International Orthodontics 2022; 20: 100597

Websites:
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www.sciencedirect.com

Original Article
Evaluation of the acceleration, skeletal
and dentoalveolar effects of low-level
laser therapy combined with fixed posterior
bite blocks in children with skeletal anterior
open bite: A three-arm randomised
controlled trial§

Amjad Ali Hasan 1, Nada Rajeh 1, Mohammad Y. Hajeer 1, Omar Hamadah 2, Mowaffak A. Ajaj 1

Available online: 6 December 2021 1. University of Damascus Dental School, Department of Orthodontics, Damascus,
Syria
2. University Damascus Dental School, Department of Oral Medicine, Damascus,
Syria

Correspondence:
Mohammad Y. Hajeer, University of Damascus Dental School, Department of
Orthodontics, Damascus, Syria.
myhajeer@gmail.com

Keywords Summary
Anterior open bite
Early treatment Objectives > To evaluate the effectiveness of the low-level laser therapy (LLLT) in accelerating the
Low-level laser therapy early treatment of the skeletal anterior open bite (AOB) and to evaluate the associated skeletal
Fixed posterior bite block and dentoalveolar changes.
Materials and methods > A three-arm, parallel-group, randomized controlled trial was conducted
on 42 patients aged 8–10 years with skeletal AOB. Patients were randomly allocated to three
groups: the fixed posterior bite block + low-level laser therapy (FPBB + LLLT) group; the fixed
posterior bite block (FPBB) group; and the untreated control group (UCG) in a 1:1:1 allocation ratio.
The LLLT dose in the FPBB + LLLT group was applied using 808-nm wavelength Ga-Al-As semicon-
ductor laser device with the energy of 4-joules/point and irradiation time of 16 seconds/point.
LLLT was applied in the first visit; then, it was applied on day 3, 7 and 14 of the first month.
Afterwards, it was applied every 15 days until the end of the treatment. Lateral cephalometric
images were taken at the beginning of the treatment (T0) and at the end of the active phase (T1).
The primary outcome measures were the overall time needed to correct the AOB and the skeletal
and dentoalveolar changes.
Results > The correction of the AOB required significantly less mean time in the FPBB + LLLT group
compared to the FPBB group (x̄ = 7.07, x̄ = 9.42 months, respectively; P = 0.001). The mean upper

§
Registration: anzctr.org.au (Trial ID: ACTRN12619001740189); prospectively registered on 1/1/2020; URL: https://www.anzctr.org.au/trial/MyTrial.aspx.

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https://doi.org/10.1016/j.ortho.2021.10.005
© 2021 CEO. Published by Elsevier Masson SAS. All rights reserved.
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 A.A. Hasan, N. Rajeh, M.Y. Hajeer, O. Hamadah, M.A. Ajaj

Original Article
first molar intrusion in the FPBB + LLLT group was 1.21 mm and significantly greater than that of
the FPBB group (0.82 mm; P = 0.018). However, there was a slight mean extrusion of the upper
first molar in the UCG (0.32 mm).
Conclusions > The overall time needed to correct the AOB was shorter in the FPBB + LLLT group. The
LLLT appeared to be effective in accelerating orthodontic tooth movement. FPBB alone or LLLT were
effective in the early treatment of anterior open bite (AOB). The two interventional groups
produced similar dentoalveolar and skeletal changes; most of which were dentoalveolar in the
correction of the anterior open bite.

O rthodontists find the anterior open bite (AOB) a major

problem that creates a great challenge in orthodontic treatment
because of many factors, most important of which are facial
esthetics and the incidence of relapse [1]. Early treatment of the
skeletal AOB is beneficial in controlling the vertical dimension
and avoiding a more complicated treatment plan in the future
[2], as well as enhancing the child's self-confidence through
improved facial aesthetics and chewing [3].
The long orthodontic treatment time is one of the biggest
obstacles that make patients refrain from undergoing it [4]; it
leads to an increase in the risk of root resorption, gingival
infections, and dental caries [5]. In recent years, low-level laser
therapy (LLLT) has been shown to be effective in biomodulation
[6], which leads to acceleration of orthodontic tooth movement
(OTM) and pain relief [7].
Some of these studies have demonstrated that the LLLT has an
inducing effect on tissues, which increases the speed of OTM
[6,8–12]. In this context, Rajeh stated in her research work on
adult patients with skeletal AOB (unpublished Ph.D. thesis) that
using LLLT was effective in accelerating the intrusion of upper
posterior teeth in patients aged 16 to 28 years [13]. However,
other studies have indicated that laser application is not effec-
tive in accelerating OTM [14,15].
Reviewing the available literature indicates that no clinical trials
have been conducted to evaluate the effect of LLLT in accelerat-
ing the intrusion of upper posterior teeth in the early treatment
of skeletal AOB. Furthermore, several recent systematic reviews
have highlighted the need for high-quality randomized con-
trolled trials in this field [16–19].
The present study aimed to evaluate the effectiveness of the
LLLT in accelerating the upper posterior teeth intrusion using a
Glossary
AOB Anterior open bite
LLLT Low-level laser therapy
OTM Orthodontic tooth movement
FPBB Fixed posterior bite block
PBB Posterior bite block
fixed posterior bite block (FPBB) during the early treatment of
AOB and to quantify the related skeletal and dentoalveolar
changes. The related two null-hypotheses were: (1) there
was no effect of the low-level laser therapy in accelerating
the early treatment of skeletal anterior open bite; and (2) there
was no effect of applying the fixed posterior bite blocks alone or
in conjunction with LLLT on the skeletal and dentoalveolar
structures.
Materials and methods
Study design and setting
This trial was reported according to the CONSORT statement
guidelines. This study was a three-arm, parallel-group, random-
ized controlled trial. In order to assess the skeletal and dentoal-
veolar changes following the use of fixed posterior bite planes
without being affected by growth-related changes, a control
group of untreated subjects was necessary. Ethical approval was
obtained from the Local Ethical Committee of the Faculty of
Dentistry, Damascus University (UDDS-385-03072018/SRC-
2317). Informed consent was signed from parents or guardians
of participants before trial initiation. This RCT was registered in
the Australian New Zealand Clinical Trials Registry (ANZCTR)
(Trial ID: ACTRN12619001740189).
Sample size calculation
The sample size was calculated using the G*Power 3.1.9.2
software (University of Kiel, Germany). The level of significance
was set at 0.05, and the statistical power of the study was set at
90%. The intended test was the one-way ANOVA. The mean and
standard deviation of the treatment time [13] and overbite [20]
(taken from two previous similar studies) were used. Therefore,
the sample size calculation was performed twice, and the larger
estimated number of patients was adopted to avoid underpow-
ered statistical results. Sample size calculations revealed the
need for 13 and 12 patients in each group for the "treatment
time'' and "overbite'' variables, respectively. Therefore, the first
calculation was adopted. In order to compensate for any possi-
ble dropout, one patient was added to each group (i.e., 14) with
a total required sample size of 42 patients.

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International Orthodontics 2022; 20: 100597
Settings, participants and eligibility criteria
The study was conducted at the Department of Orthodontics and
Dentofacial Orthopedics and the Laser Research Unit of Dam-
ascus University between January 2020 and June 2021.
Ninety-six patients with AOB were examined. Thirty-seven
patients were excluded from treatment because they did not
meet the inclusion criteria. Consequently, 59 patients were
deemed suitable for inclusion. The objectives and methods of
the study were explained to each candidate patient and his/her
parent/guardian using an information sheet. Informed consent
forms were signed by parents/guardians. However, three
patients refused to participate; therefore, 42 out of 56 patients
who agreed were randomly selected, as shown in the CONSORT
flow diagram (figure 1).
The following clinical inclusion criteria were used by the princi-
pal investigator (A.A.H): patients between 8–10 years of age,
with fully erupted upper and lower permanent incisors, class I or
class II skeletal, a 1 mm (minimum) AOB, with no previous
orthodontic treatment and good oral health. In addition, they
Figure 1
CONSORT flow diagram of patients' recruitment and follow-up
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Original Article
were excluded if they had unilateral or bilateral crossbite,
craniofacial syndromes, systemic diseases or previous facial
traumas. The same principal investigator (A.A.H) screened eli-
gible participants using lateral cephalometric images. Radio-
graphically, eligible AOB patients had to conform to the
following additional criteria: (SN/GoMe) the angle between
the anterior cranial base (SN) and mandibular plan (GoMe)
was greater than 348, the MM-angle was greater than 308,
and Björk sum was greater than 408. Forty-two patients met
the inclusion criteria and were enrolled in this study.
Randomization and allocation concealment
The study sample was randomly allocated into three groups as
follows: fixed posterior bite block with low-level laser therapy
(FPBB + LLLT) group, fixed posterior bite block (FPBB) group, and
control group of untreated subjects. An orthodontic specialist not
involved in this research project used simple randomization. A
randomization list was created using Minitab® (Version 17;
Minitab, LLC, State College, Pa) with an allocation ratio of
A.A. Hasan, N. Rajeh, M.Y. Hajeer, O. Hamadah, M.A. Ajaj
1:1:1. The allocation sequence was concealed using opaque
numbered and sealed envelopes. To prevent subversion of
the allocation sequence, the name and the date of birth of each
participant were written on the envelope, and these data were
transferred onto the allocation card inside each envelope. Cor-
responding envelopes were only opened after completing all
baseline assessments.
Fixed Posterior Bite Block (FPBB) group
FPBB used in this study was a modification of the posterior bite
block (PBB) presented by Turkkahraman and Cetin [20]. This
device consisted of the following parts (figure 2): the trans-
palatal arch that connected the two acrylic blocks, as it extended
through the palate between the primary second and the per-
manent first molars from the right side to the left side. This arch
was 4 mm away from the palatine mucosa, so that it was
adapted on two layers of wax to avoid being embedded in
the palatine mucosa during the posterior teeth intrusion.
Acrylic posterior bite-block covered the occlusal surfaces of the
primary upper first and second molars and the permanent first
upper molar. The thickness of the bite block was 2 mm greater
Figure 2
Laser application points on the upper posterior teeth from the
(A) buccal view and (B) palatal view
4
Original Article
than the freeway space, according to Meibodi et al. [21]. Also,
the device had a tongue crib which was manufactured from a
stainless-steel round wire with a diameter of 0.9 mm. In the
present study, the wire was adapted to the cast, and vertical
loops were made. After that, FPBB was evaluated intraorally to
ensure that simultaneous contact with opposing teeth was
achieved bilaterally. Then, cementation was performed using
Glass Ionomer Cement (Vivaglass® CEM PL, Ivoclar Vivadent).
Written instructions for maintaining oral health were given for
each patient.
Patients were recalled for a follow-up every month to monitor
patient's compliance, adjust the tongue crib, measure the
amount of overbite and observe the change in incisor
relationship.
The active treatment period was ended when a positive overbite
of 1–2 mm was achieved. Then, a lateral cephalometric image
was taken at the end of this active treatment (T1). The retentive
period was based on using a removable posterior bite block in
conjunction with a tongue crib for ten months following the
active period.
Fixed posterior bite block + low-level laser therapy
(FPBB + LLLT) group
In this group, the same procedures for manufacturing, testing
and cementing the FPBB were followed as the previous group.
After the application of the FPBB, the gallium aluminum arse-
nide (Ga-Al-As) laser with a continuous wavelength of 808 nm
was applied on the first day and on days 3, 7, and 14 of the first
month, then every 15 days until the end of the treatment [10].
The laser was applied in contact with the mucosa of the buccal
(3 points) and palatal (3 points) sides of the permanent upper
first molar and the first and second upper primary molars root
tips on each side, as shown in figure 2. The location of the LLLT on
the primary upper molars was determined according to the
location of the root tips of these molars on the panorama.
Rajeh's protocol was modified to suit the protocol of laser
application as applied in the mixed dentition in this study [13].
The irradiation parameters of the LLL were standardized through
the whole treatment period and were set as follows: the power
of 250 MW, the energy at 4 J, and the application time was
16 seconds per point. Patients were followed up in the same
manner as what was performed in the FPBB group. The criteria
for finishing the active phase of treatment and the retention
protocols were similar to those in the FPBB group.
The untreated control group (UCG)
Patients in the control group did not receive any intervention
and were monitored for nine months. Then, the lateral cepha-
lometric image was taken. For ethical reasons, patients in this
group were provided orthodontic treatment after the end of the
observational period.
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International Orthodontics 2022; 20: 100597

Original Article
Primary outcome measures: treatment time and
cephalometric variables
The primary outcome measures were the overall time needed to
correct AOB and the skeletal and dentoalveolar changes.
All cephalometric radiographs were taken with the same imag-
ing apparatus, PaX-i3D (VATEH Corporation, Ltd., Hwaseong,
Korea), with the same settings. Focus-mid-sagittal-plane dis-
tance was fixed at 150 cm, and film-mid-sagittal-plane distance
was fixed at 15 cm. Lateral cephalometric images were taken
for each patient at the beginning of the treatment (T0) and at
the end of the active phase of treatment (T1), and 18 variables
were evaluated for each patient using Viewbox® (version
4.0.0.98; dHAL Software, Kifissia, Greece). Nine angular and
nine linear measurements employed in the current work were

TABLE I
Definitions of the angular and linear measurements.

1 SNA8 Angle between the anterior cranial base

(SN) and A point

2 SNB8 Angle between SN plane and B point

3 ANB8 Angle between NA and NB lines

4 SN/MP8 Angle between SN plane and mandibular

plane (GoMe)

5 PP-MP (MM)8 Angle between the palatal plane (PP) and

mandibular plane

6 Björk Sum8 Sum of N-S-Ar, S-Ar-Go, and Ar-Go-Me

7 Y-axis8 Angle between Nasion, Sella, and Gnathion

8 S-Go mm Distance between S and Go (posterior facial

height)

9 N-Me mm Distance between N and Me (anterior facial

height)

10 S-Go/N-Me Ratio of posterior facial height to anterior

facial height

11 U1-PP mm Upper anterior dentoalveolar height

12 U6-PP mm Upper posterior dentoalveolar height

13 L1-MP mm Lower anterior dentoalveolar height

14 L6-MP mm Lower posterior dentoalveolar height

15 U1/SN8 Angle between the long axis of the upper

incisor and SN plane Figure 3
16 L1/MP8 Angle between the long axis of the lower Cephalometric measurements
incisor and MP plane A: angular: 1, SNA; 2, SNB; 3, ANB; 4, SN.GoMe; 5, MM; 6, Y axis; 7, Björk Sum (N.S.Ar
+ S.Ar.Go + Ar.Go.Me); 8, U1.SN; 9, L1.GoM
17 Overbite mm Vertical overlap between the upper and B: linear: 1, S-Go; 2, N-Me; 3, U1-SPP; 4, U6-SPP; 5, L1-GoMe; 6, L6-GoMe; 7, Overbite;
lower incisors 8, Overjet

18 Overjet mm Horizontal overlap between the upper and

lower incisors

These definitions are based on Jacobson [22] and Riolo et al. [23].

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Original Article
defined according to Jacobson [22] and Riolo et al. [23]. Their Results
definitions are given in table I and are illustrated in figure 3. Participant flow and follow-up
Measurements were exported as Excel files (Office Excel 2007; Forty-two patients were enrolled (16 males, 26 females; mean
Microsoft Corporation, Redmond, Washington, USA) and then age 8.95  0.51 years, table II), 14 patients in each group, and
analyzed statistically. no patients were lost to follow-up as given in figure 1.

Method error
Twenty lateral cephalometric were randomly selected at T1 and
retraced by (A.A.H) with a two-month interval between assess-
ment times. The intra-examiner reliability (random error) was
determined using the intraclass correlation coefficients (ICCs),
whereas paired-sample t-tests were used to detect any possible
systematic error [24].
Statistical analysis
Statistical analyses were performed using SPSS program (ver-
sion 22.00; IBM Corporation, Chicago, IL, USA) and the level of
significance was set at (0.05).
The Shapiro–Wilk test was used to verify the normality of the
data. Chi2 test was used to detect any intergroup differences in
sex distribution, whereas one-way ANOVA was used to evaluate
any intergroup differences in age and observation period. This
was followed by Bonferroni's post hoc tests for pairwise com-
parisons. Paired-sample t tests was used to detect significant
differences over time in each group (i.e., intragroup changes) for
the 18 cephalometric variables. Bonferroni's correction was used
to adjust for the number of variables assessed and the number
of comparisons made (i.e., the adjusted alpha level was
a/18  3  0.001). For the intergroup comparisons of the ceph-
alometric variables, one-way ANOVA was employed. This was
followed by Bonferroni's post hoc tests for pairwise compari-
sons. Again, the alpha level was adjusted for the 18 variables
being tested (a/18  0.003).
Method error
It was found that ICC ranged from 0.970 to 0.999, which meant
that one tracing was sufficient to determine the values of each
of the variables measured. Paired-sample t-tests showed that
there were no significant differences between the two assess-
ment times (P > 0.05). Therefore, systematic errors were small
and insignificant.
Treatment time and cephalometric variables
A statistical significance was found in treatment time between
the two treatment groups. The FPBB + LLLT group required less
mean time (7.07  1.54 months) to correct the AOB compared
to the FPBB group (9.42  2.31 months; P = 0.001), which
meant a 25% decrease in the overall active treatment time
(table II).
The increase in the SNB in both experimental groups was signi-
ficantly greater than that of the control group (P < 0.003). The
decrease in the SN/MP angle and the MM angle in both experi-
mental groups was significantly greater than that of the control
group (P < 0.001). The overbite increased significantly in both
experimental (interventional) groups when compared with the
control group (P < 0.001), without any significant difference
between them (P = 1.000). The two interventional groups
showed significantly more upper and lower incisors retraction
than the control group (P < 0.05).
The results showed that the mean upper first molar intrusion in
the FPBB + LLLT and FPBB groups was 1.21 mm and 0.82 mm,
respectively. Whereas there was a slight mean extrusion of the
upper first molar in the control group (0.32 mm). There was a

TABLE II
Basic sample characteristics with regard to age, gender and observation period for each group.

Group FPBB + LLLT FPBB Control P-value FPBB + LLLT FPBB + LLLT FPBB
vs. FPBBc vs. controlc vs. controlc

Age: years (mean  SD) 8.97  0.58 9.02  0.51 8.87  0.44 0.741a NS NS NS
b
Sex distribution: male/female 5/9 6/8 5/9 0.123 NS NS NS
a
Observation period: months (mean  SD) 7.07  1.54 9.42  2.31 9 0.001** 0.001** 0.009** 1.000

FPBB + LLLT: fixed posterior bite block with low-level laser therapy; FPBB: fixed posterior bite block; SD: standard deviation; *: P < 0.05; **: P < 0.01, ***: P < 0.001; NS, non-
significant.
a
Employing one-way ANOVA test.
b
Employing Chi2 test.
c
Bonferroni's post hoc tests for pairwise comparisons.

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TABLE III
Descriptive statistics of the angular and linear cephalometric measurements in each group as well as the P-values of significance testinga

Variable FPBB + LLLT (n = 14) FPBB (n = 14) Control (n = 14)

T0 T1 P-value T0 T1 P-value T0 T1 P-value

Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

SNA8 79.68 2.35 79.04 2.37 < 0.001* 79.14 3.09 78.67 2.85 0.002 78.39 3.04 78.46 3.08 0.165

SNB8 73.18 2.43 74.43 2.53 < 0.001* 73.64 2.20 74.46 2.23 < 0.001* 72.64 2.84 72.89 2.85 0.013

ANB8 6.50 1.70 4.61 1.62 < 0.001* 5.50 1.99 4.21 1.77 < 0.001* 5.75 2.51 5.57 2.30 0.055

SN/MP8 44.75 2.79 43.14 2.82 < 0.001* 44.29 4.81 43.39 4.79 < 0.001* 45.50 3.39 45.64 3.45 0.165

MM8 35.93 3.22 33.82 3.41 < 0.001* 35.18 4.60 33.82 4.68 < 0.001* 36.93 3.88 37.04 3.87 0.189

Bjork Sum8 405.04 2.91 402.82 3.04 < 0.001* 406.50 4.83 404.61 4.49 < 0.001* 405.43 3.82 405.54 3.60 0.512

Y-axis8 74.86 2.21 73.32 2.09 < 0.001* 74.43 2.56 73.64 2.58 < 0.001* 75.21 2.39 75.32 2.43 0.487

S-Go mm 59.04 2.80 60.93 2.71 < 0.001* 60.00 1.59 61.39 1.51 < 0.001* 58.68 1.87 58.86 1.85 0.055

N-Me mm 101.50 4.15 100.96 4.13 0.008 103.21 4.35 102.86 4.09 0.136 101.25 3.71 101.75 3.67 0.029

S-Go/N-Me 58.18 2.22 60.38 2.49 < 0.001* 58.18 2.74 59.80 2.91 < 0.001* 58.01 2.45 57.90 2.43 0.082

U1-PP mm 27.39 1.99 28.14 1.96 < 0.001* 27.21 1.66 27.93 1.74 < 0.001* 26.93 1.33 27.04 1.34 0.189

U6-PP mm 19.50 0.94 18.29 1.10 < 0.001* 19.25 1.34 18.43 1.14 < 0.001* 19.36 0.93 19.68 0.95 0.007

L1-MP mm 36.18 2.06 36.64 2.14 < 0.001* 35.96 2.06 36.54 2.10 < 0.001* 35.71 2.26 35.79 2.26 0.165

L6-MP mm 26.75 1.85 26.79 1.79 0.752 26.25 1.40 26.39 1.33 0.040 26.36 1.60 26.46 1.61 0.082

U1:SN8 107.36 3.15 104.50 3.08 < 0.001* 108.00 4.08 104.11 4.55 < 0.001* 104.68 5.56 104.68 5.59 1.000

L1:PM8 97.93 4.87 93.64 4.48 < 0.001* 95.25 5.34 91.21 5.91 < 0.001* 94.79 5.48 95.29 5.40 0.265

Overbite mm 3.36 1.17 1.18 0.42 < 0.001* 3.07 1.16 1.25 0.33 < 0.001* 3.68 1.85 3.54 2.02 0.302

Overjet mm 5.07 1.89 3.75 1.48 < 0.001* 3.86 2.13 2.61 1.58 < 0.001* 4.43 1.64 4.32 1.64 0.189

FPBB + LLLT: fixed posterior bite block with low-level laser therapy; FPBB: fixed posterior bite block. Bonferroni's correction was applied due to multiplicity with and adjusted a level
of 0.001; *: statistically significant at P < 0.001.
a
Employing paired-sample t-test; SD: standard deviation.

significant difference in the upper molar height between the
three groups (P < 0.001). Pairwise comparisons showed that
there was a significant difference in the intrusion of the upper
first molar between the two interventional groups (P = 0.018).
In addition, there was a significant difference in the upper molar
height between the interventional groups and the control group
(P < 0.001). Pairwise comparisons showed that there was a
significant difference in the upper molar height between the
interventional groups and the control group (P < 0.001). On the
other hand, there was no significant difference in the lower
posterior dentoalveolar height between groups (P > 0.05)
(tables III and IV).

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TABLE IV
Descriptive statistics of the angular and linear cephalometric measurements between the three groups as well as the P-values of
significance testing.

Variables FPBB + LLLT FPBB Control

(n = 14) (n = 14) (n = 14)
T1-T0 T1-T0 T1-T0 P-valuea FPBB + LLLT FPBB + LLLT FPBB
vs. FPBBb vs. Controlb vs. Controlb

Mean SD Mean SD Mean SD

SNA8 0.64 0.46 0.46 0.45 0.07 0.18 < 0.001* 0.692 < 0.001* 0.002*

SNB8 1.25 0.51 0.82 0.42 0.25 0.33 < 0.001* 0.033 < 0.001* 0.003*

ANB8 1.89 0.68 1.28 0.57 0.18 0.32 < 0.001* 0.017 < 0.001* < 0.001*

SN/MP8 1.61 0.96 0.89 0.45 0.14 0.36 < 0.001* 0.018 < 0.001* < 0.001*

MM8 2.11 0.92 1.36 0.53 0.11 0.29 < 0.001* 0.011 < 0.001* < 0.001*

Bjork Sum8 2.21 0.97 1.89 0.79 0.11 0.59 < 0.001* 0.885 < 0.001* < 0.001*

Y-axis8 1.54 1.25 0.79 0.54 0.11 0.56 < 0.001* 0.074 < 0.001* 0.025

S-Go mm 1.89 1.24 1.39 0.84 0.18 0.32 < 0.001* 0.428 < 0.001* 0.002*

N-Me mm 0.54 0.63 0.36 0.84 0.50 0.76 0.002* 1.000 0.002* 0.013

S-Go/N-Me mm 2.20 1.29 1.63 0.95 0.11 0.22 < 0.001* 0.339 < 0.001* < 0.001*

U1-PP mm 0.75 0.33 0.71 0.38 0.11 0.29 < 0.001* 1.000 < 0.001* < 0.001*

U6-PP mm 1.21 0.32 0.82 0.37 0.32 0.37 < 0.001* 0.018 < 0.001* < 0.001*

L1-MP mm 0.46 0.31 0.57 0.33 0.07 0.18 < 0.001* 0.960 0.002* < 0.001*

L6-MP mm 0.04 0.41 0.14 0.23 0.11 0.21 0.635 1.000 1.000 1.000

U1:SN8 2.86 2.32 3.89 2.60 0.00 1.04 < 0.001* 0.598 0.003* < 0.001*

L1:GoMe8 4.29 3.34 4.04 1.99 0.50 1.61 < 0.001* 1.000 < 0.001* < 0.001*

Overbite mm 4.54 1.06 4.32 1.05 0.14 0.50 < 0.001* 1.000 < 0.001* < 0.001*

Overjet mm 1.32 0.61 1.25 0.80 0.11 0.29 < 0.001* 1.000 < 0.001* < 0.001*

FPBB + LLLT: fixed posterior bite block with low-level laser therapy; FPBB: fixed posterior bite block; SD: standard deviation. Bonferroni's correction was applied due to multiplicity
with and adjusted a level of 0.003; * statistically significant at P < 0.003.
a
Employing one-way ANOVA test.
b
Employing Bonferroni's post hoc tests for pairwise comparisons.

Harms dependence on the patient's cooperation [25]. Thus, in this trial,

No serious harms were observed in the current trial.
Discussion
To the best of our knowledge, this is the first randomized
controlled trial to evaluate the effectiveness of LLLT in acceler-
ating the upper posterior teeth intrusion in the early treatment
of AOB. This is in contrast to other studies which dealt with the
canines' distalization and cases of leveling and alignment by
using LLLT to accelerate OTM [9–12].
Many orthodontic devices have been proposed for molar intru-
sion and vertical growth restriction in AOB patients, yet one of
the biggest problems in the therapeutic mechanism is their
an FPBB device was used without the need for patient cooper-
ation. In addition, the thickness of the bite block was deter-
mined to be more than 2 mm from the freeway space to
stimulate the masticatory muscles producing intrusion forces
on the posterior teeth. It was reported in the study of Kuster and
Ingervall that the application of PBB can increase the effective-
ness of the temporalis muscle and the masseter muscle during
the treatment of the AOB [26]. The control group was included in
the study to identify the changes caused by growth without
being affected by the intervention used.
In general, the long period of orthodontic treatment is one of the
main factors that make the patient refuse to undergo treatment

tome 20 > n81 > March 2022

8
International Orthodontics 2022; 20: 100597
[27]. So, the acceleration of orthodontic movement is consid-
ered desirable to motivate those patients [12]. Systematic
reviews have indicated that there is a lack of evidence regarding
the efficacy of LLLT in accelerating OTM and recommended the
need for further randomized controlled studies in different
orthodontic tooth movement strategies [18,28,29].
In this study, the average time of AOB treatment in the FPBB
group was similar to that of other studies which applied PBB in
the mixed dentition and reported a treatment time of about 9-
10 months [21,30]. Moreover, Turkkahraman and Cetin [20]
reported that the AOB was corrected within 12 months. This
can be due to the fact that the use of the PBB with high-pull
headgear may lead to a prolonged treatment period to correct
AOB due to the patient's difficulty in accepting this device.
The results of this study showed that the intrusion using the
FPBB in combination with an LLLT was faster than using the FPBB
alone. This is in line with the findings of other studies, which
have revealed that the LLLT has accelerated OTM in the treat-
ment of canines distalization or leveling and alignment proce-
dures [9–12]. Conversely, other studies have found that LLLT
application has not been effective in accelerating OTM during
upper canine retraction [14,15]. This can be attributed to the
variability in the radiation parameters among these studies and
the small sample sizes in studies that reported no statistically
significant differences.
As for the skeletal changes, there was a statistically significant
increase in the mean value of the SNB angle in the FPBB + LLLT
group (x̄ = 1.258) and the FPBB group (x̄ = 0.828) compared to
the control group (x̄ = 0.258). The increase of the SNB angle's
mean value in the two interventional groups could be explained
by the anterior rotation of the mandible, which was induced
during the posterior teeth intrusion. The slight increase in SNB
angle in the control group could be due to the spontaneous
sagittal growth of the mandible. This was in agreement with
most of the previous randomized studies, such as the Iscan and
Sarisoy trial [30] and Albogha et al. study [31], where there was
a statistically significant increase in the SNB angle (x̄ = 0.858,
x̄ = 0.98, respectively).
The FPBB + LLLT group induced a slight decrease in the SN/GoMe
angle and in the sum of Bjork by a mean of 1.618 and 2.28,
respectively. This was slightly larger than what Mousa et al. [32]
reported (SN/GoMe; x̄ = 0.988, sum of Bjork; x̄ = 0.948) in the
RPBB/C group. Also, the FPBB group induced a slight decrease in
the SN/GoMe angle and in the sum of Bjork by a mean of 0.898
and 1.88, respectively. This confirms the slight skeletal effect of
the FPBB in the vertical dimension. On the other hand, there was
a slight increase in the control group (SN/GoMe; x̄ = 0.148, the
sum of Bjork; x̄ = 0.118).
The findings showed that the greatest increase in the overbite
was observed in the FPBB + LLLT group (x̄ = 4.54 mm), then in
the FPBB group x̄ = 4.32 mm), while a modest correction of the
AOB was noticed in the control group x̄ = 0.14 mm). The AOB
tome 20 > n81 > March 2022
9
Original Article
was successfully corrected in both interventional groups which
can be mainly attributed to the palatal tip of the upper incisors,
lingual tip of the lower incisors, extrusion of the upper and lower
incisors and upper posterior teeth intrusion. This correction
was slightly affected by the mandibular autorotation. As for
the control group, the slight increase in the overbite was due
to the slight extrusion of the upper and lower incisors.
The observed increase in overbite in the experimental groups is
in line with the study of Çinsar et al. (x̄ = 4.5 mm) and the study
of Mousa et al. (x̄ = 4.91 mm), where the AOB was treated in
these two studies using a rapid molar intruder device and an
open bite Bionator (OBB), respectively [25,32].
On the other hand, the amount of overbite increase in some of
the previous studies was less than the one obtained in the
current trial. Iscan and Sarisoy reported a mean overbite correc-
tion of 2.73 mm, whereas Turkkahraman and Cetin reported a
mean value of 3.79 mm [20,30]. However, the findings of the
present study indicated that the amount of vertical skeletal
discrepancy was greater than that of the previous studies.
In Rajeh's research work, it was found that there was a signifi-
cant intrusion of the upper first molar (x̄ = 1.2 mm) when apply-
ing the PBB for adult patients in conjunction with LLLT; a result
which was similar to the one found in the FPBB + LLLT group in
the current trial [13]. On the other hand, intrusion of upper
molars was not statistically significant in the study of Meibodi
et al. (x̄ = 0.5 mm), and the study of Albogha et al. (x̄ = 0.4 mm)
[21,31]. However, the LLLT used in the present study seemed to
increase the effectiveness of FPBB in the intrusion of the upper
posterior teeth.
The upper incisors extruded significantly in the FPBB + LLLT
group (x̄ = 0.75 mm) and the FPBB group (x̄ = 0.71 mm) as
compared to the control group (x̄ = 0.11 mm). There was also
a statistically significant extrusion of the lower incisors in
each of the FPBB + LLLT (x̄ = 0.46 mm) and the FPBB groups
(x̄ = 0.57 mm) as compared to the slight increase in the control
group (x̄ = 0.07 mm).
The reason for this statistically significant extrusion in the upper
and lower anterior teeth is due to the presence of a tongue crib
that prevented the placement of the tongue between the
anterior teeth. This was also noticed in the studies of Mousa
et al. [32] and Rossato et al. [33], where a removable tongue
crib with PBB and a fixed tongue crib were used, respectively.
Most of the changes in these studies were dentoalveolar resul-
ting from the extrusion of the upper and lower incisors.
It was also noted that there was a statistically significant
decrease in the amount of the overjet in the FPBB + LLLT group
(x̄ = 1.32 mm) and the FPBB group (x̄ = 1.25 mm) compared to
the slight decrease in the control group (x̄ = 0.11 mm). This
decrease can be attributed to the counter-clockwise rotation
of the mandible and the palatal tipping of the upper incisors,
which was consistent with the findings of Turkkahraman and
Cetin and Albogha et al. study [20,31].
A.A. Hasan, N. Rajeh, M.Y. Hajeer, O. Hamadah, M.A. Ajaj

A statistically significant upper incisors retraction occurred in
both the FPBB + LLLT group (x̄ = 2.868) and the FPBB group
(x̄ = 3.898) compared to the control group in which there was
no significant change in the incline of the upper incisors. Also, a
statistically significant retraction of the lower incisors occurred
in both the FPBB + LLLT group (x̄ = 4.298) and the FPBB group
(x̄ = 4.048) compared to the slight buccal tipping of the lower
incisors in the control group (x̄ = 0.508). This can be explained by
Original Article
Conclusions
Low-level laser therapy seems to be an effective method for
accelerating the early treatment of the skeletal anterior open
bite. The two interventional groups produced similar dentoal-
veolar and skeletal changes? most of which were dentoalveolar
in the correction of the anterior open bite.
Acknowledgments: Not applicable.

the fact that the use of the PBB increases the height of the Ethics approval and consent to participate: ethical approval was obtained
anterior face, which causes a retraction of the upper and lower from the Local Ethics Research Committee at the University of Damascus
incisors due to the increase in pressure arising from the lower lip Dental School (reference number: UDDS-385-03072018/SRC-2317).

when the patient tries to close his mouth [30], besides the
presence of the tongue crib.
Limitations
The short evaluation period is one of the limitations of the study.
A longer follow-up period is highly required to identify relapse
changes following the AOB correction. In addition, the levels of
patients' pain, discomfort and functional impairments associ-
ated with use of FPBB were not evaluated in the present study.
Therefore, future research work should take into consideration
patient-centered outcome measures.
Generalizability
The generalizability of the current findings of this trial is limited
because of the strict inclusion criteria (i.e., interventional groups
with a specific type of malocclusion in a specific age range), the
use of only one appliance design (i.e., the fixed posterior bite
block), and the dependence on only one teaching Hospital (i.e.,
a mono-center study).
Consent for publication: not applicable.
Availability of data and materials: the datasets used and/or analyzed
during the current study are available from the corresponding author on
reasonable request.
Funding: University of Damascus Postgraduate Research Budget (Ref No.
92132735390DEN).
Author Contributions: AAH conducted data collection, performed statistical
analysis, interpreted the results and wrote the manuscript. NR, supervised
this research project, helped in study design and writing-up the first drafts
of this manuscript. MYH helped with the research concept and design and
critically revised the article. OH was a co-supervisor of laser-assisted
intervention, and helped in the interpretation of the data analysis. MAA
contributed to the study design, helped in data collection, revised the first
drafts of this manuscript. All of the authors provided feedback on the
revisions of the manuscript. All authors read and approved the final
manuscript.
Disclosure of interest: the authors declare that they have no competing
interest.

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