could
result in proclined maxillary incisors. The resulting over-
bite loss is not dramatic considering the significant
improvement in the anterior overbite. To prevent further
relapse and maintain the current occlusion, a retainer
was designed with a hole in the palate to promote
a proprioceptive lingual habit.25 Cal-Neto et al26 recom-
mended long-term retention of open-bite patients.
As shown in the superimpositions, we found intrusion
of the mandibular incisors and proclination of the maxillary
incisors. The molar inclination was corrected as well and,
although minimal, caused some loss of anterior overbite.
CONCLUSIONS
Skeletal malocclusions follow a natural course until
the end of growth. The beneficial or harmful conse-
quences of dentoalveolar compensations must be fore-
seen and assessed. As the reader will understand, this
type of treatment is contraindicated in patients with sig-
nificant vertical excess of the lower third of the face, but
it could nevertheless be a valid alternative for patients
with minor problems, or when orthognathic surgery is
rejected by the patient. The decisions made should not
limit future options, especially in Class III malrelation-
ships, when extractions before the patient stops growing
could erase the dentoalveolar compensation and elimi-
nate further options of correction, since the maloclusion
has not completely developed. Vertical control in
patients with increased lower facial height should be
addressed by intruding the posterior segments or
restricting their vertical growth.
An early intervention can change the progression of
some patients. Class III corrections should be performed
February 2013  Vol 143  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Espinar-Escalona et al
in the early mixed dentition, especially if there is a cross-
bite. The prognosis of the sagittal result depends on
future mandibular growth. Moreover, sagittal improve-
ments could be more efficient in early stages rather
than later, but, as previously stated, the remaining
growth could ultimately transform the case into a surgi-
cal one. As in every treatment involving intermaxillary
elastics, special care and control must be taken not to
distract the condyle from the fossa.
The association between Class III and skeletal open
bite exacerbates the problem. A dental compensation
can significantly improve the malocclusion. In open
bites, changes in the occlusal plane can help its correc-
tion. The segmented arch approach is an effective tool
when used in the correction of open bites. The resulting
compensation generally produces an efficient dentoal-
veolar improvement, at the expense of individualizing
the anterior and posterior segments of the mandible by
using the maxillary arch as a guide.
The tongue habit at rest generated an insignificant
relapse in this patient. Her long-term prognosis is
good thanks to the use of a more specific retainer, a lon-
ger retention period, and the completion of facial
growth.
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