CASE REPORT

Long-term stability of a Class III

malocclusion with severe anterior open
bite and bilateral posterior crossbite in a
hyperdivergent patient
Oscar Mario Antelo,a Thiago Martins Meira,a Dauro Douglas Oliveira,b Matheus Melo Pithon,c
and Orlando Motohiro Tanakaa
Curitiba, Belo Horizonte, Minas Gerais, and Bahia, Brazil

Anterior open bite malocclusion is generally associated with several causes. This case report describes the 2-
phase treatment of a 13-year-old boy with a Class III malocclusion, severe anterior open bite, and bilateral pos-
terior crossbite treated without surgical intervention. An orthopedic approach was performed in phase 1 with a
hyrax-type palatal expander, followed by maxillary protraction with a facemask for a 10-month period to promote
the correction of transverse and sagittal deviations. In phase 2, a comprehensive orthodontic approach using
fixed preadjusted appliances associated with intermaxillary elastics was performed. These approaches, com-
bined with good patient compliance, established a functional and esthetic occlusal relationship, normal overjet
and overbite, and a well-balanced facial appearance. The 4.5-year follow-up indicated that treatment results
were stable. (Am J Orthod Dentofacial Orthop 2020;157:408-21)

A
nterior open bite malocclusion represents one of
the most challenging issues in orthodontics, and
relapse is prone to occur after treatment.
Furthermore, treatment difficulty increases considerably
when associated with a Class III malocclusion and bilat-
eral posterior crossbite. Anterior open bite etiology is
multifactorial, including unfavorable vertical growth
pattern, mouth breathing, oral habits, and abnormal po-
sition and function of the tongue.1,2 The morphology of
an anterior open bite with a skeletal component includes
an open mandibular plane angle and an increase in ante-
rior facial height, which primarily reflects the clockwise
rotation of the mandible and the vertical growth of the
maxilla.3
a
Graduate Dentistry Program, School of Life Sciences, Pontifical Catholic Univer-
sity of Paran
a, Curitiba, Brazil.
b
Department of Orthodontics, Pontifical Catholic University of Minas Gerais, Belo
Horizonte, Minas Gerais, Brazil.
c
Southwest Bahia State University, Jequi
e, Bahia, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Orlando Motohiro Tanaka, Graduate Dentistry Pro-
gram in Orthodontics, School of Life Sciences, Pontif
ıcia Universidade Cat
olica
do Paran
a, R. Imaculada Conceiç~ao, 1155, Curitiba 80215-901, Brazil; e-mail,
tanakaom@gmail.com.
Submitted, revised, August 2018; accepted, October 2018.
0889-5406/$36.00
Ó 2019 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2018.10.029
408
Posterior crossbite can be of skeletal origin when a
transverse skeletal deficiency of the maxilla is present,
or it can be of dental origin when an altered tooth posi-
tion in the palatal or buccal direction is present.4,5
Class III malocclusion etiology is multifactorial and
occurs because of interactions involving heredity and
environmental factors.6 Moreover, Class III malocclusion
may present dental or skeletal implications.7 However,
the Class III dental relationship can be treated orthodon-
tically with a good prognosis. Depending on its severity,
a skeletal Class III relationship is more difficult to treat
and tends to relapse and require, on several occasions,
to perform orthodontic-surgical procedures for
adequate correction.8 This problem is characterized by
the presence of one or a combination of the following
factors: maxillary retrognathism and mandibular prog-
nathism.9
This case report presents the clinical case of a
13-year-old boy with a Class III malocclusion, severe
anterior open bite, and bilateral posterior crossbite
treated without surgery over 2 phases of treatment us-
ing orthopedic and comprehensive orthodontic ap-
proaches.
DIAGNOSIS AND ETIOLOGY
A 13-year-old boy arrived with his older sister to the
orthodontic consultation with the chief complaint of
Antelo et al
Fig 1. Pretreatment facial and intraoral photographs.
open and inverted bite. An extraoral evaluation showed a
hyperdivergent pattern of growth, symmetrical face, and
a straight profile with a relatively strong chin projection
(Fig 1).
Intraorally, he exhibited a severe angle Class III
malocclusion on both sides, bilateral posterior cross-
bite, and a 4.5-mm anterior open bite. The maxillary
arch presented an excess of space of 8 mm, and an
excess of space of 3.5 mm was in the mandibular
arch (Fig 2). Maxillary and mandibular midlines were
coincident with his facial midline. No signs and symp-
toms of temporomandibular joint disorder were
observed. The patient exhibited a habit of anterior
American Journal of Orthodontics and Dentofacial Orthopedics
409
position of the tongue at rest and a tongue-thrust
swallowing pattern.
The panoramic radiograph indicated that the third
molars were in development (Fig 3). Despite the dental
Class III malocclusion presented (AoBo5 -7
), the lateral
cephalometric analysis indicated a skeletal Class I rela-
tionship (ANB 5 3
) with a marked hyperdivergent
growth pattern (SN-GoGn 5 42
; FMA 5 37
). The
maxillary incisors were slightly proclined (U1-
NA 5 24
), and the mandibular incisors were also pro-
clined (L1-NB 5 30
) but uprighted considering the
IMPA angle 5 80
. In the concave profile, the Z
angle 5 70
(Table).
March 2020  Vol 157  Issue 3
410 Antelo et al

Fig 2. Pretreatment dental casts.

Fig 3. Pretreatment panoramic, lateral cephalometric radiograph, and tracing.

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Antelo et al 411

Table. Cephalometric measurements

Measurements Norms Pretreatment Progress Posttreatment Follow-up
SNA angle (
) 82 87 87 87 86
SNB angle (
) 80 84 82 82 82
ANB angle (
) 2 3 5 5 4
Ao-Bo (mm) 0 6 2* 7 2 1 0
1 6 2y
Facial angle (
) 87 91 90 91 91
Convexity (
) 0 6 12 8 7
FMA (
) 25 37 38 37 37
GoGn-SN (
) 32 42 44 43 44
y-axis (
) 59 62 63 62 62
1-NA (mm) 4 4 4 3 3
1-NA (
) 22 24 23 22 25
1-NB (mm) 4 7 6 7 7
1-NB (
) 25 30 28 24 23
IMPA 90 80 76 74 74
Interincisal angle (
) 132 124 127 133 134
Z angle (
) 75 74 76 78 81

*Denotes female; yDenotes male.

TREATMENT OBJECTIVES (3) Perform RME with an acrylic splint hyrax-type

The following treatment objectives were established:
(1) correct bilateral posterior and anterior crossbite, (2)
correct the habit of anterior posture of the tongue at
rest and tongue-thrust swallowing, (3) correct anterior
open bite (4) obtain Class I molar and canine relationship
on both sides, (5) obtain normal overjet and overbite,
and (6) maintain facial profile.
TREATMENT ALTERNATIVES
The following treatment alternatives were proposed:
(1) Perform rapid maxillary expansion (RME) with a
banded hyrax palatal expander, followed by maxillary
protraction with a facemask. In phase 2, bond complete
fixed appliances and bilaterally insert miniplates in the
maxillary and mandibular bones to perform intrusion
of the maxillary posterior teeth and intrusion and dis-
talization of the mandibular ones, thereby aiding open
bite closure and correction of the sagittal discrepancy.
Perform orofacial myofunctional therapy to correct the
anterior posture of the tongue at rest.
(2) Perform RME with a banded hyrax expander, fol-
lowed by maxillary protraction with a facemask and
placement of tongue spurs in the mandibular arch to
control the anterior posture of the tongue at rest. In
phase 2, bond complete fixed appliances and bilaterally
insert miniscrews between the maxillary and mandib-
ular first and second molars, performing intrusion of
maxillary and mandibular posterior teeth to aid open
bite closure and use of Class III and vertical elastics.
expander, followed by maxillary protraction with a
facemask. In phase 2, bond complete fixed appliances
and use Class III and vertical elastics. Perform orofacial
myofunctional therapy to correct the anterior posture
of the tongue at rest.
TREATMENT PLAN
The selected treatment approach was conservative,
commensurate with the patient's young age and the par-
ents' wishes.
TREATMENT PROGRESS
At phase 1 of treatment, an 11-mm opening hyrax-
type palatal expander with occlusal acrylic plate was
bonded in the maxillary arch to perform correction of
the bilateral posterior crossbite, with hooks for maxillary
protraction. The hyrax-type expander was activated
twice per day for 22 days, with 1 activation in the morn-
ing and another at night. After 11 mm of expansion, the
patient was instructed to use a facemask for 14 hours per
day over a period of 10 months with 600 g of force per
side to perform maxillary protraction for anterior cross-
bite correction (Fig 4).
After 10 months, the hyrax-type expander was
removed (Figs 4-6). At this point, the patient was at an
appropriate age to begin phase 2 treatment with
comprehensive fixed appliances. Two weeks later, MBT
0.022 3 0.028-inch slot preajdusted fixed appliances
were bonded in the maxillary and mandibular dental

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412 Antelo et al

Fig 4. Final phase 1 facial and intraoral photographs.

arches. Aligning and leveling were performed using 0.016
inch and 0.019 3 0.025-inch nickel titanium heat-
activated archwires. Subsequently, 0.019 3 0.025-inch
stainless steel archwires were placed in both dental arches
to improve leveling and to close spaces by sliding me-
chanics (Fig 7).
At this time, the maxillary incisors were reshaped with
composite resin to increase their mesiodistal size to
obtain adequate occlusion. Furthermore, Class III elastics
were used to maintain the sagittal correction achieved
during phase 1, whereas vertical elastics were used in
the anterior segment to achieve the correct overbite
(Fig 7).
Throughout the treatment process, the patient was
instructed to place his tongue on the upper part of the
palate to correct the anterior position of the tongue at
rest and lingual interposition swallowing pattern, thus
establishing a suitable environment for closing the ante-
rior open bite, thereby enhancing the stability of results.
During the completion stage, a segmented 0.014-inch
stainless steel archwire extending from the maxillary
right lateral incisor to the left lateral incisor was placed,
and all teeth were tied together. Furthermore, in the
mandibular arch, the 0.019 3 0.025-inch stainless steel
archwire remained for proper settling of dentition using
vertical elastics in the premolar and canine areas (Fig 7).

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Antelo et al 413

Fig 5. Final phase 1 dental casts.

Fig 6. Final phase 1 panoramic, cephalometric radiograph, and tracing.

TREATMENT RESULTS appliances were removed (Fig 8). Teeth were well leveled
After 4 years and 10 months of treatment, corre- and aligned, and ideal overbite and overjet were estab-
sponding to 10 months for phase 1 and 4 years for phase lished with molars, premolars, and canines in a Class I
2, all treatment objectives were achieved, and the relationship (Fig 9).

American Journal of Orthodontics and Dentofacial Orthopedics March 2020  Vol 157  Issue 3
414
Fig 7. Phase 2 treatment progress.
In phase 1, the transversal and sagittal discrep-
ancies were corrected (Figs 4-6). In phase 2, the
vertical discrepancy of anterior open bite was
adequately corrected, and the habits of anterior
posture of the tongue at rest and tongue-thrust swal-
lowing were eradicated. Correction of the dental Class
III relationship performed in phase 1 was maintained
in phase 2 through the use of Class III elastics (Fig
7). The favorable results obtained justify the adopted
treatment procedure decisions (Figs 8-10).
Furthermore, orthodontic records for the 3.5-year
follow-up indicate that the treatment results remained
stable (Figs 11-13; Table).
At the 4.5-year follow-up appointment, the results of
treatment remained stable with good healthy peri-
odontal tissues and a harmonious facial appearance
(Fig 14). The patient is in the postretention phase and
does not use the retainers since the finalization of the
second-year after treatment. (Fig 15).
DISCUSSION
The present case report shows a 13-year-old boy that
presented with a Class III malocclusion, severe anterior
open bite, and bilateral posterior crossbite. This patient
March 2020  Vol 157  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Antelo et al
was successfully treated over 2 phases of treatment
that included orthopedics and orthodontics. Treating
anterior open bite malocclusion is challenging for any
orthodontist, and relapse is common after treatment.10
Moreover, treatment difficulty considerably increases
when it is associated with a Class III malocclusion and
bilateral posterior crossbite.
Correction of severe open bite has frequently
been obtained using a combination of orthodon-
tics and orthognatic surgery. Although this pro-
cedure has been proven successful, our patient
and parents rejected it because of the treat-
ment's apparent aggressiveness and financial
constraints.
Treatment of Class III malocclusion in growing pa-
tients involving RME followed by facemask protrac-
tion therapy is commonly described in the
literature.11,12 In the present case report, an orthope-
dic approach was applied to our 13-year-old patient
over 10 months for 14 hours per day, which achieved
dentoalveolar changes and, to a lesser extent, skeletal
changes.
According to Cordasco et al,13 skeletal modifications
induced by facemask therapy include forward
Antelo et al
Fig 8. Posttreatment facial and intraoral photographs.
displacement of maxilla, backward displacement of
mandible, clockwise rotation of the mandibular plane,
and counterclockwise rotation of the maxillary plane.
Although such changes improve facial esthetic aspect
and correct the Class III relationship, this method could
be worse for anterior open bite tendency, particularly in
vertically growing patients (such as the patient featured
in the present study). To reduce the extrusive effect of
this mechanic, a hyrax-type expander was designed
with an occlusal acrylic plate.
Several treatment modalities have been advocated to
intercept and correct anterior open bite malocclusion,
each with varying degrees of success in terms of long-
term correction stability.14,15 Temporary skeletal
anchorage devices are typically used for posterior teeth
intrusion because they are minimally invasive and
American Journal of Orthodontics and Dentofacial Orthopedics
415
involve rational and efficient mechanics in the control
of the vertical plane by intrusion of molars without
extruding the incisors. This approach could, thereby,
improve the dentofacial esthetic of patients with skeletal
open bite tendency.16 In addition, Kuroda et al17 sug-
gested that it is more practical to treat anterior open
bite malocclusion by intrusion of posterior teeth with
temporary skeletal anchorage, rather than performing
surgery.
The use of miniplates represents another option,
particularly for correcting skeletal anterior open bite
malocclusion,18,19 and little patient discomfort is asso-
ciated with their placement, maintenance, and
removal.20 Regarding the patient featured in the pre-
sent study, any type of treatment involving surgery
was unacceptable to the patient's family. For this
March 2020  Vol 157  Issue 3
416 Antelo et al

Fig 9. Posttreatment dental casts.

Fig 10. Posttreatment panoramic, lateral cephalometric radiograph, and tracing.

March 2020  Vol 157  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Antelo et al
Fig 11. Follow-up facial and intraoral photographs after 3.5 years.
reason, the patient was treated using nonsurgical tech-
niques in 2 phases of treatment that involved orthope-
dics and orthodontics.
Concerning the habit of anterior position of the
tongue at rest and tongue-thrust swallowing presented
by our patient, it was indicated to place soldered tongue
spurs in the maxillary arch. It has been well established
that tongue spurs are an excellent device for intercepting
and correcting anterior open bite caused by inadequate
tongue position and function.21 These spurs re-educate
the tongue by proprioceptive reflex, placing it in a supe-
rior position in contact with the palate.22 Unfortunately,
the patient's family also rejected this option. Therefore,
we performed myofunctional orofacial therapy to
improve and correct the inadequate tongue position
American Journal of Orthodontics and Dentofacial Orthopedics
417
and function. Fortunately, this type of approach was
accepted by the parents.
During phase 2 (using fixed appliances), the patient
was motivated and received orofacial myofunctional
therapy to acquire adequate tongue function and posi-
tion. Smithpeter and Covell23 stated that orofacial myo-
functional therapy, in conjunction with orthodontic
treatment, is highly effective at keeping anterior open
bites closed, compared with patients treated only with
orthodontics. Moreover, we believe that the observed
long-term stability of results in the present case likely
had a strong influence on correction of tongue function
and position.
Performing such treatment in our 13-year-old pa-
tient with severe anterior open bite malocclusion
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418 Antelo et al

Fig 12. Follow-up dental casts.

Fig 13. Follow-up panoramic and lateral cephalometric radiographs. Superimposition of cephalometric
tracings: black, pretreatment; red, posttreatment; green, follow-up.

associated with a dental Class III relationship and bilat- to permanently deal with unfavorable vertical growth
eral posterior crossbite posed a significant challenge by using vertical and Class III-orientated elastics that
because of the vertical, sagittal, and transverse devia- could compromise the stability of the results in the
tions presented. During the entire treatment, we had short and long term. Although an open bite

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Antelo et al
Fig 14. Follow-up facial and intraoral photographs after 4.5 years.
malocclusion in patients with a vertical growth pattern
often requires surgery, a more conservative approach
that respects the patient's choice should be consid-
ered.24
The overall superimposition demonstrates that the
patient underwent a significant facial growth.
Furthermore, the resulting observed mandible auto-
rotation was minimal, and the vertical dimension
was well controlled. Moreover, partial maxillary
superimposition exhibited successful vertical control
of the maxillary molars and extrusion of the incisors
that were initially above the maxillary plane of occlu-
sion.
This patient could have been satisfactorily treated
using other modalities. Also, treatment duration was
acceptable based on the high level of commitment of
the patient and his family. Appointments were
American Journal of Orthodontics and Dentofacial Orthopedics
419
routinely attended, and the use of buccal elastics was
superlative.
After 4 years and 10 months of orthopedic-
orthodontic treatment and following confirmation
that the habit of anterior position of the tongue at
rest and tongue-thrust swallowing were corrected,
the appliances were removed, and a removable wrap-
around Hawley-type retainer and fixed mandibular
canine-to-canine retainer were placed. The patient
was instructed to continuously wear the retainers
for a period of 1 year and only at night thereafter.
At the 4.5-year follow-up, the occlusion looked
remarkable, and the patient was pleased with the sta-
bility of results in the long term. We strongly believe
that the preserved stability was due above all to the
re-education in the function and position of the
tongue.
March 2020  Vol 157  Issue 3
420
Fig 15. Profile superimpositions. Pretreatment, final phase 1, posttreatment, 3.5 years follow-up, and
4.5 years follow-up.
CONCLUSION
A Class III malocclusion associated with severe ante-
rior open bite and bilateral posterior crossbite in a hyper-
divergent patient was successfully treated in 2 phases of
treatment without surgery. A functional occlusion,
harmonious profile, and patient satisfaction were
achieved. Also, negative tongue habit was eradicated,
and the patient retained stable results at the 4.5-year
follow-up examination.
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