Oral Maxillofacial Surg Clin N Am 19 (2007) 321–338

Anterior Open Bite Correction by Le Fort I

or Bilateral Sagittal Split Osteotomy
Johan P. Reyneke, BChD, MChD, FCMFOS (SA), PhDa,b,*,
Carlo Ferretti, BDS, MDent (MFOS), FCD (SA) MFOSa,c
a
Department of Maxillofacial and Oral Surgery, Faculty of Health Sciences,
University of the Witwatersrand, Johannesburg, South Africa
b
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry,
University of Oklahoma, Oklahoma City, OK, USA
c
Department of Maxillofacial and Oral Surgery, Chris Hani Baragwanath Hospital,
Faculty of Health Sciences,
University of the Witwatersrand, Johannesburg, South Africa

Some of the most challenging dentofacial de- causative mechanisms, and the question remains
formities facing surgeons and orthodontists are incompletely answered.
anterior open bite malocclusions. Determining the Nonnutritive sucking is a normal developmen-
cause of an anterior open bite and formulating tal phenomenon whose frequency decreases with
a diagnosis are complicated by the role of age. Persistence of the habit beyond the age of 6
neuromuscular and genetic influences. Long-term years is strongly associated with open bite maloc-
skeletal and dental stability are a concern because clusion [1]. Complicating the issue is the fact that
of the influence that the neuromusculature has on there is a wide racial variation in the incidence of
the repositioned jaws and stability of teeth after anterior open bite, which suggests a modulating ef-
vertical orthodontic mechanics required for clos- fect of genetic control of skeletal proportions [2,3].
ing open bites. Nasopharyngeal and oropharyngeal obstruction as
a result of one of several possible conditions, such
malformation secondary to functional as allergic rhinitis, enlarged adenoids, and enlarged
Etiology aberrations
tonsils, has been associated with development of
Mechanistic insights on the development of the anterior open bite deformity [4].
anterior open bite malocclusion remain subject to It is proposed that obstruction to normal nasal
debate and discussion. Patently, two philosophies breathing triggers an adaptive neuromuscular
may concur with research findings: the morpho- response that results in open rotation of the
genetic theory and the adaptive theory. The mandible, inferior and anterior repositioning of
anterior open bite may be the result of aberrant the tongue, and extended head posture giving rise
genetic control of morphology via growth pat- to the classical ‘‘adenoidal facies.’’ There are
terns, or a malformation secondary to functional several implications of these functional adapta-
aberrations of the naso-oropharyngeal apparatus. tions to nasal breathing. First, a change in the
It has proven difficult to separate these two direction of mandibular growth from horizontal
to vertical results in increased lower facial height.
Second, inferior and anterior repositioning of the
Hypertrophy of the lymphoid tissues, the adenoids is the most common cause of nasal obstruction in
children, long face syndrom tongue has several dental effects, including
* Corresponding author. Centre for Orthognathic
narrowing of the maxillary dental arch caused
Surgery and Implantology, Sunninghill Hospital, PO by the unopposed action of the buccinator muscle,
BOX 5386, Rivonia, South Africa. retroclination of the upper incisors caused by
E-mail address: drjprey@global.co.za (J.P. Reyneke). the unopposed actions of orbicularis oris, and
1042-3699/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2007.04.004 oralmaxsurgery.theclinics.com

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322
proclination of the lower incisors caused by
increased tongue pressure. The case for this
mechanism has been strengthened by the finding
that early removal of the obstruction and return
to nasal breathing often results in normalization
of anterior height. Finally, chronic mouth breath-
ing can cause alterations in head posture, most
commonly extension or upward rotation of the
head, in an attempt to improve oropharyngeal
patency. This altered posture has been associated
with several disturbances in craniofacial morphol-
ogy, including increased lower facial height,
mandibular and maxillary retrognathism, and
steep mandibular plane.
Increased vertical development of the maxilla
also has been associated with several muscle
weakness syndromes. Weakness of the mandibu-
lar elevators and decreased biting force allow the
posterior teeth to overerupt and the mandible to
rotate downward. It has been reported that the
biting forces of patients with long faces are below
normal, although the bite force of preadolescent
patients with long face characteristics is normal
[5,6]. The role of decreased bite force as an etio-
logic factor in the development of vertical maxil-
lary excess and anterior open bite is not clear,
however.
In the past, tongue thrust or abnormal tongue
activity during speech has been blamed for the
development of anterior open bite malocclusion
and poor stability after treatment. Various at-
tempts to change patients’ swallowing patterns,
such as speech therapy and removable appliance
with a crib, have been used to control anterior
open bite problems. Contemporary research has
shown, however, that tongue thrust swallow is
a physiologic adaptation to an anterior open bite
rather than the cause of it. An abnormally large
tongue or true macroglossia should first be
differentiated from pseudomacroglossia and only
then considered as an etiologic factor in the
development of an anterior open bite. A large
tongue also may be the cause of poor stability
after treatment [7].
It seems that an anterior open bite is pre-
dominantly the result of alterations in mandibular
growth patterns, and more attention is required
for treatment philosophies that address this fact.
Diagnosis
As with the diagnosis of all malocclusion, it is
important to identify the cause of the anterior
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REYNEKE & FERRETTI
open bite. Because vertical problems (in particular
in patients with anterior open bite) can result from
habits, environmental influences, or vertical skel-
etal growth problems, the diagnosis has two
important components: the specific anatomic
location of the discrepancy (eg, maxilla, mandible,
or both) and identification of a cause. In young
growing individuals, the major cause of anterior
open bite is sucking habits and environmental
influences. The open bite as a result of thumb
sucking is usually limited to the anterior region,
with a narrow palate, often posterior cross bites,
and relatively normal facial proportions. The
most important step in the treatment is to stop
the habit. For this purpose a removable appliance
with a crib is used. The sucking habit stops
immediately in approximately 50% of patients
and the open bite starts to close rapidly. In the
remaining children the thumb sucking may persist
for a few weeks; however, the device is usually
effective in 85% to 90% of cases [1]. At this stage,
orthodontic correction of the cross bites solves the
transverse and anterior open bites. The long-term
prognosis depends on the growth pattern, how-
ever, and a poor response to treatment suggests
persistent excessive vertical growth. These patients
most probably develop vertical maxillary excess
and an anterior open bite malocclusion.
Not all children who are thumb suckers de-
velop anterior open bites. In children with chronic
mouth breathing, one, or all, of three neuromus-
cular responses must be present for an anterior
open bite malocclusion and altered skeletal re-
sponse to develop: (1) altered mandibular posture,
(2) altered tongue posture, (3) extended head
posture [4]. Several studies have shown that an
obstructed upper airwaydassociated with altered
mandibular posturedis related to increased lower
facial height [8,9]. Removal of the cause of the na-
sopharyngeal obstruction (eg, enlarged adenoids
or tonsils, allergic rhinitis) has been reported to
decrease the open bite [4]. Upper airway obstruc-
tion may be one factor in the multifactorial etio-
logic complex that influences the dentition and
morphogenetic facial pattern.
In young individuals in whom vertical growth
persists and in patients who have reached adoles-
cence, environmental causes for anterior open bite
become less important than skeletal factors. Skel-
etal anterior open bite malocclusion in adults is
basically a vertical dentofacial problem caused by
excessive vertical development of the maxilla,
shortening of the mandibular ramus, or a combina-
tion of both. It is important to distinguish between
 ANTERIOR OPEN BITE CORRECTION 323

Fig. 1. An anterior open bite (A) in an 8-year-old patient was treated by orthodontic expansion of the maxillary dental arch
combined with habit control (thumb sucking) (B). The arrow indicates the ‘‘gate’’ incorporated into a removable appliance.
A stable posttreatment result was achieved (C). (Courtesy of T. McCollum, BDS, MDent, Johannesburg, South Africa.)

the two skeletal deformities because it ultimately headgear and class III elastics [12], titanium screw
determines the surgical treatment plan. anchorage [13], a rapid molar intruder appliance
[14], reverse headgear combined with class III

Treatment of growing individuals

Box 1. Clinical, dental, and
Anterior open bites in children with mixed cephalometric findings of patients
dentition and good facial proportions are usually with anterior open bite deformity
caused by prolonged thumb sucking (beyond the
age of 6 years) or other environmental influences, Aesthetic features
and the most important corrective measure in Lower third of the face almost always
these patients is cessation of the habit. Posterior elongated
cross bites are usually the result of narrowing of Excessive incisor exposure under the
the maxilla. Removable and fixed appliances can upper lip
be effective in the correction. Maxillary dental Increased interlabial gap
expansion not only corrects the cross bites but Gummy smile
also assists in closing the anterior open bite and Obtuse nasolabial angle
should be combined with habit control (Fig. 1). Retrusive chin
By the time adolescence is reached, environmental Dental characteristics
causes become less important. Skeletal factors Open bites may be associated with all
should be considered after poor response to habit types of malocclusion; however,
control and maxillary expansion [10]. relative or absolute mandibular
deficiency and class II malocclusion
are most common
Treatment of nongrowing individuals Tendency for the maxillary arch to be
V-shaped and the mandibular arch to
Orthodontic correction of anterior open bite be U-shaped
Posterior cross bites
The treatment of patients with anterior open
Flat or reverse mandibular occlusal plane
bite by means of orthodontic treatment alone
curve
usually focuses on three areas: (1) extrusion of
Stepped maxillary occlusal plane
upper and lower incisor teeth, (2) intrusion of
molar teeth, and (3) expansion of the maxillary Cephalometric features
dental arch. This orthodontic treatment requires Increased anterior facial height
almost exclusively the use of vertical mechanics. Steep mandibular and occlusal plane
Extrusion of incisor teeth can be accomplished in angle
three ways: (1) the use of anterior elastics, (2) Normal mandibular ramus height
using a continuous arch wire from molar to molar Saddle cranial base
to level an excessive occlusal curve in the maxil- Increased distance from tooth apices to
lary arch, and (3) leveling a reverse curve of Spee the nasal floor
in the lower arch in the same manner. The Palatal plane is tipped up anteriorly and
mechanics to intrude the molars include intrusion down posteriorly
of molars with miniplate anchorage [11], high-pull

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324 REYNEKE & FERRETTI

Fig. 2. This 17-year-old patient developed an anterior open bite as a result of excessive vertical growth of her maxilla.
The mandible rotated clockwise, which resulted in a class II anterior open bite malocclusion (A–F). The maxillary dental
arch was aligned in two segments (11 to 17 and 21 to 27) (G–L). The open bite was surgically corrected by superior
repositioning of the maxilla (more in the posterior area than anterior) and expanded, which allowed the mandible to
autorotate (O). A balanced aesthetic result and functional occlusion were achieved (M–R).

and anterior box elastics [15], zygomatic anchor-
age [16], and bite blocks with repelling magnets
[17]. Expansion of the maxillary posterior teeth
in adult individuals with skeletal transverse
deficiency usually results in dental tipping and
questionable stability [18,19].
Most of the reports in the literature regarding
orthodontic correction of skeletal anterior open
bite are case reports that discuss specific ortho-
dontic techniques or introduce new orthodontic
mechanics. There is, however, a paucity of studies
regarding results after orthodontic correction of

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 ANTERIOR OPEN BITE CORRECTION 325

Fig. 2 (continued)

anterior open bite malocclusions to draw any
evidence-based conclusions [20–22]. Few studies
have reported on the pretreatment aesthetic con-
siderations and facial aesthetic outcomes. Regard-
less of the specific mechanism used to achieve the
tooth movements, stability is unpredictable and in
many cases results in compromised aesthetics
[23,24]. In cases in which the anterior open bite
is associated with increased incisor angulation
(as may be found in cases with bimaxillary
protrusion), correction of the incisor angulation
by tipping the incisors has a relative extrusion
effect, thus closing the bite.
Combined orthodontic and surgical treatment
Anterior open bite secondary to vertical maxillary
excess: Le Fort I maxillary osteotomy with or
without mandibular surgery
The common but variable clinical, dental, and
cephalometric findings of patients with skeletal
anterior open bite deformity as a result of vertical
maxillary excess are as shown in Box 1 (Fig. 2):
Presurgical orthodontic treatment
Presurgical orthodontic mechanics should not
be directed toward correcting vertical, transverse,
or anteroposterior skeletal problems. Orthodontic
tooth movements for the correction of these
problems have questionable long-term stability
and may build relapse into the surgical result. The
basic goal of presurgical orthodontic treatment
should be to align the maxillary teeth (either in
segments or in one piece) and avoid any mechanics
that are intended to close the bite. Segmental
surgery is indicated when the maxillary dental
arch has a tendency to natural segments or to level
the occlusal curves surgically. This does not mean
that individual teeth within a segment should not be
leveled; intrusion of the incisors or maintaining
their pretreatment height is recommended. Open-
ing the bite before surgery improves stability
because relapse of incisor intrusion serves to further
close the bite after surgery. Orthodontic alignment
of the maxilla in segments can be done with or
without extractions. The need for extractions in
these cases is dictated by the amount of crowding
and the dental movements necessary to place the
upper and lower incisors in their desired angulation
and in the central trough of bone. Keep in mind that
the angulation of the incisor and posterior teeth can
be altered with segmental surgery. In cases in which
segmental surgery is contemplated, care should be
taken to coordinate the arch form of the maxillary
segments with the mandibular arch and deviate the
roots of the teeth adjacent to the intended in-
terdental osteotomy sites.

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326 REYNEKE & FERRETTI

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 ANTERIOR OPEN BITE CORRECTION 327

Although the mandible may require surgical
advancement or setback, the lower dental arch
serves as the ‘‘template’’ and ultimately dictates
the symmetry and form of the upper arch. The
presurgical orthodontic treatment goals are to
place the lower dentition symmetrically in the
ideal anteroposterior, vertical, and transverse
positions in relation to its supporting bone. In
individuals with a severe reverse curve of Spee in
the lower arch, consideration should be given to
surgically leveling the mandibular arch by means
of segmental mandibular surgery.
Orthodontic mechanics expressly intended to
close the bite should be avoided during the
presurgical orthodontic phase. Bite blocks with
repelling magnets, high-pull headgear, miniplate
anchorage for molar intrusion, vertical elastics,
molar expansion beyond its alveolar bone base, or
any other device used to close the bite are
inadvisable. Previous attempts to close a skeletal
anterior open bite orthodontically without con-
sidering surgical correction will leave the clinician
with a dilemma. After orthodontic attempts to
close the bite, pretreatment orthodontic records
must be compared with current records to evalu-
ate the potential for dental relapse. It is recom-
mended to discontinue all vertical mechanics and
allow vertical relapse by placing light sectional
arch wires to maintain alignment and rotations.
Once no further vertical opening of the bite
occurs, the patient can be re-evaluated for appro-
priate surgery and orthodontics.
Surgery
The anterior open bite in this group of patients
is caused by excessive vertical growth of the
maxilla. The vertical deformity often occurs in
conjunction with either a primary or secondary
sagittal deformity. During treatment planning
three factors should be considered: (1) the amount
of superior repositioning of the maxilla, (2) the
position of the mandible after autorotation, and
:
(3) the need for surgical correction of a transverse
discrepancy.
The amount of superior repositioning of the max-
illa. The amount of superior repositioning of the
anterior and posterior maxilla is influenced by two
aspects: (1) The planned ideal maxillary incisor/
upper lip relationship determines the amount of
vertical and anteroposterior repositioning of the
anterior maxilla. In most cases the incisor teeth
require superior repositioning. In some cases,
however, the incisor height may need to be
maintained, whereas in other cases the anterior
maxilla may have to be inferiorly repositioned.
The final anteroposterior and vertical positions of
the maxillary incisor are the key to treatment
planning [25,26]. (2) The final occlusal plane is
determined by the mandibular occlusal plane after
autorotation of the mandible. The amount of
superior repositioning of the posterior maxilla is
determined by the height of the mandibular
posterior teeth after autorotation.
The position of the mandible after autorotation.
The anteroposterior position of the lower incisor
after autorotation determines whether mandibular
surgery is indicated. Individuals with a class I
molar relation, combined with vertical maxillary
excess and an anterior open bite malocclusion,
end with a class III dental relationship after
maxillary superior repositioning. Based on the
aesthetic requirements of the case, the clinician
must decide whether the class III dental relation-
ship should be corrected by advancement of the
maxilla (Fig. 3) or mandibular setback (Fig. 4).
The mandible of an individual with vertical
maxillary excess and a class II occlusion rotates
to a class I relation after superior repositioning
of the maxilla and may not require mandibular
surgery. Patients with class III anterior open bite
and vertical maxillary excess end with a class III
occlusion of increased severity after vertical
correction of the maxilla and anterior rotation
of the mandible. These cases most probably need
a mandibular setback procedure in conjunction

Fig. 3. The typical clinical signs of vertical maxillary excess (ie, increased lower facial height, the appearance of
mandibular deficiency, and convex profile caused by the backward rotation of the mandible). A gummy smile and an
increased interlabial gap are well demonstrated in this 19-year-old patient (A–D). He had a class I open bite malocclusion
and a tendency to bilateral posterior cross bites (E). The upper dental arch was orthodontically aligned in one segment
and the lower arch leveled (F). The surgical treatment plan consisted of a three-piece Le Fort I maxillary osteotomy with
superior repositioning and expansion of the maxilla. The mandible autorotated into a class III dental relation. The facial
aesthetics required maxillary advancement rather than mandibular setback. For optimization of facial aesthetics, the
chin was advanced by means of a genioplasty (G,H). The posttreatment results (I–M).

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 328 REYNEKE & FERRETTI

it is board case

Fig. 4. This 22-year-old male patient presented with an increased lower facial height, mandibular prognathism and asym-
metry to the left, and a class III anterior open bite malocclusion (A–C). The preoperative orthodontic treatment consisted of
the aligning the maxillary arch in three segments (the anterior segment, including the four incisor teeth), and leveling the
lower dental arch (D–F). The treatment plan consisted of superior repositioning and expanding the posterior maxilla by
means of a three-piece Le Fort I osteotomy, which allowed the mandible to autorotate and close the open bite. The class
III dental and skeletal relation, however, worsened after autorotation of the mandible, which necessitated mandibular set-
back and correction of the mandibular asymmetry at the same time (G, H). The posttreatment results (I–N).

with maxillary advancement (see Fig. 4). This
decision is based on the aesthetic requirements
of each case. Individuals who have vertical maxil-
lary excess and severe class II malocclusion and
anterior open bites end with a class II occlusal re-
lationship after maxillary superior repositioning.
To establish a class I occlusion, these cases often
require additional mandibular advancement pro-
cedures (Fig. 5).
Poor midface esthetics are usually the conse-
quence of maxillary setback procedures (>3 mm).
A combination of maxillary superior reposition-
ing and setback will compromise the esthetics even
more and should be avoided. The mandible
should rather be advanced in these cases, and
the maxilla superiorly repositioned and preferably
slightly advanced. The slight advancement (2–3
mm) has the added technical advantage that the

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 ANTERIOR OPEN BITE CORRECTION 329

Fig. 4 (continued)

posterior maxilla is moved away from the
pterygoid plates, which avoids difficulty in re-
moving bone posteriorly to allow for adequate
superior repositioning of the posterior maxilla.
Because of the disproportionate vertical excess
of the posterior maxilla in open bite deformities,
it often requires more bone removal in this area
than in correction of non–open bite deformities
with vertical maxillary excess. In all of these
treatment scenarios the chin contour and posi-
tion should be evaluated to enhance the aes-
thetic outcome. When considering a genioplasty
procedure, two important aspects should be kept
in mind: (1) genioplasty is not a substitute for
mandibular surgery and (2) chin shape or
contour is more important than chin position
(anteroposterior position of pogonion).
The need for surgical correction of a transverse
discrepancy. An individual with an open bite
malocclusion and skeletal vertical maxillary excess
often has a transverse skeletal deficiency of the
maxillary arch. These cases require surgical expan-
sion of the maxilla by segmental surgery. Surgical
expansion of the maxilla has been shown to be one
of the most unstable orthognathic procedures,
however [27]. Transverse relapse is one of the
most common postsurgical complications and in-
evitably leads to recurrence of the anterior open
bite. The problem often stems from poor preopera-
tive diagnosis, inappropriate presurgical orthodon-
tics, poor surgical management, and poor
postsurgical orthodontic control [28]. Initially the
clinician should determine whether the discrepancy
is skeletal or dental in nature and whether it is rel-
ative or absolute. Only when the dental casts are
held in their correct sagittal relationship with the
canines in a class I occlusion can an absolute cross
bite be revealed. When the cross bite is obviously
skeletal in nature, compensatory dental expansion,
headgear, arch wires or through-the-bite elastics
should be avoided. These dental changes have
a high potential for relapse that may only manifest
long after treatment [29].
Presurgical orthodontic tipping of molar teeth
that leaves the lingual cusps hanging below the
occlusal plane has additional surgical problems.
Hanging palatal cusps of the molars increase the
amount of surgical expansion of the palate that is
required. Surgical palatal expansion in these cases
would involve expansion of the bony base and an
element of uprighting of the molar teeth. The
increased amount of expansion leads to increased
potential for relapse (Fig. 6).
Transverse stability can be enhanced by
placing a bone graft in the palatal defect.
Stabilization of the bone graft can be facilitated
by performing the palatal osteotomy in the

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330 REYNEKE & FERRETTI

Fig. 5. A 16-year-old female patient with a class II anterior open bite malocclusion (A–C). Her maxilla was vertically
excessive and mandible anteroposteriorly deficient. Both dental arches were orthodontically leveled, aligned, and coor-
dinated before surgery (D). After the superior repositioning of her maxilla, the bite was closed and the mandible rotated
into a class II occlusion. Her mandible was advanced by means of a bilateral sagittal split osteotomy and her chin
augmented by means of a sliding genioplasty (E, F). The posttreatment results (G–J).

mid-palate, where the bone is thickest. The loss of the graft. Performing bilateral osteoto-
disadvantage is that the mucosa in this area of mies in the palate facilitates larger expansion;
the palate is at its thinnest. A tear in the palatal however, grafting these areas where the bone is
mucosa exposes the graft and eventually leads to thin is more difficult.

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 ANTERIOR OPEN BITE CORRECTION 331

very important clinical note to rememeber

Fig. 6. With the maxillary posterior teeth in good angulation, a 5-mm expansion of the upper dental arch creates a 5-mm
bony defect in the palate (A, B). When the posterior teeth are orthodontically expanded, however, the molar teeth are
tipped buccally and the palatal cusps tend to hang. The expansion of the upper arch also needs to include a rotational
movement to ‘‘tuck’’ the buccal cusps in. A 5-mm dental expansion leads to a 10.5-mm bony defect (C, D).

The use of a splint during surgery and Preoperative orthodontic treatment

maintaining the splint in position for at least 6
weeks after surgery allow stabilization during
bone healing and may enhance skeletal stability.
Obtaining immediate postsurgical orthodontic
control by placing a palatal bar or a strong arch
wire or both to support the palatal expansion
further enhances stability of the result. In patients
who have macroglossia, reduction of the tongue
at the time of orthognathic surgery should be
considered. An abnormally large tongue does not
adjust to the decreased oral volume after surgical
correction and plays an important role in relapse.
A normal-sized tongue with forward posturing
does adjust to the smaller volume after surgery,
however. Pretreatment tongue thrust swallowing
disappears after correction of the anterior open
bite because the physiologic necessity for tongue
thrust has been eliminated.
Open bite secondary to short mandibular ramus
with a normal condyle: mandibular surgery
The clinical features of individuals with
anterior open bites as a result of deficiency of
the mandibular ramus height differ from patients
with vertical maxillary excess. Although variable,
the clinical features are as shown in Box 2 (Fig. 7).
In general, avoidance of presurgical bite-closing
mechanics also applies in these cases. A transverse
discrepancy between the upper and lower arch may
exist. The absolute or true transverse discrepancy
can be measured by holding the models in the
desired class I relation. The potential cross bites
should be corrected orthodontically if the discrep-
ancy falls within the range of stable orthodontic
movement. When an absolute cross bite exists
because of a transverse maxillary deficiency that
is not the result of dental tipping, three surgical
options should be considered: (1) surgically assisted
expansion of the maxillary dental arch [30], (2) nar-
rowing of the mandibular arch by an osteotomy
through the symphysis [31,32], and (3) two-jaw sur-
gery with surgical expansion of the maxilla by
means of segmental surgery [33].
Surgery
Individuals who have anterior open bite as
a result of short mandibular rami do not have the
typical facial, skeletal, and occlusal features asso-
ciated with patients with vertical maxillary excess
and open bite. Aesthetic and functional correction
in these cases demands a different surgical
approach, and consideration should be given to
correcting this type of dentofacial deformity by

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332
Box 2. Features of anterior open bite
caused by deficiency in mandibular
ramus height
Aesthetic features
Normal incisor upper lip relations
Normal paranasal configurations and
alar base widths
Sufficient upper lip support and nasal tip
projections
Slightly increased anterior lower facial
height
Convex profile and retrusive chin
Dental characteristics
Class II occlusion is usually present (the
dental relation should be seen in the
context of the horizontal change after
back and downward rotation of the
mandible as a result of the short
mandibular ramus)
Maxillary and mandibular dental arches
exhibit normal occlusal curves
although the occlusal planes deviate
Transverse dimensions of the dental
arches are usually coordinated
Cephalometric features
No posterior vertical maxillary excess
Short mandibular ramus heights, which
may be associated with mandibular
anteroposterior excess or deficiency
Mandible of an individual with class III
occlusal relation appears excessive
with a concave profile; individuals with
class II occlusions exhibit convex
profiles and retrusive chins
means of mandibular surgery. Surgical closure of
an anterior open bite by mandibular surgery in-
volves counterclockwise rotation of the mandible
at the posterior teeth. Historically this surgical
movement of the mandible has been considered to
be unstable [27]. Reports in the literature identify
three main factors that may influence the stability
after orthognathic surgical procedures: (1) stretch-
ing of soft tissue, (2) neuromuscular adaptation,
and (3) alteration of the muscle orientation [27].
These factors are particularly important when clos-
ing an open bite by counterclockwise rotation of
the mandible.
Stretching of soft tissue. If the mandible is rotated
counterclockwise by means of a bilateral sagittal
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REYNEKE & FERRETTI
ramus osteotomy, two muscle groups are
stretched: the suprahyoid muscles and the medial
pterygoid and masseter muscle. The suprahyoid
musculature is lengthened when the symphysis of
the mandible is rotated superiorly and is further
stretched after mandibular advancement and gen-
ioplasty. Although suprahyoid myotomies have
been used successfully in animal studies to de-
crease postsurgical relapse [34], human studies
have not supported these results [35]. Epker advo-
cated clinical evaluation of the patient and careful
examination of the cephalometric prediction to
determine the possible need for suprahyoid myot-
omies [36]. Measurement of the potential length-
ening of the suprahyoid muscles is made from
the surgical treatment prediction tracing. If the
suprahyoid muscles will lengthen more than
30%, a suprahyoid myotomy is indicated [37].
The amount of suprahyoid muscle stretch would
be influenced directly by the amount of mandibu-
lar rotation required to close the open bite. The
authors believe, however, that the role of supra-
hyoid muscle stretch in long-term stability needs
further research.
When the sagittal split ramus osteotomy is
performed (as described by Trauner and Obwe-
geser [38] and modified by Dal Pont [39]) and the
distal segment is rotated counterclockwise, the
posterior mandibular height is increased (Fig. 8).
Downward rotation of the distal segment at the
mandibular angle and lengthening of the ramus
stretches the pterygomandibular sling and soft tis-
sue envelope. Postoperative muscular force leads
to poor proximal segment control and causes skel-
etal relapse [40]. Splitting the mandibular ramus
along the lower border followed by counterclock-
wise rotation also stretches the medial pterygoid
muscle and the stylomandibular ligament on the
medial aspect of the mandibular ramus (Fig. 9).
When the sagittal split of the mandibular
ramus is performed according to the modified
technique suggested by Epker [41], the mandibu-
lar ramus is not lengthened during counterclock-
wise rotation of the distal segment, and the
pterygomandibular sling is not stretched
(Fig. 10) if the mandible is advanced.
Epker rec short vs long split
Neuromuscular adaptation. The postoperative
adaptation of the neuromusculature after most
orthognathic procedures is good. Backward rota-
tion of the ramus (proximal segment) may stretch
the medial pterygoid muscle and stylomandibular
ligament attached at the medial side of the ramus,
however (see Figs. 9 and 10). The muscle and
 ANTERIOR OPEN BITE CORRECTION 333

Fig. 7. This 20-year-old patient had a severe class II anterior open bite as a result of a short mandibular ramus. The
typical soft tissue, skeletal, and dental characteristics of patients who have open bite and short mandibular rami are
exhibited (A–D). The presurgical orthodontic treatment consisted of retraction of the upper and lower incisor teeth, level
and alignment, and coordination of both dental arches (E). A functional occlusion was established by mandibular
advancement, and an aesthetic chin contour was achieved by advancement and slight downgraft of the chin by a genio-
plasty (H). The posttreatment results 3 years after debanding (F–I).

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334 REYNEKE & FERRETTI

Fig. 8. The medial side of the mandible demonstrates the sagittal split osteotomy performed through the lower border of
the body and posterior border of the ramus of the mandible (the so-called ‘‘long split’’) (A). The mandible is advanced by
10 mm and rotated counterclockwise by 3.5 mm at the incisor area, which increases the ramus height by 8 mm (B).

ligament attachment also interfere with posterior
repositioning the distal segment and lead to
backward and downward rotation of the proximal
segment. Stripping the attachments of the medial
pterygoid muscle and stylomandibular ligament
from the medial side of the angle of the mandible
during surgery is recommended. The length of the
temporalis muscle is also influenced by backward
rotation of the ramus, and control of the proximal
segment is important to facilitate neuromuscular
adaptation (Fig. 11).
Muscle orientation. Muscular adaptation is least
possible when muscle orientation is changed. The
changes in the inclination of the mandibular
ramus alter the orientation of the mandibular
elevators. The three masseter muscle bundle
groups and temporalis muscle with their respec-
tive attachments and orientations are demon-
strated in Fig. 11.
There is a paucity of studies in the literature
regarding the long-term postoperative stability
after surgical closure of anterior open bite dento-
facial deformities by surgical counterclockwise
rotation of the mandible. However, skeletal
stability after counterclockwise rotation of the
mandible as part of the rotation of the maxillo-
mandibular complex was studied and reported by

Fig. 9. The medial view of the mandible illustrates the attachments of the medial pterygoid muscle and stylomandibular
ligament and their relation to the medial aspect of the sagittal osteotomy design, which includes the lower and posterior
border [37,38]. Counterclockwise rotation of the distal segment increases the height of the ramus and stretches the muscle
and ligament (A). When the osteotomy is performed according to the Epker [40] modification, the height of the ramus is
not increased and the muscle and ligament are not stretched (B). The arrow indicates the anterior border of the
pterygomandibular sling.

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 ANTERIOR OPEN BITE CORRECTION 335

Fig. 10. The medial side of the mandible illustrates the sagittal osteotomy. The horizontal osteotomy is extended just
posterior to the lingula, whereas the vertical osteotomy is performed through the buccal cortex and extended through
the inferior border to include the medial cortex. This osteotomy design results in the medial osteotomy running
from just posterior to the lingula downward to the lingual side of the vertical osteotomy (the so-called ‘‘short split’’)
(A). The mandible is advanced by 10 mm and rotated counterclockwise by 3.5 mm at the lower incisor tip. Note that
there is no increase in the posterior ramus height (B).

Reyneke [42] and Chemello and colleagues, [43].
With this surgical design, an anterior open bite
is created by surgical counterclockwise rotation
of the maxillary occlusal plane. The counterclock-
wise rotation of the maxilla is followed by the
surgical rotation of the mandible. Long-term
postoperative stability in both studies was found
to be comparable to other mandibular surgical
procedures.
Open bite secondary to a combination of vertical
maxillary excess and short mandibular ramus
Many individuals with anterior open bite may
display a combination of the clinical, dental, and

Fig. 11. The deep muscle group of the masseter tends to have a vertical orientation, whereas the superficial masseter
muscle groups have a more oblique orientation (A). The orientation of the temporalis muscle is more vertical, and
any posterior rotation of the proximal segment changes the orientation and length of the muscle (B).

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 336
cephalometric features of excessive vertical de-
velopment of the maxilla and deficient develop-
ment of the mandibular rami. In these cases the
treatment objectives should be aimed at address-
ing the specific skeletal, soft tissue, and dental
problems as discussed for each of the two
groups.
in patient with b/l ICR
Open bite secondary to short mandibular ramus
with condylar resorption
Any process of resorption of the condyle alters
the morphology of the condyle and its position in
the glenoid fossa. Resorption of the condyles and
consequent shortening of the mandibular rami
lead to the development of a class II anterior open
bite malocclusion. When considering correction of
an anterior open bite caused by resorption of the
condyle, the clinician should differentiate between
idiopathic condylar resorption, degenerative joint
disease, and rheumatic arthritis with destruction
of the condyle.
Idiopathic condylar resorption (condylysis). Al-
though condylysis may occur in any patient
population, it often presents in relatively young
caucasian women with high mandibular and
occlusal plane angles and develops into a class II
anterior open bite malocclusion. The anterior
open bite usually develops progressively with no
pain or hypomobility. The process is usually self-
limiting and may last from 6 months to 2 years. It
is thought that the resorption may be related to
chronic excessive loading of the mandibular
condyle, which produces progressive remodeling
of the condyle. There are two important aspects
when planning the correction of the existing
dentofacial deformity: (1) ensuring that the re-
sorption process is inactive and (2) treating the
deformity in such a way that the loads on the
condyles are not increased. To establish whether
the condition is still active, the patient’s previous
dental records, cephalometric radiographs, and
occlusal models can be compared with current
records. An alternative method, such as a radio-
isotope bone scan of the temporomandibular
joints, may help to detect the presence of any
resorptive activity in the condyle. Treatment
should be delayed until the disease becomes
quiescent.
Surgical correction should focus on the max-
illa, and mandibular advancement should be
avoided if possible. Maxillary setback, which
may compromise the aesthetic outcome, may
have to be considered. If mandibular surgery
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REYNEKE & FERRETTI
cannot be avoided, however, use of rigid fixation
is not recommended but rather a period of 3 to 4
weeks of intermaxillary fixation. Any orthodontic
treatment, such as class III elastics, that increases
the loading of the condyles (and could reinitiate
the condylar resorption process) should be
avoided.
Degenerative joint disease (osteoarthrosis). Osteo-
arthrosis of the temporomandibular joint is not an
acute entity but rather a progressive degenerative
disease that alters the position, morphology, and
physiology of the bony joint structures. It involves
the progressive uncontrollable degeneration of the
mandibular condyle, and unfortunately, the
diagnosis and treatment selection are complicated
by the variability of the rate of progression of
resorption. Patients experience chronic signs of
joint pain, crepitus, and hypomobility with pe-
riods of acute exacerbations. It may be possible to
obtain short-term relief of the symptoms by
conservative partial reconstruction of the joint
and orthognathic surgery; however, in most
patients the natural progression of the degenera-
tive process leads to recurrence of the open bite
and increasing joint symptoms. Total joint re-
placement combined with orthognathic correction
of the dentofacial deformity is often the final
treatment solution.
Treatment planning for combined orthog-
nathic surgery and total joint replacement does
not differ from conventional orthognathic treat-
ment planning. There is, however, a limited
amount of mandibular advancement that can be
obtained by the placement of a joint prosthesis.
To maintain satisfactory contact between the
implant and the mandibular ramus, the advance-
ment should be limited to 7 to 8 mm.
Summary
Development of an anterior open bite is
predominantly the result of an altered growth
pattern that involves excessive vertical growth of
the maxilla, lack of vertical mandibular ramus
development, or both. Successful correction of
anterior open bite dentofacial deformities requires
careful assessment of the specific anatomic
location of the discrepancy and an understanding
of all factors that may influence the stability of
results. The flowchart (Fig. 12) summarizes the
suggested principles of surgical orthodontic treat-
ment of anterior open bite dentofacial deformities.
 ANTERIOR OPEN BITE CORRECTION
Posterior vertical
maxillary excess
Le Fort I Osteotomy
(superior repositioning)
Mandibular closed rotation
Correction of AP
Acceptable
discrepancy with
mandibular AP
maxilla and BSSO
position
(if necessary)
Genioplasty
Fig. 12. The flowchart summarizes the suggested treatment philosophies that focus on anterior open bite correction, in
which surgical correction is aimed at the specific anatomic location of the discrepancy.
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