dentistry journal

Case Report
The Use of High Frequency Vibration and Clear
Aligners in Management of an Adult Patient with
Class III Skeletal Malocclusion with Open Bite and
Severe Bimaxillary Protrusion: Case Report
Tarek El-Bialy
Division of Orthodontics, Katz Group Centre for Pharmacy and Health Research, School of Dentistry,
University of Alberta, Edmonton, AB T6G 2T9, Canada; telbialy@ualberta.ca; Tel.: +1-780-492-2751




Received: 27 April 2020; Accepted: 6 July 2020; Published: 14 July 2020


Abstract: Adult orthodontic patients with skeletal Class III malocclusion, open bite and bimaxillary
dentoalveolar protrusion are complex problems that normally require surgical intervention to correct.
This is a report of an adult female with a skeletal Class III jaw relationship; in addition, the patient had
anterior open bite and bimaxillary dentoalveolar protrusion. The patient also had three premolars
in the lower left quadrant. Treatment involved extracting the extra premolar distal to lower left
canine, retraction of lower anterior teeth, closing extraction space and anterior open bite utilizing
Invisalign clear aligners. The patient initially changed aligners every week before this was changed
to 3–5 days after starting to use a high frequency vibration (HFV = 120 Hz) device. Satisfactory
results were achieved in a relatively shorter period. Comparing before and after treatment cone beam
computed tomography revealed that new bone has been formed labial to the lower incisors after their
retraction/correction of their initial proclined position and the use of HFV and myofunctional therapy
without gingival graft. The present case report shows the comprehensive multidisciplinary team
approach in treatment for such cases and the advantage of using HFV to improve bone formation.

Keywords: Class III malocclusion; clear aligners; clear aligners; myofunctional therapy

1. Introduction
Class III malocclusion is challenging to treat with satisfactory results especially in adults. Many
techniques have been reported about the management of these cases with different orthodontic
appliances with or without surgical interventions especially in adults. In recent years, clear aligners
became more demanded than regular fixed orthodontic appliances due to their acceptability by adults.
In addition, clear aligners provide less pain and are more hygienic as well as being more acceptable by
adult patients compared to fixed orthodontic appliances. The first reported anterior cross bite case
treated by serial clear aligners was in 2009 by Park and Kim [1] that showed serial clear aligners made in
the laboratory were able to move teeth sequentially into normal occlusion. A recent study showed that
clear aligners are as effective as fixed orthodontic appliances in correcting open bite cases [2]. Recent
case reports showed that clear aligners could be successfully used to correct Class III malocclusion and
open bite cases with or without surgery. In surgical cases, clear aligners have been successfully used for
the correction of the skeletal Class III jaw relationship in adults by surgery first then clear aligners were
used to finish the patient’s occlusion [3–5]. Extraction of lower incisor also has long been reported to
be an acceptable treatment approach in Class III malocclusion cases especially in adults [6–8]. The use
of high frequency vibration (HFV) has been introduced in orthodontics and recent reports showed
that it does not only accelerate tooth movement, but also it increases bone density at the end of
active treatment in human as well as after extraction in rats [9–15]. The anabolic effect of HFV during

Dent. J. 2020, 8, 75; doi:10.3390/dj8030075 www.mdpi.com/journal/dentistry

Dent. J. 2020, 8, x FOR PEER REVIEW 2 of 9

Dent. J. 2020, 8, 75 2 of 9
increases bone density at the end of active treatment in human as well as after extraction in rats [9–
15]. The anabolic effect of HFV during orthodontic treatment makes it unique especially in cases with
gingival recession
orthodontic or compromised
treatment makes it unique crown/root
especiallyratio. The increased
in cases osteoblastic
with gingival recessionactivity of HFV is
or compromised
reported
crown/rootdueratio.
to its The
upregulation
increasedof osteogenic activity
osteoblastic transcription
of HFV factors (RUNX2,
is reported dueFoxo1,
to itsOsterix and Wnt
upregulation of
signaling
osteogenicfactors) [13]. Infactors
transcription cases with severe
(RUNX2, proclination
Foxo1, Osterix ofandlower
Wntincisors,
signalingloss of alveolar
factors) bone
[13]. In casescan be
with
seen
severelabial to the proclined
proclination of lowerincisors
incisors,that
lossmay also show
of alveolar bone gingival
can be recession
seen labial[16–19]. Interdisciplinary
to the proclined incisors
treatment planshow
that may also including
gingivalorthodontics and myofunctional
recession [16–19]. therapy
Interdisciplinary have shown
treatment successful
plan including results in
orthodontics
similar cases [20]. This
and myofunctional case report
therapy show the
have shown utilization
successful of HFV
results and myofunctional
in similar cases [20]. Thistherapy to facilitate
case report show
orthodontic treatment
the utilization of HFV and of anmyofunctional
adult with skeletal Class
therapy III jaw relationship
to facilitate orthodonticwith anterior
treatment ofopen bitewith
an adult and
bimaxillary
skeletal Class protrusion in additionwith
III jaw relationship to gum recession
anterior open bitelabial
andtobimaxillary
lower incisor withoutin
protrusion the need for
addition to
gingival graft. labial to lower incisor without the need for gingival graft.
gum recession

2.
2. Materials
Materials and
and Methods
Methods

2.1. Case
2.1. Case Presentation
Presentation
This forty-five
This forty-fiveyear
yearoldoldfemale
female presented
presented withwith
chiefchief
concerns that she
concerns thatwanted to closetoher
she wanted anterior
close her
open biteopen
anterior and bite
closeand
spaces
closebetween anterior teeth
spaces between anterioras well
teethasasmove
well her protruded
as move front teeth
her protruded lingually
front teeth
and correct
lingually hercorrect
and under bite. Initial clinical
her under records
bite. Initial (Figures
clinical 1 and(Figures
records 2) show1concave
and 2) profile with prominent
show concave profile
chin projection and competent lips. She reported that she breaths through
with prominent chin projection and competent lips. She reported that she breaths through her nose her nose but she had an
anterior tongue thrusting habit. Intraoral examination revealed that the patient
but she had an anterior tongue thrusting habit. Intraoral examination revealed that the patient had had an extra (third)
premolar
an extra in the lower
(third) left quadrant
premolar in the of her mouth.
lower Right molars
left quadrant of herand canineRight
mouth. relationships
molars revealed
and canine half
cusp Class IIIrevealed
relationships occlusionhalf
andcusp
left side
Classmolars and canine
III occlusion relationships
and left side molars wereandClass
canineI occlusion (Figures
relationships were1
and 2b). The patient also presented with anterior and lateral cross bites that were
Class I occlusion (Figures 1 and 2b). The patient also presented with anterior and lateral cross bites extended from upper
rightwere
that to upper left first
extended frompremolars
upper right with a 3-mm
to upper leftopen
firstbite. In addition,
premolars with a the
3-mm patient
openhad bite.upper 5-mm
In addition,
andpatient
the lower had
12-mm spacing
upper 5-mm(considering
and lower 12-mm the spaces
spacing of the lower leftthe
(considering extra (third)
spaces premolar).
of the lower leftBolton
extra
(third) premolar). Bolton analysis revealed total mandibular excess of 0.72 mm (total ratio anterior
analysis revealed total mandibular excess of 0.72 mm (total ratio 92.02%) and mandibular 92.02%)
excess
and of 1.04 mmanterior
mandibular (anteriorexcess
ratio ofof79.39%).
1.04 mmUpper dental
(anterior midline
ratio was centered
of 79.39%). Upper to the patient’s
dental midlinefacialwas
midline and lower dental midline was deviated to the left by 2 mm from
centered to the patient’s facial midline and lower dental midline was deviated to the left by the upper dental midline.
2 mm
The patient
from gavedental
the upper her informed
midline. consent for inclusion
The patient gave her before they participated
informed consent forininclusion
the study.before
The study
they
was conducted in accordance with the Declaration of Helsinki, and the protocol
participated in the study. The study was conducted in accordance with the Declaration of Helsinki, was approved by
the Ethics Committee of the University of Alberta (Project identification
and the protocol was approved by the Ethics Committee of the University of Alberta (Project code: Pro00074117, date of
approval: 13 December 2017).
identification code: Pro00074117, date of approval: 13 December 2017).

Figure
Figure 1.
1. Initial
Initial clinical
clinical records
records showing
showing anterior
anterior open
open bite
bite with
with bi-maxillary
bi-maxillary protrusion
protrusion with
with extra
extra
third
third premolar
premolar distal
distal to
to lower
lower left
left canine.
canine.
 Dent.Dent.
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Dent. J. 2020, 8, x FOR PEER REVIEW 3 of 9
Initial and final cone-beam computed tomographs (CBCT) were obtained using the i-CAT FLX
Initial
(Imaging and final
Sciences
Initial cone-beam
andInternational,
final cone-beamcomputed
Hatfield,
computedtomographs
PA) with (CBCT)
a scanning
tomographs wereof
time
(CBCT) obtained
3.7 s,
were using
18.54
obtained mA, the
120
using i-CAT
kVp,
the FLX
withFLX
i-CAT
(Imaging Sciences International, Hatfield, PA) with a scanning time of
a field of view of 23 cm × 17 cm and slice thickness of 0.3 mm. All CBCT images were taken by one
(Imaging Sciences International, Hatfield, PA) with a scanning time 3.7
of s,
3.7 18.54
s, mA,
18.54 120
mA, kVp,
120 with
kVp, with a
atrained
field of view
fieldand of 23
calibrated
of view cm × 17
of 23 examiner cm
cm × 17 cm and
using slice thickness
andstandardized
slice thickness of 0.3
imaging mm. All CBCT
of 0.3 techniques.
mm. All CBCT images were
Cephalometric
images were taken by
radiographsone
taken by one
trained and
trained calibrated
and examiner
calibrated using
examiner standardized
using standardized imaging
imagingtechniques.
and analysis (Figure 3a, Table 1) revealed a Class III apical base relationship (ANB = −0.5°) with Cephalometric
techniques. Cephalometricradiographs both
radiographs
and analysis (Figure 3a, Table 1) revealed a Class III apical base relationship
maxillary and mandibular apical base prognathism relative to the anterior cranial base.−0.5
and analysis (Figure 3a, Table 1) revealed a Class III apical base (ANB
relationship = −0.5°)
(ANB with
= both
◦ ) with
Upper
maxillary
incisors
bothwereand mandibular
proclined
maxillary apical
relative to SN
and mandibular base prognathism
(119°)
apical andprognathism
base relative
protruded relative to the anterior
relativetotoNAthe(7.5 cranial base.
mm).cranial
anterior Lowerbase. Upper
incisors
Upper
incisors were proclined relative to SN (119°) and◦ ) protruded relative to NA
were severely proclined relative to mandibular plane (106.3°) and protruded relative to NB (9.4 mm).
incisors were proclined relative to SN (119 and protruded relative to (7.5
NA mm).
(7.5 Lower
mm). incisors
Lower incisors
were severely
Together
were withproclined
lower
severely relative
incisors
proclined to mandibular
forward
relative toposition,
mandibularplane (106.3°)
thereplane
was lack
(106.3and ◦ protruded
of )labial relative
bone relative
and protruded to
to NB to(9.4
lower
relative NB mm).
incisors
(9.4 mm).
Together
(Figure with
2a)
Together andlower
with4-mm incisors
lower forward
gingival
incisors recession
forwardposition,
labialthere
position, was lack
to lower
there of labial
left central
was lack bonebone
incisor.
of labial relative
However, to lower
relative there incisors
to lowerwasincisors
no
(Figure 2a) and 4-mm gingival recession labial to lower left central incisor.
other deep periodontal pocket or other periodontal concern. The patient also had lower third molars no
(Figure 2a) and 4-mm gingival recession labial to lower left central However,
incisor. there
However, was
there no
was
other
missingdeep
other andperiodontal
deep super pocket
erupted
periodontal or other
upper
pocket third periodontal
molars
or other concern.
(Figure
periodontal 3b). The patient
concern. also had
The patient also lower thirdthird
had lower molarsmolars
missing and super
missing erupted
and super upper
erupted thirdthird
upper molars (Figure
molars 3b). 3b).
(Figure

(a) (b)
(a) (b)
Figure 2. (a) Cone-beam computed tomographs (CBCT)-driven sagittal screen of lower incisor
FigureFigure (a) Cone-beam
(a)2.severe
2. its Cone-beam computedtomographs
computed tomographs(CBCT)-driven
(CBCT)-driven sagittal screen of of
lower incisor showing
showing proclination with no bone appears on most of sagittal screen
the labial surface lower
of incisor
the root; (b)
its severe
showing proclination
its severe withwith
proclination no bone appears
no bone on on
appears most of of
most thethelabial surface
labial of of
surface the root;
the root;(b)
(b)Initial
Initial digital models.
Initialdigital
digitalmodels.
models.

(a) (b)
(a) (b)
Figure 3. (a)3.CBCT-driven
Figure cephalometric
(a) CBCT-driven radiograph
cephalometric showing
radiograph anterior
showing crosscross
anterior bite and openopen
bite and bite as well
bite as well
Figure 3. (a) CBCT-driven cephalometric radiograph showing anterior cross bite and open
as bimaxillary protrusion; (b) CBCT-driven panoramic radiograph showing extra premolar distal to to
as bimaxillary protrusion; (b) CBCT-driven panoramic radiograph showing extra bite as
premolar well
distal
as bimaxillary
lowerlower left protrusion;
left canine and and
canine (b)
missing CBCT-driven
lower
missing lower panoramic
thirdthird
molars asradiograph
as well
molars as over
well showing
erupted
as over extra
upper
erupted premolar
third
upper molars.
third distal to
molars.
lower left canine and missing lower third molars as well as over erupted upper third molars.
Dent. J. 2020, 8, 75 4 of 9

Table 1. Cephalometric analysis of before and after treatment.

Measurement Initial Final Norm

SNA (◦ ) 86.2 86.3 82
SNB (◦ ) 86.7 86 80.9
SN - MP (◦ ) 28.9 29.8 32.9
FMA (MP-FH) (◦ ) 20.8 18.9 23.9
ANB (◦ ) −0.5 0.3 1.6
U1 - NA (mm) 7.5 4.8 4.3
U1 - SN (◦ ) 119 109.9 102.8
L1 - NB (mm) 9.4 3.7 4
L1 - MP (◦ ) 106.3 87.4 95
Lower Lip to E-Plane (mm) 0.5 −2.8 −2
Upper Lip to E-Plane (mm) −6.8 −6 −6

2.2. Treatment Plan and Progress

Different treatment options were discussed with the patient including orthognathic surgery to
reposition upper and lower jaws relative to the anterior cranial base and periodontal gingival graft
to cover lower incisors gingival recession in addition to orthodontic treatment with either fixed
orthodontic appliance or clear aligners. However, the patient declined the surgical options and
accepted clear aligners orthodontic option. It was important to remove the third (extra) premolar
distal to lower left canine and also the removal of the over erupted upper third molars as they had
no opposing teeth. The patient was referred to a periodontist for periodontal consultation regarding
her periodontal status and consultation for gum graft labial to lower incisors; however, the patient
declined periodontal surgery. Initial digital treatment planning (Clincheck) instructions were to
virtually remove 3.4 (lower left first (buccally tilted extra-premolar)) premolar, to distalize 3.3 into the
extraction space after virtually removing the extra-premolar and to move lower incisors posteriorly
and to move lower midline to patient’s left side to match upper midline. Additionally, instruction was
to avoid mesializing the lower left buccal segment, maintain initial molar relationship but improve
their occlusion. In addition, IPR was prescribed between 3.2 and 3.1 and between 4.1 and 4.2 to
minimize black triangle and to manage lower mandibular Bolton excess. Anchorage consideration
during anterior teeth retraction was the utilization of horizontal extrusion attachments on the mesial
parts of all molars to provide crown tip back and counter root moment in the mesial direction to
counteract the mesial reaction force on the posterior teeth during anterior teeth retraction. Initial set
of aligners included 35 aligners (Figure 4) to move lower left canine to the extraction space of the
extra (third) premolar and to help with lower midline correction. The patient was instructed to wear
the aligners full time and change them only when the new aligners would fit her teeth without too
much pressure felt by the patient. Myofunctional therapy exercises provided to the patient in verbal
and written format to bite on her back teeth during swallowing and to keep her tongue in the palate
where her tip of the tongue to touch the incisive papilla. The patient managed to change her aligners
every 7–10 days. At aligner 22/35 of the first set of aligners, lower left canine was not tracking very
well, so a new digital scan was obtained for additional aligners (27 more aligners) (Figure 5). Upon
insertion of the new aligners set, the patient was given the HFV (Vpro5, Propel, NY, USA) device to
ensure best fit or best aligners seating to minimize possible future non tracking of teeth and the patient
was instructed to use this for 5 min per day to help in accelerating the tooth movement and to help
with aligners seating to ensure that teeth track very well into the aligners. The patient reported that
she could change her aligners every 3–5 days without too much pressure felt from the new aligners
when she used the Vpro5 for 5 min every day. Two more additional aligners sets (32 more aligners)
(Figures 6 and 7) sets were ordered for fine-tuning the occlusion for a total of 94 aligners. Since the
second set of aligners, the patient changed her aligners on average every 4 days. Patient was given four
sets of Invisalign Vivera retainers to use for full time for a year and nighttime forever. It is important to
Dent. J. 2020, 8, 75 5 of 9

Dent.
Dent. J.
mentionJ. 2020,
2020, 8,
8, xx the
that FOR PEER
PEER REVIEW
FORpatientREVIEW
had to go through extensive myofunctional 55 of
of 99
therapy (instructions) to retrain
Dent.
Dent. J. 2020, 8,
J. 2020, 8,tox FOR
x FOR PEER REVIEW 55 of
of 99
the tongue stayPEER REVIEW
in the patient’s palate to avoid relapse.

aa b
b cc
aa b
b cc
Figure
Figure 4.
4. Images
Images of
of the
the beginning
beginning of
of first
first Clincheck
Clincheck (a):
(a): right
right side;
side; (b)
(b) frontal
frontal view
view and
and (c)
(c) left
left side.
side.
Figure 4. Images of the beginning of first Clincheck (a): right side; (b) frontal view and (c)
Figure 4. Images of the beginning of first Clincheck (a): right side; (b) frontal view and (c) left
Figure 4. Images of the beginning of first Clincheck (a): right side; (b) frontal view and (c)left side.
leftside.
side.

aa b
b cc
aa b
b cc
Figure
Figure 5.
5. Images
Images of
of the
the beginning
beginning of
of second
second Clincheck
Clincheck (a):
(a): right
right side;
side; (b)
(b) frontal
frontal view
view and
and (c)
(c) left
left side.
side.
Figure5.
Figure Imagesof
5.Images ofthe
thebeginning
beginningof
ofsecond
secondClincheck
Clincheck(a):
(a):right
rightside;
side;(b)
(b)frontal
frontalview
viewand
and(c)
(c)left
leftside.
side.
Figure 5. Images of the beginning of second Clincheck (a): right side; (b) frontal view and (c) left side.

aa b
b cc
aa b
b cc
Figure
Figure 6.
Figure 6. Images
6. Images of
Images of the
of the beginning
the beginning of
beginning of third
of third Clincheck
third Clincheck (a):
Clincheck (a): right
(a): right side;
right side; (b)
side; (b) frontal
(b) frontal view
frontal view and
view and (c)
and (c) left
(c) left side.
left side.
side.
Figure 6. Images of the beginning of third Clincheck (a): right side; (b) frontal view and (c)
Figure 6. Images of the beginning of third Clincheck (a): right side; (b) frontal view and (c) left side.left side.

aa b
b cc
aa b
b cc
Figure
Figure 7.
Figure 7. Images
7. Images of
Images of the
of the beginning
the beginning of
beginning of final
of final Clincheck
final Clincheck (a):
Clincheck (a): right
(a): right side;
right side; (b)
side; (b) frontal
(b) frontal view
frontal view and
view and (c)
and (c) left
(c) left side.
left side.
side.
Figure 7. Images of the beginning of final Clincheck (a): right side; (b) frontal view and (c)
Figure 7. Images of the beginning of final Clincheck (a): right side; (b) frontal view and (c) left side. left side.
3. Results
Patient completed her active treatment over 15 months and final records (Figures 8–10) show
acceptable occlusion relative to her initial malocclusion.
 Dent. J. 2020, 8, x FOR PEER REVIEW 6 of 9

3. Results
Dent. J. 2020, 8, 75 6 of 9
Patient completed her active treatment over 15 months and final records (Figures 8–10) show
acceptable occlusion relative to her initial malocclusion.
3.1. Clinical Records
3.1. Clinical Records
The patient had no gingival graft done and final photos (Figure 8) show very good covering of the
The patient
lower incisors had no gingival
by maintaining goodgraft
oraldone and final
hygiene photos (Figure
and retraction 8) show
of lower veryinto
incisors good covering
normal of
position
the lower incisors by maintaining good oral hygiene and retraction of lower
compared to initial photos. Anterior cross bite and spacing have been corrected. incisors into normal
position compared to initial photos. Anterior cross bite and spacing have been corrected.

Figure
Figure 8.8.Final
Finalphotos
photosshowing
showing improvement
improvement in
in the
thepatient’s
patient’sinitial
initialchief
chiefcomplaints including
complaints open
including open
bite and spacing as well as cross bite.
bite and spacing as well as cross bite.

3.2.
3.2. CBCT-DrivenRadiographs
CBCT-Driven Radiographs

3.2.1.Cephalometric
3.2.1. CephalometricRadiographs
Radiographs and
and Analysis
Analysis
Finalcephalometric
Final cephalometricanalysis
analysis shows
shows improvement
improvementininupper
upperandandlower
lower incisors inclinations
incisors andand
inclinations
protrusion
protrusion relative
relative toto apical
apical
Dent. J. 2020, 8, x FOR PEER REVIEW
bases
bases compared
compared to
to the
the initial
initial values
values (Table
(Table 1,
1,Figure
Figure 9a,b).
9a,b). 7 of 9

(a) (b)
Figure
Figure9.9.(a)(a)Final
FinalCBCT-driven
CBCT-drivencephalometric
cephalometricradiograph
radiographandand(b)
(b)cephalometric
cephalometricsuperimposition
superimpositionofof
before
before(black)
(black)andandafter
after(red)
(red)treatment
treatmentcephalometric
cephalometrictracings
tracingsshowing
showingimprovement
improvementininthe
thepatient’s
patient’s
initial
initialchief
chiefcomplaints
complaintsincluding
includingopenopenbite
biteand
andspacing
spacingasaswell
wellasascrossbite.
crossbite.

3.2.2. Panoramic and Sagittal Screen Radiographs

Figure 10a,b show the final CBCT-driven panoramic radiograph; the extraction space of the third
premolars has been closed by bodily retraction of lower left canine and lower incisors as well.
Additionally, it can be noted that upper third molars have been removed during the course of
 (a) (b)

Dent. J.Figure
2020, 8,9.75(a) Final CBCT-driven cephalometric radiograph and (b) cephalometric superimposition of 7 of 9
before (black) and after (red) treatment cephalometric tracings showing improvement in the patient’s
initial chief complaints including open bite and spacing as well as crossbite.
3.2.2. Panoramic and Sagittal Screen Radiographs
Figure 10a,b show the final CBCT-driven panoramic radiograph; the extraction space of the
third premolars has been closed by bodily retraction of lower left canine and lower incisors as well.
Additionally, it can be noted that upper third molars have been removed during the course of treatment.
Final CBCT-driven sagittal screen of lower incisor (Figure 10b) shows more bone labial to lower incisor
compared to the initial similar sagittal screen (2a).

(a) (b)
Figure 10.
Figure 10. (a)
(a) Final
Final CBCT-driven
CBCT-driven panoramic
panoramic radiograph
radiograph showing
showing complete
complete retraction
retraction of
of lower
lower left
left
canine; (b)
canine; (b)final
final CBCT-driven
CBCT-driven sagittal
sagittal screen
screen showing
showing bone formation
bone formation labial to labial to lower
lower incisors incisors
compared
compared
to to with
initial one initialseverely
one with severelylower
proclined proclined lower incisor.
incisor.

4. Discussion
4. Discussion
Treatment of
Treatment of open
open bite
bite using
using thethe extraction
extraction of of teeth
teeth utilizing
utilizing clear
clear aligners
aligners hashas been
been recently
recently
reported [2,3,5];
reported [2,3,5];however,
however, thethe
useuse
of HFVof HFV in conjunction
in conjunction with myofunctional
with myofunctional therapy therapy without
without gingival
gingival graft is the most important and new finding in this case report. The important observation
graft is the most important and new finding in this case report. The important observation to report
to report
here is thehere
new is
bonethe formation
new bonelabialformation
to thelabial to proclined
initially the initially proclined
lower incisorslower
after incisors
using HFV after using
without
HFV without gingival graft to cover the gum recession labial to the affected lower incisor (Figure
gingival graft to cover the gum recession labial to the affected lower incisor (Figure 6 b). It has been6
b). It has been reported before that HFV not only can accelerate tooth movement with clear aligners
reported before that HFV not only can accelerate tooth movement with clear aligners [10–12] but also
[10–12]
it increasebutbonealsoformation
it increaseand bone formation
density and density
after orthodontic after orthodontic
treatment treatmentofand
and after extraction after
teeth as
extraction of teeth as well [12–16]. Previous reports have shown that the increased bone density effect
well [12–16]. Previous reports have shown that the increased bone density effect of HFV is mediated
of HFV its
through is upregulation
mediated through its upregulation
of osteogenic transcription of osteogenic
factors (RUNX2,transcription factorsand
Foxo1, Osterix (RUNX2, Foxo1,
Wnt signaling
Osterix [13].
factors) and Wnt signaling mechanism
The biological factors) [13].ofThe biologicaltooth
accelerating mechanism
movement of accelerating
by HFV has tooth movement
been reported in
by HFV has been reported in detailed before [16]. This supports the reported findings in this case
detailed before [16]. This supports the reported findings in this case report that new bone formation
report
has beenthat new bone
observed formation
labial to lower hasincisors
been observed labial to lower
after orthodontic incisors
treatment andafter
the orthodontic
use of HFV.treatment
This also
and the use of HFV. This also supports the hypothesis that the increased bone density by HFV can be
supports the hypothesis that the increased bone density by HFV can be helpful during the retention
helpful[12],
period during the retention
though this needsperiod [12], though
to be studied this in
in detail needs
future to be studied
studies. in detailorthodontic
Although in future studies.
labial
movement of lower incisors may not be a risk factor in inducing gingival recession [17], the reverse
could be true that moving lower incisors lingually after being proclined can help with the use of HFV.
The multidisciplinary approach done in this case report that myofunctional therapy to rehabilitate the
tongue in severely proclined lower incisors can be corrected by moving lower incisors to their normal
position using clear aligners without free gingival graft [18–20]. It is important to consider the use of
HFV in similar cases in the future so as to help bone formation in areas with previous gingival recession.
The utilization of myofunctional therapy to rehabilitate the tongue from anterior tongue thrusting
habit is extremely important to implement to assure long-term stability of the achieved results [21].
Some limitations of the results in this case report included root parallelism of lower left first premolar
and lower canine as well as maximum interdigitation in this area; however, the patient was satisfied
and did not want to proceed with any further occlusal detailing. Moreover, another limitation is that if
finishing the case without deep overbite to consider, possible future relapse may occur in the open
bite correction.
Dent. J. 2020, 8, 75 8 of 9

5. Conclusions
1. The use of multidisciplinary approach in treating similar cases of severe open bite and the
coordination between the orthodontist and myofunctional therapist is extremely important to
ensure timely treatment and long-term stability.
2. The use of HFV can be an important treatment adjunctive therapy in similar cases to minimize
orthodontic treatment time as well as to help bone formation where gingival recession was
initially present due to the severely proclined incisors.

Funding: No funding was received for this manuscript.

Acknowledgments: The author would like to acknowledge the collaboration with the myofunctional therapist,
Vera Horn, in treating this patient.
Conflicts of Interest: The author (T.E.B.) has spoken on behalf of Propel Orthodontics in the past. The author
declares no additional conflict of interest.

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