Journal of Orthodontics

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Molar intrusion in the management of anterior

openbite and ‘high angle’ Class II malocclusions

Richard R J Cousley

To cite this article: Richard R J Cousley (2014) Molar intrusion in the management of anterior
openbite and ‘high angle’ Class II malocclusions, Journal of Orthodontics, 41:sup1, s39-s46, DOI:
10.1179/1465313314Y.0000000108

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Published online: 16 Dec 2014.

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 MINI-IMPLANT SUPPLEMENT Journal of Orthodontics, Vol. 41, 2014, S39–S46

Molar intrusion in the management of anterior

openbite and ‘high angle’ Class II malocclusions
Richard R. J. Cousley
Department of Orthodontics, Peterborough and Stamford Hospitals NHS Foundation Trust, UK

Orthodontic correction of anterior openbite has conventionally involved extraction therapy or an adjunctive
maxillary impaction osteotomy. However, bone anchored molar intrusion treatments have been reported in recent
years as a less invasive alternative for such patients. This paper describes the concepts and treatment processes
involved with mini-implant molar intrusion to correct anterior openbite and reduce patients’ excessive vertical
facial proportions.
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Key words: Orthodontic mini-implant, mini-screw, TAD, anterior openbite, molar intrusion

Received 24 March 2014; accepted 30 May 2014

Introduction growth of the posterior dentofacial growth (Ibitayo

Orthodontists regard anterior openbite (AOB) as being
a difficult malocclusion trait to correct, especially if it is
associated with increased vertical facial proportions,
reflected by a high maxillo-mandibular planes angle
(MMPA) and excessive lower anterior face height
(LAFH). AOB treatment becomes even more challen-
ging if there is an increased vertical display of the upper
incisor crowns and possibly also the gingivae. Premolar
or molar extractions have often been suggested as a
means to assist with the correction of mild AOBs. This
extraction decision appears to be influenced by the
prevailing notion that the extraction of posterior teeth
causes mesial movement of the molars, which in turn
would reduce the mandibular ‘hinge axis’ and conse-
quently, increase the overbite. However, recent research
refutes this ‘wedge-effect’ hypothesis (Deguchi et al.,
2011; Gkantidis et al., 2011). Indeed, extrusion and
excessive mesial tipping of molar teeth may negate
incisor-related overbite improvements by increasing the
lower facial height and MMPA. Instead, extraction
treatments cause an increase in the overbite by facilitat-
ing incisor retroclination and extrusion (Janson et al.,
2006; Deguchi et al., 2011; Gkantidis et al., 2011), but
these movements may be neither aesthetically beneficial
nor stable. A combination of headgear and functional
(orthopaedic) appliances, such as the Twin Block, has
also been advocated for use in high angle case/AOB.
However, this approach only slightly retards vertical
et al., 2011).
Orthognathic surgery, typically involving a Le Fort I
maxillary impaction osteotomy, has been regarded as
the gold standard treatment for moderate to severe
AOBs, especially where there is a related skeletal
discrepancy and/or increased upper incisor display.
However, problems may occur with intra-operative
surgical imprecision, maxillary rotational relapse, and
with long term stability of the AOB correction
(Hoppenreijs et al., 1997; Jensen and Ruf, 2010; Maia
et al., 2010; Teittinen et al., 2012). This is particularly
the case if immediate post-operative elastic traction has
been used to ‘close the bite’, since the resultant incisor
extrusion and retroclination is prone to subsequent
relapse (Kuroda et al., 2007). Finally, orthognathic
surgery comes at a cost in terms of both patient
morbidity, and (both individual and health service)
financial factors, and it cannot be performed until the
late adolescent phase when facial growth has largely
ceased.
The least invasive and most effective orthodontic
option for AOB correction now appears to involve the
use of skeletal anchorage, using either mini-implants or
mini-plates to apply vertical traction to the maxillary
molar teeth, and to a lesser extent, the mandibular
molars. This intrusion treatment works in a similar
fashion to surgical correction of AOB in the sense that
superior and inferior repositioning of the maxillary and
mandibular molars, respectively, causes the mandible to

Address for correspondence: R. Cousley, Department of

Orthodontics, Peterborough City Hospital, Bretton Gate,
Peterborough PE3 9GZ, UK.
Email: Richard.Cousley@pbh-tr.nhs.uk
# 2014 British Orthodontic Society DOI 10.1179/1465313314Y.0000000108
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Figure 1 Pre-treatment facial (a–c) and intra-oral (d–f) photographs of a 14-year-old girl presenting with a Class II
division 2 malocclusion on a skeletal II base. The upper central incisors have over-erupted, camouflaging the full
extent of the AOB
auto-rotate in a counter-clockwise direction, i.e.
upwards and forwards. The incisor relationship
improves as an indirect consequence of these molar
and mandibular changes. Several comparative studies
have shown that molar intrusion produces similar
occlusal results in adults to treatment involving pre-
molar extractions and headgear anchorage. The crucial
difference is that molar intrusion treatment also
improves the vertical skeletal and soft tissue parameters,
e.g. FMPA, LAFH and lip competence, with minimal
incisor extrusion (Xun et al., 2007; Lee and Park, 2008;
Baek et al., 2010; Buschang et al., 2011; Deguchi et al.,
2011). The counter-clockwise mandibular rotation also
results in an increase in mandibular prominence (SNB),
making this treatment favourable in Class II patients
(but relatively contra-indicated in Class III cases). A
recent study has also indicated that intrusion treatment
has no effects on temporo-mandibular and masticatory
muscle function (Akan et al., 2013). It is arguable that
the favourable long-term stability observed in two small
case series of intrusion patients (Lee and Park, 2008;
Baek et al., 2010) is due to the avoidance of substantial
incisor extrusion (as part of the AOB closure). Notably,
it appears that most relapse occurs within the first year
of retention, which is helpful as a guide to clinical
retention protocols in these cases.
JO September 2014
Unlike orthognathic surgery, molar intrusion treat-
ment may be undertaken in both adult and adolescent
patients. Buschang et al. (2011) showed favourable,
statistically significant vertical and Class II improve-
ments in a pilot study of nine consecutive adolescent
patients. This has been corroborated by a recent
retrospective study of 21 adolescent and 10 adult
intrusion cases where growing patients demonstrated
more favourable mandibular auto-rotation (Class II)
correction than the adult group (Hart et al., unpublished
data). Such effective vertical control appeared to
counteract the negative effects of progressive vertical
facial growth, even though the total face height
continued to increase with growth.
The biological process involved in molar intrusion has
been demonstrated in several seminal animal studies.
For example, molar intrusion in a dog model resulted in
remodelling of the maxillary alveolar bone and nasal
floor (which is equivalent to the sinus floor in humans)
without causing loss of pulp vitality or clinically
significant root resorption (Daimaruya et al., 2003;
Ramirez-Echave et al., 2011). A micro-CT study of
human molar teeth has corroborated the findings that
root resorption does not occur at a clinically significant
level, despite the observation of resorption lacunae over
large surface areas of the intruding roots (Carillo et al.,
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Figure 2 Intra-oral photographs of the patient shown in Figure 1. Initial quadhelix expansion and molar alignment
have been performed, before insertion of palatal mini-implants (a–c). The remaining maxillary teeth were then
bonded once a positive OB was evident (d, e). After 11 months of intrusion, the quadhelix and palatal traction
have been removed (f–h), and both the incisor and canine relationships have greatly improved. Cephalometric
analysis of these changes shows upper molar intrusion, a maintained upper incisor position and favourable
mandibular autorotation changes (i)
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Figure 3 Pre-treatment photographs and lateral cephalogram of a 16-year-old boy who presented with a Class III
malocclusion on a skeletal I base with a 12 mm AOB and reduced upper incisor display (a–d). The smile aesthetics
have been greatly improved by treatment (e–h) and a small positive OB is present, but bilateral molar crossbites
and (coincidental) lower labial recession problems are evident. The lateral cephalogram (g) shows the dento-
skeletal features at the end of the principal intrusion phase, when a molar openbite had been created

2007). The effect of vertical traction on the molars is
that the adjacent alveolar height reduces, rather than
there being a permanent reduction in clinical crown
height of the molars due to ‘simple’ dental intrusion
(Kanzaki et al., 2007).
Molar intrusion technique considerations
My clinical experience, coupled with the emerging
literature on mini-implant-assisted intrusion of the
molars, has led me to gradually refine and standardize
my clinical approach to patients presenting with a
combination of AOB and a high MMPA/increased
vertical facial dimensions. The key features of this
treatment approach are outlined and illustrated here by
the following six clinical considerations and steps.
Diagnosis and treatment planning
Molar intrusion represents a paradigm shift in the
orthodontic management of AOB and also the effects
of excess MMPA/LAFH. Since it is now possible to treat
such vertical problems orthodontically, it is important
that orthodontists adequately recognize the significance
of these vertical discrepancies rather than continuing with
the traditional approach of classifying malocclusions
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Figure 4 Pre-treatment intra-oral photographs of a 15-year-old girl who presented with a Class III malocclusion on a
skeletal I base with bilateral buccal crossbites (a, b). Treatment commenced with RME (c) followed by maxillary arch
alignment. The maxillary arch expansion was maintained, while palatal mini-implant intrusion treatment (d, e) resulted
in correction of the AOB (f)

primarily as Class I, II or III cases and viewing an
excessive vertical dimension as a less important (or
correctable) after-thought. This can be highlighted in two
respects. Firstly, remember that incisors can exhibit
vertical compensation by their over-eruption masking
the true extent of the underlying excess vertical problem
(Figure 1). Secondly, some Class II malocclusions are a
result of excessive clockwise rotation of the mandible,
rather than retrognathia per se. Consequently, it is
arguable that these patients would be managed best by
molar intrusion as the primary treatment, rather than an
approach involving a functional (orthopaedic) appliance,
premolar extractions, or a mandibular osteotomy
(Figure 2).
If there is any uncertainty over the appropriateness of
molar intrusion treatment, as an alternative to maxillary
surgery, then it is beneficial for the patient to be seen on
a multi-disciplinary orthognathic clinic. This provides
an opportunity for a formal discussion of the ‘pros and
cons’ of surgical treatment and assists with both
informed consent and even subsequent patient motiva-
tion. In my experience, patients who present with an
AOB as their primary concern are very keen to avoid
surgery when given a viable alternative such as molar
intrusion. Perhaps this is best exemplified by the case of
an adolescent who presented with an extreme (12 mm)
AOB (Figure 3). The initial treatment plan involved
molar intrusion to reduce the AOB a more manageable
discrepancy (e.g. 6 mm) during late adolescence, and
then perform a maxillary osteotomy. However, the
patient repeatedly declined surgery on multiple occa-
sions and requested continuation of the intrusion
treatment, in spite of the knowledge that this could
not achieve an optimal occlusal result.
Maxillary arch expansion
When planning molar intrusion treatment, it is almost
always necessary to expand the maxillary arch in order to
achieve transverse arch coordination. This is because of
the effect of mandibular auto-rotation on inter-arch
relationships, and is similar to the need for maxillary arch
expansion during functional appliance and Class II
surgical planning. Indeed, if traction is being applied
from palatal mini-implants then a sensible rule-of-thumb
is to initially over-expand the maxillary arch since this
can be readily constricted later in treatment, especially if
molar torque is required. Buschang et al. (2011) used a
Rapid Maxillary Expansion (RME) appliance for initial
arch expansion in all of their adolescent patients, but this
appliance must be removed before the intrusion phase
(Figure 4). Alternatively, I have found that many patients
with a moderate expansion requirement can be managed
with a removable quadhelix, with the added benefit of this
remaining in situ during the molar intrusion (Figure 5).
Mini-implant insertion sites
Patients with high MMPA tend to have thinner buccal
cortical bone than average MMPA cases and therefore
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Figure 5 Pre-treatment intra-oral photographs of a 24-year-old woman who presented with a Class II malocclusion,
AOB, and absence of the upper right lateral incisor and the first premolar tooth from the other quadrants (a, b).
Treatment commenced with quadhelix expansion and posterior sectional fixed appliances and then palatal mini-
implants were inserted (c, d). The rest of the maxillary dentition was bonded once the AOB had been corrected
and anterior occlusal interferences occurred (e, f). Full alignment, Class II and AOB corrections were achieved,
without the use of intermaxillary elastics, and remain stable 15 months after debond (g, h)

maxillary buccal mini-implants have higher failure rates
in such patients (Antoszewska et al., 2009; Moon et al.,
2010). Given that the cortex is thicker on the palatal
alveolus than the corresponding buccal side, and that
there is more interproximal space between the palatal
roots, it has been recommended that palatal alveolar
insertion sites are used for molar intrusion (Cousley,
2010; Cousley, 2013). The palatal alveolus also has a
favourable length of attached gingiva, assisting with
hygiene around the mini-implant. Palatal mini-implants
may be readily inserted distal to the second molar teeth,
enabling direct intrusion and better torque control of
these teeth (Figure 5). However, mini-implants cannot
be inserted distal to the first molars in adolescent
patients where the second molars are still erupting. The
adjacent palatal soft tissue appears to be too mobile or
thick in these circumstances. The final consideration is
that a contra-angle handpiece, with sufficient speed
reduction (e.g. below 100 rev/min) and torque delivery,
is recommended to assist with optimum access and
directional control during the insertion of palatal mini-
implants (Cousley, 2013).
Lower molar control
Maxillary molar intrusion may result in molar openbites,
especially if anterior teeth develop premature contacts
during bite closure. Unfortunately, this may result in over-
eruption of the mandibular molars, negating the beneficial
effects of maxillary intrusion, especially in growing
patients (Hart et al., unpublished data). Mandibular
mini-implant placement may cause intrusion, or at least
stabilisation of the mandibular molars, but their position
may also be controlled by simpler means. For example,
a full occlusal coverage thermoplastic (retainer-like)
 JO September 2014 Mini-implant Supplement
appliance may be used, or if a lower fixed appliance is
bonded, then relatively early inclusion of the second
molars will stabilize their vertical position.
Incisor control
It has become recognized that molar intrusion, with a full
arch fixed appliance in place, may cause incisor extrusive
changes (Cousley, 2013). This is because the whole
maxillary dental arch rotates around its centre of rotation
as the molars intrude. While modest coronal movement
of the incisors may be appropriate for smile aesthetics,
this change would be detrimental in patients with normal
or increased upper incisor display. Therefore, it is
important that the orthodontist measures the active and
passive upper incisor display at the start and then as
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treatment progresses. This rotational effect may be
countered by the addition of an exaggerated curve of
Spee to a steel maxillary archwire. This paradoxical use of
a bite-opening curve (in an AOB case) also incidentally
helps to improve incisor torque.
Stability
Several studies have demonstrated that most AOB
relapse occurs during the first year of the retention
phase (Lee and Park, 2008; Baek et al., 2010). Given the
potentially unstable nature of AOB corrections, then it
is appropriate to err on over-correcting the AOB. This
may be best achieved through over-intrusion of the
molars (to create molar openbites) coupled with efforts
to minimize extrusive incisor changes during treatment.
Following debond, the author instructs these patients to
wear (full occlusal coverage) thermoplastic retainers for
at least three months of ‘full-time’ wear (compared to a
two-week regimen for other treatment groups). This
appears to be beneficial because these retainers help to
control the vertical level of the molar teeth, although
they provide much less vertical retention of any
extrusive incisor changes.
Conclusions
While some orthodontists may view extractions for
AOB correction as an ‘easy’ option, the patient and their
dentist may well not share this view. Relative to the
other treatment options, extraction therapy is favour-
able in AOB cases if the incisors are proclined or in a
Class III relationship, but detrimental if the incisors are
retroclined and/or have increased vertical display.
Similarly, orthognathic surgery may be regarded as
simplifying the orthodontic aspects of AOB treatment
and offer a ‘quick fix’, but it is invasive and costly (in
several aspects). Therefore, it is arguable that surgery
should be reserved for severe AOBs, especially when
Molar intrusion in anterior openbite S45
there is a concomitant ‘gummy smile’, and/or Class III
skeletal discrepancy. In contrast, mini-implant molar
intrusion treatment involves more complex orthodon-
tics, but it has low risks and morbidity and directly
addresses the main concern of many AOB patients.
Disclaimer statements
Contributors None.
Funding None.
Conflicts of interest The author has a commercial
interest in the Infinitas mini-implant system, but the
treatment principles described here are not limited to a
specific brand of mini-implant.
Ethics approval None.
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