CASE REPORT

Severe anterior open bite with mandibular

retrusion treated with multiloop edgewise
archwires and microimplant anchorage
complemented by genioplasty
Ziqing Xu,a Zheng Hu,b Xudong Wang,c and Gang Shend
Shanghai, China

In this case report, we introduce the combined use of multiloop edgewise archwire and microimplant anchorage
to treat an 18-year-old Chinese woman who had a severe anterior open bite and a retrusive chin. Her diagnosis
included a skeletal Class II base with severe anterior open bite, backward rotated mandible, and mesially tipped
buccal dentition. The treatment plan emphasized vertical control of the posterior dentoalveolar dimension. Micro-
implant anchors were placed in the mandibular buccal segment to provide rigid anchorage and deliver intruding
forces to the posterior teeth; a multiloop edgewise archwire was applied to generate uprighting forces to the
maxillary and mandibular posterior teeth. Intrusion and uprighting of the posterior teeth contributed to the coun-
terclockwise rotation of the mandibular plane, which consequently contributed to the facial profile improvement.
Orthognathic genioplasty was implemented to further improve the chin prominence. After 1.5 years of retention,
ideal intercuspation was evident, and the improved facial contour was stable. (Am J Orthod Dentofacial Orthop
2014;146:655-64)

I
n this case report, we introduce the combined use of posterior teeth. Intrusion and uprighting of the posterior
multiloop edgewise archwire (MEAW) and microim- teeth contributed to the counterclockwise rotation of
plant anchorage (MIA) to treat an 18-year-old Chi- the mandibular plane, which consequently contributed
nese woman with a severe anterior open bite and a to the facial profile improvement. Orthognathic genio-
retrusive chin. The patient had a skeletal Class II base plasty was implemented to further improve the chin
with severe anterior open bite, backward rotated prominence. After 1.5 years of retention, ideal intercus-
mandible, and mesially tipped buccal dentition. The pation was evident, and the improved facial contour was
treatment plan was designed with an emphasis on verti- stable. The mechanism and efficacy of MIA combined
cal control of the posterior dentoalveolar dimension. The with MEAW in treating patients with skeletal Class II
MIA placed in the mandibular buccal segment provided open bite are discussed.
rigid anchorage and delivered intruding forces to the Skeletal Class II malocclusion with severe anterior
posterior teeth; the MEAW was applied to generate up- open bite is one of the most difficult malocclusions to
righting forces to both the maxillary and mandibular treat orthodontically because it is often caused by clock-
wise rotation of the mandible or excessive growth in the
From Shanghai Ninth People's Hospital, Shanghai Jiao Tong University,
Shanghai, China. vertical dimensions in the buccal segments.1-3
a
Postgraduate student, Department of Orthodontics. In Chinese people, a skeletal open bite is often accom-
b
Assistant professor, Department of Orthodontics. panied by a retrusive and undersized chin and a
c
Professor, Department of Oral and Maxillofacial Surgery.
d
Chair, Department of Orthodontics. clockwise-rotated mandible, leading to a facial profile
All authors have completed and submitted the ICMJE Form for Disclosure of Po- with marked convexity and excessive lower facial height.
tential Conflicts of Interest, and none were reported. In adults, the most effective treatment of skeletal open
Address correspondence to: Gang Shen, Shanghai Ninth People's Hospital,
Shanghai Jiao Tong University, 639 Zhi-Zao-ju Rd, Shanghai, China; e-mail, bite is surgical repositioning of the maxilla or both
[email protected]. jaws.1,4,5 However, surgical invasiveness and economic
Submitted, August 2013; revised and accepted, November 2013. cost considerations are greater than for orthodontic
0889-5406/$36.00
Copyright Ó 2014 by the American Association of Orthodontists. treatment alone, which is cause for rejection by many
http://dx.doi.org/10.1016/j.ajodo.2013.11.025 patients and their families.6,7
655
656 Xu et al

Fig 1. Pretreatment facial and intraoral photographs show incompetent lips, retrognathic mandible,
and severe anterior open bite.

The MEAW technique has been found to be effective A convex profile due to a retrognathic mandible was
in treating patients with open-bite malocclusions.2 The noted. A shallow labiomental fold, an increased lower
treatment mechanism is mainly uprighting of the poste- facial height, and circumoral musculature strain on lip
rior teeth and partial extrusion of the anterior teeth, with closure were observed. The patient had an Angle Class
limited effects in posterior intrusion.8 I molar relationship with a severe anterior open bite up
Recently, the use of MIA for anterior open-bite to 7 mm and moderate crowding in both the maxillary
correction by intruding the buccal segment has been re- and mandibular dentitions (Figs 1 and 2).
ported.1,3,7,9-12 Intrusion of the molars enables The lateral cephalometric analysis showed a skeletal
counterclockwise rotation of the mandible, thus Class II jaw relationship with mandibular retrusion
correcting the open bite and improving the facial (ANB, 8.5 ) and a severe high mandibular plane angle
profile of patients with skeletal Class II open bite. In (FMA, 38.5 ). Both the maxillary and mandibular inci-
this case report, we introduce the combined use of sors were proclined labially (Fig 3, A; Table).
MEAW and MIA, aiming to correct a severe skeletal No symptoms of temporomandibular disorder were
open bite by simultaneous uprighting and intruding of detected.
the buccal segment. This patient was diagnosed with an Angle Class I
malocclusion with a skeletal Class II base, a high
DIAGNOSIS AND ETIOLOGY mandibular plane angle, and a severe anterior open bite.
The patient was an 18-year-old woman with chief
complaints of frontal open bite and chin retrusion. She TREATMENT OBJECTIVES
admitted to a habit of tongue thrusting and could not The treatment objectives were to (1) correct the
achieve lip closure at rest. tongue habits through musculature enforcement; (2)

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Xu et al 657

Fig 2. Pretreatment dental casts; note the mesially tilted buccal teeth and constricted dental arch.

Fig 3. Pretreatment cephalograph, tracing, and panoramic radiograph.

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658 Xu et al

Table. Skeletal and dental changes indicated by the

cephalometric measurements
Norm
Pretreatment Posttreatment
Measurement Mean SD (18 y 2 mo) (20 y 0 mo) Difference
Angular ( )
SNA 82.8 4.0 78.3 77.7 0.6
SNB 80.1 3.9 69.9 70.5 0.6
ANB 2.7 2.0 8.4 7.2 1.2
OP/SN 16.1 5.0 30.9 29.2 1.7
U1/SN 105.7 6.3 105.9 91.4 14.5
U1/MxP 118.0 6.0 121.7 108.4 13.3
IMPA 96.5 6.4 102.2 90.1 10.1
FMA 27.3 7.1 38.5 35.8 2.7
Linear (mm)
Me-MxP 64.0 4.0 66.5 65.2 1.3
N-Mxp 54.0 3.5 47.9 48.3 0.4
U6-MxP 28.0 2.1 26.9 25.8 1.1
L6-MnP 32.0 2.0 34.6 33.2 1.4

align and level the dental arch; (3) normalize the overjet
and overbite relationships, closing the dental open bite;
(4) upright the maxillary and mandibular posterior teeth,
accomplishing normal and stable interdigitation; (5) Fig 4. Computerized predictive image used to help the
intrude the mandibular posterior teeth and reduce the parents to better understand the potential esthetic
mandibular plane angle; and (6) improve the facial pro- improvement through genioplasty surgery (blue lines,
surgical cuts).
file.

TREATMENT ALTERNATIVES
When the 0.016 3 0.022-in nickel-titanium archwire
Three treatment choices were considered for this was placed in the mandibular arch, MIAs (diameter,
patient. The first was orthodontics with orthognathic 1.6 mm; length, 10 mm; Cibei Medical Treatment Appli-
surgery, with a LeFort I osteotomy for maxillary impac- ance, Ningbo, China) were inserted into the mandibular
tion and a bilateral sagittal split ramus osteotomy alveolar bone on both sides under local anesthesia. The
for mandibular autorotation. The second choice was a mandibular molars at both sides were intruded by elastic
pure fixed-appliance approach, aiming to achieve a chains from the MIA to the archwire with forces of
compromised result without skeletal correction. The approximately 80 g per side (Fig 5, B).
third option was fixed-appliance therapy complemented The MEAW was bent with a 0.017 3 0.025-in stain-
by localized surgery in the chin. The first option was not less steel archwire for the mandibular arch first. Class III
adopted because of the patient's skeptical attitude to- elastics (1/4 in, 4.5 oz) were worn full time (Fig 5, C).
ward the extensive surgery, nor was the second option Two months later, the MEAW was engaged in the maxil-
because of its limited improvement in facial esthetics. lary arch, and box elastics (1/4 in, 4.5 oz) were worn full
With the third option, the genioplasty surgery was fully time (Fig 5, D).
explained to the parents, and the predictive computer- After an optimal interdigitation in the buccal
generated tracings and photographs of the genioplasty segment was achieved, 0.016 3 0.022-in stainless steel
helped the parents to realize the esthetic changes of preformed archwires were placed in both arches. Class I
this localized surgery (Fig 4). elastics (5/16 in, 4.5 oz) were worn full time for space
closure and incisor retraction (Fig 5, E). The overall
TREATMENT PROGRESS active treatment time was 17 months. At the end of
The patient consented to the final treatment plan, and active treatment, the MIAs were removed. After debond-
it was approved by the ethics committee of Shanghai ing, full records were taken for treatment assessment,
Ninth People's Hospital, Shanghai, China. Under local and Hawley retainers were suggested for full-time
anesthesia, all first premolars and mandibular third mo- wear (Figs 6-8).
lars were extracted. Straight-wire appliances were bonded One week after debonding, the genioplasty surgery
on both arches for initial alignment and leveling (Fig 5, A). was performed under general anesthesia (Figs 9 and 10).

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Xu et al 659

Fig 5. Detailed treatment progression: A, fixed appliances engaged with initial archwires; B, intrusive
effects to the mandibular molars by the MIA; C, the MEAW placed in the mandibular dental arch to up-
right the tilted posterior teeth; D, the MEAWs placed in both arches; E, space closure and interdigitation
detailing.

TREATMENT RESULTS decreased by 1.2 , Me-MxP decreased by 1.2 mm, L6-

The assessment of the treatment outcome showed MnP decreased by 1.4 mm, and U1/MxP and L1/MnP
counterclockwise rotation of the mandible (Fig 11, A), decreased by 13.3 and 12.1 , respectively (Fig 8, A;
uprighting of the maxillary and mandibular molars, Table).
intrusion of the mandibular molars, and retraction of After the genioplasty, there were also dramatic
the maxillary and mandibular incisors (Fig 11, B and changes in the facial profile and the occlusion. The defi-
C). These changes were further evidenced by the cepha- cient chin was corrected, and the lower facial height was
lometric analysis, indicating that the FMA decreased by reduced, resulting in a straight facial profile (Fig 9). Ideal
2.7 , the SNB angle increased by 0.6 , the ANB angle overjet and overbite of the anterior teeth were created,

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Fig 6. Posttreatment facial and intraoral photographs show improved facial profile, ideal intercuspa-
tion, and normalized overjet and overbite.

Fig 7. Posttreatment dental casts show corrected open bite and widened dental arch.

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Xu et al 661

Fig 8. Posttreatment cephalograph, tracing, and panoramic radiograph.

Fig 9. Facial photographs 1 month after genioplasty showing further improved facial profile.

and an Angle Class I molar relationship was achieved (Fig DISCUSSION

6). The chin was moved forward by approximately 6 mm Skeletal Class II malocclusion with an open bite is
by the genioplasty. The panoramic radiographs after identified as excessive vertical dimensions of the poste-
treatment showed no obvious apical root resorption, rior segments; divergent maxillary and mandibular
and root parallelism was acceptable (Fig 10). occlusal planes; high gonial angle and mandibular plane
At the follow-up at 1 year 7 months, the patient had angle; clockwise rotation of the mandibular ramus; and
stable intercuspation and a harmonious facial balance increased total and lower anterior facial height.13 Our
(Fig 12).

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Fig 10. Cephalograph and posteroanterior radiograph after genioplasty.

Fig 11. Cephalometric superimpositions show marked differences between pretreatment (black) and
posttreatment (red): A, the SN plane; B, the maxillary plane; C, the mandibular plane.

patient demonstrated a hyperdivergent skeletal defor- extrusion provides a noninvasive solution to correct an
mity with a severe anterior open bite that indicated sur- open bite.1,9 However, camouflage incisor extrusion
gical intervention in both jaws. However, because it was can cause excessive incisal exposure. Furthermore, lack
evident that dental malpositioning at both the labial and of stability of extruded incisors and intruded molars
buccal segments contributed partially to the formation of orthodontically is a widely recognized cause of relapse.14
the open bite, an orthodontic approach, if well designed Based on the information mentioned above, the
and carefully implemented, might be a pragmatic alter- treatment plan was carefully designed with 3 options.
native to surgical correction. Molar intrusion or incisor The first option was to correct the skeletal discrepancies

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Xu et al 663

Fig 12. Follow-up at 1 year 7 months showing stable occlusion and dental arch width.

via 2-jaw surgical operations: LeFort I osteotomy with

impaction in the maxilla and bilateral sagittal split ramus
osteotomy with possible genioplasty in the mandible.
The second option aimed to correct the open-bite
malocclusion with specially designed fixed appliances:
MEAW with MIA. The third option was to achieve correc-
tion of the open-bite malocclusion by fixed appliances
and to improve the facial profile by limited surgical
intervention with genioplasty. We fully explained to
the patient and her parents the advantages and disad-
vantages of all alternatives with computerized predictive
illustrations. After they considered comprehensively
both the nature of the malocclusion and their socioeco-
nomic status, the third option was taken as the final
treatment modality; the predictive simulation further
Fig 13. Diagrammatic illustration explaining the working
convinced the patient and her parents that this was mechanism of the combined MEAW and MIA. The acti-
the best option (Fig 4). vated loops deliver the uprighting force to the molars
MEAW therapy has been proved to be effective for the (bold red arrows), whereas the MIA loading produces
treatment of open-bite malocclusions. Kim et al,2 when intruding force (thin red arrow). The intermaxillary elastics
evaluating the treatment stability of MEAW, found no sig- are worn to prevent proclination of the front teeth (bold
nificant relapse at the long-term follow-ups. Whereas the black arrows).
MEAW mechanism is useful in retraction and extrusion of
anterior teeth and uprighting of posterior teeth, there is
no consensus in the literature on its efficacy for intruding Recently, molar intrusion using skeletal anchorage
posterior teeth. Furthermore, MEAW therapy requires has been reported to be an effective and stable method
high professional skills and great dependence on patient for open-bite treatment.1,3,7,9-12 In an attempt to reduce
compliance for treatment success.15 Although the adop- the vertical dimension efficiently, MIAs were inserted in
tion of the MEAW mechanism for this patient resulted the buccal segments to serve as skeletal anchorage for
in significant uprighting of the buccal-segment dentition molar intrusion (Fig 5, B). They had a complementary
(Figs 5, C-E, and 11, B and C), it did not contribute sub- effect to the molar uprighting resulting from the
stantially to vertical dimension control, which was critical MEAW. The novel combination of MEAW and MIA for
not only for correction of the open bite, but also, more this patient is clearly depicted in Figure 13, where the
importantly, for improvement of facial esthetics. posterior teeth were uprighted due to the activated

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664 Xu et al

multiple loops of the MEAW, and they were also favorable rotation of the mandible, and ideal restora-
intruded simultaneously as the result of MIA loading. tions of overjet and overbite. Genioplasty surgery can
To minimize the adverse effects of MEAW on the frontal be implemented as a complementary approach to mark-
teeth, intermaxillary elastics should be used to prevent edly improve the facial esthetics of patients with a severe
them from proclining (Fig 13). Furthermore, with the undersized and retrusive chin.
combined use of MEAW and MIA, a favorable counter-
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