A functional

approach
of skeletal open bite
Rolf Frllnkel
Zwichau,

and Christine

German

Democratic

to treatment

Frlnkel
Republic

In general
orthopedics
the relationship
between
postural
behavior
and skeletal
deformities
has long been
recognized.
The primary
therapeutic
problem
in functional
orthopedics
is to overcome
functional
disorders.
In this
article the applicability
of this functional
concept
to orofacial
orthopedics
is discussed
on the basis of a
longitudinal
study of skeletal
open bite. A comparison
of a series of lateral cephalograms
of thirty patients
with
skeletal
open bite who were treated with functional
regulators
developed
by Frankel
and those of eleven
untreated
open bite cases suggests
that some dentofacial
deformities
in the skeletal
open bite cases can be
corrected
to the average
norms.
In addition,
as a result of overcoming
the poor postural
pattern
of the orofacial
musculature
and re-establishment
of a competent
lip seal, a considerable
change
in the soft-tissue
profile
occurred.

Key words:

Skeletal open bite, Frankel method, dentofacial orthopedics, abnormal posture

keletal open bite is produced by a combination of dental and skeletal irregularities, the latter of
which is the more dominant. The facial morphology of
this dysplasia is characterized primarily by striking
vertical disproportions caused by abnormal ratios between anterior and posterior facial heights (AFH/PFH)
and between upper and lower anterior facial heights
(UFH/LFH). A short ramus and an increased gonial
angle also contribute to the hyperdivergent skeletal pattern. As there is normal biologic variation, so each
dentofacial malformation has its own characteristics
and uniqueness. Therefore, the type of skeletal open
bite must be defined by various additional parameters.
The skeletal pattern of such a severe dysplasia as
skeletal open bite is difficult to change by means of
conventional orthodontic appliances. Some clinicians
have warned against any orthodontic treatment and,
instead, recommend corrective measures such as surgical and prosthetic intervention. It is not surprising,
therefore, that the hyperdivergent pattern of this dysplasia is assumed to be primarily the expression of inherited vertical proportions. This view is substantiated
by the results of Hunters investigations which support
the hypothesis that vertical dimensions of the craniofacial skeleton are more genetically controlled than are
anteroposterior dimensions. However, as claimed by
Dullemeijer, all structures are genetically and environmentally influenced. In view of the character of
This study is part of an investigation entltled Functional Aspects of Skeletal
Open Bite submitted by Christine Frlnkel in fulfillment of the requirements
for the doctoral degree at the University of Jena, German Democratic Republic.

54

biology, it is impossible to study form without also

studying function, and vice versa. There is a specific
order to the influences of each structure. As the skeletal
unit is the last unit to exert its influence, its shape is
completely subordinate to the other elements or to the
functional matrices in Moss terminology. Poultonj
holds that the recurrence of some anterior open bite
problems is the result of muscle imbalance creating a
dentofacial problem. The teeth and jaws may be
brought into a position of excellent anatomic function,
but if the muscles which work together to close the jaws
remain weak and flaccid, the open bite may reappear.
Corrective therapy in these situations must include
work to build up the strength and function of the weak
muscles if long-term stability is to be achieved.
The purpose of this article is to test the hypothesis
that a functional approach will provide a better understanding of how local environmental factors contribute
to the development of the hyperdivergent pattern in the
facial skeleton. On the basis of our clinical experience,
we will attempt to show that the principles of general
orthopedics can be successfully applied to the treatment
of skeletal open bite. We believe that this type of treatment allows a more optimistic attitude to be taken toward the long-term stability of skeletal open bite cases
treated by dentofacial orthopedics than by other treatment methods.
DEVELOPMENT
OF A FUNCTIONAL
STRATEGY
FOR TREATMENT
OF SKELETAL
OPEN BITE

It was Edward Angle,4 the founder of modem orthodontics. who emphasized the morphogenetic relevance

approach

to treatment of skeletal open bite

55

Volume 84
Number I

Functional

of the soft-tissue environment to the dentition. Angles

belief that relapse is caused by forces on the teeth resulting from an improper soft-tissue environment appeared to be a rational conclusion from a biomechanical
point of view. After World War II, interest in the role
of the soft tissues in the etiology of malocclusion increased enormously. With regard to the development of
an open bite, particular emphasis was placed on abnormal patterns of tongue behavior. Deviant patterns of
swallowing or tongue thrust were considered to be a
major factor in opening the bite. Clinically, the advocates of myofunctional therapy recommended various kinds of exercises to overcome the abnormal behavior pattern of the tongue in combination with speech
therapy.-
An alternative therapeutic approach to the treatment
of open bite at that time was the use of a palatal crib
attached to either fixed or removable appliances. In
the 1950s we used such tongue-habit
appliances,
and they were quite successful in a high percentage of
cases in which an anterior open bite had persisted to the
age of 6 or 7 years. However, some patients exhibited
relapse after treatment. We thought that the duration of
treatment with tongue-habit
appliances might have
been too short to re-educate tongue behavior in these
cases. However, relapse occurred even after renewed
treatment with a palatal crib appliance.
In an attempt to find a plausible reason for the relapse in these patients, we examined them and found
that they all showed a marked discrepancy between lip
length and lower face height. This finding corresponded to Ballards suggestion that, in an evaluation
of habit behaviors and their clinical relevance, more
attention should be paid to the size and shape of the soft
tissues. He stated that each case must be judged in
relation to disproportions in the facial skeleton and,
from his clinical observations, concluded that tongue
thrust as the major cause of open bite had been overemphasized. He argued that the faulty interdental posture
of the tongue appeared to be a compensatory or adaptive behavior which established an anterior oral seal
when the lips were incapable of doing so.
It was during this same period that we were working on the development of a functional orthopedic approach using skeletal vestibular shields.- In contrast
to a structural concept, we believed that lip incompetence was not a consequence of a discrepancy between
skeletal and soft-tissue growth. Therefore, we hypothesized that the deficiency of an oral seal might be due,
at least in part, to a poor postural behavior of the facial
musculature (particularly in the lip area), even in cases
of skeletal discrepancies associated with a steep mandibular plane. Thus, we decided to institute functional
therapy with vestibular shields and lip-seal training for

anterior open-bite relapse patients. After a relatively

short treatment time, we observed that a normal overbite was established and remained stable, provided that
a competent anterior oral seal was also established.
The clinical experience gained in the treatment of
open-bite relapse patients was fundamental to the
further development of functional orofacial orthopedics. The clinical observation that an open bite can be
closed without using any device which interferes with
tongue movement or tongue posture suggests that
tongue thrust alone may not be the primary cause of
that malocclusion and that there may be a functional
relationship between the postural behavior of the
tongue and lips. The impact of postural behavior patterns has been substantiated by the more recent work of
Proffit which deals with the orofacial muscular environment and its influence on the morphology of the
dentition. Proffit suggests that rapid-movement functions, such as swallowing, chewing, and speaking,
have little impact on the morphology of the dentition,
while the impact of postural alterations leading to
changes in lip and tongue resting pressure and posture
is significant.
Since the late 1800s general orthopedists have
learned a great deal about the form/function relationship in skeletal morphogenesis. In the last 50 years an
evolution has occurred in the development of a functional concept. Clinical evidence accumulated during
this long period supports the idea that, as far as functional factors are concerned, aberrant postural behavior
does play a primary role in the etiology of skeletal
deformities. Biostatistical studies suggest that a poor
postural performance affecting related muscles plays a
part in the development of skeletal malformations. la In
general orthopedics, therefore, functional therapy is
commonplace, and the primary therapeutic problem in
functional orthopedics is to overcome a faulty postural
performance pattern. Thus, it seems logical to examine
whether aberrant postural behavior of the orofacial
muscles plays a causative role in the development of
dentofacial deformities. Therefore, in developing a
functional approach to orofacial orthopedics, the orthodontist should look not only to his own training as a
specialist of dentistry but to the field of general orthopedics as well. For example, in contrast to the trunk
and limbs, the twenty-two bones of the skull are almost
exclusively of membranous origin. The intermediate
connective tissues have an adaptive and compensatory
growth capacity which is highly susceptible to biomechanical influences and hence to functional forces.
Therefore, there is reason to believe that treatment designed to overcome a poor postural performance would
be effective in the orofacial complex.
There are certainly difficulties in developing a

I. Average changes between the initial and final cephalometric measurements in the nontreated group
N (n = 11) and the treated group T (n = 30) and a comparison of the differences by analysis of variance
and by the paired t test and Fisher-Behrens test

Table

7 ,ziLgfor------Angles
1.
2.
3.
4.
5.

(degrees)

SN-MP
SN-PP
PP-MP
Go
z

6. AFH-PFH
quotient (Jarabak)
7. Ratio UFH-LFH
(Nahoum)
Significance:
**p < 0.01 (t value 2.70).
***p < 0.001 (t value 3.56).
Fisher-Behrens
test f = 11.2633.

t 0.05:

+ 2.32
-0.36
+ 2.68
+0.23
+2.68

-5.47
+2.30
-1.42
-6.37
-5.12

-0.32
-0.018

+5.40
+0.053

D$erences
1.19
2.66
10.10
6.60
8.40
5.72
0.071

F value

I per&

Signijicuncx~

2.92
2.09
1.54
1.35
3.70

3.54
5.24
3.95
5.54
7-.- 4

**
***
***
***
**

2.72
I .09

6.96
4.67

***
***

11 = 2.20.

functional approach to orofacial orthopedics because

the orofacial region is a multifunctional area of considerable complexity. The postural performance of the
orofacial musculature cannot be separated from the
functional demands of the respiratory and digestive systems and the patency of the related functional spaces.
The orofacial musculature serves to maintain the vital
positional relationships that ensure a functionally adequate volume of the oral, nasal, and pharyngeal spaces.
The postural mechanisms of the head and neck play an
integral part in maintaining the mandible in an adequate
anteroposterior position and stabilizing the tongue and
posterior pharyngeal wall relationships, all of which are
necessary for the maintenance of an adequate airway.
Bosma states that airway maintenance is an extremely
important factor governing the postural behavior of the
orofacial musculature. Harvold17 has shown that there
are nonphysiologic conditions in the oronasopharyngeal spaces which contribute to the development of
craniofacial deformities. He observed dramatic changes
in mandibular morphology of rhesus monkeys in which
pieces of plastic were placed in the palatal vault, displacing the tongue inferiorly. This experimental finding
suggests that diminution of lingual volume which leads
to alteration in tongue posture may also change the
postural position of the mandible as well. It appears
reasonable, therefore, to assume that there is a functional relationship between space conditions in the oral
cavity and the postural position of the tongue and
mandible.
A similar relationship between the tongue and
mandibular posture is seen in another experiment in
which rhesus monkeys were forced to breathe through
the mouth. It is noteworthy that changes in mandibular
morphology could be observed only in those animals

that, in order to breathe, turned the tongue into a tube,

forcing the mandible to maintain a lower postural position. The lips remain open at varying intervals, suggesting that an alteration in the postural behavior of the lip
musculature also occurred. The evidence that in these
experiments a normal occlusion often could be transformed into a severe open bite, accompanied by the
deviant mandibular morphology seen in skeletal openbite cases, emphasizes the impact of postural performance pattern on dentofacial morphology.
It appears reasonable to assume that if alterations in
the postural activity of the orofacial musculature can
lead to skeletal open bite, as well as to other types of
malocclusion (as was shown in Harvolds experiment),
the correction of faulty postural activity of the orofacial
musculature might help correct the associated skeletal
deformity. It was, therefore, a fundamental consideration in developing our therapeutic strategy to aim at
overcoming the deviant pattern of mandibular rotation
through re-establishment of nose breathing by correcting the lips-apart condition and faulty tongue posture.
This working hypothesis was also based on an interesting clinical observation. When a child with lips apart as
a usual posture is asked to close his or her lips, a
marked activity of the temporalis and masseter muscles
can be regularly palpated. In cases of severe skeletal
open bite, the large interlabial distance cannot be overcome by the force of the orbicularis oris muscle alone.
The lips can be sealed only by a concomitant activity of
the elevator and mentalis muscles pushing the lower lip
upward. From this it can be derived that the muscles
responsible for creating a lip seal are functionally related to the elevator muscles. The design and development of the functional strategy discussed here are based
on the assumption that concomitant lip-seal exercises

Functional

Volume 84
Number 1

II. Measurements of the initial

cephalograms of the untreated case A and the
treated cases B and C

Table

Angles

{degrees)

SN-MP
SN-PP
PP-MP
Go
B (Jarabak)
Quotient

(Jarabak)

to treatment

AF

Case A

Case B

Case C

45.0
4.0
41.0
129.0
405.0

43.5
6.0
37.5
134.5
403.0

44.5
4.0
40.5
132.5
404.0

56.5%

56.0%

56.0%

AND METHODS

Lateral cephalometric radiographs were taken of

thirty children with severe skeletal open bite before and
after treatment, the last one being taken at least 4 years
out of retention. Radiographs were also taken of a control sample of eleven untreated open bite cases. Selection of subjects was based on the presence of a hyperdivergent skeletal pattern and clinical observation of
a large interlabial distance and postural weakness of the
orofacial muscles. The subjects were followed for an
average age range of 7 to 15 years for the treated group
and 8 to 16 years for the untreated control sample.
Thus, the skeletal development in the craniofacial
complex could be observed in approximately analogous
growth periods, that is, from the first stage of the mixed
dentition through the pubertal growth spurt.
A Tu-RD, 300-2 radiographic unit was used to take
the radiographs. Its powerful rotating anode permitted a
constant focus to a distance of 3.75 meters. The fixed
distance between the ear rod of the head holder near the
cassette and the film was 2 cm. Because of the large
focal distance, enlargement error was negligible and
double contours of corresponding bilateral skeletal

i:;:;I;I
II1I
11

of skeletal

can affect not only the perioral musculature but the

elevator musculature as well. If a competent lip seal is
attained, the correction of an opening rotational pattern
of the mandible as an adaptation of form to altered
function might be expected.
The aim of this presentation is to examine whether
this theoretical concept can be materialized by the institution of functional therapy. During the past 25 years
a considerable quantity of serial cephalometric, photographic, and dental cast data has been collected on
children treated in our clinic with functional orthopedics (as developed by Frinkels-13). This permitted a
longitudinal study of the form/function relationship
present in the development of skeletal open bite by
looking at the changes that took place in the craniofacial complex of these children.
MATERIAL

approach

AFH

open

bite

57

/ PFH

!i
II !i
IIII
**
IIII
!I!I
II II
II li
iI
I
I
Ii
I
i
I
I l
I I

GO

I
I i
J.

--abe

----Case
.-.--case

B
c

Me

56%

Jarabak

56%

56.5 %

- Quotient

Fig. 1. The polygons formed by the landmarks S (sella), N

(nasion), Me (menton), Go (gonion), and Ar (articulare) as used
in the method of Jarabak representing the initial hyperdivergent
patterns of untreated Case A and treated Cases B and C. On
the right side, the ratios posterior face height (P) to anterior face
height (A) and the resultant quotient (Jarabak) are shown.

structures were not shown except in cases in which

there was asymmetrical development. The lack of
double contours contributed considerably to an exact
definition of the landmarks used for determining the
reference lines, an important factor in the reliability of
longitudinal comparative studies.
The series consisted of an average of eight cephalograms each for those in the treated sample and five
cephalograms each for those in the untreated group. All
measurements were made directly on the cephalograms
and were done three times by a trained assistant. Each
series of cephalograms was analyzed by the method of
Frinkel , Is with the occipital coordinate system as a
cephalometric reference. The reliability of the vertical
and horizontal axes oriented to the first registration of
the natural head posture has been described elsewhere. ls This method permits the measurements of the
serial cephalograms to be checked because the positional changes of the various landmarks in extent and
direction can be followed from one radiograph to another. Thus, we can examine whether the displacement
of the various landmarks during the intervals between
radiographs were within the limits of probability. Considering the fact that in the treated sample an average of
eight radiographs were taken for each patient, any inaccuracies in defining the landmarks and their positional
changes can be assumed to be minimized. The final
measurements of this study were made after the last
cephalogram was available, which allowed for another
check of landmark location.
In this article the use of the Frankel analysisls for a

58

Friinkel

and Friinkel

AFH

/ PFH

II
II
I l
II

Ii
ii
i

53. ! . 63%
63.5%
Jarsbak
- Quotient
Fig. 2. The polygons
and the ratios
AFH/PFH
of untreated
Case A and treated
cases
B and C exhibit
a marked
developmental
difference
in skeletal
pattern.
The quotient
(Jarabak)
expressing
the ratio AFH/PFH
worsened
in Case A in the observation
period of 6 years 6 months,
while it was in a normal
range (norm = 62 percent)
in the final cephalograms
of Case B
8 years
2 months
out of retention
and of Case C 4 years
1
month out of retention,
demonstrating
stability
of the treatment
results.

statistical evaluation of the differences in the skeletal

development between the treated and untreated groups
was confined to the angles formed by sella nasion (SN),
palatal plane (PP), mandibular plane (MP), and the
vertical axis of the occipital coordinate system (OS). In
order to avoid errors in quantifying the deviations in
skeletal pattern and the changes that occurred during
treatment and observation, some parameters used in the
cephalometric analyses of NahoumzO, 21 and Jarabak2
also were applied: the sella-nasion and palatal plane
angle (SN-PP), the sella-nasion and mandibular plane
angle (SN-MP), the palatal and mandibular plane angle
(PP-MP), the gonial angle, the upper facial height/
lower facial height ratio, the total of the angles between
sella-nasion, sella-articulare-gonion (S-Ar-Go), and
gonion-menton (Go-Me), and the quotient determining
the anterior to posterior facial height ratio. Each mean
angular dimension and ratio listed above for the treated
and untreated groups was compared by analysis of variance and by t tests. For statistical analysis of the differences between the variables of the total of the facial
angles of Jarabak,22 the Fischer-Behrens test was
applied (Table I).
RESULTS

Table I presents some parameters used in the

cephalometric analysis of the longitudinal comparative

Fig. 3. The
observation

polygons
(see solid

of untreated
lines in Figs.

Case A before
1 and 2).

and

after

study mentioned above. The cephalometric data of the

nontreated group (IV) indicate that the angles SN-PP,
PP-MP, gonial angle, and the total of the angles between sella-nasion, sella-articulare-gonion (S-Ar-Go),
and gonion-menton increased during observation, while
the angle SN-PP decreased slightly. In the treated
group (T), there was a considerable decrease of the
angles SN-MP, PP-MP, gonial angle, and the total of
the facial angles (2) as used in the Jarabak analysis.
The abnormal ratios between upper and lower anterior
facial height (UFH/LFH) and between anterior and
posterior facial height (AFH/PFH) as characteristic features of hyperdivergency worsened in the nontreated
sample (N) but changed to average norms in the treated
group (T). The analysis of variance and t tests showed
that there was a highly significant difference between
the mean changes of the parameters measured in the
nontreated (N) and treated groups. Therefore, it is assumed that the correction of hyperdivergency in the
treated group (T) as evidenced by the changes of the
parameters tabulated in Table I, 1 to 6, may be attributed to the method of functional orthopedics applied.
For a better understanding of the findings of this
study, the measurements made in three cases will be
used to illustrate the cephalometric appraisal of the degree of hyperdivergency present in skeletal open bite.
In each of these three cases a Class II relationship between the maxillary and mandibular arches was present
initially. In untreated Case A the distocclusion in the
molar relationship was 3 mm., in treated Cases B and C

volume 84
Number 1

Functional

approach

to treatment of skeletal open bite

UFH I LFH

UFH I LFH

-\

.i

Fig. 4. The initial and final polygons

of Case 6. During treatment and retention
a considerable
elongation
of the PFH and
ramus
relative
to AFH and LFH occurred.
The length of UFH
was nearly equal to that of LFH measured
in the final cephalogram. There is evidence
that the skeletal
pattern
changed
to a
horizontal
type.

it was 3 mm. and 5.5 mm., respectively. No teeth

were removed in any of these cases during the observation, treatment, or retention periods. It is not the purpose of this article to give a detailed description of the
course of treatment with functional regulators and lipseal training. Rather, this article reports the findings
of a comparison of those skeletal open bite patients
treated with functional therapy and untreated patients
monitored for a similar period of time.
In the evaluation of the initial skeletal pattern of
each case, it should be noted that the first radiograph of
the untreated child was taken at the age of 8 years 11
months, while those of the two treated cases were taken
at the age of 6 years 5 months. This difference in age
may explain why the dimension of the polygon of the
untreated case (Fig. 1, solid lines) is relatively larger
than that of the two treated children. Notwithstanding
this age difference, the almost identical hyperdivergency in skeletal pattern of the three cases is obvious.
The SN-MP angles are nearly equal in size, which can
also be seen in Table II. The relatively low angle
formed between the mandibular plane and the palatal
plane in treated Case B is compensated for by the size
of the gonial angle, which is 5.5 degrees larger than
that of untreated Case A. The likeness in skeletal pattern is also evident from the abnormal ratios between
upper and lower anterior facial height (UFH/LFH) and
between anterior and posterior facial height (AFH/

59

Fig. 5. The initial and final polygons

of treated
Case C. In addition to the angular
changes
and the normalization
of the ratio
UFH/LFH,
the upward
cant of Spp relative
to MP changed,
showing
skeletal
alterations
in the anterior
part of the middle
face.

Table III. Measurements of the final

cephalograms of the untreated Case A and the
treated Cases B and C
Angles (degrees)
SN-MP
SN-PP
PP-MP
GO

Z (Jarabak)
Quotient

(Jarabak)

Case
A

Case
B

Case
c

52.0
3.5
48.5
130.5
412.5

36.0
8.0
28.0
130.0
395.5

38.0
8.0
30.0
121.0
398.0

53.5%

63.5%

63.5%

The average time interval between the first and last radiographs
measured was 8 years 0 months in the nontreated group N and 7 years 11
months in the treated sample T.
B indicates the total sum of the angles between S-N, S-Ar, Ar-Go,
and Go-Me.

PFH), the latter of which is the most characteristic feature of hyperdivergency.

The difference in skeletal development between
untreated Case A and treated Cases B and C is clearly
recognizable (Figs. 1 to 5, Table III). The most important change in the skeletal pattern of the treated cases is
the considerable elongation of the posterior facial
height (S-Go) relative to the anterior facial height
(N-Me). The anterior to posterior facial height ratio
expressed in Jarabaks quotient changed to an average
norm of 63.5 percent in treated Cases B and C, while in
untreated Case A it became worse, changing from 56

60

Friinkrl

and

Friinkel

OS

O!
mm---

.--m--SN

.--e.-------PP
\

1
PP

----w-w-

+4
(W-+95)

MP

\
\

Fig. 6. Angular changes of SN, PP, and MP formed with the

vertical axis (OS) of the occipital coordinate system representing the true vertical determined by a photographic registration of
natural head posture in untreated Case A.

percent to 53 percent. There was also a difference in the

ratio of upper facial height to lower facial height. In the
treated cases the distance between nasion and the palatal plane after treatment was approximately equal to
the distance between Me and the palatal plane, while
in untreated Case A the upper facial height/lower facial
height ratio worsened. The angular measurements also
indicate the difference in skeletal development, particularly the decrease in the gonial angle in Case C by 11.5
degrees and that of angle PP-MP in Case B by 9.5
degrees and in Case C by 10.5 degrees.
DISCUSSION

It should be noticed that initially there was a slight

difference in skeletal pattern between the two treated
cases. Angle SN-PP was 6 degrees in Case B and 4
degrees in Case C. Angle PP-MP was 37.5 degrees in
Case B and 40.5 degrees in Case C. As already mentioned, the occipital reference system with the horizontal coordinate adjusted to the earths surface permits a
more realistic interpretation of angular measurements,
which has been described in detail. lg In order to find an
explanation for the difference in size of angles SN-PP
and PP-MP in the treated cases, the occipital coordinate
system can be used. In the comparative study in this
article, only the angles formed by sella nasion, the

Fig. 7. Angular changes in treated Case B, measured by the

Frankel method.

palatal plane, and the mandibular plane with the vertical coordinate of the occipital reference cross are used
for cephalometric analysis and statistical evaluation of
the differences between the two groups (Figs. 6 to 8).
With reference to the angles formed by the sella-nasion
line, the palatal plane, and the mandibular plane with
the vertical coordinate (that is, the true vertical as determined by the first registration of the natural head
posture being transferred to the subsequent radiographs), there is no marked difference between untreated Case A and Case B. By comparison, in Case C
the inclination of sella nasion and particularly of the
palatal plane was initially quite different. The upward
canting of the palatal plane suggests that in Case C the
vertical disproportions are also manifested in the middle face. Our investigations using the occipital reference system confirm the statements of Nahoum and
co-workerszl that, in a cephalometric appraisal of the
hyperdivergent pattern, the contribution of the palatal
plane to the ratio of upper facial height to lower facial
height must be emphasized. Its position and inclination
provide valuable information on the nature of the differential growth in the middle and lower face, respectively . Nahoum and co-workerG found that the distance
from the first maxillary molar to the palatal plane was
not significantly different from that of the normal subjects. This contradicts the findings of others who reported excess eruption of maxillary posterior teeth.

Functional

Volume 84
Number I

OS

approach

to treatment of skeletal open bite

61

+0,5
de

(76,5+77)

Fig. 8. Angular
changes
of treated
Case C showing
that PP
dropped
anteriorly
more than in Case 6 (Fig. 7). In contrast,
a
slight upward
canting
of PP occurred
in untreated
Case A.

Sassouni and Nanda2 explained an existing deviant

inclination of the palatal plane as a downward tipping
of the posterior half of the palate carrying the molars
further downward. Speidel and co-workersz4 arrived at
the conclusion that an excessive height of the posterior
maxillary process was an important factor in developing a high mandibular growth pattern.
The marked increase of upper facial height relative
to lower facial height and the concomitant increase in
the SN-PP angle suggest that the vertical disproportions
of the middle face in Case C are manifested more anteriorly (Figs. 5 and 8).
Certainly, the pattern of skeletal development can
be determined by an analysis of angular measurements.
It should be remembered, however, that any change in
an angle is the result of changes in at least three points
(the vertex and one point on either side). The change of
the angle between sella nasion and the palatal plane
may be attributed to the positional changes of the landmarks N, S, Nsp, and PNS. When the occipital coordinate system (which enables us to determine those
landmarks, the positional changes of which caused the
angular alterationslg) is used, it can be seen that the
angle between the occipital coordinate system and the
mandibular plane increased during the observation period, indicating a worsening of the opening rotation of
the mandible in the control case while in Cases B and C
it decreased significantly (Figs. 6 to 8). The dropping
of the nasal floor anteriorly, as indicated by an average
increase of the PP-OS angle (Fig. 8), shows that during

Fig. 9. Tracings
of the first and last radiographs
sponding
polygons
of Case A (see text).

with the corre-

treatment of Case C skeletal changes occurred in both

the middle and the lower face.
Our studies1-13 suggest that in the presence of a
hyperdivergent skeletal pattern the entire splanchnocranium is affected. In addition to the deviant vertical

62

Friinkel

and Friinkrl

Fig. 11. Tracings

from
perimposed
on Frankfort

Fig. 10. Tracings

of the first
sponding
polygons
of Case

and last radiographs

B (see text).

with the corre-

proportions below the palatal plane, a characteristic

feature present in every case, the middle face is affected as well.
The tracings shown in Figs. 9 and 10 may provide a
better understanding of the measurements made in this
study. The initial tracings of Cases A and B show that
there was originally an almost identical developmental
pattern in the splanchnocranial area. The midfacial
structures do not show a difference in either sagittal or
vertical proportions. The slightly advanced eruption of

the lateral
horizontal.

radiographs

of Case

A su-

the first maxillary molar in Case A may be attributed to

the fact that the first radiograph was taken at an age 2%
years older than that of Case B. It is interesting to note
that in both cases the migration of the first maxillary
molars occurred to almost the same extent. The distance between the sella-nasion line and the nasal floor
increased more during treatment of Case B than in untreated Case A. The final radiographs of both cases
were taken approximately at the age of 15% years.
However, it must be mentioned that the first radiograph
in Case B was taken at an age approximately 2% years
earlier than that of Case A. Notwithstanding this difference in patients ages when the first radiographs were
taken, there is evidence of normal sutural and alveolar
growth in the posterior half of the midface in Case B.
Therefore, the FR appliance may not have had any
intrusive effect on the maxillary molars or a depressive
function on the vertical development of the posterior
midfacial structures. The correction of the mandibular
steepness, therefore, apparently is not due to mechanical interruption of sutural or alveolar growth of
the posterior portion of the maxilla.
Another interesting phenomenon observed in Case
B was that the distance of the root apices from the
lower mandibular border increased to the same extent
as that in untreated Case A. That could mean that
treatment with the FR did not retard alveolar growth in
the posterior area of the mandible. The correction of
hyperdivergency and the considerable increase in

Volume 84
Number 1

Functional

Fig. 12. Tracings

perimposed

from
on Frankfort

the lateral
horizontal.

radiographs

of Case

approach

to treatment qf skeletal open bite

63

B su-

posterior facial height relative to anterior facial height

concomitant with normal alveolar growth in the
posterior parts of the maxilla and mandible during
treatment suggest that compensatory growth at the condyle must have occurred. There is another interesting
phenomenon supporting this hypothesis. The tracings
of Case B exhibit a marked change in axial inclination
of the mandibular molars in the course of treatment.
Bjijrk and SkielleP have emphasized the influence of
the rotation of the face on the paths of eruption of the
teeth during eruption. The significant uprighting of the
mandibular molars during treatment could thus be explained, at least in part, as the result of a change in the
rotational pattern of the mandible.
Figs. 11 and 12 show the skeletal development of
Cases A and B when the tracings of the radiographs are
superimposed on the Frankfort reference line. The differential change in profile anteriorly indicates that the
initial vertical growth pattern of Case B changed to a
horizontal one during treatment, whereas it was maintained in Case A. The amount of the combined vertical
sutural and alveolar growth of the maxilla and alveolar
growth of the mandible in treated Case B equals that of
untreated Case A. There is no difference in the change
of the maxillary molar vertical positions, and apparently no intrusive mechanics on the upper molars were
operating during treatment. Therefore, the closing of
the anterior vertical relation during treatment of Case B
cannot be the result of autorotation of the mandible as it
is observed after surgical superior repositioning of the
maxilla. The results of surgical correction of aperto-

Fig. 13. The working

principle
of the FR in establishing
the
mandibular
forward
rotation with the posterior
edges of the buccal shields
as a rotational
center.
Anteriorly,
the mandible
is
raised by the force of the anterior
vertical
muscle
chain being
strengthened
by lip seal exercises.

gnathia have led to the suggestion that vertical posterior

maxillary excess constitutes an important factor in
causing opening rotation. 26However, this factor cannot
account for the different pattern of mandibular rotation
between Cases A and B as the initial vertical dimension
of the posterior middle face and the vertical positional
changes of the maxillary molars in Case A were identical to those of Case B. From the evidence of our
long-term observations, we do not believe that maxillary dentoalveolar excess is the essential or even the
sole factor in causing apertognathia.
In an evaluation of the clinical manifestation of
skeletal open bite, a variety of vertical skeletal and
dental components must be included. Nemeth and
Isaacson* proposed that the impact of the combined
sutural and alveolar growth of the maxilla and alveolar
growth of the mandible on the pattern of mandibular
rotation must be seen in a close relation to the mandibular condylar growth. When comparing the tracings of
Cases A and B, the most striking difference in skeletal
development is the increase of ramus length in Case B,
suggesting that condylar growth could keep pace with
the vertical alveolar growth in the posterior part of the
face. In contrast, in Case A vertical growth at the condyle remained behind that of the posterior dentoalveolar structures. On the basis of our clinical experience,
the increase of ramus length being larger than that of

64

Friinkel

und

Friinkcl

the lower anterior face height (LFH) was a phenomenon regularly observed in all cases of skeletal
open bite when, after treatment with FRs, a competent
oral seal was established. This is also due to cases of
severe skeletal open bite where molars had been extracted.
Wessberg and associates,28 on the basis of their
clinical experience, proposed application of a functional approach. They suggested that an occlusal
programming feedback mechanism within the central
nervous system mediates the compensatory autorotation of the mandible following surgical superior repositioning of the maxilla. We agree to the suggestion that
the significance of vertical dentoalveolar growth on the
pattern of mandibular rotation may be appraised only
by a functional analysis (that is, by incorporation of the
musculature suspending the mandible). Therefore, the
possible influence of vertical molar positions on the
pattern of mandibular rotation should not be interpreted
as a wedge effect separating the developing vertical
relations between the jaws. Rather, occlusal contacts
may be regarded a factor programming the neuromuscular system determining the mandibular rest position.
Thus, the erupting tooth as an occlusal programming
factor may influence the postural performance pattern
of the suspending musculature. Conversely, the
postural behavior of the musculature determining the
mandibular position may, as a result of feedback,
influence the positional changes of the erupting teeth as
well.
In the study by Frost and co-worker? the longterm postoperative linear measurements exhibited an
average decrease in the sella-gonion distance from 76.1
to 75.2 mm. and in the posterior nasal spine-gonion
distance from 40.1 to 39.1 mm., which means a decrease in ramus length. It seems reasonable to assume
that, after molar extraction, there would be skeletal
changes similar to those observed following maxillary
surgery, that is, a relative decrease in the lower anterior
face height with the ramus length unchanged. Theoretically, the mandibular autorotation following either
maxillary surgery or molar extractions does not necessarily require compensatory growth at the condyle.
In attempting to interpret the increase in ramus
length as a result of the treatment with the function
regulator, the possible effect of the buccal shields
should be taken into consideration (Fig. 13). Provided
that the working models were correctly trimmed, the
posterior edges of the buccal shields are deeply positioned in the sulci and provoke pressure sensation in
this area. On could argue that, with insertion of the
function regulator, the factor of occlusal programming is replaced by a factor of soft-tissue pro-

Am. J. Orthocf.
Julx 19X:\

gramming. It is suggested that the mechanoreceptors

in the soft-tissue environment around the posterior
edges of the shields may induce the central nervous
system to respond and to eliminate the disturbing signal
of pressure. As a result of the sensory motor feedback
mechanism, the posterior part of the mandible is lowered, leading to a distraction of the condyle away from
the glenoid fossa. The increase in ramus length might
thus be explained as a result of compensatory translative growth at the condyle effected by the inferior translation of the posterior part of the mandible.
In order to find reasonable-sounding reasons for the
closure of open bite with a concomitant increase in
ramus length we suggest that, concomitant with the
lowering of the posterior part of the mandible, its anterior part be raised with the posterior edges of the FR
as a rotational center. We hypothesize that such a forward rotation of the mandible is brought about by the
force of the anterior vertical muscle chain being
strengthened by lip seal exercises. This hypothesis is
supported by the clinical evidence that the increase in
PFH and ramus length with a concomitant relative decrease in AFH and the lower face height appeared to be
accomplished only when the postural weakness in the
orolabial zone could be overcome. We conclude that
the change in the anterior to posterior facial height ratio
appears to be due to normal sutural and alveolar growth
in the maxilla with a concomitant stimulation of development of the ramus in length. As a tentative explanation, the change in dimension of the vertical components might be the result of lip seal training with the
function regulator as an exercise device leading to a
postural balance between the forward- and backwardrotating muscles.
The demonstrated results achieved by our method
of functional orthopedics may be a challenge to orthodontists who use appliances of the intrusive type frequently combined with surgical procedures, such as
removal of molars or superior repositioning of the
posterior part of the maxilla as recently described by
KimzY and Frost and Hall. In an attempt to find some
plausible-sounding explanation of how the changes in
skeletal pattern might be brought about by the functional therapy applied, the investigations of Hixon and
Klein31 on the characteristics of diverse appliance systems should be considered. Regardless of type, the
appliances used for correction of dentofacial abnormalities represent a mechanical intervention. Pressure
exerted by any appliance, even if produced by muscular
forces, is and remains an application of pressure. The
sensorium in the tissues coming under pressure generated by the appliance is able only to register its magnitude, duration, and direction but not to discriminate

Volume 84
Number 1

Functional approach to treatment of skeletal open bite 65

its source or origin. In this view, we believe that the

designationfunctional appliance is incorrect and confusing and should be abandoned. However, we cannot
agree with the statement: The common denominator
of all appliances, whatever their construction, is that
they apply pressure to teeth. The acrylic shields, as
the most important parts of the FR appliances, do not
contact teeth and therefore are not capable of exerting
direct pressure on the teeth. In contrast to activators,
the shields of the FRs become effective when standing
away from the dentition. Basically, they are intended to
operate in the muscular environment, aiming at correcting an existing deviant functional pattern. Thus, the
morphologic alterations in the dentofacial area are secondary and result primarily from the change of the
aberrant functional pattern in the muscular environment, including the tongue. If we are to use the principles of functional orthopedics, the critical factor is that
the appliance used meets the criterion of an exercise
device. Nemeth and Isaacson, in their studies on
vertical anterior relapse, have recognized the effect of
the facial musculature upon tooth-to-bone and boneto-bone changes. They suggest that the musculature
may be the dominant force in ultimately determining
molar vertical position and vertical jaw relations. Experimental evidence from studies on the function-form
relationship in craniofacial morphogenesis in the research centers around the world has shown the need to
apply principles derived from experimental studies to
clinical situations.
Our approach to functional orthopedics should be
regarded as an attempt to apply these research findings
at the clinical level. The scope of this article will not
permit more than a brief comment on the basic principle of our method of functional orthopedics. The FR
appliance fulfills the task of an exercise device for
overcoming the faulty postural behavior of the orofacial
musculature. l3 This is particularly the case in the presence of a hyperdivergent skeletal pattern. For example,
the tracings of Figs. 9 and 10 show the considerable
changes in the soft-tissue profile in treated Case B. In
contrast to Case A, the mentalis activity previously
evident during lip closure completely disappeared. At
the end of treatment, a proper interlabial posture was
evident: that is, the adhesive areas of the epithelium of
the upper lip were in contact with those of the lower lip.
We believe that this is a very important objective, as
the sticky effect of those epithelial areas is indispensable for a proper hermetic seal function of the labial
valve .32Note also the equally increased thickness of the
soft-tissue cover in the lower face.
With reference to the complex network of systems
of mutual adaptability in the orofacial area, a discus-

sion of the findings in this study can be only a tentative

introduction into the relationship between function and
form in the development of skeletal open bite. As already mentioned, our concept of a functional approach
is based on long clinical experience and, more important, on long-term posttreatment examinations. Retrospectively, two clinical observations were fundamental
to change our purely morphologic view to a functional
one in appraising the factors possibly contributing to
the deviant pattern of hyperdivergency.
1. When an open bite was associated with a hyperdivergent skeletal pattern, relapse occurred in all
treated cases unless a competent anterior oral seal had
been achieved, regardless of whether or not posterior
teeth had been removed.
2. Posttreatment functional analysis revealed that
our appraisal of lip competence at the end of the active
treatment period was often self-deceptive. Our assumption that after the bite had closed (often accomplished by a concomitant extraction of posterior teeth)
the establishment of a competent lip seal occurred spontaneously was wrong. The treatment results remained
stable but only when the lips were sealed without the
appearance of any muscular strain. Proper assessment
of this requires a trained and skilled eye.
The results accomplished by functional orthopedics
suggest that the lips-apart condition as a characteristic
feature in skeletal open bite cannot be regarded as simply a structural discrepancy between lip length and
lower face height resulting from differential growth between soft and skeletal tissues. Rather, we believe that
the incompetence of the anterior oral seal associated
with poor postural behavior of the lips basically reflects
a disturbed interaction between the rapidly and differentially growing skeleton and the maturing neuromuscular system. As shown by Bosma,16 during the
process of postnatal development there are various patterns of change of performance. The acquisition of new
performance patterns is intimately related to central
neurologic maturation. The tongue of the newborn fills
the lingual cavity, and its tip is constantly in contact
with the lower lip. The oral seal is brought about by
approximation of the tongue and palate, particularly
closure at the junction of the tongue and palate, particularly closure at the junction of the mouth and pharynx.
In early infancy tongue posture is the basic factor in
establishing an oral seal. Thus, the mouth is closed and
the pharynx is open, even if the lips are incidentally
apart. Vertical growth in the neck area and the sensory
input of the eruption of deciduous teeth require the
development of new motor and postural patterns. During this period of growth the maturation of the postural
performance of the lip musculature becomes increas-

66

Friinkel

and Friinkal

ingly important for establishing a competent anterior

oral seal and maintaining nasal respiration. Bosma6
has emphasized that the posterior soft-tissue barrier
formed by the soft palate and the tongue is an important
factor in controlling and coordinating functional performance of the entire orofacial area. The positional
stabilization of the pharyngeal airway is the initial
manifestation of the distinctive coordination of posture.
With maturation, the postural stabilization extends to
the stabilization of the front of the mouth and caudal
progression to the neck and trunk.
The studies by Moyers3 on the maturation of the
orofacial musculature stressed the alteration of the
functional relationships between lips and tongue during
downward and forward mandibular growth. At this developmental stage the lips elongate and become more
selectively mobile. The tongue develops discrete movements and posture separate from those of the lips and
the other orofacial muscles. As in the past when emphasis was placed on functional disorders of the tongue
and explained as immature patterns or infantile
swallowing, so we believe that the incompetence of
the anterior oral seal associated with poor postural behavior of the lips deserves the designation of immaturity. This also seems to be reflected in the popular
German expression Geschlossene Persiinlichkeit
which, translated, means closed personality. It is
our concluding suggestion that the re-establishment of a
competent anterior oral seal by lip-seal training with
FRs may be interpreted as making up for an imperfect or failed maturation of the labial valve function.
In this context, the interesting investigations of
GershateP, 35 must be mentioned. He observed an extremely high incidence of skeletal open bite in emotionally disturbed and mentally retarded children. This
finding is in agreement with the attitude of those general orthopedists who argue that aberrant muscle tone
does not constitute a physical problem alone but must
also be seen in the context of the accompanying neural
and psychic disturbances. The extensive representation
of the oral region in the brain explains why emotional
and nervous stresses are particularly manifested in the
muscular environment around the mouth. This neurophysiologic fact suggests that the poor postural performance of the orofacial muscles as a characteristic
feature of skeletal open bite may, in part, be attributed
to an adverse psychosocial milieu of the affected child.
The considerable morphologic alteration that occurs
during treatment supports a functional approach to correction of skeletal deformities, an approach that has
been used in general orthopedics for a long time. In this
regard, the poor postural behavior of the orofacial
muscles deserves particular attention. Our clinical ex-

Am. .I. Orihod.

./LA 19x3

perience suggests that the anterior sealing of the oral

functional space may have a primary role in maintaining the integrity of the interacting systems in the orofacial complex. It is therefore suggested that the concomitant use of lip-seal exercises and the Frinkel
appliance produces alterations in the functional environment at essential points which may induce a chain of
changes in the postural performance patterns of the
whole orofacial complex. There is evidence that lipseal exercises train the elevator muscles as well as the
orbicularis oris muscles.
When one conceives of muscular forces as playing
a role in craniofacial morphogenesis, one runs the risk
of being accused of taking an environmentalist
view. Such an opinion overlooks the fact that the muscles are located within the human body and constitute
an integral part of the musculoskeletal apparatus.
Therefore, it is misleading to classify muscular influences simply as environmental factors. Muscle growth
is strongly controlled by genetic factors. The same is
true of the neural tissues inducing and controlling muscular functions. Thus, the biomechanical induction derived from muscular forces, as far as they operate
within a physiologic range, may be assumed to have the
quality of epigenetic information, providing the fullest
accomplishment of the growth and development of the
related skeletal structures.
In view of this, the muscles suspending the mandible play an important role in the epigenetic control
mechanism determining the postural position of the
mandible. This is particularly valid for the establishment of the rotational pattern of the mandible. On the
basis of the leverage principle, it seems irrational to
assume that the control of the rotational pattern is located at the end of the lever arm, in this case the mandibular condyle. We cannot imagine that Nature could
be so unwise as to ignore this basic principle and that
the direction and magnitude of condylar growth are the
primary determinants of the rotational pattern of the
mandible.
From our clinical observations, it may be assumed
that in the process of maturation of postural performances, which, as claimed by Bosma,j begins from
the posterior muscular wall of the oral space, the anterior muscular valve may constitute an important link
for the maturation in the network of postural systems
prevailing in the entire orofacial area. We suggest that,
in the presence of an opening rotation of the mandible,
the concomitant poor postural behavior of the related
masticatory muscles should be seen in context with the
postural incompetence of the anterior valve, which may
be regarded as a more dominant member in the chain of
maturing processes. The results achieved by our

Volume 84
1

Functional

method of functional orthopedics, therefore, could

possibly be explained as the result of overcoming the
immature postural pattern of the anterior muscular
chain which subsequently led to maturation of the
postural behavior of the posterior muscular chain. The
changes in the contours of lips, chin, and floor of the
mouth that occurred during treatment are evidence of a
significant difference in the postural behavior in the
whole orofacial area. The weakness of the facial muscles, flaccid lips, mentalis bulk, and the deep mentolabial crease, all of which may well be attributed to immature patterns of behavior, disappeared, leading to a
striking improvement in facial appearance. The psychosocial aspects of overcoming the unattractiveness
of the physiognomic features should not be underestimated.
As a final note, it is not the intent of this article to
advocate a new appliance system. The reader should
realize that the essential motivation for developing our
method of functional orthopedics was the example set by
the general orthopedists. Another stimulating factor was
the progress in research of craniofacial growth. The
experimental evidence that the growth sites in the
craniofacial area are susceptible to biomechanical and
functional stimuli promises clinical applicability. Thus,
we felt compelled to search for new ways to use the
experimental findings at the clinical level.
The main concern in developing our approach to
functional orthopedics was to design an orthopedic
exercise device capable of overcoming functional disorders and re-establishing physiologic conditions in the
orofacial complex. The results achieved suggest that
the projecting vestibular shields meet the criterion of an
exercise device for overcoming the poor postural pattern of the vertical muscle chains providing the anterior
oral seal and controlling the postural position of the
mandible. The exercise device in the vestibule directly
interfering with the facial musculature produces a considerable improvement of facial appearance which may
possibly be explained as an overcoming of an immature
postural pattern of the orofacial musculature.

dren with severe open bite were used in this study;

eleven of the children who did not undergo treatment
served as controls, and thirty were treated with lip-seal
training and a functional regulator appliance. A radiographic analysis was made by the methods of Nahoum,
Jarabak, and Fr$nkel. With the Frankel analysis, there
were significant differences in skeletal development between the treated and the nontreated groups after an
average treatment/observation period of approximately
8 years. The values for angles SN-MP and PP-MP and
for the ratios of anterior upper facial height to lower
facial height and anterior facial height to posterior face
height changed in the treated group to fall within the
normal range, whereas the respective values for the
untreated controls remained unchanged or became
worse. The findings of this comparative study suggest
that the functional strategy as developed in general orthopedics can be applied to orofacial orthopedics, provided that faulty postural performances are seen in a
functional interrelationship with spatial disorders in the
oronasopharyngeal spaces. The striking improvement
in facial appearance evident after treatment may result
as much from changes in the soft-tissue mask as from
the skeletal changes.

Number

SUMMARY

The functional concept of treatment used in general

orthopedics is based on the clinical experience that poor
postural behavior plays an important causative role in
the development of skeletal deformities. Therefore, the
primary therapeutic problem in functional orthopedics
is to overcome these functional disorders. The purpose
of this study was to determine whether or not such a
functional approach could also be applied to orofacial
orthopedics.
A series of lateral cephalograms of forty-one chil-

for

We wish
his great

approach

to treatment of skeletal open bite

67

to express
our thanks to Dr. James A McNamara
help in preparing
this article
in English.

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Reprint requests to:
Dr. Rolf Frinkel
Ulmenweg
42
95 Zwichau,
German

Democratic

Republic