CASE REPORT

Nonsurgical treatment of a Class III patient with

a lateral open-bite malocclusion
John E. Bilodeau
Springfield, Va

A 15.3-year-old white girl with a skeletal Class III malocclusion and a severe lateral open bite was treated with
conventional orthodontics and directional force mechanics and elastics. She had 5 congenitally missing premo-
lars. The maxillary right canine was ectopically erupted and in contact with the maxillary right first molar. An Angle
Class I molar relationship was achieved with canine protected occlusion and incisal guidance. A wrap-around
retainer was placed on the maxillary arch and a lingual bonded retainer on the mandibular arch. Treatment
time was 38 months. (Am J Orthod Dentofacial Orthop 2011;140:861-8)

E
dward H. Angle described a Class III malocclusion surgery? Can a nonsurgical compromise be accomplished,
as a condition in which the mandibular first molar even if it is not the optimum choice? All these questions
is positioned mesially to the maxillary first molar.1 must be answered by the clinician in planning treatment
This relationship could include a skeletally recessive max- to correct the patient’s malocclusion.
illa and a normal mandible, a prognathic mandible and
a normal maxilla, or a combination of both. This dental re- DIAGNOSIS AND ETIOLOGY
lationship could also have a normal maxillary-mandibular The patient was a white girl, aged 15.3 years, with an
relationship. The treatment of choice is normally to correct unremarkable medical history. She had a Class III dental
the faulty skeletal component and the dental malrelation- malocclusion, a lateral open bite, and a slightly convex
ship. A pseudo-Class III can be caused by a forward shift of facial profile. Her maxilla appeared to be recessive. The
the mandible to avoid incisal interferences.2 In the United maxillary right canine erupted next to the maxillary right
States, true Class III malocclusions are found in less than first permanent molar. Her chief concerns were “my
1% of the general population.3,4 underbite and my side teeth don’t touch.” The primary
An open bite with any malocclusion classification is etiology was heredity.
a difficult and complex anomaly to correct. It is particu- The facial and intraoral photographs (Fig 1) demon-
larly troublesome when it is associated with a Class III strate a slightly convex facial profile. The patient was
malocclusion. Open bite can be caused by an abnormal able to close her lips without mentalis strain. The maxil-
growth pattern, finger sucking, airway obstruction, or lary midline was deviated toward her left.
tongue posture and function.5 The dental casts (Fig 2) show an Angle Class III occlu-
Class III malocclusions are difficult for treatment sion on the left and a Class I dental relationship on the
planning. The clinician must choose either a camouflage right. The maxillary right canine had erupted ectopically
treatment to mask the Class III malocclusion or a surgical next to the maxillary right first molar and was in an ex-
alternative to correct the skeletal imbalance. Certainly, an treme Class III position in relation to the mandibular right
open bite, whether it is lateral or anterior, complicates the canine. The maxillary right deciduous canine was present
Class III correction. In many instances, it can make the in the permanent canine position. The maxillary left sec-
Class III malocclusion worse. What if the patient grows? ond deciduous molar was present. The mandibular sec-
What if the patient’s parents are adamantly opposed to ond deciduous molars were also present. There was
a crossbite of the maxillary teeth on the right and a neg-
Private practice, Springfield, Va. ative overjet of 1 mm. There was 1 mm of mandibular
The author reports no commercial, proprietary, or financial interest in the prod- anterior crowding. Lateral open bites of 6 mm on the right
ucts or companies described in this article.
Reprint requests to: John E. Bilodeau, 6116 Rolling Rd, Springfield, VA 22152; and 5 mm on the left were present. The maxillary second
e-mail, [email protected]. molars were not erupted. Her teeth occluded only on the
Submitted, November 2009; revised and accepted, September 2010. terminal molars. The midlines deviated by 3 mm.
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists. The pretreatment cephalogram and its tracing (Fig 3)
doi:10.1016/j.ajodo.2010.09.032 showed an ANB angle of 1 . The Wits appraisal of 8 mm
861
862 Bilodeau

Fig 1. Pretreatment facial and intraoral photographs.

Fig 2. Pretreatment dental casts.

December 2011  Vol 140  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Bilodeau 863

Fig 3. Pretreatment cephalometric radiograph and tracing.

confirmed a skeletal Class III alveolar imbalance.6,7 The

FMA of 30 suggested a vertical skeletal discrepancy.
The facial height index (posterior facial height/anterior
facial height) of .78 suggested a skeletal deepbite
tendency.8 The Z-angle of 69 confirmed a mildly pro-
truded soft-tissue overlay.9 The incisors were not in con-
tact. The panoramic radiograph (Fig 4) showed that the
maxillary right first and second premolars, the maxillary
left second premolar, the mandibular second premolars,
and all third molars were congenitally missing. The max-
illary left second deciduous molar, the maxillary right de-
ciduous canine, and the mandibular second deciduous Fig 4. Pretreatment panoramic radiograph.
molars were present. The maxillary second permanent
molars were unerupted.
After the casts, the radiographs, the photos, and the space for premolar replacement. The maxillary left
patient were studied, it was decided to approach her second deciduous molar would be left in place to
problem as a Class III open-bite correction. maintain space for an osseointegrated implant
crown, and the maxillary left first molar would oc-
TREATMENT OBJECTIVES clude with the mandibular left second molar in
The treatement objectives were to (1) obtain a normal a Class I relationship. The maxillary left second mo-
profile line to nose relationship and a normal Z-angle, lar would be without an antagonist tooth.
(2) obtain normal canine and incisal guidance, (3) correct 2. Level both arches and maintain all remaining decid-
the lateral open bite, (4) correct the Class III dental rela- uous teeth in their current positions for prosthetic
tionship, (5) place the maxillary right canine in its correct replacements except for the maxillary right decidu-
Class I position, (6) place the dental midlines in the mid- ous canine. The maxillary right deciduous canine
dle of the patient’s face, and (7) prepare the dentition to would be extracted to allow the maxillary right per-
be prosthetically restored. manent canine to be moved mesially to contact the
right lateral incisor so that space could be gained for
TREATMENT ALTERNATIVES a premolar implant. After leveling and detailing the
arches with this plan, a maxillary LeFort impaction
1. Extract the mandibular left and right deciduous mo- and a mandibular setback osteotomy would correct
lars and upright the mandibular incisors over basal the open bite, the crossbite, and the Class III dental
bone. Extract the maxillary right deciduous canine relationship. The patient’s parents were adamantly
and move the right permanent canine forward to opposed to surgery and the added expense of im-
contact the maxillary right lateral incisor to create plants to replace the congenitally missing teeth.

American Journal of Orthodontics and Dentofacial Orthopedics December 2011  Vol 140  Issue 6
864 Bilodeau

TREATMENT PLAN be convinced that an implant was necessary. She agreed

Merrifield’s total space analysis 10,11
was used to only to the implant in the maxillary right quadrant be-
determine space requirements. A decision was made to cause the tooth was missing. Fortunately, the patient
extract the mandibular second deciduous molars. The was wonderfully compliant and did not grow. The family
extraction of these teeth would provide space to further was informed that the maxillary left second deciduous
upright the mandibular incisors over basal bone. This molar will need to be replaced eventually by an implant
uprighting movement would help correct the Class III and a crown.
appearance and improve the Z-angle. The maxillary Vertical, triangular, and Class III elastics were used as
right deciduous canine would be extracted so that the needed. When a Class I canine relationship was achieved
maxillary canine could be positioned in its proper place on the right side and the open bite had been corrected,
in the arch. The maxillary left second deciduous molar the maxillary right first molar remained in a Class III po-
would be retained to prevent mesial movement of the sition. At this time, an implant was inserted to replace
maxillary left first molar. The maxillary left second the missing maxillary right premolar. Ideal finishing
molar would have no antagonist with this plan. wires stabilized the teeth, while the implant osseointe-
grated and the occlusion settled. After the implant was
integrated, a temporary crown was placed. The implant
TREATMENT PROGRESS
crown was banded and used to move the right first molar
All teeth were sequentially banded or bonded with mesially into a Class I position. The maxillary left first
a 0.022-in standard nontorqued, nonangulated edge- molar occluded with the mandibular left second molar
wise appliance. The 10-2 system of Merrifield12 was in an end-on Class I dental relationship. The maxillary
used. A hyrax expander was placed and given 2 turns left second molar has no antagonist. A maxillary wrap-
per day to open the midpalatal suture or to at least around retainer and a mandibular bonded retainer
gain some expansion to correct the posterior crossbite. were placed. Total treatment time was 38 months.
Triangular and vertical elastics were used to help control
the bite opening that this widening of the palate would TREATMENT RESULTS
create. After 15 days with the expander, the posterior The posttreatment facial and intraoral photographs
crossbite was corrected, and the appliance was stabilized. (Fig 5) illustrate the improvement in the patient’s profile.
At the same time, the patient was instructed to wear Her midlines are coincident and in the center of her face.
a J-hook straight-pull headgear with the J-hooks placed The posttreatment dental casts and intraoral photos
directly against the mandibular canine brackets to move (Fig 6) show a Class I canine occlusion with normal overjet,
the mandibular canines and first premolars distally. Man- overbite, and canine and incisal guidance. As planned, the
dibular canine and premolar retraction was augmented maxillary left first molar occluded with the mandibular left
with elastic power chains. When the canines and first second molar. The maxillary left second molar had no an-
premolars were completely retracted, the mandibular in- tagonist and will be extracted. The maxillary left second
cisors were retracted with a 0.021 3 0.025-in closing- deciduous molar is present and not in occlusion. Eventu-
loop archwire. A high-pull J-hook headgear was attached ally, it will be extracted, and an implant and a crown
to hooks soldered on the archwire between the mandib- placed. The implant replacing the missing maxillary right
ular central and lateral incisors. The maxillary expander premolar has been restored with an implant crown.
was left in place for almost 24 months so that it could The posttreatment cephalometric radiograph and its
serve as an anchor unit, while the maxillary right canine tracing (Fig 7) illustrate the changes achieved with treat-
was moved mesially with an open coil on the archwire. ment. The mandibular incisors were further uprighted
Toward the end of treatment, when the maxillary right over basal bone to an IMPA angle of 81 . This uprighting
canine was in its proper position, and the hyrax appliance caused the Z-angle to improve to 77 . The FMA angle
was removed, the maxillary right first molar remained in increased to 34 . The Wits appraisal improved to 2
a Class III relationship. The space remaining was too large mm. The facial height index decreased to .67. The post-
for 1 implant and too small for 2. One implant was placed. treatment panoramic radiograph (Fig 8) exhibits no pa-
After it had integrated, a temporary crown was placed so thology. The maxillary right implant is osseointegrated,
that the implant could be used to close the excess space and the crown is functional.
and serve as an anchor to bring the maxillary right first Intraoral photographs and dental casts taken 1 year
molar into a Class I dental relationship. later show the result to be stable (Figs 9 and 10). The max-
The patient’s mother had unreasonable expectations illary left second molar with no antagonist has been
and objectives during most of the treatment. She abso- extracted. The maxillary right second molar has settled
lutely could not accept orthognathic surgery and had to nicely into occlusion. Slight spaces developed between

December 2011  Vol 140  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Bilodeau 865

Fig 5. Posttreatment facial and intraoral photographs.

Fig 6. Posttreatment dental casts.

American Journal of Orthodontics and Dentofacial Orthopedics December 2011  Vol 140  Issue 6
866 Bilodeau

Fig 7. Posttreatment cephalometric radiograph and tracing.

the mandibular first premolars and the canines; these will

be closed by the restorative dentist with bonding material.
Since the parents did not want the expense of another
implant, the maxillary left second deciduous molar was
built up with composite and brought into occlusion.

DISCUSSION
Ellis and McNamara13 studied the frequency and dif-
ferences in the dental and skeletal components with and
without open bite in a large sample of Class III adults.
One-half of the subjects had an anterior open bite.
When compared with the nonopen-bite group, signifi- Fig 8. Posttreatment panoramic radiograph.
cant differences were found: the posterior maxilla ex-
hibited vertical excess in the open-bite group, the with a LeFort I osteotomy. Denison et al17 studied the
maxillary occlusal plane was less steep in the open-bite posttreatment stability of open-bite and nonopen-bite
group, the mandibular occlusal plane and the mandibu- LeFort I osteotomies that repositioned the maxilla supe-
lar plane angle were higher in the open-bite group, and riorly. They found more postsurgical decrease in overbite
total anterior face height and lower face height were in- in the open-bite patients. Profitt et al18 studied 54 pa-
creased in the open-bite group. The mandible was less tients who had correction of an anterior open bite with
protrusive in the open-bite group. Their findings indi- maxillary LeFort I osteotomy alone or a combination
cated that the average Class III open-bite malocclusion of LeFort I and mandibular ramus osteotomies. It was
has aberrations in both the maxilla and the mandible; found that, when the maxilla is moved superiorly in
therefore, it could require surgical intervention in both the treatment of open bite because of skeletal discrep-
jaws to correct the deformity. ancies with or without an accompanying ramus osteot-
Cangialosi14 studied a large sample of treated patients omy, there is a 10% chance of developing a 2 to 4 mm
who had open bites before treatment and compared the open bite in the long term. Lopez-Gavito et al19 studied
treatment results with a sample of treated Class I normal nonsurgical open-bite malocclusions at 10 years postre-
patients. He found a decrease in the posterior to anterior tention and found that over a third of the patients had
facial height ratio in the open-bite sample. Stuani et al,15 a significant relapse.
in a later study, confirmed this finding. Correction of maxillary retrusion in children less the 8
The difficulty of treating an open-bite Class III mal- years of age can be accomplished with a facemask that
occlusion is well recognized. Many would agree that uses the forehead and chin as an anchor with elastics at-
this problem is best treated with a combination of ortho- tached to either a maxillary splint or an orthodontic ap-
dontics and orthognathic surgery. In 1975, Bell16 pliance. This treatment regimen moves both the teeth
showed that a skeletal open bite could be corrected and the maxilla forward. After 9 years of age, however,

December 2011  Vol 140  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Bilodeau 867

Fig 9. Intraoral photographs taken 1 year posttreatment.

Fig 10. Dental casts taken 1 year posttreatment.

more tooth movement and little skeletal displacement presented case reports using open-bite strategies that
occur.20 Qazi and Amjad21 published a case report of included 4 premolar extractions, 4 first molar extrac-
a hyperdivergent Class III open bite in a 10-year-old tions, and active vertical corrector therapy. They found
girl with a recessive maxilla, who was treated for 8 that tipping of the anterior teeth was an important con-
months with a protraction facemask that displaced the tributor to open-bite correction.
maxilla anteriorly. Hamamci et al22 documented an Most functional appliances, which are used for early
adult with a skeletal Class III and open-bite malocclusion correction of Class III malocclusions, cause the maxillary
successfully treated without surgical intervention. A molars to erupt vertically while holding the mandibular
fixed edgewise technique, reverse headgear, and Class molars in place. The net effect is rotation of the occlusal
III and anterior box elastics were used. Saito et al23 re- plane. The rotation of the occlusal plane causes the mal-
ported the successful nonsurgical treatment of an adult occlusion to change from Class III to Class I.20
open-bite Class III malocclusion with an edgewise appli- Recently, Sakai et al25 described the correction of
ance combined with occipital high-pull headgear and a severe open-bite Class III malocclusion with skeletal
Class III elastics. Hans et al,24 in an evidenced-based ap- miniplate anchorage and mandibular third molar
proach to treatment of open bite and deep overbite, extractions. Weisner26 described the treatment of an

American Journal of Orthodontics and Dentofacial Orthopedics December 2011  Vol 140  Issue 6
868 Bilodeau

asymmetric Class III malocclusion with a single mini- 10. Merrifield LL. Differential diagnosis with total space analysis. J
screw temporary anchorage device. Several authors Charles Tweed Found 1978;6:10-5.
have reported closing open bites and correcting Class 11. Vaden JL, Dale JG, Klontz HA. The Tweed-Merrifield philosophy.
In: Graber TM, Vanarsdall RL, editors. Orthodontics: current prin-
III malocclusions using temporary anchorage devices or ciples and techniques. St Louis: C. V. Mosby; 1994. p. 627-84.
zygomatic anchorage.27-29 12. Merrifield LL. Edgewise sequential directional force technology. J
Implant therapy is highly predictable and successful. Charles Tweed Found 1986;14:22-37.
Astrand et al30 studied 48 consecutive patients 20 years 13. Ellis E 3rd, McNamara JA Jr. Components of adult Class III
after treatment with Branemark-design titanium open-bite malocclusion. Am J Orthod 1984;86:277-90.
14. Cangialosi TJ. Skeletal morphologic features of anterior open bite.
implant-supported prostotheses (Nobel Biocare AB, Go-
Am J Othod 1984;85:28-36.
teborg, Sweden). The survival rate was 99.2%. Kao31 15. Stuani AS, Matsumoto MA, Stuani MB. Cephalometric evaluation
stated that, although implant success can be rewarding, of patients with anterior open-bite. Braz Dent J 2000;11:35-40.
all parties need to be involved in treatment planning. 16. Bell WH. Le Fort I osteotomy for the correction of maxillary defor-
He stated that poor planning can result in increased mities. J Oral Surg 1975;33:412-26.
17. Denison TF, Kokich VG, Shapiro PA. Stability of maxillary surgery
surgical needs and costs, and even failure. Klokkevold
in openbite versus nonopenbite malocclusions. Angle Orthod
and Han32 studied the effects of smoking, diabetes, 1989;59:5-10.
and periodontitis on implant success rates and found 18. Proffit WR, Bailey LJ, Phillips C, Turvey T. Long-term stability of
that patients who smoked or had diabetes had a greater surgical open-bite correction by Le Fort I osteotomy. Angle Orthod
risk for failure. 2000;70:112-7.
Uslu and Akcam33 investigated the long-term postre- 19. Lopez-Gavito G, Wallen TR, Little RM, Joondeph DR. Anterior
open-bite malocclusions: a longitudinal 10-year postretention
tention satisfaction rate among skeletal Class III patients evaluation of orthodontically treated patients. Am J Othod
who had received orthodontic treatment without surgery 1985;87:175-86.
for correction of a Class III malocclusion. Most patients 20. Proffit WR. Contemporary orthodontics. St Louis: C. V. Mosby;
were satisfied with their facial appearance and final esthetic 1986. p. 382-6.
profile. Of the 5% who were dissatisfied with their final pro- 21. Qazi HS, Amjad AT. Modified maxillary protraction headgear for
the correction of Class III skeletal malocclusion with anterior
files, a prognathic mandible was given as the reason. open bite. J Coll Physicians Surg Pak 2005;15:823-5.
22. Hamamci N, Basaran G, Sahin S. Nonsurgical correction of an adult
CONCLUSIONS skeletal Class III and open-bite malocclusion. Angle Orthod 2006;
76:527-32.
This treatment improved the patient’s profile, cor- 23. Saito I, Yamaki M, Hanada K. Nonsurgical treatment of an open
rected the open bite, and gave her an acceptable func- bite using edgewise appliance combined with high-pull headgear
tional occlusion. This treatment result could not have and Class III elastics. Angle Orthod 2005;75:277-83.
been accomplished without excellent patient cooperation. 24. Hans MG, Teng CM, Liao CC, Chen YH, Yan CY. An evidenced based
approach to treatment of open bite and deep bite; case reports.
World J Orthod 2007;8:45-64.
REFERENCES
25. Sakai Y, Kuroda S, Murshid SA, Takano-Yamamoto T. Skeletal
1. Angle EH. Treatment of malocclusion of the teeth and fractures of Class III severe openbite treatment using implant anchorage. Angle
the maxillae, Angle’s system. 6th ed. Philadelphia: S. S. White Den- Orthod 2008;78:157-66.
tal Manufacturing; 1900. p. 5-15. 26. Weisner SM. Treatment of a Class III malocclusion with mandibular
2. Proffit WR. Contemporary orthodontics. St Louis: C. V. Mosby; asymmetry using a single miniscrew. J Clin Orthod 2009;43:335-41.
1986. p. 47-9. 27. Seres L, Kocsis A. Closure of severe anterior open bite with zygo-
3. Kelly JE, Sanchez M, Van Kirk LE. An assessment of the occlusion matic anchorage. J Craniofac Surg 2009;20:478-82.
of the teeth of children. Publication no. (HRA) 74-1612. Washing- 28. Keim RG. The latest on skeletal anchorage. J Clin Orthod 2009;43:
ton DC: National Center for Health Statistics, US Public Health Ser- 289-90.
vice; 1973. 29. Sugawara Y, Kuroda S, Tamamura N, Takano-Yamamoto T. Adult
4. Kelly J, Harvey C. An assessment of the teeth of youths 12-17 patient with mandibular protrusion and unstable occlusion treated
years. Publication no. (HRA) 74-1644. Washington DC: National with titanium screw anchorage. Am J Orthod Dentofacial Orthop
Center for Health Statistics, US Public Health Service; 1977. 2008;133:102-11.
5. Sankey WL, Buschang PH, English J, Owen AH. Early treatment of 30. Astrand P, Ahlqvist J, Gunne J, Nilson H. Implant treatment of pa-
vertical skeletal dysplasia: the hypodivergent phenotype. Am J Or- tients with edentulous jaws: a s0-year followup. Clin Implant Dent
thod Dentofacial Orthop 2000;118:317-27. Relat Res 2008;10:207-17.
6. Jacobson A. The “Wits” appraisal of jaw disharmony. Am J Orthod 31. Kao RT. Implant treatment planning considerations. J Calif Dent
1975;67:125-38. Assoc 2008;36:256-8.
7. Jacobson A. Wits appraisal. In: Jacobson A, editor. Radiographic 32. Klokkevold PR, Han TJ. How do smoking, diabetes, and periodon-
Cephalometry. Quintessence: Carol Stream, IL; 1995. p. 97-112. titis affect outcomes of implant treatment. Int J Oral Maxillofac
8. Horn AJ. Facial height index. Am J Orthod 1992;101:180-6. Implants 2007;22(Suppl):173-202.
9. Merrifield LL. The profile line as an aid in critically evaluating facial 33. Uslu O, Akcam MO. Evaluation of long-term satisfaction with orthodon-
esthetics. Am J Orthod 1966;52:804-22. tic treatment for skeletal Class III individuals. J Oral Si 2007;49:31-9.

December 2011  Vol 140  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics