ORIGINAL ARTICLE

Comparison of orthodontic treatment outcomes

in adults with skeletal open bite between
conventional edgewise treatment and
implant-anchored orthodontics
Toru Deguchi,a Hiroshi Kurosaka,b Hiraku Oikawa,c Shingo Kuroda,b Ichiro Takahashi,d Takashi Yamashiro,e
and Teruko Takano-Yamamotof
Sendai and Okayama, Japan

Introduction: Open bites are known to be difficult malocclusions to treat. Generally, with conventional edgewise
treatment, incisor extrusion rather than molar intrusion is observed. Recently, the use of miniscrews as anchor-
age has markedly increased. In this study, orthodontic treatment outcomes after conventional edgewise treat-
ment and implant-anchored treatment were investigated by cephalometric analysis and several occlusal
indexes. In addition, the stability of these patients 2 years after the retention phase was also analyzed.
Methods: Thirty adults (15 for nonimplant treatment [non-IA group] and 15 for implant-anchored treatment [IA
group]) were our subjects. Cephalometric analysis, peer assessment rating, discrepancy index, and objective
grading system were used. Results: From the cephalometric values in the non-IA group, open-bite patients
were generally treated by extrusion of the maxillary and mandibular incisors that resulted in clockwise
rotation of the mandibular plane angle. In the IA group, intrusion of the maxillary and mandibular molars that
resulted in counterclockwise rotation was noted. Furthermore, in the IA group, the soft-tissue analysis
showed decreases in the facial convexity and the inferior labial sulcus angle that resulted in the
disappearance of incompetent lips. In the retention phase, extrusion of the mandibular molars was observed
in the IA group. From the objective grading system evaluation, significant reductions of overbite in canines
and premolars were observed in both groups. Furthermore, less stability was observed in the IA group
compared with the non-IA group according to the total objective grading system score. Conclusions: Ideal
occlusion can be achieved in adults with severe open bite with both conventional edgewise and implant-
anchored orthodontic treatment. However, absolute intrusion of the molars and improvement in esthetics
might be achieved more effectively by using miniscrews as an anchorage device. In addition, since
a significant amount of tooth movement occurs with miniscrews, careful attention is required during the
retention phase. (Am J Orthod Dentofacial Orthop 2011;139:S60-8)

S
keletal open bite is known to be one of the most
difficult malocclusions to treat in orthodontics.
Since the cause of open bite is related to unfavor-
able growth pattern,1-3 tongue posture and function,4,5
habits,6 and nasopharyngeal airway obstructions,7,8 an
a
Assistant professor, Division of Orthodontics and Dentofacial Orthopedics,
Tohoku University Graduate School of Dentistry, Sendai, Japan.
b
Assistant professor, Department of Orthodontics and Dentofacial Orthopedics,
Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical
Sciences, Okayama, Japan.
c
Postgraduate student, Division of Orthodontics and Dentofacial Orthopedics,
Tohoku University Graduate School of Dentistry, Sendai, Japan.
d
Associate professor, Division of Orthodontics and Dentofacial Orthopedics,
Tohoku University Graduate School of Dentistry, Sendai, Japan.
e
Professor and chair, Department of Orthodontics and Dentofacial Orthopedics,
Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical
Sciences, Okayama, Japan.
f
Professor and chair, Division of Orthodontics and Dentofacial Orthopedics,
Tohoku University Graduate School of Dentistry, Sendai, Japan.
orthopedic approach during the deciduous or mixed
dentition periods might result in favorable treatment
results.4,9 In growing patients, high-pull headgear,10,11
habit-breaking appliances,12,13 bite-blocks,14-16 and
vertical chincups17,18 are generally used to decrease
Supported by Grants-in-Aid for Scientific Research from the Japan Society for the
Promotion of Science.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Teruko Takano-Yamamoto, Division of Orthodontics and
Dentofacial Orthopedics, Tohoku University Graduate School of Dentistry, 4-1,
Seiryomachi, Aoba-ku, Sendai, 980-8575, Japan; e-mail, t-yamamo@mail.
tains.tohoku.ac.jp.
Submitted, October 2008; revised and accepted, April 2009.
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2009.04.029

S60
Deguchi et al
the vertical dimension of the dentoalveolar process. If
there is an increase in growth at the posterior vertical
facial height, counterclockwise mandibular rotation
occurs, resulting in a decrease in the amount of open
bite.
On the other hand, in nongrowing patients, vertical
control tends to be difficult without growth. Dental
compensations are generally observed with conventional
orthodontic treatment such as extrusion of incisors or
molars resulting in clockwise rotation of the mandible
that leads to unfavorable treatment outcomes.19-21
Treatment options for nongrowing patients include the
use of elastics combined with the multiloop edgewise
archwire technique21 or nickel-titanium archwires.20
The use of titanium miniplates22,23 or miniscrews24
as orthodontic anchorage devices in correcting patients
with open bite has been reported. With these miniplates
and miniscrews, significant amounts of intrusion of the
molars are possible, resulting in counterclockwise rota-
tion of the mandible. Recently, we reported a compara-
tive study on the outcomes between implant-anchored
orthodontic treatments and surgically treated patients
with open bite.25 In that report, both treatment methods
resulted in acceptable outcomes, such as increased
overbite and reduced total facial height. Moreover, in
patients treated by implant-anchored orthodontics, an
increase in the amount of overbite was achieved by
intrusion of the molars rather than via extrusion of the
incisors that was the result of surgically corrected pa-
tients with open bite. However, no study has compared
the treatment outcomes between implant-anchored
orthodontics and conventional orthodontics in treating
these patients.
In this study, quantitative evaluations of the ortho-
dontic treatment outcomes of skeletal and facial features
and soft tissues were undertaken with cephalometric
analysis, and of dental (occlusal) features by the peer
assessment rating (PAR),26 the discrepancy index (DI),27
and the objective grading system (OGS)28 between
implant-anchored and conventional orthodontics in
adults with skeletal open bite. In addition, skeletal and
dental stabilities after 2 years of retention were also
analyzed between the groups.
MATERIAL AND METHODS
A total of 30 consecutively finished adult patients
(ages, 18 to 46 years; mean 6 SD, 24.3 6 5.9 years)
from 2002 to 2005 with an anterior open bite of more
than 3.0 mm (range,
3.0 to
7.5 mm; mean 6 SD,

4.6 6 1.4 mm) were analyzed. We excluded patients
less than 18 years old at the start of treatment, those
without appropriate records, those who transferred
from other clinics, and those who had phase 1 treatment.
American Journal of Orthodontics and Dentofacial Orthopedics
S61
Patients undergoing conventional edgewise treat-
ment without implants as anchorage (non-IA group) in-
cluded 15 women (mean age, 22.9 6 4.9 years; average
open bite,
4.6 6 1.5 mm; range,
3.0 to
7.5 mm). In
the non-IA group, 4 patients were skeletal Class I, and 11
patients were Class II. All patients were treated with pre-
molar extractions. The non-IA group was treated with
a combination of anterior elastics and either
accentuated-curve archwires or the multiloop edgewise
archwire technique. High-pull headgear was also used
in all patients in this study. In addition, before the start
of edgewise treatment, all patients were evaluated with
a myofunctional checklist, which included (1) size of
the adenoids, (2) the presence of vomiting reflex,
(3) size of the tongue, (4) any abnormality in the lingual
frenum, (5) position of the tongue at rest, (6) lip condi-
tion during rest, (7) any lip or chin (mentalis) strain,
(8) whether the patient bites during swallowing, (9) con-
dition of the palate (hard and soft) during rest and
swallowing, (10) activity of the masseter muscle,
(11) lip strength, (12) maximum opening, and (13) pres-
ence of mouth breathing. The subjects also answered
a questionnaire including a history of habits.
The other group of 15 female patients (mean age,
25.7 6 6.4 years; average open bite,
4.4 6 1.2 mm;
range,
3.0 to
7.4 mm) was treated with miniscrews
as anchorage (IA group). The IA group also consisted
of 5 patients with skeletal Class I and 10 patients with
Class II. All were treated with premolar extractions.
In the IA group, miniscrews (Absoanchor, Dentos,
Taegu, Korea; diameter, 1.3 mm, length, 6-8 mm;
Gebr€ uder Martin, Tuttlingen, Germany; diameter, 1.5
mm, length, 9 mm) were placed under local anesthesia
between either the second premolar and the first molar
or the first and second molars in the buccal region by
the orthodontist. The miniscrews were loaded 0 to 4
weeks after placement. Before miniscrew placement,
sectional archwires of 0.016 3 0.022-in stainless steel
were placed from the second premolar to the second mo-
lar. Intrusion was performed by using either a power
chain or ligature wires from the miniscrew to the sec-
tional archwire. Generally, incisor and canine brackets
were bonded after the overbite had in an edge-to-edge
relationship.
The initial occlusion was evaluated by using the PAR
(Table I) and the DI (Table II). Cephalometric radiographs
were taken before and after treatment for cephalometric
evaluation (Figs 1 and 2; Table III) and soft-tissue
analysis (Fig 3; Table IV) in both groups.29 Soft-tissue
measurements were analyzed according to a previous
study.30 Final occlusion was evaluated by using the
OGS (Table V) and the PAR in both groups. All cephalo-
metric tracings and measurements were made by the
April 2011  Vol 139  Issue 4  Supplement 1
S62 Deguchi et al

Table I. PAR scores

Non-IA group IA group

Pretreatment Posttreatment Retention Pretreatment Posttreatment Retention

PAR Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

Mx. ant. 3.6 2.2 0.0* 0.0 0.2 0.4 3.0 2.2 0.0* 0.0 0 0
Mx. post. 5.9 3.5 1.0* 1.4 1.7 1.8 4.9 3.7 1.3* 1.0 1.6 1.8
Md. ant. 2.1 2.6 0.4* 0.7 0.3 0.6 1.9 2.2 0.1* 0.4 0.3 0.9
Md. post. 5.7 3.5 0.7* 0.6 1.6 1.5 4.0 2.9 0.8* 1.0 1.1 1.2
AP 1.8 1.6 0.3* 0.6 0.6 0.9 1.3 0.9 0.1* 0.4 0.3 0.5
Vertical 1.1 1.5 0.2* 0.4 0.1 0.3 1.1 0.8 0.2* 0.6 0.2 0.4
Transverse 2.2 1.8 0.1* 0.4 0.2 0.6 2.1 1.6 0.1* 0.4 0.5 1.2
Overjet 2.3 1.3 0.1* 0.4 0.6 0.8 2.3 1.3 0.3* 0.5 0.4 0.5
Overbite 2.9 1.2 0.1* 0.3 0.2 0.4 2.5 0.9 0.1* 0.4 0.1 0.3
Midline 0.3 0.5 0.1 0.3 0 0 0.4 0.5 0.1 0.4 0 0
Total 28.0 9.4 3.0* 2.9 5.5 2.8 23.5 8.6 3.5* 2.2 4.4 2.9

Mx. post., maxillary posterior alignment; Mx. ant., maxillary anterior alignment; Md. post., mandibular posterior alignment; Md. ant., mandibular
anterior alignment; AP, anterior-posterior.
*Significant difference compared with pretreatment (P \0.05).

soft-tissue analysis, and PAR in each group. The

Table II. Pretreatment DI scores
Wilcoxon signed rank test was used to compare pretreat-
Non-IA IA ment and posttreatment results of cephalometric
measurements, soft-tissue analysis, DI, PAR, and OGS
DI Mean SD Mean SD Significance
between the non-IA and IA groups. P values \0.05
OJ 2.9 1.8 3.5 1.9 NS
OB 0 0 0 0 NS were considered significant. These analyses were carried
AOB 26.4 12.8 32.9 12.7 NS out with statistical analysis software (Statview, version
LOB 6.8 8.3 7.3 11.4 NS 5.0.1, SAS Institute, Cary, NC).
Crowd 2.9 2.7 2.3 2.6 NS
Occl 3.4 2.3 2.5 2.2 NS
RESULTS
LPX 2.1 2.2 1.7 2.0 NS
BPX 0.7 1.0 0.7 1.2 NS The pretreatment cephalometric characteristics of
ANB 5.1 3.4 5.3 3.2 NS both groups are shown in Table III. There were no signif-
SNMp 13.3 8.3 17.5 11.4 NS
icant differences in any of the analyzed cephalometric
IMPA 1.3 2.7 1.2 2.7 NS
Total 62.4 26.7 76.9 30.1 NS measurements between the non-IA and IA groups.
PAR scores of the pretreatment cast models in both
NS, No significant difference between groups (P .0.05); OJ, overjet;
OB, overbite; AOB, anterior overbite; LOB, lateral overbite; Crowd, groups are given in Table I. The total average PAR scores
crowding; Occl, occlusion; LPX, lingual posterior crossbite; BPX, were 28.0 6 9.4 in the non-IA group and 23.5 610.2 in
buccal posterior crossbite. the IA group. There were no significant differences in
any variables assessed between the 2 groups.
DI scores of the pretreatment cast models in both
same examiner (T.D.). All cephalometric measurements groups are presented in Table II. The total average scores
were repeated after 4 weeks, and the method error was were 62.4 6 26.7 in the non-IA group and 76.9 6 30.1
calculated from the equation: in the IA group. There were no significant differences in
rffiffiffiffiffiffiffiffiffiffiffi
P 2 any variables assessed between the 2 groups.
D
Sx 5 The posttreatment cephalometric characteristics are
2N presented in Table III. In the non-IA group, significant
where Sx is the error of the measurement, D is the differ- differences were observed between pretreatment and
ence between duplicated measurements, and N is the posttreatment in Mp-SN, IIA, OJ, OB, PP-U1, and Mp-
number of double measurements.31 The errors of the L1. In the IA group, Mp-SN, IIA, OJ, OB, and PP-U6
measurements were 0.18 mm. showed significant differences between pretreatment
Statistical analyses were performed with the Mann- and posttreatment cephalometric variables.
Whitney U test to examine the differences between There was also a significant difference between
pretreatment and posttreatment cephalometric analyses, groups regarding posttreatment cephalometric variables

April 2011  Vol 139  Issue 4  Supplement 1 American Journal of Orthodontics and Dentofacial Orthopedics
Deguchi et al
1
7 2
SN’
3
6 4
9
5
Fig 1. Angular measurements: 1, SNA angle (SNA); 2, SNB
angle (SNB); 3, ANB angle (ANB); 4, SN to mandibular
plane (Mp-SN); 5, gonial angle (Go.A); 6, SN to occlusal
plane (Occl Pl); 7, SN to upper incisor (SN-U1); 8, mandib-
ular plane to mandibular incisor (L1-Mp); 9, interincisal
angle (IIA).
(Table III). Cephalometric variables such as SNB, ANB,
Mp-SN, Go.A, Occl Pl, N-Me, Me/PP, PP-U1, PP-U6,
and Mp-L6 showed significant differences between the
non-IA and the IA groups.
In the soft-tissue analysis, significant changes from
pretreatment to posttreatment were observed in upper
and lower lip protrusions in the non-IA group (Table
IV). In the IA group, significant differences were ob-
served in facial convexity, upper and lower lip protru-
sions, and inferior labial sulcus angle. Significant
differences were observed in the posttreatment values
between the groups regarding facial convexity and the
inferior labial sulcus angle.
The results of the posttreatment PAR evaluation are
presented in Table I. The total average raw PAR scores
were 3.0 6 2.9 in the non-IA group and 3.5 6 2.2 in
the IA group. By calibrated weightings, the total post-
treatment PAR scores were 3.3 6 4.5, 5.1 6 5.3, 3.9
6 4.7, and 5.9 6 5.5 for United States non-IA, United
States IA, United Kingdom non-IA, and United Kingdom
IA, respectively. Furthermore, the percentates of reduc-
tion rates were 91.5% 6 11.7%, 84.2% 6 21.3%,
90.0% 6 11.9%, and 82.8% 6 20.1% for United States
non-IA, United States IA, United Kingdom non-IA, and
United Kingdom IA, respectively. There was no signifi-
cant difference between groups concerning any PAR
score.
American Journal of Orthodontics and Dentofacial Orthopedics
S63
Fig 2. Linear measurements: 1, anterior cranial base
(S-N); 2, anterior facial height (N-Me); 3, lower anterior fa-
cial height (Me/PP); 4, mandibular ramus height (Ar-Go);
5, mandibular length (Ar-Me); 6, horizontal distance be-
tween the maxillary and mandibular incisal edges (OJ);
7, vertical distance between the maxillary and mandibular
incisal edges (OB); 8, maxillary incisal edge to palatal
plane (PP-U1); 9, maxillary molar cusp to palatal plane
(PP-U6); 10, mandibular incisal edge to mandibular
plane (Mp-L1); 11, mandibular molar cusp to mandibular
plane (Mp-L6).
The average OGS scores were 28.9 6 10.1 and
23.3 6 5.2 for the non-IA and IA groups, respectively
(Table V). There was no significant difference between
the groups regarding any of the 8 OGS categories.
No significant difference was observed between the
posttreatment and retention cephalometric analyses in
the non-IA group (Table III). The only significant differ-
ence in the IA group was Mp-L6. A significant difference
was observed in PP-U1 between the groups.
The average PAR scores in retention were 5.5 6 2.8
in the non-IA group and 4.4 6 2.9 in the IA group
(Table I). No significant difference was observed between
posttreatment and retention in the groups. There was
also no significant difference between groups in reten-
tion PAR scores.
The average OGS scores were 30.0 6 5.5 in the non-
IA group and 31.3 6 5.8 in the IA group (Table V). In the
IA group, significant differences were observed in overjet
and total OGS score compared with the posttreatment
scores.
From our data of the myofunctional checklist, 11 pa-
tients in the non-IA group and 12 patients in IA group
had tongue thrusting. No patient had an oversized
tongue (when glossotomy was necessary) or an abnor-
mal lingual frenum. Six patients in the non-IA group
and 7 patients in the IA group received active
April 2011  Vol 139  Issue 4  Supplement 1
S64 Deguchi et al

Table III. Pretreatment, posttreatment, and retention cephalometric measurements

Non-IA group IA group

Pretreatment Posttreatment Difference Retention Difference Pretreatment Posttreatment Difference Retention Difference

Variables Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
Angular ( )
SNA 82.0 3.1 81.8 2.9
0.3 1.0 82.2 2.8 0.4 0.5 81.1 4.2 80.8 4.5
0.2 0.9 81.1 4.5 0.3 0.5
SNB 76.6 3.4 76.4 3.4
0.2 1.0 77.1 3.3 0.7 1.1 75.3 6.0 76.7 6.6 1.4y 1.1 76.8 6.9 0.1 1.2
ANB 5.4 2.4 5.4 2.4 0.0 1.5 5.1 2.2
0.3 1.1 5.7 3.6 4.2 4.1
1.6y 1.0 4.3 4.2 0.2 1.3
Mp-SN 43.0 4.3 45.7 4.5 2.7* 3.2 46.0 4.6 0.3 1.6 45.8 6.0 42.2 6.7
3.6*,y 2.1 43.8 6.5 1.6 2.7
Go.A 127.3 5.5 128.0 4.8 0.7 1.5 128.1 3.8 0.1 1.8 127.3 5.1 126.8 5.0
0.5y 1.4 126.8 5.1 0.1 1.6
Occl Pl 22.7 5.8 24.5 5.0 1.8 2.9 24.4 4.2
0.2 1.7 20.9 5.1 19.5 4.7
1.4y 1.6 20.3 5.1 0.8 0.9
SN-U1 109.7 11.2 104.4 10.4
5.3 3.2 105.3 10.1 0.9 1.8 110.7 8.0 105.4 9.8
5.3 4.2 105.0 9.8
0.4 1.4
L1-Mp 94.9 7.9 93.2 6.2
1.7 3.9 94.9 5.6 1.7 2.0 94.3 5.6 92.6 5.7
1.7 2.4 93.4 5.0 0.8 2.2
IIA 117.7 7.0 123.6 5.6 5.9* 4.4 121.8 6.1
1.9 2.5 111.6 8.4 118.3 6.5 6.7* 5.8 118.3 6.5 0 1.1
Linear (mm)
S-N 70.1 4.1 70.7 4.0 0.5 0.9 71.0 3.9 0.3 0.7 70.1 2.8 70.3 2.9 0.2 0.3 70.6 2.9 0.3 0.6
N-Me 132.8 7.4 135.7 6.7 2.9 1.7 136.7 7.0 1.0 1.0 134.6 6.7 131.0 6.7
3.6y 3.8 131.2 6.5 0.2 0.5
Me/NF 75.3 5.4 78.0 5.5 2.7 0.9 78.8 5.4 0.8 0.6 74.7 5.9 72.2 5.1
2.6y 2.5 72.2 5.1 0.8 1.1
Ar-Go 46.5 3.6 46.6 4.0 0.1 1.9 47.0 3.1 0.4 2.0 44.1 6.0 44.5 6.6 0.4 2.7 45.4 6.5 0.9 0.9
Ar-Me 106.7 5.1 107.0 5.6 0.3 1.6 107.5 5.3 0.4 1.4 106.5 7.9 106.1 7.7
0.3 2.1 107.0 7.5 0.9 0.9
OJ 5.5 2.6 2.3 0.6
3.1* 2.4 2.0 0.6
0.3 0.6 4.9 3.4 1.9 1.0
3.0* 2.9 2.2 1.0 0.3 0.5
OB
4.6 1.5 1.9 1.1 6.5* 2.2 1.4 0.9
0.5 1.4
4.4 1.2 1.8 1.1 6.2* 1.7 1.0 0.9
0.8 1.1
PP-U1 31.9 3.0 35.4 2.6 3.5* 1.9 35.2 3.1
0.2 1.4 32.4 2.3 33.4 2.3 1.0y 1.6 33.4 2.3 0.1y 1.2
PP-U6 25.5 3.3 26.9 3.4 1.5 1.3 27.6 3.1 0.6 1.4 26.9 3.0 24.6 2.5
2.3*,y 1.3 25.1 2.8 0.5 0.9
Mp-L1 47.2 3.7 49.0 4.3 1.8* 1.8 49.1 4.5 0.1 0.8 46.3 3.4 46.6 2.8 0.3 2.3 46.3 3.1
0.3 1.3
Mp-L6 37.0 2.9 38.5 2.9 1.5 0.6 39.0 3.1 0.6 2.1 36.0 2.5 35.2 1.9
0.8y 1.3 37.0 1.9 1.7* 1.0

*Significant difference between pretreatment and posttreatment, or posttreatment and retention (P\0.05); ySignificant difference between groups
(P \0.05).

myofunctional therapy during edgewise treatment. The
average durations were 7 and 9 months in the non-IA
and IA groups, respectively. After debonding (during
the retention phase), 2 patients in the non-IA and 3 pa-
tients in IA group had continued myofunctional therapy.
One patient from the non-IA group and 2 from the IA
group had some relapse tendency.
DISCUSSION
In this study, most patients with open bite in both
groups had a skeletal open bite, with almost no growth
during active orthodontic treatment. Our open-bite
subjects showed higher tendencies toward an increased
mandibular plane angle (average, 43 -45 ), skeletal Class
II (average, 5.3 -5.7 ), increased lower facial height
(average, 75%), and reduced overbite (average,
4.4 to

4.6 mm), indicating that they had severe skeletal open
bites compared with subjects in previous open-bite
studies.20,21,32,33 In addition, their mean age was 23
years, indicating that there would be little growth during
treatment. If there is a significant amount of growth
during active treatment, the true effect of orthodontic
treatment might be difficult to analyze. In this study,
the pretreatment cephalometric characteristics showed
no significant differences between the non-IA and IA
groups. Furthermore, there were also no significant differ-
ences in the PAR and DI scores between the 2 groups. The
results of posttreatment PAR evaluation were similar to
those of past studies.34,35 However, from the DI
evaluation, the subjects in this study showed higher
scores (more than 3 times) compared with those of past
reports.27,35 The reason for the higher DI scores (non-IA,
66; IA, 75) in this study was because of the high scores
for overbite and the high mandibular plane angles.
Thus, we suggest that the patients with skeletal open
bite treated in this study might be the most difficult
ones to treat among other malocclusions.
By correcting an open bite with conventional edge-
wise treatment, it generally results in extrusion of the
molars and incisors, causing the mandibular plane angle
to increase.20,32 In this study, in the non-IA group, open
bite was corrected by approximately 3.0 mm of extrusion
of the maxillary incisors and 2.0 mm of extrusion of the
mandibular incisors. This is consistent with previous
studies that used similar mechanics to those used here.
One reason for the extrusion of the maxillary and
mandibular incisors was the use of vertical elastics.
Furthermore, due to extrusion of the molars, approxi-
mately 3.0 of increase in the mandibular plane angle,
and 3.0 mm of increase in the vertical length of N-Me

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Deguchi et al
Fig 3. Soft-tissue measurements: 1, facial convexity
(G0 -Sn-Pg0 ); 2, vertical height ratio (G0 -Sn/Sn-Me0 ); 3, na-
solabial angle (Cm-Sn-Ls); 4, upper lip protrusion (Ls to
Sn-Pg0 ); 5, lower lip protrusion (Li to Sn-Pg0 ); 6, inferior la-
bial sulcus angle; 7, Z-angle (chin-lip line to the Frankfort
horizontal plane).
and Me/PP were observed. Therefore, we believe that
open-bite patients treated without implants as anchor-
age were mainly corrected by the extrusion of both
maxillary and mandibular incisors, resulting in clockwise
rotation of the mandible.
On the other hand, the use of miniplates22,23 and
miniscrews24,25 has been reported in the treatment of
open-bite patients in the past. Successful treatment
was achieved with molar intrusion with both miniplates
and miniscrews. However, in contrast with miniplates,
miniscrews tend to cause less pain and discomfort to
the patient, since they are placed without an incision
or flap surgery.36 Thus, if a sufficient amount of molar
intrusion with miniscrews could be achieved, as in the
case of miniplates, it would be a more suitable method
from the patient’s perspective. In previous studies that
corrected open bite without miniscrews, the maxillary
molars generally had a slight extrusion20,32,37 or
intrusion (within 1 mm),21 and the mandibular molars
were always slightly extruded.20,21,32,37 In this study,
by cephalometric analysis, significant molar intrusion
was observed. The maxillary molars were intruded by
approximately 2.0 mm, and 1.0 mm of intrusion was
also achieved in the mandibular molars, resulting in
about a 3.0 counterclockwise rotation of the
mandible. The difference in the amount of intrusion
American Journal of Orthodontics and Dentofacial Orthopedics
S65
between the maxilla and the mandible might be
related to the difference in the anatomic structures
between the jaws. Since the mandible is composed of
thick cortices and more radially oriented trabeculae
compared with the maxiila with thin cortices and
trabecular bone, it might offer more resistance to the
intrusion force. Furthermore, we were able to keep
incisor extrusion to a minimum (maxilla, 0.8 mm;
mandible, 0.7 mm). Therefore, we suggest that
successful intrusion of the maxillary and mandibular
molars can be achieved by miniscrews compared with
conventional edgewise treatment, and sufficient molar
intrusion is possible as with miniplates.
Soft-tissue analysis showed a significant difference
between pretreatment and posttreatment in the changes
of upper and lower lip protrusion in both groups. The IA
group tended to be retracted more than the non-IA
group, but there was no statistically significant differ-
ence between the groups. Since reinforced anchorage re-
sults with the use of miniscrews, more retraction of
incisors might be possible. There were significant differ-
ences between groups in the changes of facial convexity
and the inferior labial sulcus angle. In the IA group, there
was a decrease in the amount of facial convexity, but it
slightly increased in the non-IA group. This was because
forward positioning (counterclockwise rotation) of the
mandible occurred in the IA group. This result was con-
sistent with the decreased cephalometric value of ANB.
The inferior labial sulcus angle also decreased in the IA
group. This was because decreased facial height by in-
trusion of the molars resulted in the disappearance of
the incompetent lips (hyper-muscle activity of the men-
talis). Thus, we suggest that a favorable profile such as
improvement of incompetent lips is possible with minis-
crews compared with conventional treatment without
them. However, as mentioned earlier, since forward po-
sitioning of the mandible was observed in the IA group,
Class III patients might not be suitable for treatment
with miniscrews from an esthetic point of view.
Not only cephalometric analysis, but also morpho-
logic analysis by using cast models were assessed in
this study. The reduction rates of the PAR score were
higher in both groups than in previous studies that
analyzed various malocclusions.34,35 Furthermore, the
OGS score in both groups also showed lower (better)
values in this study in the treatment of open-bite pa-
tients compared with past studies.35,38 This was due to
a lower overjet score than in our previous study.35 In
general, an increased overjet is a common problem in
the posttreatment occlusion in Asian patients. However,
increased overjet was not observed in the open-bite pa-
tients analyzed in this study. Moreover, the greatest neg-
ative impact was due to insufficient torque control
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S66 Deguchi et al

Table IV. Pretreatment and posttreatment soft-tissue analysis

Non-IA group IA group

Average Pretreatment Posttreatment Difference Pretreatment Posttreatment Difference

Variables Norm SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

Facial form
Facial convexity 13.2 4.9 19.1 5.0 18.5 5.2
0.6 2.7 22.4 2.2 16.4 4.1
6.0*,y 3.4
Vertical height ratio 0.9 0.1 1.0 0.1 1.0 0.1 0.0 0.1 1.0 0.1 1.0 0.1 0.0 0.1
Lip position
Nasolabial angle 99.8 8.5 95.5 12.3 106.0 8.1 10.5 12.1 101.1 9.9 107.4 9.3 6.3 10.7
Upper lip protrusion 6.5 1.5 9.9 1.0 6.5 1.7
3.4* 1.4 10.3 1.1 6.7 1.1
4.6y 1.5
Lower lip protrusion 6.4 1.9 10.6 2.2 7.6 2.3
2.9* 2.0 10.4 2.0 7.3 2.1
3.1* 2.7
Inferior labial sulcus angle 140.5 13.8 147.6 18.0 147.8 13.7 0.1 11.5 158.4 27.8 148.6 27.7
8.5*,y 3.0
Z-angle 66.6 7.1 52.0 4.5 56.6 7.9 3.4 2.5 47.4 12.1 56.4 8.0 9.0 7.0

*Significant difference compared with pre-treatment (P \0.05); ySignificant difference between groups (P \0.05).

the significant amounts of molar intrusion in the IA

Table V. OGS scores
group and of extrusion of incisors in the non-IA group,
Posttreatment Retention (2 years) most cephalometric values and PAR scores showed no
Non-IA IA Non-IA IA
significant differences 2 years after the retention phase.
The only significant difference compared with the post-
OGS Mean SD Mean SD Mean SD Mean SD treatment cephalometric value was Mp-L6 in the IA
Alignment 3.6 2.2 2.9 1.5 4.0 1.7 3.4 1.4 group. Although no significant difference was found in
Marginal 3.4 1.2 3.1 1.3 3.6 1.7 3.1 2.3
Buccolingual 7.5 2.7 6.7 3.5 8.1 3.1 8.5 3.0
Mp-L6 in the non-IA group, a similar tendency (extru-
Overjet 3.6 2.2 2.1 2.3 4.7 1.9 4.5* 2.2 sion of the mandibular molars) was observed. Thus,
Occl. cont. 4.3 2.9 3.2 2.1 4.4 3.0 6.4 5.3 extrusion of the mandibular molars might contribute
Occl. relat. 3.5 2.2 2.9 2.4 3.2 1.8 3.4 1.6 to worsening the amount of overbite in the retention
Root ang. 2.6 1.9 2.1 0.3 1.4 1.3 1.6 0.9 phase. To minimize the relapse tendency, a retainer
Interprox. 0.3 0.6 0.3 0.5 0.6 0.8 0.6 0.7
Total 28.9 10.1 23.3 5.2 30.0 5.5 31.3* 5.8
with occlusal stops in the mandibular molars or minis-
crews in the mandible could be kept for an additional
Alignment, alignment/rotations; Marginal, marginal ridges; Bucco- time to prevent mandibular molar extrusion during the
lingual, buccolingual inclination; Occl. cont., occlusal contact; Occl. initial phase of retention.
relat., occlusal relationship; Root ang., root angulation; Interprox.,
interproximal contact.
Not only the skeletal, but also the dental (occlusal)
*Significant difference compared with posttreatment (P \0.05). aspects were analyzed after 2 years of retention. With
the OGS evaluation, overjet in both groups and total
OGS score in IA group showed significant changes com-
(buccolingual inclination) in the molars, consistent with pared with posttreatment. The different results of the
the results of our previous study.35 Thus, from an occlu- overjet scores in the OGS and the PAR are related to
sal point of view, ideal occlusion can be achieved even in how it is scored in both scoring systems. In the PAR,
patients with severe open bite, as in any other malocclu- overjet is scored only in the incisor area, whereas in
sion. However, the results might differ with a larger sam- the OGS, not only in incisors, but also all overjet from
ple size. In addition, there was no significant difference canine to second molar is scored. Moreover, in both
in any categories of PAR and OGS evaluation between groups, overjets in the canines and the premolars were
the IA and non-IA groups. Therefore, ideal occlusion significantly reduced rather than in the incisor area.
could be achieved by both methods (with or without im- Therefore, the reduction in overjet score was related to
plants), and there seemed to be no significant difference canines and premolars in both groups; as a result, not
in the quality of posttreatment occlusion between the IA only vertical but also transverse problems should be con-
and non-IA groups from cast evaluation analysis. cerns during treatment and retention in these open-bite
Another important factor in treating open-bite pa- patients. Thus, overcorrection in the amount of overjet
tients is stability. A previous report indicated a tendency might be necessary in the incisors, canines, and premo-
for poor and unstable results in the retention phase for lars. We suggest that 1 reason for decreased overjet
skeletal open-bite patients.39 In this study, in spite of might be related to a functional problem such as tongue

April 2011  Vol 139  Issue 4  Supplement 1 American Journal of Orthodontics and Dentofacial Orthopedics
Deguchi et al
pressure during retention. In this study, few patients had
tongue thrusting that remained during the retention
phase. However, in these patients, some relapse ten-
dency was observed, although an edge-to-edge relation-
ship of the overbite was maintained. Thus, a functional
approach such as myofunctional therapy might be
required during the retention phase in open-bite
patients.40 In addition, to prevent overjet relapse, over-
correction such as increased overjet might be necessary
not only in the incisors but also in the canine and premo-
lar areas. There was also a significant change in the total
OGS score in the IA group. Thus, more change during the
retention phase in the IA group might be related to the
difference in the amount of tooth movement during
the active treatment compared with the non-IA group.
However, it is not clear why there was more change in
the occlusion in the IA group than in the non-IA group.
The increased OGS total scores might be the result of
a combination of skeletal (extrusion of the mandibular
molar) and dental (reduced overjet in canines and
premolars) relapse.
In this study, the stability in only a short term (2 years)
of retention was evaluated. In the past study, the long-
term (average, 5 years) stability of open-bite patients
was evaluated.37 In that study, only a slight skeletal
change was observed with a slight change in the amount
of overbite. This was similar to our results, but those
authors did not evaluate occlusal changes. In addition,
with miniscrews, significantly more intrusion of molars
was observed in our IA samples that might have a greater
tendency to relapse after longer retention periods.
Therefore, long-term evaluation is necessary to elucidate
the problems during the retention phase in treating skel-
etal open-bite patients with miniscrews in the future.
CONCLUSIONS
1. The non-IA group was corrected by extrusion of the
incisors and the molars, resulting in clockwise rota-
tion of the mandibular plane angle.
2. In the IA-group, open-bite patients had counter-
clockwise rotation of the mandibular plane angle
due to intrusion of the molars.
3. Soft-tissue analysis showed more favorable changes
in the IA group compared with the non-IA group.
4. There was no significant difference in the occlusal
indexes between the IA and the non-IA groups, sug-
gesting that ideal occlusions can be achieved by
both methods.
5. After 2 years of retention, from the skeletal perspec-
tive, there was a relapse tendency in the IA group.
6. From the dental perspective, in the IA group, addi-
tional approaches such as the use of occlusal stops
American Journal of Orthodontics and Dentofacial Orthopedics
S67
in the mandibular molars, overcorrection in the buc-
cal overjet, and the use of myofunctional therapy
might be recommended for skeletal open-bite
patients. Furthermore, if miniscrews were used in
the mandible, they can be kept for a longer time
during the initial phase of retention.
REFERENCES
1. Bjork A. Prediction of mandibular growth rotation. Am J Orthod
1969;55:585-99.
2. Cangialosi TJ. Skeletal morphologic features of anterior open bite.
Am J Orthod 1984;85:28-36.
3. Nielsen IL. Vertical malocclusions: etiology, development, diag-
nosis and some aspects of treatment. Angle Orthod 1991;61:
247-60.
4. Frankel R, Frankel C. A functional approach to treatment of
skeletal open bite. Am J Orthod 1983;84:54-68.
5. Lowe AA. Tongue movements—brainstem mechanisms and clinical
postulates. Brain Behav Evol 1984;25:128-37.
6. Mizrahi E. A review of anterior open bite. Br J Orthod 1978;5:21-7.
7. Linder-Aronson S, Adenoids. Their effect on mode of breathing
and nasal airflow and their relationship to characteristics of the
facial skeleton and the denition. A biometric, rhino-manometric
and cephalometro-radiographic study on children with and with-
out adenoids. Acta Otolaryngol Suppl 1970;265:1-132.
8. Sassouni V, Friday GA, Shnorhokian H, Beery QC, Zullo TG,
Miller DL, et al. The influence of perennial allergic rhinitis on facial
type and a pilot study of the effect of allergy management on facial
growth patterns. Ann Allergy 1985;54:493-7.
9. Torres F, Almeida RR, de Almeida MR, Almeida-Pedrin RR,
Pedrin F, Henriques JF. Anterior open bite treated with a palatal
crib and high-pull chin cup therapy. A prospective randomized
study. Eur J Orthod 2006;28:610-7.
10. Gehring D, Freeseman M, Frazier M, Southard K. Extraction treat-
ment of a Class II, Division 1 malocclusion with anterior open bite
with headgear and vertical elastics. Am J Orthod Dentofacial
Orthop 1998;113:431-6.
11. Alexander CD. Open bite, dental alveolar protrusion, Class I maloc-
clusion: a successful treatment result. Am J Orthod Dentofacial
Orthop 1999;116:494-500.
12. Haryett RD, Hansen FC, Davidson PO. Chronic thumb-sucking. A
second report on treatment and its psychological effects. Am J
Orthod 1970;57:164-78.
13. Huang GJ, Justus R, Kennedy DB, Kokich VG. Stability of anterior
openbite treated with crib therapy. Angle Orthod 1990;60:
17-24.
14. Kuster R, Ingervall B. The effect of treatment of skeletal open bite
with two types of bite-blocks. Eur J Orthod 1992;14:489-99.
15. Noar JH, Shell N, Hunt NP. The performance of bonded magnets
used in the treatment of anterior open bite. Am J Orthod Dentofa-
cial Orthop 1996;109:549-56.
16. Akkaya S, Haydar S, Bilir E. Effects of spring-loaded posterior
bite-block appliance on masticatory muscles. Am J Orthod Dento-
facial Orthop 2000;118:179-83.
17. Pearson LE. Vertical control in treatment of patients having
backward-rotational growth tendencies. Angle Orthod 1978;48:
132-40.
18. Iscan HN, Dincer M, Gultan A, Meral O, Taner-Sarisoy L. Effects of
vertical chincap therapy on the mandibular morphology in
open-bite patients. Am J Orthod Dentofacial Orthop 2002;122:
506-11.
April 2011  Vol 139  Issue 4  Supplement 1
S68
19. Arat M, Iseri H. Orthodontic and orthopaedic approach in the treat-
ment of skeletal open bite. Eur J Orthod 1992;14:207-15.
20. K€uç€
ukkeles N, Acar A, Demirkaya AA, Evrenol B, Enacar A. Ceph-
alometric evaluation of open bite treatment with NiTi arch wires
and anterior elastics. Am J Orthod Dentofacial Orthop 1999;116:
555-62.
21. Kim YH, Han UK, Lim DD, Serraon ML. Stability of anterior
openbite correction with multiloop edgewise archwire therapy:
a cephalometric follow-up study. Am J Orthod Dentofacial Orthop
2000;118:43-54.
22. Sherwood KH, Burch JG, Thompson WJ. Closing anterior open
bites by intruding molars with titanium miniplate anchorage.
Am J Orthod Dentofacial Orthop 2002;122:593-600.
23. Erverdi N, Keles A, Nanda R. The use of skeletal anchorage in open
bite treatment: a cephalometric evaluation. Angle Orthod 2004;
74:381-90.
24. Kuroda S, Katayama A, Takano-Yamamoto T. Severe anterior
open-bite case treated using titanium screw anchorage. Angle
Orthod 2004;74:558-67.
25. Kuroda S, Sakai Y, Tamamura N, Deguchi T, Takano-Yamamoto T.
Treatment of severe anterior open bite with skeletal anchorage in
adults: comparison with orthodontic surgery outcomes. Am J
Orthod Dentofacial Orthop 2007;132:599-605.
26. Richmond S, Shaw WC, Roberts CT, Andrews M. The PAR index
(peer assessment rating): methods to determine outcome of
orthodontic treatment in terms of improvement and standards.
Eur J Orthod 1992;14:180-7.
27. Cangialosi TJ, Riolo ML, Owens SE Jr, Dykhouse VJ, Moffitt AH,
Grubb JE, et al. The ABO discrepancy index: a measure of case
complexity. Am J Orthod Dentofacial Orthop 2004;125:
270-8.
28. Casko JS, Vaden JL, Kokich VG, Damone J, James RD,
Cangialosi TJ, et al. Objective grading system for dental casts
and panoramic radiographs. American Board of Orthodontics.
Am J Orthod Dentofacial Orthop 1998;114:589-99.
29. Wada K, Matsushita K, Shimazaki S, Miwa Y, Hasuike Y, Susami R.
An evaluation of a new case analysis of a lateral cephalometric
roentgenogram. J Kanazawa Med Univ 1981;6:60-70.
April 2011  Vol 139  Issue 4  Supplement 1 American Journal of Orthodontics and Dentofacial Orthopedics
Deguchi et al
30. Ioi H, Nakata S, Nakasima A, Counts AL. Anteroposterior lip posi-
tions of the most favored Japanese facial profiles. Am J Orthod
Dentofacial Orthop 2005;128:206-11.
31. Dahlberg G. Statistical methods for medical and biological
students. London: George Allen & Unwin; 1940. p. 122-32.
32. Chang YI, Moon SC. Cephalometric evaluation of the anterior
open bite treatment. Am J Orthod Dentofacial Orthop 1999;
115:29-38.
33. Janson G, Valarelli FP, Henriques JF, de Freitas MR, Cancado RH.
Stability of anterior open bite nonextraction treatment in the per-
manent dentition. Am J Orthod Dentofacial Orthop 2003;124:
265-76.
34. Dyken RA, Sadowsky PL, Hurst D. Orthodontic outcomes assessment
using the peer assessment rating index. Angle Orthod 2001;71:164-9.
35. Deguchi T, Honjo T, Fukunaga T, Miyawaki S, Roberts WE,
Takano-Yamamoto T. Clinical assessment of orthodontic
outcomes with the peer assessment rating, discrepancy index,
objective grading system, and comprehensive clinical assessment.
Am J Orthod Dentofacial Orthop 2005;127:434-43.
36. Kuroda S, Sugawara Y, Deguchi T, Kyung HM, Takano-Yamamoto T.
Clinical use of miniscrew implants as orthodontic anchorage: success
rates and postoperative discomfort. Am J Orthod Dentofacial Orthop
2007;131:9-15.
37. Janson G, Valarelli FP, Beltr~ao RT, de Freitas MR, Henriques JF.
Stability of anterior open-bite extraction and nonextraction treat-
ment in the permanent dentition. Am J Orthod Dentofacial Orthop
2006;129:768-74.
38. Yang-Powers LC, Sadowsky C, Rosenstein S, BeGole EA. Treatment
outcome in a graduate orthodontic clinic using the American
Board of Orthodontics grading system. Am J Orthod Dentofacial
Orthop 2002;122:451-5.
39. Lopez-Gavito G, Wallen TR, Little RM, Joondeph DR. Anterior
open-bite malocclusion: a longitudinal 10-year postretention
evaluation of orthodontically treated patients. Am J Orthod
1985;87:175-86.
40. Celli D, Gasperoni E, Deli R. Long-term outcome in a patient with
a dentoskeletal open-bite malocclusion treated without extrac-
tion. World J Orthod 2007;8:344-56.