CASE REPORT
Treatment of a severe Class III open bite
Z. Mirzen Arata and Ayça Armanb
Ankara, Turkey
T
he relationship between form and function has
been a matter of discussion in orthodontics for
more than a century, and open-bite treatment is
often part of this debate. The tongue appears to be a
main etiological factor in open bite.1-3 The tongue is
also held responsible for a protruding mandible, an
obtuse gonial angle, increased mandibular length, and
crossbite. The tongue can exhibit various types of
abnormal function. “Tongue thrust” refers to protrusion
during rest or function and is known to contribute to the
development of open bite. However, tongue thrusting is
not an etiological factor unique to open bite,1,4 and it is
considered a necessary adaptation during abnormal
swallowing.5-7 Most patients with adaptive swallowing
have some form of respiratory problem.8,9 Decreased
PO2 or increased PCO2 is the first link in the chain of
events during abnormal swallowing. The tongue is
most likely the last link of this chain in a patient with
open bite, but most theories have focused on the tongue
because it is easily observed.
Treatment of open bite is difficult and even more
challenging when it is associated with mandibular
prognathism. We present the treatment of a patient with
a severe Class III open bite. Initially, treatment was
started with a chincup and a tongue-crib appliance, and
Begg fixed appliances were used during the permanent
dentition period. Our intention is to encourage ortho-
dontists to attempt nonsurgical treatment approaches
for such patients.
DIAGNOSIS AND ETIOLOGY
The patient was a girl aged 7 years 3 months. She had
no history of significant medical problems and no family
history of hereditary disease. She was in the PP2⫽ stage of
pubertal growth according to her hand-wrist film. Her
parents were concerned about her appearance and won-
a
Professor, Department of Orthodontics, School of Dentistry, University of
Ankara, Ankara, Turkey.
b
Postdoctoral resident, Department of Orthodontics, School of Dentistry,
University of Başkent, Ankara,Turkey.
Reprint requests to: Prof. Z. Mirzen Arat, Ankara Üniversitesi, Diş Hekimliği
Fakültesi, Ortodonti Anabilim Dali, 06500 Beşevler-Ankara, Turkey; e-mail,
Z.Mirzen.Arat@dentistry.ankara.edu.tr.
Submitted, October 2003; revised and accepted, April 2004.
Am J Orthod Dentofacial Orthop 2005;127:499-509
0889-5406/$30.00
Copyright © 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2004.04.020
dered whether something could be done at an early age.
The child was a mouth breather and had severe lip
incompetence. Her tongue was large and positioned be-
tween the lips at rest. Tongue thrusting was also evident.
The parents mentioned that the child’s tongue had been
positioned outside her mouth since birth, and photographs
from infancy confirmed this (Fig 1). A clinical examina-
tion showed normal jaw function with no signs of tem-
poromandibular dysfunction. The patient’s soft-tissue pro-
file was concave, with a relatively prominent lower lip and
a retrusive midface. She was in the early stage of the
mixed dentition, and had a Class III molar and canine
relationship bilaterally, a negative overjet (–7 mm), and an
overbite of – 6 mm (Figs 2 and 3).
We initially suspected a genetic condition such as
Beckwith-Wiedemann syndrome3 and thus referred the
patient to our Pediatrics Department. However, no syn-
drome or pathology was detected. Consultation with the
Ear, Nose and Throat Department showed only mild
hypertrophy of the tonsils and confirmed that the child’s
airway was healthy. Computed tomographic evaluation of
the temporomandibular joint showed that all joint surfaces
and skeletal structures were normal, with no restriction of
joint movement. Cephalometric assessment showed a
prognathic mandible with increased effective length, pro-
clined mandibular incisors, a steep mandibular plane
angle, increased anterior facial height, and protrusive
upper and lower lips (Table).
TREATMENT OBJECTIVES
Six treatment objectives were identified: (1) control
the excessive sagittal and vertical growth of the man-
dible and prevent opening of the mandibular plane
angle (chincup), (2) promote forward and downward
development of the maxilla by modifying the protruded
tongue posture (tongue crib), (3) establish a normal
intermaxillary relationship, (4) eliminate the negative
overjet-overbite and level the teeth, (5) achieve an
anterior oral seal, and (6) achieve good occlusion and
acceptable facial esthetics.
TREATMENT ALTERNATIVES AND PROGRESS
Two treatment options were suggested to the patient
and her family. The first option was early orthognathic/
orthodontic treatment. The aim was to improve the
499
500 Arat and Arman
Fig 1. Photographs of patient as infant.
patient’s psychosocial well-being and appearance dur-
ing her teenage years, an important formative period.
The second option was to delay treatment and perform
orthognathic surgery after the patient stopped growing.
After discussing both alternatives in detail, the patient
and her parents chose the orthognathic/orthodontic
approach. This was carried out in 2 phases.
In the first phase of the treatment, a chincup
delivering a force of 500 g (18 hours/day) was applied
through the condylar head of the mandible with a
maxillary tongue-crib appliance (Fig 4). The appliance
was trimmed to guide the eruption of the maxillary
incisors in a more protrusive direction. Patient cooper-
ation was excellent, and an edge-to-edge incisal rela-
tionship was obtained in 6 months. When the maxillary
incisors had fully erupted, the maxillary crib was
replaced with a mandibular crib with spurs. After 22
months of chincup therapy, the deciduous teeth and the
first premolars were extracted. After the canines
erupted, Begg fixed appliances were placed.
At the start of the second phase of treatment, the
patient was 10 years 8 months of age. She had a Class III
molar relationship with 1 mm overjet and 1 mm overbite
(Fig 5). In this phase, a mandibular tongue-crib and a
chincup (only at night) were used with the Begg fixed
appliances. After the teeth were leveled and the desired
incisal relationship achieved, the remaining extraction
spaces were closed by mesial movement of the molars. To
gain anchorage in the anterior region, root-tipping springs
were used.10 Class III and box elastics were used to
achieve a Class I relationship and a positive overbite (Fig
6). In the last 6 months of treatment, lingual root torque
was applied to the mandibular incisors by using auxiliary
torque arches (Fig 6). After 26 months of treatment, the
patient’s chronological age was 12 years 11 months, and
she was in the MP3U stage of skeletal development.
American Journal of Orthodontics and Dentofacial Orthopedics
April 2005
TREATMENT RESULTS
A favorable occlusal result was achieved, with
acceptable interdigitation and incisor relationship at the
end of the treatment. The patient’s soft-tissue profile
became more balanced, and lip closure was attained
(Figs 7 and 8). The patient had no symptoms of
temporomandibular dysfunction (TMD) at the end of
active treatment.
Structural superimpositions of the cephalometric
tracings showed that the forward growth of the maxilla
had been stimulated (Fig 9). During the first phase of
treatment, the mandible grew both forward and down-
ward. The maxillary incisors erupted and become
protruded, the mandibular incisors erupted and became
significantly retruded, the maxillary molars drifted
mesially, and vertical dentoalveolar growth of the
mandibular molars was apparent after the chincup and
tongue-crib therapy. In the second phase of treatment,
the maxilla and the mandible were displaced down-
ward. Posterior rotation of the mandible was prevented
during both stages of treatment. The maxillary and
mandibular incisors were retracted and extruded, the
maxillary molars extruded and moved mesially, and the
mandibular incisors extruded.
Essix retainers were placed, and the patient was
asked to wear them full time for 6 months and at night
thereafter. The palatal part of the appliance was opened
to maintain the palatal position of the tongue during
both rest and function. Wearing the chincup at night
was also continued during retention to control mandib-
ular growth, because the patient was still in an active
growth period at the end of treatment.
The follow-up evaluation 1 year 6 months posttreat-
ment showed that this 2-phase approach had been
effective (Fig 10). Assessment of the occlusion showed
that the patient still had a Class I relationship with a
American Journal of Orthodontics and Dentofacial Orthopedics Arat and Arman 501
Volume 127, Number 4

Fig 2. Pretreatment extraoral and intraoral photographs.

Fig 3. Pretreatment dental models.

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Table. Summary of features

Pretreatment After phase I treatment Posttreatment
7 y 3 mo* 10 y 8 mo* 12 y 11 mo*
6 y 10 mo** 10 y 6 mo** 14 y 6 mo**

Skeletal measurements
SNA 81° 81° 80.5°
N perp. to A 3 mm 1 mm 2.5 mm
Co-A (eff. max. length) 81 mm 84.5 mm 89 mm
SNB 81° 80° 78°
N perp. to Pg 3 mm ⫺2 mm 0.5 mm
Po-NB ⫺1.5 mm ⫺1 mm 0 mm
Co-Gn (eff. mand. length) 112 mm 118 mm 125 mm
ANB 0° 1° 2.5°
Wits appraisal ⫺8 mm ⫺5 mm 1 mm
GoGn/SN 39.5° 40° 40°
ANS-Me 66.5 mm 72 mm 75.5 mm
Gonial angle 133° 131° 130°
Dentoalveolar measurements
U1-NA ⫺1 mm/17° 6 mm/30° 2.5 mm/17°
U1 to A vert. 1 mm 6.5 mm 4 mm
L1-NB 8 mm/37° 6.5 mm/23.5° 4 mm/20°
L1 to A-Pg 9 mm 5.5 mm 2.5 mm
Holdaway difference 9.5 mm 7.5 mm 4 mm
U1/L1 126° 126° 140°
Overjet ⫺7 mm 1 mm 2 mm
Overbite ⫺6 mm 1 mm 3 mm
Soft-tissue measurements
UL-S line 3.5 mm 4 mm 2 mm
LL-S line 9 mm 5 mm 2.5 mm

*Chronological age.
**Skeletal age

positive overbite, a positive overjet, and good arch form
(Fig 11). Mandibular growth was under control, and the
patient continued to have an acceptable appearance.
DISCUSSION
Skeletal open-bite malocclusion exhibits different
sagittal components; that is, open bite can be associated
with skeletal Class I, Class II, and Class III facial types.
This is important with respect to differential diagnosis
and treatment objectives; however, it is rarely empha-
sized.11,12 It is more difficult to treat a Class III
malocclusion when associated with a vertical growth
pattern compared with a horizontal pattern. Treatment
success depends greatly on identifying the causative
factors and establishing an accurate diagnosis.
The possible cause-effect relationship between
mouth breathing and abnormal facial growth is still
controversial. Clinical and experimental studies have
demonstrated that mouth breathing can affect a per-
son’s facial pattern by altering the functional environ-
ment.13,14 However, it is also claimed that the effect
could be indirect, the result of an adaptation of head
posture.15,16
Some authors believe that malfunction of the
tongue influences the outcome and stability of orth-
odontic treatment.2,17-19 Others have stated that tongue
thrusting is a result of open bite, not a cause.7,20 In our
opinion, tongue posture and function are 2 intercon-
nected parts of a system, and they cannot be considered
alone. “Tongue thrust,” as it appears frequently in the
literature, is a broad term that probably reflects a
combination of abnormal positioning and malfunction
of the tongue.
Our patient was a mouth breather who started
tongue thrusting at a very young age but had no serious
respiratory problem (Fig 1). We believe that the abnor-
mal size and function of her tongue, whether a primary
link or not, led to the development of mandibular
prognathism and open bite.
Recently, there has been renewed interest in how
orofacial myofunctional factors affect dentofacial de-
velopment.21 Various methods have been used to ex-
amine tongue movements, including electropalatogra-
phy,22 ultrasonography,23,24 and electromyography.2
These studies showed a relationship between tongue
movement and dentofacial morphology.22-24 On the
American Journal of Orthodontics and Dentofacial Orthopedics Arat and Arman 503
Volume 127, Number 4

Fig 4. Chincup and tongue crib appliances used in first phase of treatment.

Fig 5. Intraoral photographs at beginning of second phase of treatment.

Fig 6. Begg appliances used in second phase of treatment.

other hand, tongue thrusting has not been identified as
a specific contributing factor in the etiology of open
bite.4 This is not particularly surprising because open
bite is multifactorial, and the orofacial musculature
includes other structures in addition to the tongue.
Clinically, when the tongue seems to be a causative
factor, it is necessary to know whether its volume,
posture, or function is responsible. This information
helps determine the most appropriate treatment option,
which might be glossectomy,3,25-27 tongue-crib,2,3,28 or
myofunctional therapy.19,21,29,30 However, the decision
to perform tongue reduction should be made with
caution, because macroglossia is a disproportion or
disharmony between the size of the tongue and that of
the surrounding structures.31,32 Also, although surgeons
and orthodontists might suggest tongue reduction, this
is often difficult for a patient to accept.33,34 We did not
perform tongue reduction because we thought that our
patient had relative macroglossia. The treatment results
and outcome at 1 year of follow-up have proven that
this decision was correct.
Experimental32 and clinical studies3,25-27 have dem-
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Fig 7. Posttreatment extraoral and intraoral photographs.

Fig 8. Posttreatment dental models.

American Journal of Orthodontics and Dentofacial Orthopedics
Volume 127, Number 4
Fig 9. Cephalometric radiographs and superimpositions based on structural method.
onstrated that tongue reduction is effective for treating
open bite and maintaining stability. In a case report of
a Class III open-bite patient, Hotokezaka et al27 em-
phasized the significant effect of tongue reduction on
stability. Their patient was initially treated with edge-
wise mechanics, and a maxillary crib appliance was
used in the retention period. However, relapse occurred
in the mandibular dental arch. The patient was reeval-
uated, and tongue reduction surgery was performed.
After this, most of the patient’s problems resolved
without further orthodontic treatment. This result con-
firms that tongue reduction can have positive effects,
but it should not imply bias against the tongue-crib
approach. The indications for tongue crib and tongue
reduction surgery are different. In the above-mentioned
case, it is likely that an error was made in identifying
the indication for tongue crib, or that the crib was
applied incorrectly. The tongue should be considered
not only when applying crib appliances, but also when
assessing a patient for any intraoral appliance.35
Arat and Arman 505
In our patient, a tongue crib was used in both stages
of treatment. In the first phase, a maxillary tongue-crib
appliance was placed; it stopped the tongue’s negative
effects on eruption of the maxillary incisors. After these
teeth had erupted completely, a mandibular tongue-crib
appliance was placed. The objectives of the mandibular
crib with spurs were to widen the functional area for the
tongue as much as possible and to prevent the tongue
from spreading over the floor of the mouth and, at the
same time, to shift the tongue’s resting position from
the mandibular incisor region to the maxillary incisor
region. We assume that these 2 steps of treatment
resolved the tongue’s undesirable effects on the pa-
tient’s mandible and helped to stimulate forward max-
illary growth.
Huang et al28 showed that a tongue crib can
effectively modify tongue posture, and that it improves
stability for growing and nongrowing patients. They
reported that open bite was eliminated with a high
success rate and the results were maintained throughout
506 Arat and Arman American Journal of Orthodontics and Dentofacial Orthopedics
April 2005

Fig 10. Eighteen-month postretreatment extraoral and intraoral photographs.

Fig 11. Eighteen-month postretreatment dental models.

American Journal of Orthodontics and Dentofacial Orthopedics
Volume 127, Number 4
the follow-up period. Yashiro and Takada2 used a
maxillary tongue crib and an edgewise appliance in a
19-year-old patient with bimaxillary protrusion. Elec-
tromyographic results obtained 2 years after treatment
showed significant adaptation of genioglossus muscle
activity during swallowing.
In our patient, the tongue crib and the chincup
improved the intermaxillary relationship, reduced the
gonial angle, prevented opening of the mandibular
plane angle, and eliminated the patient’s negative
overjet (–7 mm) and open bite (– 6 mm). Significant
protrusion of the maxillary incisors and retrusion of the
mandibular incisors were observed after the first phase
of treatment (Table), and the patient’s soft-tissue profile
reflected the skeletal and dental changes.
Opinions differ,36-39 but authors have documented
distinct and stable changes with chincup treatment for
patients with Class III malocclusions.40-44 These
changes include improvement in the intermaxillary
relationship (according to ANB and Wits measure-
ments), reduction of the increase in mandibular length,
reduction of the gonial angle, and widening of the
mandibular plane angle. Most of these changes are in
line with our cephalometric findings; however, widen-
ing of the mandibular plane angle was prevented
because our patient had a Class III open-bite malocclu-
sion, not a Class III malocclusion alone.
The direction of force to be applied by the chincup
should be determined according to the vertical compo-
nent of the Class III structure. Applying a more
horizontal force is not appropriate when hyperdiver-
gency or anterior open bite accompanies a Class III
relationship. Ruttici and Nanda45 suggested applying a
force vector anterior to the condyle. Such an applica-
tion is advantageous for reducing hyperdivergency or
open bite but makes it more difficult to resolve the
Class III abnormality. In light of this, some authors
have recommended a force vector in the chin-condylar
head direction.44,46 In our patient, the chincup force
was applied through the condylar head, and the man-
dibular plane angle was maintained throughout treat-
ment (Table).
The dentofacial effects of chincup therapy depend
heavily on the patient’s age and the duration of treat-
ment.36-40,44 Most authors agree that Class III maloc-
clusions should be addressed early.45,47,48 A long re-
tention period is required when treatment is completed
at a young age; otherwise, relapse is certain.37,39 Our
recommendation concerning the timing of chincup
treatment is to start early and finish late. We began
addressing our patient’s problems at 7 years of age, and
her treatment lasted until she was 13 years old. By the
end of therapy, the patient had reached the MP3u stage
Arat and Arman 507
of pubertal growth. Chincup treatment will be contin-
ued at least until complete epiphyseal union of the
radius, the stage at which craniofacial development
ceases and orthognathic surgery procedures can begin.
Such patients must either live with their skeletal anom-
alies until this age or get rid of their malocclusion at
young age and endure a long retention period. Our
patient had reasonably good occlusion and acceptable
facial esthetics through her early teen years; this was
very important for her psychosocial well-being. This
might be the main advantage of early orthopedic
treatment over orthognathic surgery. Furthermore, it
has not been proven that surgery ensures stability in
open-bite patients.49-51
Early treatment is beneficial for patients with skel-
etal discrepancies. However, “early” is relative. Be-
cause craniofacial growth and development vary by
region, an intervention that is considered early for 1
dentofacial structure or area might be late for another.
It has been reported that the dentoalveolar response to
functional or orthognathic treatment of open bite differs
regionally according to developmental period.52,53 Be-
cause of this, it is more accurate to refer to “optimum”
or “differential” treatment times instead of “early” or
“late.” Consideration of differential craniofacial growth
is just as relevant for ensuring stability as it is for
treatment. The incidence of open-bite relapse is rela-
tively high. One reason for this is that the functional
factors in the etiology of open bite (not only the tongue)
are often overlooked. Fortunately, there appears to be
renewed interest in muscular exercises.54
One of the most important and rarely emphasized
craniomandibular effects of chincup therapy is the
anterior bending of the condylar head because of the
retractive forces. This has been demonstrated by both
cephalometric55 and magnetic resonance imaging56
studies. This finding disagrees with the idea that retrac-
tive forces on the mandible cause pressure at the
retrodiscal area and cause TMD.57,58 Several studies
have shown that chincup treatment has no harmful
effect on the temporomandibular joint.59-62 In a recent
long-term study, the effects of chincup therapy were
investigated regarding TMD signs and symptoms; it
was concluded that chincup treatment is neither a risk
factor nor a prevention for TMD.63 Just as in our
patient, no sign of TMD was detected after the treat-
ment and the follow-up period.
We initially diagnosed this girl with Class III open
bite because of the abnormal volume and function of
the tongue. This evaluation supports the theory that
form follows function. On the other hand, through
achieving normal occlusion and balanced facial struc-
ture, the malfunctions were resolved, and the treatment
508 Arat and Arman
outcomes were successfully maintained (Fig 10). This
confirms the view that normal structural relationship or
normal form allows for normal function. These 2 views
do not contradict each other. As Fränkel and Fränkel17
stated, it is impossible to study form without also
studying function, and vice versa. Form affects func-
tion, and function affects form. These 2 hypotheses
should be accepted, and treatment modalities should
target both fronts.
CONCLUSIONS
1. There is a form-function relationship in malocclu-
sion. It is not necessary to prove whether form or
function is of primary importance in malocclusion
because they are intertwined.
2. Severe Class III open-bite problems can be success-
fully treated without surgery if a good strategy is
put in place at a young age.
3. Postural and functional status should be carefully
monitored because this reflects the stability of
treatment outcomes.
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