ORIGINAL ARTICLE

Success rate of anterior open-bite

orthodontic-orthognathic surgical treatment
Ute Jensena and Sabine Rufb
Giessen, Germany
Introduction: The aim was to evaluate the short-term success rate of combined orthodontic-orthognathic
surgical correction of anterior open bite. Methods: Fifteen patients (ages, 15-28 years) with open bite treated
with a combined orthodontic-surgical approach were examined. Lateral cephalograms from before treatment,
after treatment, and after an average of 18 months (range, 10-26 months) of retention were evaluated.
Overbite was classified as normal (2-3.5 mm), borderline (0-1.5 mm), or relapse (\0 mm), and overjet as
normal (2-3.5 mm) or relapse ($4 and #1.5 mm). Results: The average overbite was 3.2 mm before treatment, 1.8 mm after treatment, and 1.3 mm after retention. During active treatment, overbite and overjet
were normalized in 53.3% and 66.7% of the subjects, respectively. After the retention period, 1 patient
(6.7%) showed a negative overbite, whereas a borderline overbite was found in 53.3% of the subjects. Overjet
relapsed in 40% of the subjects. Only 40% of the patients had a completely successful treatment with incisal
contact and normal overjet and overbite. Conclusions: Orthodontic-surgical treatment of anterior open bite
improves the overbite, but an excellent treatment outcome with normal overjet and overbite and proper incisal
contact was achieved in only 40% of the subjects. (Am J Orthod Dentofacial Orthop 2010;138:716-9)

uccessful treatment of skeletal open bite is considered a challenge. Attempts to control maxillary
development and prevent eruption of the posterior
teeth during growth are often counteracted by late
adolescent growth changes, thus resulting in a relatively
high percentage of adult open-bite treatments.1
In adult patients with milder open bites, camouflage
therapy (incisor extrusion and posterior teeth intrusion)
is a possible treatment option.1,2 On the other hand, in
adult patients with severe open bites, combined
orthodontic-orthognathic treatment3 with LeFort I
impaction or bimaxillary surgery4-7 aims at correcting
the jaw inclination and reducing the excessive anterior
facial height to achieve good facial esthetics as well as
a functional occlusion.4,8 However, relapse even after
combined orthodontic-orthognathic treatment does
occur.4,9-16
A functional occlusion that includes among other
characteristics a correct interincisal relationship with
incisal overlap and interincisal contact is a general

Assistant professor, Department of Orthodontics, University of Giessen,

Germany.
b
Professor and head, Department of Orthodontics, University of Giessen,
Giessen, Germany.
The authors report no commercial, proprietary, or financial interest in the
products or companies described in this article.
Reprint requests to: Prof. Dr. Sabine Ruf; e-mail, sabine.ruf@dentist.med.
uni-giessen.de.
Submitted, November 2009; revised and accepted, February 2010.
0889-5406/$36.00
Copyright 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.02.028

716

orthodontic treatment goal. Lack of interincisal contact

despite a positive overbite (OB)a so-called open bite
with OBwas first described by Moyers.17 It was found
to be an indicator for habits and a prognostic factor for
open-bite stability.18
However, most open-bite studies evaluated only OB
as a parameter for success and stability. Only Denison
et al10 differentiated real open bites and open bites with
OB at pretreatment, but whether interincisal contact
could be established and maintained was unfortunately
not described.
Therefore, the aim of this study was to evaluate
the short-term success rate of combined orthodonticorthognathic surgical correction of anterior open bite, giving
special emphasis to interincisal relationship and contact.
MATERIAL AND METHODS

Between 1995 and 2008, a total of 41 open-bite

patients were planned for a combined orthodonticorthognathic surgical approach at the Department of
Orthodontics of the University of Giessen in Germany.
Twenty-six patients were excluded from the study
because of no surgical treatment desired (n 5 22),
syndromes (n 5 2), and incomplete documentation
(n 5 2). The remaining 15 Angle Class I (n 5 1), Class
II (n 5 9), and Class III (n 5 5) open-bite patients
(9 male, 6 female) with a mean pretreatment age of
19.9 6 4.03 years (range, 15-28 years) were examined
retrospectively. All patients had undergone presurgical
and postsurgical orthodontic treatment with fixed appliances. The system used for all patients was a Tip-Edge

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717

Fig 1. A, Cephalometric landmarks and measurements to describe the vertical jaw base relationship
(ML/NSL [ ], NL/NSL [ ], and ML/NL [ ]); the inclination of the incisors (IsL/NL [ ], IiL/ML [ ], and IsL/IiL
[ ]); the occlusal line (OL), the line from the distobuccal cusp of the first maxillary molar to a point that
divides OB in half; and the OL perpendicular (OLp). B, Measurement of OB (mm) and OJ (mm) relative
to the OL or the OLp at T1. The OL/OLp reference grid was transferred from the T1 headfilm to the
subsequent headfilms after superimposition of the radiographs on the nasion-sella line at sella.24

bracket system (TP Orthodontics, LaPorte, Ind) with

a 0.22-in slot. No patient received any myofunctional
therapy either during or after treatment. Lateral cephalograms from before treatment (T1), after orthodonticsurgical treatment (T2), and after retentionie, after
appliance removal(T3) were evaluated. The average
length of the retention period was 18 months (range,
10-26 months). All radiographs were traced and evaluated by the same investigator (U.J.). No correction for
linear enlargement (approximately 8%) was performed.
Standard cephalometric parameters, overjet (OJ)
and OB, were measured (Fig 1). OB was classified as
normal (2-3.5 mm), borderline (0-1.5 mm), or relapse
(\0 mm), and OJ as normal (2-3.5 mm) or relapse
($4 and #1.5 mm). Furthermore, interincisal contact
was evaluated visually.
RESULTS

Average OB values were 3.2 mm at T1, 1.8 mm at

T2, and 1.3 mm at T3. During active treatment (T1-T2),
OB and OJ were normalized in 53.3% and 66.7% of the
subjects, respectively. At T3, 1 patient (6.7%) showed
a negative OB, whereas a borderline OB was found in
53.3% of the subjects (Fig 2). OJ relapsed in 40% of
the subjects.
An interincisal contact was found in 53.3% (at T2)
and 46.6% (at T3) of the patients, respectively.

However, only 40% of the patients had a completely

successful treatment with interincisal contact and normal OJ and OB.
Considering the skeletal parameters, before active
orthodontic treatment, 80% of the subjects had a hyperdivergent (.38 ) vertical jaw base relationship with an
average mandibular plane angle (ML/NSL) of 43.6 .
During the retention period (T2-T3), the ML/NSL
increased in 40% of the subjects. Half of these patients
exhibited a stable OB, 33.3% were borderline, and 1 had
a negative OB (16.7%). The interjawbase angle (ML/
NL) first decreased during active treatment (T1-T2)
from 35.5 to 31.8 , but increased slightly to 32.9
thereafter. The maxillary plane angle (NL/NSL) was
relatively stable, increasing from 8.3 to 11.1 (T1T2) and decreasing to 10.2 (T3).
Patients with a borderline or relapsed OB after retention exhibited more proclined incisors than did those
with a stable OB (Fig 3). Correspondingly, the interincisal angle (IsL/IiL) at T3 was greatest in patients
with a stable OB (140.8 ) and smallest in those with
OB relapse (84 ).
The inclination of the mandibular incisors (IiL/ML)
remained on average unchanged at about 87 during the
entire observation period. The maxillary incisor inclination (IsL/NL) was more or less unchanged during active
treatment (T1-T2) (104.3 and 104 ), but a slight proclination was seen during the retention period (106.2 ).

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American Journal of Orthodontics and Dentofacial Orthopedics

December 2010

Fig 2. Number of patients with positive or negative OB at T1, T2, and T3 according to Remmers
et al.25

Fig 3. Inclination of the incisors (rounded numbers) at T3

in relation to OB stability.
DISCUSSION

It might be argued that our follow-up was too short.

However, since most skeletal and dentoalveolar changes
have been described to occur within the first 6 months
after surgery, the 18-month follow-up period can be
considered acceptable for the evaluation of short-term
stability and success.12
The sample in our study was relatively small. However, compared with most studies in the literature, it
seems acceptable because they also included only small
to average numbers of subjects (10-58 patients).4,9-16,19
In addition, our subjects were a nearly consecutive
sample of nonsyndromic open-bite patients; only 2
patients were excluded because of partially missing
records.
The patients ages at T1 varied between 15 and 28
years. Although it can be assumed that their growth

had terminated (complete fusion of the radial epiphysis), facial growth continues at a slow rate throughout
life, and changes observed over a follow-up period
might represent a continuation of growth rather than
posttreatment relapse.20,21
There are several possible reasons for OB relapse
after surgical-orthodontic treatment. Functional factors
such as imbalanced intrinsic forces (abnormal tongue or
lip position) and extrinsic forces (persistent or newly
adopted habits) play an important role in both the etiology and the recurrence of open bite after treatment.1,22
Furthermore, surgical factors resulting from muscle
adaptation or bone healing problems, improper
positioning of the bony segments, soft-tissue tension
against the mobilized segment, temporomandibular
changes, or other factors can cause open-bite relapse.4
On the other hand, Denison et al10 proposed that posttreatment relapse was due to dentoalveolar changes
only.
An excellent treatment outcome (normal OJ, incisal
overlap, and interincisal contact) was found in only 40%
of the patients. About half of our subjects (53.3%)
exhibited a borderline OB at T3; this cannot be called
a good treatment result. Nevertheless, a true relapse
with negative OB at T3 was found in only 1 subject
(6.7%). In terms of true relapse, these findings contrast
with the results of Swinnen et al19 and Iannetti et al,23
who reported fully stable OBs 1 to 2 years after treatment. However, the results are in line with most studies
in the literature, describing anterior open bite relapse in
2% to 37% of patients.4,9-16

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CONCLUSIONS

Orthodontic-surgical treatment of anterior open-bite

patients improves the OB, but an excellent treatment
outcome with normal OJ, incisal overlap, and interincisal contact was found in only 40% of the patients.
Therefore, the treatment goals for future surgical anterior open-bite patients should be adjusted accordingly.
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