A functional approach to treatment

of skeletal open bite

Rolf Frllnkel and Christine Frlnkel
Zwichau, German Democratic Republic

In general orthopedics the relationship between postural behavior and skeletal deformities has long been
recognized. The primary therapeutic problem in functional orthopedics is to overcome functional disorders. In this
article the applicability of this functional concept to orofacial orthopedics is discussed on the basis of a
longitudinal study of skeletal open bite. A comparison of a series of lateral cephalograms of thirty patients with
skeletal open bite who were treated with functional regulators developed by Frankel and those of eleven
untreated open bite cases suggests that some dentofacial deformities in the skeletal open bite cases can be
corrected to the average norms. In addition, as a result of overcoming the poor postural pattern of the orofacial
musculature and re-establishment of a competent lip seal, a considerable change in the soft-tissue profile
occurred.

Key words: Skeletal open bite, Frankel method, dentofacial orthopedics, abnormal posture

S
keletal open bite is produced by a combi-
nation of dental and skeletal irregularities, the latter of
which is the more dominant. The facial morphology of
this dysplasia is characterized primarily by striking
vertical disproportions caused by abnormal ratios be-
tween anterior and posterior facial heights (AFH/PFH)
and between upper and lower anterior facial heights
(UFH/LFH). A short ramus and an increased gonial
angle also contribute to the hyperdivergent skeletal pat-
tern. As there is normal biologic variation, so each
dentofacial malformation has its own characteristics
and uniqueness. Therefore, the type of skeletal open
bite must be defined by various additional parameters.
The skeletal pattern of such a severe dysplasia as
skeletal open bite is difficult to change by means of
conventional orthodontic appliances. Some clinicians
have warned against any orthodontic treatment and,
instead, recommend corrective measures such as surgi-
cal and prosthetic intervention. It is not surprising,
therefore, that the hyperdivergent pattern of this dys-
plasia is assumed to be primarily the expression of in-
herited vertical proportions. This view is substantiated
by the results of Hunter’s’ investigations which support
the hypothesis that vertical dimensions of the craniofa-
cial skeleton are more genetically controlled than are
anteroposterior dimensions. However, as claimed by
Dullemeijer,’ all structures are genetically and en-
vironmentally influenced. In view of the character of
This study is part of an investigation entltled “Functional Aspects of Skeletal
Open Bite” submitted by Christine Frlnkel in fulfillment of the requirements
for the doctoral degree at the University of Jena, German Democratic Republic.
54
biology, it is impossible to study form without also
studying function, and vice versa. There is a specific
order to the influences of each structure. As the skeletal
unit is the last unit to exert its influence, its shape is
completely subordinate to the other elements or to the
functional matrices in Moss’ terminology. Poulton’j
holds that the recurrence of some anterior open bite
problems is the result of muscle imbalance creating a
dentofacial problem. The teeth and jaws may be
brought into a position of excellent anatomic function,
but if the muscles which work together to close the jaws
remain weak and flaccid, the open bite may reappear.
Corrective therapy in these situations must include
work to build up the strength and function of the weak
muscles if long-term stability is to be achieved.
The purpose of this article is to test the hypothesis
that a functional approach will provide a better under-
standing of how local environmental factors contribute
to the development of the hyperdivergent pattern in the
facial skeleton. On the basis of our clinical experience,
we will attempt to show that the principles of general
orthopedics can be successfully applied to the treatment
of skeletal open bite. We believe that this type of treat-
ment allows a more optimistic attitude to be taken to-
ward the long-term stability of skeletal open bite cases
treated by dentofacial orthopedics than by other treat-
ment methods.
DEVELOPMENT OF A FUNCTIONAL STRATEGY
FOR TREATMENT OF SKELETAL OPEN BITE
It was Edward Angle,4 the founder of modem ortho-
dontics. who emphasized the morphogenetic relevance
Volume 84
Number I
of the soft-tissue environment to the dentition. Angle’s
belief that relapse is caused by forces on the teeth re-
sulting from an improper soft-tissue environment ap-
peared to be a rational conclusion from a biomechanical
point of view. After World War II, interest in the role
of the soft tissues in the etiology of malocclusion in-
creased enormously. With regard to the development of
an open bite, particular emphasis was placed on ab-
normal patterns of tongue behavior. Deviant patterns of
swallowing or “tongue thrust” were considered to be a
major factor in opening the bite. Clinically, the advo-
cates of “myofunctional therapy” recommended vari-
ous kinds of exercises to overcome the abnormal behav-
ior pattern of the tongue in combination with speech
therapy.“-’
An alternative therapeutic approach to the treatment
of open bite at that time was the use of a palatal crib
attached to either fixed or removable appliances. In
the 1950s we used such “tongue-habit” appliances,
and they were quite successful in a high percentage of
cases in which an anterior open bite had persisted to the
age of 6 or 7 years. However, some patients exhibited
relapse after treatment. We thought that the duration of
treatment with “tongue-habit” appliances might have
been too short to re-educate tongue behavior in these
cases. However, relapse occurred even after renewed
treatment with a palatal crib appliance.
In an attempt to find a plausible reason for the re-
lapse in these patients, we examined them and found
that they all showed a marked discrepancy between lip
length and lower face height. This finding corre-
sponded to Ballard’s” suggestion that, in an evaluation
of habit behaviors and their clinical relevance, more
attention should be paid to the size and shape of the soft
tissues. He stated that each case must be judged in
relation to disproportions in the facial skeleton and,
from his clinical observations, concluded that tongue
thrust as the major cause of open bite had been overem-
phasized. He argued that the faulty interdental posture
of the tongue appeared to be a compensatory or adap-
tive behavior which established an anterior oral seal
when the lips were incapable of doing so.
It was during this same period that we were work-
ing on the development of a functional orthopedic ap-
proach using skeletal vestibular shields.“-‘” In contrast
to a structural concept, we believed that lip incompe-
tence was not a consequence of a discrepancy between
skeletal and soft-tissue growth. Therefore, we hypoth-
esized that the deficiency of an oral seal might be due,
at least in part, to a poor postural behavior of the facial
musculature (particularly in the lip area), even in cases
of skeletal discrepancies associated with a steep man-
dibular plane. Thus, we decided to institute functional
therapy with vestibular shields and lip-seal training for
Functional approach to treatment of skeletal open bite 55
anterior open-bite relapse patients. After a relatively
short treatment time, we observed that a normal over-
bite was established and remained stable, provided that
a competent anterior oral seal was also established.
The clinical experience gained in the treatment of
open-bite relapse patients was fundamental to the
further development of functional orofacial orthope-
dics. The clinical observation that an open bite can be
closed without using any device which interferes with
tongue movement or tongue posture suggests that
tongue thrust alone may not be the primary cause of
that malocclusion and that there may be a functional
relationship between the postural behavior of the
tongue and lips. The impact of postural behavior pat-
terns has been substantiated by the more recent work of
Proffit’” which deals with the orofacial muscular envi-
ronment and its influence on the morphology of the
dentition. Proffit suggests that rapid-movement func-
tions, such as swallowing, chewing, and speaking,
have little impact on the morphology of the dentition,
while the impact of postural alterations leading to
changes in lip and tongue resting pressure and posture
is significant.
Since the late 1800s general orthopedists have
learned a great deal about the form/function relation-
ship in skeletal morphogenesis. In the last 50 years an
evolution has occurred in the development of a func-
tional concept. Clinical evidence accumulated during
this long period supports the idea that, as far as func-
tional factors are concerned, aberrant postural behavior
does play a primary role in the etiology of skeletal
deformities. Biostatistical studies suggest that a poor
postural performance affecting related muscles plays a
part in the development of skeletal malformations. la In
general orthopedics, therefore, functional therapy is
commonplace, and the primary therapeutic problem in
functional orthopedics is to overcome a faulty postural
performance pattern. Thus, it seems logical to examine
whether aberrant postural behavior of the orofacial
muscles plays a causative role in the development of
dentofacial deformities. Therefore, in developing a
functional approach to orofacial orthopedics, the ortho-
dontist should look not only to his own training as a
specialist of dentistry but to the field of general ortho-
pedics as well. For example, in contrast to the trunk
and limbs, the twenty-two bones of the skull are almost
exclusively of membranous origin. The intermediate
connective tissues have an adaptive and compensatory
growth capacity which is highly susceptible to bio-
mechanical influences and hence to functional forces.
Therefore, there is reason to believe that treatment de-
signed to overcome a poor postural performance would
be effective in the orofacial complex.
There are certainly difficulties in developing a
Table I. Average changes between the initial and final cephalometric measurements in the nontreated group
N (n = 11) and the treated group T (n = 30) and a comparison of the differences by analysis of variance
and by the paired t test and Fisher-Behrens test
Angles (degrees) N T
1. SN-MP + 2.32 -5.47
2. SN-PP -0.36 +2.30
3. PP-MP + 2.68 -1.42
4. Go +0.23 -6.37
5. z +2.68 -5.12
6. AFH-PFH quotient (Jarabak) -0.32 +5.40
7. Ratio UFH-LFH (Nahoum) -0.018 +0.053
Significance:
**p < 0.01 (t value 2.70).
***p < 0.001 (t value 3.56).
Fisher-Behrens test f’ = 11.2633. t 0.05: 11 = 2.20.
functional approach to orofacial orthopedics because
the orofacial region is a multifunctional area of con-
siderable complexity. The postural performance of the
orofacial musculature cannot be separated from the
functional demands of the respiratory and digestive sys-
tems and the patency of the related functional spaces.
The orofacial musculature serves to maintain the vital
positional relationships that ensure a functionally ade-
quate volume of the oral, nasal, and pharyngeal spaces.
The postural mechanisms of the head and neck play an
integral part in maintaining the mandible in an adequate
anteroposterior position and stabilizing the tongue and
posterior pharyngeal wall relationships, all of which are
necessary for the maintenance of an adequate airway.
Bosma’” states that airway maintenance is an extremely
important factor governing the postural behavior of the
orofacial musculature. Harvold17 has shown that there
are nonphysiologic conditions in the oronasopharyn-
geal spaces which contribute to the development of
craniofacial deformities. He observed dramatic changes
in mandibular morphology of rhesus monkeys in which
pieces of plastic were placed in the palatal vault, dis-
placing the tongue inferiorly. This experimental finding
suggests that diminution of lingual volume which leads
to alteration in tongue posture may also change the
postural position of the mandible as well. It appears
reasonable, therefore, to assume that there is a func-
tional relationship between space conditions in the oral
cavity and the postural position of the tongue and
mandible.
A similar relationship between the tongue and
mandibular posture is seen in another experiment” in
which rhesus monkeys were forced to breathe through
the mouth. It is noteworthy that changes in mandibular
morphology could be observed only in those animals
7 ,ziLgfor-------
D$erences F value I per& Signijicuncx~
1.19 2.92 3.54 **
2.66 2.09 5.24 ***
10.10 1.54 3.95 ***
6.60 1.35 5.54 ***
8.40 3.70 7-.- ‘4 **
5.72 2.72 6.96 ***
0.071 I .09 4.67 ***
that, in order to breathe, turned the tongue into a tube,
forcing the mandible to maintain a lower postural posi-
tion. The lips remain open at varying intervals, suggest-
ing that an alteration in the postural behavior of the lip
musculature also occurred. The evidence that in these
experiments a normal occlusion often could be trans-
formed into a severe open bite, accompanied by the
deviant mandibular morphology seen in skeletal open-
bite cases, emphasizes the impact of postural perfor-
mance pattern on dentofacial morphology.
It appears reasonable to assume that if alterations in
the postural activity of the orofacial musculature can
lead to skeletal open bite, as well as to other types of
malocclusion (as was shown in Harvold’s experiment),
the correction of faulty postural activity of the orofacial
musculature might help correct the associated skeletal
deformity. It was, therefore, a fundamental considera-
tion in developing our therapeutic strategy to aim at
overcoming the deviant pattern of mandibular rotation
through re-establishment of nose breathing by correct-
ing the lips-apart condition and faulty tongue posture.
This working hypothesis was also based on an interest-
ing clinical observation. When a child with lips apart as
a usual posture is asked to close his or her lips, a
marked activity of the temporalis and masseter muscles
can be regularly palpated. In cases of severe skeletal
open bite, the large interlabial distance cannot be over-
come by the force of the orbicularis oris muscle alone.
The lips can be sealed only by a concomitant activity of
the elevator and mentalis muscles pushing the lower lip
upward. From this it can be derived that the muscles
responsible for creating a lip seal are functionally re-
lated to the elevator muscles. The design and develop-
ment of the functional strategy discussed here are based
on the assumption that concomitant lip-seal exercises
Volume 84 Functional approach to treatment of skeletal open bite 57
Number 1

i:;:;I;I
Table II. Measurements of the initial s N AFH / PFH

cephalograms of the untreated case A and the

treated cases B and C
Angles {degrees) Case A Case B Case C
AF II1I I l
I I !i

11
II !i
IIII **
IIII !I!I
SN-MP 45.0 43.5 44.5
SN-PP 4.0 6.0 4.0 II II
PP-MP 41.0 37.5 40.5 II li
Go 129.0 134.5 132.5 GO I iI
Ii

1
404.0 I
B (Jarabak) 405.0 403.0 I
I i
I i
Quotient (Jarabak) 56.5% 56.0% 56.0% I

J.
1

can affect not only the perioral musculature but the
elevator musculature as well. If a competent lip seal is
attained, the correction of an opening rotational pattern
of the mandible as an adaptation of form to altered
function might be expected.
The aim of this presentation is to examine whether
this theoretical concept can be materialized by the in-
stitution of functional therapy. During the past 25 years
a considerable quantity of serial cephalometric, photo-
graphic, and dental cast data has been collected on
children treated in our clinic with functional ortho-
pedics (as developed by Frinkels-13). This permitted a
longitudinal study of the form/function relationship
present in the development of skeletal open bite by
looking at the changes that took place in the craniofa-
cial complex of these children.
MATERIAL AND METHODS
Lateral cephalometric radiographs were taken of
thirty children with severe skeletal open bite before and
after treatment, the last one being taken at least 4 years
out of retention. Radiographs were also taken of a con-
trol sample of eleven untreated open bite cases. Selec-
tion of subjects was based on the presence of a hy-
perdivergent skeletal pattern and clinical observation of
a large interlabial distance and postural weakness of the
orofacial muscles. The subjects were followed for an
average age range of 7 to 15 years for the treated group
and 8 to 16 years for the untreated control sample.
Thus, the skeletal development in the craniofacial
complex could be observed in approximately analogous
growth periods, that is, from the first stage of the mixed
dentition through the pubertal growth spurt.
A Tu-RD, 300-2 radiographic unit was used to take
the radiographs. Its powerful rotating anode permitted a
constant focus to a distance of 3.75 meters. The fixed
distance between the ear rod of the head holder near the
cassette and the film was 2 cm. Because of the large
focal distance, enlargement error was negligible and
double contours of corresponding bilateral skeletal
--abe A
----Case B Me 56% 56% 56.5 %
.-.--case c Jarabak - Quotient
Fig. 1. The polygons formed by the landmarks S (sella), N
(nasion), Me (menton), Go (gonion), and Ar (articulare) as used
in the method of Jarabak representing the initial hyperdivergent
patterns of untreated Case A and treated Cases B and C. On
the right side, the ratios posterior face height (P) to anterior face
height (A) and the resultant quotient (Jarabak) are shown.
structures were not shown except in cases in which
there was asymmetrical development. The lack of
double contours contributed considerably to an exact
definition of the landmarks used for determining the
reference lines, an important factor in the reliability of
longitudinal comparative studies.
The series consisted of an average of eight cepha-
lograms each for those in the treated sample and five
cephalograms each for those in the untreated group. All
measurements were made directly on the cephalograms
and were done three times by a trained assistant. Each
series of cephalograms was analyzed by the method of
Frinkel , Is with the occipital coordinate system as a
cephalometric reference. The reliability of the vertical
and horizontal axes oriented to the first registration of
the natural head posture has been described else-
where. ls This method permits the measurements of the
serial cephalograms to be checked because the posi-
tional changes of the various landmarks in extent and
direction can be followed from one radiograph to an-
other. Thus, we can examine whether the displacement
of the various landmarks during the intervals between
radiographs were within the limits of probability. Con-
sidering the fact that in the treated sample an average of
eight radiographs were taken for each patient, any inac-
curacies in defining the landmarks and their positional
changes can be assumed to be minimized. The final
measurements of this study were made after the last
cephalogram was available, which allowed for another
check of landmark location.
In this article the use of the Frankel analysisls for a
58 Friinkel and Friinkel

AFH / PFH

II Ii
II ii
I l
II i

53. ! ‘. 63% 63.5%

Jarsbak - Quotient

Fig. 2. The polygons and the ratios AFH/PFH of untreated

Case A and treated cases B and C exhibit a marked devel-
opmental difference in skeletal pattern. The quotient (Jarabak)
expressing the ratio AFH/PFH worsened in Case A in the ob- Fig. 3. The polygons of untreated Case A before and after
servation period of 6 years 6 months, while it was in a normal observation (see solid lines in Figs. 1 and 2).
range (norm = 62 percent) in the final cephalograms of Case B
8 years 2 months out of retention and of Case C 4 years 1
month out of retention, demonstrating stability of the treatment
results. study mentioned above. The cephalometric data of the
nontreated group (IV) indicate that the angles SN-PP,
PP-MP, gonial angle, and the total of the angles be-
statistical evaluation of the differences in the skeletal tween sella-nasion, sella-articulare-gonion (S-Ar-Go),
development between the treated and untreated groups and gonion-menton increased during observation, while
was confined to the angles formed by sella nasion (SN), the angle SN-PP decreased slightly. In the treated
palatal plane (PP), mandibular plane (MP), and the group (T), there was a considerable decrease of the
vertical axis of the occipital coordinate system (OS). In angles SN-MP, PP-MP, gonial angle, and the total of
order to avoid errors in quantifying the deviations in the facial angles (2) as used in the Jarabak analysis.
skeletal pattern and the changes that occurred during The abnormal ratios between upper and lower anterior
treatment and observation, some parameters used in the facial height (UFH/LFH) and between anterior and
cephalometric analyses of NahoumzO, 21 and Jarabak2’ posterior facial height (AFH/PFH) as characteristic fea-
also were applied: the sella-nasion and palatal plane tures of hyperdivergency worsened in the nontreated
angle (SN-PP), the sella-nasion and mandibular plane sample (N) but changed to average norms in the treated
angle (SN-MP), the palatal and mandibular plane angle group (T). The analysis of variance and t tests showed
(PP-MP), the gonial angle, the upper facial height/ that there was a highly significant difference between
lower facial height ratio, the total of the angles between the mean changes of the parameters measured in the
sella-nasion, sella-articulare-gonion (S-Ar-Go), and nontreated (N) and treated groups. Therefore, it is as-
gonion-menton (Go-Me), and the quotient determining sumed that the correction of hyperdivergency in the
the anterior to posterior facial height ratio. Each mean treated group (T) as evidenced by the changes of the
angular dimension and ratio listed above for the treated parameters tabulated in Table I, 1 to 6, may be attrib-
and untreated groups was compared by analysis of vari- uted to the method of functional orthopedics applied.
ance and by t tests. For statistical analysis of the differ- For a better understanding of the findings of this
ences between the variables of the total of the facial study, the measurements made in three cases will be
angles of Jarabak,22 the Fischer-Behrens test was used to illustrate the cephalometric appraisal of the de-
applied (Table I). gree of hyperdivergency present in skeletal open bite.
In each of these three cases a Class II relationship be-
RESULTS tween the maxillary and mandibular arches was present
Table I presents some parameters used in the initially. In untreated Case A the distocclusion in the
cephalometric analysis of the longitudinal comparative molar relationship was 3 mm., in treated Cases B and C
volume 84 Functional approach to treatment of skeletal open bite 59
Number 1

UFH I LFH UFH I LFH

-\
‘.i Fig. 5. The initial and final polygons of treated Case C. In addi-
tion to the angular changes and the normalization of the ratio
Fig. 4. The initial and final polygons of Case 6. During treat-
UFH/LFH, the upward cant of Spp relative to MP changed,
ment and retention a considerable elongation of the PFH and
showing skeletal alterations in the anterior part of the middle
ramus relative to AFH and LFH occurred. The length of UFH
face.
was nearly equal to that of LFH measured in the final cephalo-
gram. There is evidence that the skeletal pattern changed to a
horizontal type.
Table III. Measurements of the final
cephalograms of the untreated Case A and the
it was 3 mm. and 5.5 mm., respectively. No teeth treated Cases B and C
were removed in any of these cases during the observa- Case Case Case
tion, treatment, or retention periods. It is not the pur- Angles (degrees) A B c
pose of this article to give a detailed description of the SN-MP 52.0 36.0 38.0
course of treatment with functional regulators and lip- SN-PP 3.5 8.0 8.0
seal training. Rather, this article reports the findings PP-MP 48.5 28.0 30.0
of a comparison of those skeletal open bite patients GO 130.5 130.0 121.0
Z (Jarabak) 412.5 395.5 398.0
treated with functional therapy and untreated patients
monitored for a similar period of time. Quotient (Jarabak) 53.5% 63.5% 63.5%
In the evaluation of the initial skeletal pattern of
each case, it should be noted that the first radiograph of The average time interval between the first and last radiographs mea-
the untreated child was taken at the age of 8 years 11 sured was 8 years 0 months in the nontreated group N and 7 years 11
months in the treated sample T.
months, while those of the two treated cases were taken
B indicates the total sum of the angles between S-N, S-Ar, Ar-Go,
at the age of 6 years 5 months. This difference in age and Go-Me.
may explain why the dimension of the polygon of the
untreated case (Fig. 1, solid lines) is relatively larger
than that of the two treated children. Notwithstanding PFH), the latter of which is the most characteristic fea-
this age difference, the almost identical hyperdiver- ture of hyperdivergency.
gency in skeletal pattern of the three cases is obvious. The difference in skeletal development between
The SN-MP angles are nearly equal in size, which can untreated Case A and treated Cases B and C is clearly
also be seen in Table II. The relatively low angle recognizable (Figs. 1 to 5, Table III). The most impor-
formed between the mandibular plane and the palatal tant change in the skeletal pattern of the treated cases is
plane in treated Case B is compensated for by the size the considerable elongation of the posterior facial
of the gonial angle, which is 5.5 degrees larger than height (S-Go) relative to the anterior facial height
that of untreated Case A. The likeness in skeletal pat- (N-Me). The anterior to posterior facial height ratio
tern is also evident from the abnormal ratios between expressed in Jarabak’s quotient changed to an average
upper and lower anterior facial height (UFH/LFH) and norm of 63.5 percent in treated Cases B and C, while in
between anterior and posterior facial height (AFH/ untreated Case A it became worse, changing from 56
60 Friinkrl and Friinkel
O!
.--m--- mm---
SN
.--e.-------- - 1
PP
\
\
\
\
\
\
MP ‘\
\ \
\
Fig. 6. Angular changes of SN, PP, and MP formed with the
vertical axis (OS) of the occipital coordinate system represent-
ing the true vertical determined by a photographic registration of
natural head posture in untreated Case A.
percent to 53 percent. There was also a difference in the
ratio of upper facial height to lower facial height. In the
treated cases the distance between nasion and the pal-
atal plane after treatment was approximately equal to
the distance between Me and the palatal plane, while
in untreated Case A the upper facial height/lower facial
height ratio worsened. The angular measurements also
indicate the difference in skeletal development, particu-
larly the decrease in the gonial angle in Case C by 11.5
degrees and that of angle PP-MP in Case B by 9.5
degrees and in Case C by 10.5 degrees.
DISCUSSION
It should be noticed that initially there was a slight
difference in skeletal pattern between the two treated
cases. Angle SN-PP was 6 degrees in Case B and 4
degrees in Case C. Angle PP-MP was 37.5 degrees in
Case B and 40.5 degrees in Case C. As already men-
tioned, the occipital reference system with the horizon-
tal coordinate adjusted to the earth’s surface permits a
more realistic interpretation of angular measurements,
which has been described in detail. lg In order to find an
explanation for the difference in size of angles SN-PP
and PP-MP in the treated cases, the occipital coordinate
system can be used. In the comparative study in this
article, only the angles formed by sella nasion, the
OS
+4
----w-w-
PP (W-+95)
Fig. 7. Angular changes in treated Case B, measured by the
Frankel method.
palatal plane, and the mandibular plane with the verti-
cal coordinate of the occipital reference cross are used
for cephalometric analysis and statistical evaluation of
the differences between the two groups (Figs. 6 to 8).
With reference to the angles formed by the sella-nasion
line, the palatal plane, and the mandibular plane with
the vertical coordinate (that is, the true vertical as de-
termined by the first registration of the natural head
posture being transferred to the subsequent radio-
graphs), there is no marked difference between un-
treated Case A and Case B. By comparison, in Case C
the inclination of sella nasion and particularly of the
palatal plane was initially quite different. The upward
canting of the palatal plane suggests that in Case C the
vertical disproportions are also manifested in the mid-
dle face. Our investigations using the occipital refer-
ence system confirm the statements of Nahoum and
co-workerszl that, in a cephalometric appraisal of the
hyperdivergent pattern, the contribution of the palatal
plane to the ratio of upper facial height to lower facial
height must be emphasized. Its position and inclination
provide valuable information on the nature of the dif-
ferential growth in the middle and lower face, respec-
tively . Nahoum and co-workerG found that the distance
from the first maxillary molar to the palatal plane was
not significantly different from that of the normal sub-
jects. This contradicts the findings of others who re-
ported excess eruption of maxillary posterior teeth.
Volume 84 Functional approach to treatment of skeletal open bite 61
Number I

+0,5
OS de (76,5+77)

Fig. 8. Angular changes of treated Case C showing that PP

dropped anteriorly more than in Case 6 (Fig. 7). In contrast, a
slight upward canting of PP occurred in untreated Case A.

Sassouni and Nanda2” explained an existing deviant

inclination of the palatal plane as a downward tipping
of the posterior half of the palate carrying the molars
further downward. Speidel and co-workersz4 arrived at
the conclusion that an excessive height of the posterior
maxillary process was an important factor in develop-
ing a high mandibular growth pattern.
The marked increase of upper facial height relative
to lower facial height and the concomitant increase in
the SN-PP angle suggest that the vertical disproportions
of the middle face in Case C are manifested more an-
teriorly (Figs. 5 and 8).
Certainly, the pattern of skeletal development can
be determined by an analysis of angular measurements.
It should be remembered, however, that any change in
an angle is the result of changes in at least three points
(the vertex and one point on either side). The change of
the angle between sella nasion and the palatal plane
may be attributed to the positional changes of the land-
marks N, S, Nsp, and PNS. When the occipital coordi-
nate system (which enables us to determine those
landmarks, the positional changes of which caused the Fig. 9. Tracings of the first and last radiographs with the corre-
angular alterationslg) is used, it can be seen that the sponding polygons of Case A (see text).
angle between the occipital coordinate system and the
mandibular plane increased during the observation pe-
riod, indicating a worsening of the opening rotation of treatment of Case C skeletal changes occurred in both
the mandible in the control case while in Cases B and C the middle and the lower face.
it decreased significantly (Figs. 6 to 8). The dropping Our studies1°-13 suggest that in the presence of a
of the nasal floor anteriorly, as indicated by an average hyperdivergent skeletal pattern the entire splanchno-
increase of the PP-OS angle (Fig. 8), shows that during cranium is affected. In addition to the deviant vertical
62 Friinkel and Friinkrl

Fig. 11. Tracings from the lateral radiographs of Case A su-

perimposed on Frankfort horizontal.

the first maxillary molar in Case A may be attributed to

Fig. 10. Tracings of the first and last radiographs
sponding polygons of Case B (see text).
proportions below the palatal plane, a characteristic
feature present in every case, the middle face is af-
fected as well.
The tracings shown in Figs. 9 and 10 may provide a
better understanding of the measurements made in this
study. The initial tracings of Cases A and B show that
there was originally an almost identical developmental
pattern in the splanchnocranial area. The midfacial
structures do not show a difference in either sagittal or
vertical proportions. The slightly advanced eruption of
the fact that the first radiograph was taken at an age 2%
years older than that of Case B. It is interesting to note
that in both cases the migration of the first maxillary
molars occurred to almost the same extent. The dis-
tance between the sella-nasion line and the nasal floor
increased more during treatment of Case B than in un-
treated Case A. The final radiographs of both cases
were taken approximately at the age of 15% years.
However, it must be mentioned that the first radiograph
in Case B was taken at an age approximately 2% years
earlier than that of Case A. Notwithstanding this differ-
ence in patients’ ages when the first radiographs were
taken, there is evidence of normal sutural and alveolar
growth in the posterior half of the midface in Case B.
Therefore, the FR appliance may not have had any
with the corre- intrusive effect on the maxillary molars or a depressive
function on the vertical development of the posterior
midfacial structures. The correction of the mandibular
steepness, therefore, apparently is not due to me-
chanical interruption of sutural or alveolar growth of
the posterior portion of the maxilla.
Another interesting phenomenon observed in Case
B was that the distance of the root apices from the
lower mandibular border increased to the same extent
as that in untreated Case A. That could mean that
treatment with the FR did not retard alveolar growth in
the posterior area of the mandible. The correction of
hyperdivergency and the considerable increase in
Volume 84
Number 1
Fig. 12. Tracings from the lateral radiographs
perimposed on Frankfort horizontal.
posterior facial height relative to anterior facial height
concomitant with normal alveolar growth in the
posterior parts of the maxilla and mandible during
treatment suggest that compensatory growth at the con-
dyle must have occurred. There is another interesting
phenomenon supporting this hypothesis. The tracings
of Case B exhibit a marked change in axial inclination
of the mandibular molars in the course of treatment.
Bjijrk and SkielleP have emphasized the influence of
the rotation of the face on the paths of eruption of the
teeth during eruption. The significant uprighting of the
mandibular molars during treatment could thus be ex-
plained, at least in part, as the result of a change in the
rotational pattern of the mandible.
Figs. 11 and 12 show the skeletal development of
Cases A and B when the tracings of the radiographs are
superimposed on the Frankfort reference line. The dif-
ferential change in profile anteriorly indicates that the
initial vertical growth pattern of Case B changed to a
horizontal one during treatment, whereas it was main-
tained in Case A. The amount of the combined vertical
sutural and alveolar growth of the maxilla and alveolar
growth of the mandible in treated Case B equals that of
untreated Case A. There is no difference in the change
of the maxillary molar vertical positions, and appar-
ently no intrusive mechanics on the upper molars were
operating during treatment. Therefore, the closing of
the anterior vertical relation during treatment of Case B
cannot be the result of autorotation of the mandible as it
is observed after surgical superior repositioning of the
maxilla. The results of surgical correction of aperto-
Functional approach to treatment qf skeletal open bite 63
of Case B su-
Fig. 13. The working principle of the FR in establishing the
mandibular forward rotation with the posterior edges of the buc-
cal shields as a rotational center. Anteriorly, the mandible is
raised by the force of the anterior vertical muscle chain being
strengthened by lip seal exercises.
gnathia have led to the suggestion that vertical posterior
maxillary excess constitutes an important factor in
causing opening rotation. 26However, this factor cannot
account for the different pattern of mandibular rotation
between Cases A and B as the initial vertical dimension
of the posterior middle face and the vertical positional
changes of the maxillary molars in Case A were iden-
tical to those of Case B. From the evidence of our
long-term observations, we do not believe that maxil-
lary dentoalveolar excess is the essential or even the
sole factor in causing apertognathia.
In an evaluation of the clinical manifestation of
skeletal open bite, a variety of vertical skeletal and
dental components must be included. Nemeth and
Isaacson*’ proposed that the impact of the combined
sutural and alveolar growth of the maxilla and alveolar
growth of the mandible on the pattern of mandibular
rotation must be seen in a close relation to the mandibu-
lar condylar growth. When comparing the tracings of
Cases A and B, the most striking difference in skeletal
development is the increase of ramus length in Case B,
suggesting that condylar growth could keep pace with
the vertical alveolar growth in the posterior part of the
face. In contrast, in Case A vertical growth at the con-
dyle remained behind that of the posterior dentoalveo-
lar structures. On the basis of our clinical experience,
the increase of ramus length being larger than that of

64 Friinkel und Friinkcl
the lower anterior face height (LFH) was a phe-
nomenon regularly observed in all cases of skeletal
open bite when, after treatment with FRs, a competent
oral seal was established. This is also due to cases of
severe skeletal open bite where molars had been ex-
tracted.
Wessberg and associates,28 on the basis of their
clinical experience, proposed application of a func-
tional approach. They suggested that an “occlusal
programming feedback mechanism” within the central
nervous system mediates the compensatory autorota-
tion of the mandible following surgical superior reposi-
tioning of the maxilla. We agree to the suggestion that
the significance of vertical dentoalveolar growth on the
pattern of mandibular rotation may be appraised only
by a functional analysis (that is, by incorporation of the
musculature suspending the mandible). Therefore, the
possible influence of vertical molar positions on the
pattern of mandibular rotation should not be interpreted
as a wedge effect separating the developing vertical
relations between the jaws. Rather, occlusal contacts
may be regarded a factor programming the neuromus-
cular system determining the mandibular rest position.
Thus, the erupting tooth as an “occlusal programming
factor” may influence the postural performance pattern
of the suspending musculature. Conversely, the
postural behavior of the musculature determining the
mandibular position may, as a result of feedback,
influence the positional changes of the erupting teeth as
well.
In the study by Frost and co-worker? the long-
term postoperative linear measurements exhibited an
average decrease in the sella-gonion distance from 76.1
to 75.2 mm. and in the posterior nasal spine-gonion
distance from 40.1 to 39.1 mm., which means a de-
crease in ramus length. It seems reasonable to assume
that, after molar extraction, there would be skeletal
changes similar to those observed following maxillary
surgery, that is, a relative decrease in the lower anterior
face height with the ramus length unchanged. Theoreti-
cally, the mandibular autorotation following either
maxillary surgery or molar extractions does not neces-
sarily require compensatory growth at the condyle.
In attempting to interpret the increase in ramus
length as a result of the treatment with the function
regulator, the possible effect of the buccal shields
should be taken into consideration (Fig. 13). Provided
that the working models were correctly trimmed, the
posterior edges of the buccal shields are deeply posi-
tioned in the sulci and provoke pressure sensation in
this area. On could argue that, with insertion of the
function regulator, the factor of “occlusal program-
ming ” is replaced by a factor of “soft-tissue pro-
Am. J. Orthocf.
Julx 19X:\
gramming. ” It is suggested that the mechanoreceptors
in the soft-tissue environment around the posterior
edges of the shields may induce the central nervous
system to respond and to eliminate the disturbing signal
of pressure. As a result of the sensory motor feedback
mechanism, the posterior part of the mandible is low-
ered, leading to a distraction of the condyle away from
the glenoid fossa. The increase in ramus length might
thus be explained as a result of compensatory transla-
tive growth at the condyle effected by the inferior trans-
lation of the posterior part of the mandible.
In order to find reasonable-sounding reasons for the
closure of open bite with a concomitant increase in
ramus length we suggest that, concomitant with the
lowering of the posterior part of the mandible, its an-
terior part be raised with the posterior edges of the FR
as a rotational center. We hypothesize that such a for-
ward rotation of the mandible is brought about by the
force of the anterior vertical muscle chain being
strengthened by lip seal exercises. This hypothesis is
supported by the clinical evidence that the increase in
PFH and ramus length with a concomitant relative de-
crease in AFH and the lower face height appeared to be
accomplished only when the postural weakness in the
orolabial zone could be overcome. We conclude that
the change in the anterior to posterior facial height ratio
appears to be due to normal sutural and alveolar growth
in the maxilla with a concomitant stimulation of devel-
opment of the ramus in length. As a tentative explana-
tion, the change in dimension of the vertical compo-
nents might be the result of lip seal training with the
function regulator as an exercise device leading to a
postural balance between the forward- and backward-
rotating muscles.
The demonstrated results achieved by our method
of functional orthopedics may be a challenge to ortho-
dontists who use appliances of the intrusive type fre-
quently combined with surgical procedures, such as
removal of molars or superior repositioning of the
posterior part of the maxilla as recently described by
KimzY and Frost and Hall.“’ In an attempt to find some
plausible-sounding explanation of how the changes in
skeletal pattern might be brought about by the func-
tional therapy applied, the investigations of Hixon and
Klein31 on the characteristics of diverse appliance sys-
tems should be considered. Regardless of type, the
appliances used for correction of dentofacial abnor-
malities represent a mechanical intervention. Pressure
exerted by any appliance, even if produced by muscular
forces, is and remains an application of pressure. The
sensorium in the tissues coming under pressure gen-
erated by the appliance is able only to register its mag-
nitude, duration, and direction but not to discriminate
Volume 84
Number 1
its source or origin. In this view, we believe that the
designationfunctional appliance is incorrect and con-
fusing and should be abandoned. However, we cannot
agree with the statement: “The common denominator
of all appliances, whatever their construction, is that
they apply pressure to teeth.” The acrylic shields, as
the most important parts of the FR appliances, do not
contact teeth and therefore are not capable of exerting
direct pressure on the teeth. In contrast to activators,
the shields of the FRs become effective when standing
away from the dentition. Basically, they are intended to
operate in the muscular environment, aiming at correct-
ing an existing deviant functional pattern. Thus, the
morphologic alterations in the dentofacial area are sec-
ondary and result primarily from the change of the
aberrant functional pattern in the muscular environ-
ment, including the tongue. If we are to use the princi-
ples of functional orthopedics, the critical factor is that
the appliance used meets the criterion of an “exercise
device. ” Nemeth and Isaacson, in their studies on
vertical anterior relapse, have recognized the effect of
the facial musculature upon tooth-to-bone and bone-
to-bone changes. They suggest that “the musculature
may be the dominant force in ultimately determining
molar vertical position and vertical jaw relations. ” Ex-
perimental evidence from studies on the function-form
relationship in craniofacial morphogenesis in the re-
search centers around the world has shown the need to
apply principles derived from experimental studies to
clinical situations.
Our approach to functional orthopedics should be
regarded as an attempt to apply these research findings
at the clinical level. The scope of this article will not
permit more than a brief comment on the basic princi-
ple of our method of functional orthopedics. The FR
appliance fulfills the task of an exercise device for
overcoming the faulty postural behavior of the orofacial
musculature. l3 This is particularly the case in the pres-
ence of a hyperdivergent skeletal pattern. For example,
the tracings of Figs. 9 and 10 show the considerable
changes in the soft-tissue profile in treated Case B. In
contrast to Case A, the mentalis activity previously
evident during lip closure completely disappeared. At
the end of treatment, a proper interlabial posture was
evident: that is, the adhesive areas of the epithelium of
the upper lip were in contact with those of the lower lip.
We believe that this is a very important objective, as
the sticky effect of those epithelial areas is indispens-
able for a proper hermetic seal function of the labial
valve .32Note also the equally increased thickness of the
soft-tissue cover in the lower face.
With reference to the complex network of systems
of mutual adaptability in the orofacial area, a discus-
Functional approach to treatment of skeletal open bite 65
sion of the findings in this study can be only a tentative
introduction into the relationship between function and
form in the development of skeletal open bite. As al-
ready mentioned, our concept of a functional approach
is based on long clinical experience and, more impor-
tant, on long-term posttreatment examinations. Retro-
spectively, two clinical observations were fundamental
to change our purely morphologic view to a functional
one in appraising the factors possibly contributing to
the deviant pattern of hyperdivergency.
1. When an open bite was associated with a hy-
perdivergent skeletal pattern, relapse occurred in all
treated cases unless a competent anterior oral seal had
been achieved, regardless of whether or not posterior
teeth had been removed.
2. Posttreatment functional analysis revealed that
our appraisal of lip competence at the end of the active
treatment period was often self-deceptive. Our as-
sumption that after the bite had closed (often accom-
plished by a concomitant extraction of posterior teeth)
the establishment of a competent lip seal occurred spon-
taneously was wrong. The treatment results remained
stable but only when the lips were sealed without the
appearance of any muscular strain. Proper assessment
of this requires a trained and skilled eye.
The results accomplished by functional orthopedics
suggest that the lips-apart condition as a characteristic
feature in skeletal open bite cannot be regarded as sim-
ply a structural discrepancy between lip length and
lower face height resulting from differential growth be-
tween soft and skeletal tissues. Rather, we believe that
the incompetence of the anterior oral seal associated
with poor postural behavior of the lips basically reflects
a disturbed interaction between the rapidly and differ-
entially growing skeleton and the maturing neu-
romuscular system. As shown by Bosma,16 during the
process of postnatal development there are various pat-
terns of change of performance. The acquisition of new
performance patterns is intimately related to central
neurologic maturation. The tongue of the newborn fills
the lingual cavity, and its tip is constantly in contact
with the lower lip. The oral seal is brought about by
approximation of the tongue and palate, particularly
closure at the junction of the tongue and palate, particu-
larly closure at the junction of the mouth and pharynx.
In early infancy tongue posture is the basic factor in
establishing an oral seal. Thus, the mouth is closed and
the pharynx is open, even if the lips are incidentally
apart. Vertical growth in the neck area and the sensory
input of the eruption of deciduous teeth require the
development of new motor and postural patterns. Dur-
ing this period of growth the maturation of the postural
performance of the lip musculature becomes increas-
66 Friinkel and Friinkal
ingly important for establishing a competent anterior
oral seal and maintaining nasal respiration. Bosma’6
has emphasized that the posterior soft-tissue barrier
formed by the soft palate and the tongue is an important
factor in controlling and coordinating functional per-
formance of the entire orofacial area. The positional
stabilization of the pharyngeal airway is the initial
manifestation of the distinctive coordination of posture.
With maturation, the postural stabilization extends to
the stabilization of the front of the mouth and caudal
progression to the neck and trunk.
The studies by Moyers3” on the maturation of the
orofacial musculature stressed the alteration of the
functional relationships between lips and tongue during
downward and forward mandibular growth. At this de-
velopmental stage the lips elongate and become more
selectively mobile. The tongue develops discrete move-
ments and posture separate from those of the lips and
the other orofacial muscles. As in the past when em-
phasis was placed on functional disorders of the tongue
and explained as “immature patterns ’ ’ or “infantile
swallowing, ” so we believe that the incompetence of
the anterior oral seal associated with poor postural be-
havior of the lips deserves the designation of immatu-
rity. This also seems to be reflected in the popular
German expression Geschlossene Persiinlichkeit
which, translated, means “closed personality.” It is
our concluding suggestion that the re-establishment of a
competent anterior oral seal by lip-seal training with
FRs may be interpreted as “making up” for an imper-
fect or failed maturation of the labial valve function.
In this context, the interesting investigations of
GershateP, 35 must be mentioned. He observed an ex-
tremely high incidence of skeletal open bite in emo-
tionally disturbed and mentally retarded children. This
finding is in agreement with the attitude of those gen-
eral orthopedists who argue that aberrant muscle tone
does not constitute a physical problem alone but must
also be seen in the context of the accompanying neural
and psychic disturbances. The extensive representation
of the oral region in the brain explains why emotional
and nervous stresses are particularly manifested in the
muscular environment around the mouth. This neu-
rophysiologic fact suggests that the poor postural per-
formance of the orofacial muscles as a characteristic
feature of skeletal open bite may, in part, be attributed
to an adverse psychosocial milieu of the affected child.
The considerable morphologic alteration that occurs
during treatment supports a functional approach to cor-
rection of skeletal deformities, an approach that has
been used in general orthopedics for a long time. In this
regard, the poor postural behavior of the orofacial
muscles deserves particular attention. Our clinical ex-
Am. .I. Orihod.
./LA 19x3
perience suggests that the anterior sealing of the oral
functional space may have a primary role in maintain-
ing the integrity of the interacting systems in the orofa-
cial complex. It is therefore suggested that the con-
comitant use of lip-seal exercises and the Frinkel
appliance produces alterations in the functional envi-
ronment at essential points which may induce a chain of
changes in the postural performance patterns of the
whole orofacial complex. There is evidence that lip-
seal exercises train the elevator muscles as well as the
orbicularis oris muscles.
When one conceives of muscular forces as playing
a role in craniofacial morphogenesis, one runs the risk
of being accused of taking an “environmentalist”
view. Such an opinion overlooks the fact that the mus-
cles are located within the human body and constitute
an integral part of the musculoskeletal apparatus.
Therefore, it is misleading to classify muscular influ-
ences simply as environmental factors. Muscle growth
is strongly controlled by genetic factors. The same is
true of the neural tissues inducing and controlling mus-
cular functions. Thus, the biomechanical induction de-
rived from muscular forces, as far as they operate
within a physiologic range, may be assumed to have the
quality of epigenetic information, providing the fullest
accomplishment of the growth and development of the
related skeletal structures.
In view of this, the muscles suspending the mandi-
ble play an important role in the epigenetic control
mechanism determining the postural position of the
mandible. This is particularly valid for the establish-
ment of the rotational pattern of the mandible. On the
basis of the leverage principle, it seems irrational to
assume that the control of the rotational pattern is lo-
cated at the end of the lever arm, in this case the man-
dibular condyle. We cannot imagine that Nature could
be so unwise as to ignore this basic principle and that
the direction and magnitude of condylar growth are the
primary determinants of the rotational pattern of the
mandible.
From our clinical observations, it may be assumed
that in the process of maturation of postural per-
formances, which, as claimed by Bosma,“j begins from
the posterior muscular wall of the oral space, the an-
terior muscular valve may constitute an important link
for the maturation in the network of postural systems
prevailing in the entire orofacial area. We suggest that,
in the presence of an opening rotation of the mandible,
the concomitant poor postural behavior of the related
masticatory muscles should be seen in context with the
postural incompetence of the anterior valve, which may
be regarded as a more dominant member in the chain of
maturing processes. The results achieved by our
Volume 84 Functional approach to treatment of skeletal open bite 67
Number 1

method of functional orthopedics, therefore, could dren with severe open bite were used in this study;
possibly be explained as the result of overcoming the eleven of the children who did not undergo treatment
immature postural pattern of the anterior muscular served as controls, and thirty were treated with lip-seal
chain which subsequently led to maturation of the training and a functional regulator appliance. A radio-
postural behavior of the posterior muscular chain. The graphic analysis was made by the methods of Nahoum,
changes in the contours of lips, chin, and floor of the Jarabak, and Fr$nkel. With the Frankel analysis, there
mouth that occurred during treatment are evidence of a were significant differences in skeletal development be-
significant difference in the postural behavior in the tween the treated and the nontreated groups after an
whole orofacial area. The weakness of the facial mus- average treatment/observation period of approximately
cles, flaccid lips, mentalis bulk, and the deep mentola- 8 years. The values for angles SN-MP and PP-MP and
bial crease, all of which may well be attributed to im- for the ratios of anterior upper facial height to lower
mature patterns of behavior, disappeared, leading to a facial height and anterior facial height to posterior face
striking improvement in facial appearance. The psy- height changed in the treated group to fall within the
chosocial aspects of overcoming the unattractiveness normal range, whereas the respective values for the
of the physiognomic features should not be underes- untreated controls remained unchanged or became
timated. worse. The findings of this comparative study suggest
As a final note, it is not the intent of this article to that the functional strategy as developed in general or-
advocate a new appliance system. The reader should thopedics can be applied to orofacial orthopedics, pro-
realize that the essential motivation for developing our vided that faulty postural performances are seen in a
method of functional orthopedics was the example set by functional interrelationship with spatial disorders in the
the general orthopedists. Another stimulating factor was oronasopharyngeal spaces. The striking improvement
the progress in research of craniofacial growth. The in facial appearance evident after treatment may result
experimental evidence that the growth sites in the as much from changes in the soft-tissue mask as from
craniofacial area are susceptible to biomechanical and the skeletal changes.
functional stimuli promises clinical applicability. Thus, We wish to express our thanks to Dr. James A McNamara
we felt compelled to search for new ways to use the for his great help in preparing this article in English.
experimental findings at the clinical level.
The main concern in developing our approach to
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