ORIGINAL ARTICLE

Evaluation of long-term stability of skeletal

anterior open bite correction in adults treated
with maxillary posterior segment intrusion using
zygomatic miniplates
Eiman S. Marzouk and Hassan E. Kassem
Alexandria, Egypt

Introduction: This study evaluated the long-term stability of maxillary molar intrusion and anterior open-bite
correction in adults treated by maxillary posterior teeth intrusion with zygomatic miniplates. Methods: The sam-
ple included 26 skeletal anterior open-bite patients, who had maxillary posterior segment intrusion with
zygomatic miniplates. Lateral cephalograms were taken at pretreatment, posttreatment, 1 year posttreatment,
and 4 years posttreatment. Results: The mean maxillary molar intrusion was 3.04 mm (P #0.01), and the
mean bite closure was 6.93 mm (P #0.01). The intruded maxillary molars relapsed by 10.20% in the rst
year after treatment and by 13.37% by 4 years after treatment. Overbite relapsed by 8.19% and 11.18% after
1 year and 4 years posttreatment, respectively. The rst year after treatment accounted for 76.29% and
73.2% of the total relapses of molar intrusion and overbite, respectively. The 4-year posttreatment relapse
amounts of maxillary molar intrusion and overbite were positively correlated with the amount of pretreatment
maxillary molar height and the initial open-bite severity, respectively, but negatively correlated with the
amounts of maxillary molar intrusion and open-bite correction gained by treatment. Conclusions: Molar intru-
sion with zygomatic miniplates appears to be stable 4 years after treatment. (Am J Orthod Dentofacial Orthop
2016;150:78-88)

A
nterior open bite has been considered a chal-
lenging malocclusion in treatment, especially
in adults, and in retention, owing to its likeli-
hood to relapse.1-3 The deformity is caused by
combined inuences from skeletal, dental, respiratory,
neurologic, and habitual factors.1,3-6
Skeletal anterior open bite is characterized by a steep
mandibular plane, an obtuse gonial angle, and increased
height of the lower third of the face.7,8 Generally,
patients with an anterior open bite and a
hyperdivergent skeletal pattern have excessive
posterior vertical growth of the dentoalveolar complex
in the maxilla, the mandible, or both.
Lecturer, Faculty of Dentistry, Department of Orthodontics, Alexandria Univer-
sity, Alexandria, Egypt.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conicts of Interest, and none were reported.
Address correspondence to: Eiman S. Marzouk, 75 Ahmed Kamha St, Camp
Caesar, Alexandria, Egypt; e-mail, eiman.marzouk@yahoo.com.
Submitted, June 2015; revised and accepted, December 2015.
0889-5406/$36.00
Copyright 2016 by the American Association of Orthodontists. All rights
reserved.
http://dx.doi.org/10.1016/j.ajodo.2015.12.014
78
Conventionally, treatment options for skeletal open
bite in adults include the use of elastics combined with
the multiloop edgewise archwire technique9 or nickel-
titanium archwires.10 However, these mechanics cannot
reduce the increased lower facial height of skeletal open
bite in adults, since the open bite has been mainly
masked by the extrusion of anterior teeth rather than
by molar intrusion. Moreover, the extrusion of maxillary
anterior teeth to close large open bites might compro-
mise esthetic goals by causing excessive incisal and
gingival display.11
As a result, treatment of severe skeletal anterior open
bite in adults consists chiey of orthognathic surgery to
reposition the maxilla, the mandible, or both.2,12-14
Stability of the open-bite correction was noted in
approximately 75% to 85% of the patients treated with
various surgical procedures.12,14-16 In addition, the
long-term stability of surgical therapies for anterior
open-bite correction was investigated in a meta-
analysis and indicated 82% stability of the various surgi-
cal treatments, measured by positive overbite at 12
or more months after treatment.17 Despite the relative
stability of the surgically corrected anterior open bite,
Marzouk and Kassem
complications, postoperative pain, edema, discomfort,
hazards of general anesthesia, costs, and rehabilitation
after surgery have made the surgical decision not usually
preferred by most patients.
With the introduction of temporary anchorage de-
vices, especially miniscrews and miniplates, intruding
the molars into their bony support, producing mandib-
ular autorotation and bite closure, nally is
possible.11,18-23 It has been publicized that skeletal
anchorage placed with a minor surgical intervention
can achieve equivalent treatment results to those
obtained by orthognathic surgery.21 Molar intrusion
with skeletal anchorage has now become an accepted
treatment protocol for treating skeletal anterior open-
bite patients.
Only a few studies in addition to case reports have
evaluated the stability of open-bite patients treated by
intrusion of the posterior teeth with skeletal anchorage.
Sugawara et al19 reported about a 30% relapse rate of
intruded molars 1 year after treatment in a case series
of 9 open-bite patients treated with mandibular molar
intrusion. Lee and Park22 found a 10.36% relapse rate
for intruded maxillary molars and an 18.1% relapse
rate for overbite after a 17.4-month retention period
in 11 adults. Baek et al23 found a maxillary molar relapse
rate of 22.88% and an overbite relapse rate of 17% over
a 3-year follow-up period in 9 open-bite patients. Degu-
chi et al24 noted approximately a 21.7% maxillary molar
relapse rate and an overbite relapse rate of 13% after
2 years of retention in 15 female open-bite patients
treated with miniscrews. Recently, Schefer et al25 stud-
ied the stability of anterior open-bite treatment in 33
patients treated by intrusion of the maxillary posterior
teeth with a maxillary occlusal splint and skeletal
anchorage at 1 year and 2 or more years posttreatment.
They concluded that 11% of their patients had greater
than 2 mm of maxillary molar relapse after 1 year and
16% at 2 years. The same was true for the relapse in
overbite: 15% of the patients had relapses in overbite
greater than 1 mm after 1 year and 22% at 2 years,
but none had more than a 2-mm change.
Most expert orthodontists can obtain a positive over-
bite of the teeth in anterior open bite with orthodontic
treatment alone or combined with surgical intervention,
but maintaining the vertical overlap can be problematic
after treatment. Because of the susceptibility for relapse
after any orthodontic correction, it is essential to eval-
uate further than the immediate posttreatment interval
to determine long-term stability.26,27
There are few reports with adequate numbers of sub-
jects in long-term investigations of stability of maxillary
molar intrusion with skeletal anchorage. Hence, this
study was conducted to evaluate the 4-year posttreat-
American Journal of Orthodontics and Dentofacial Orthopedics
79
ment stability of maxillary molar intrusion and overbite
correction in adults with anterior open bite treated by
intrusion of the posterior teeth with zygomatic
miniplates.
MATERIAL AND METHODS
The sample size estimation was calculated for the dif-
ference in maxillary molar height based on a paired-
samples t test using the software PS Power and Sample
Size Calculations (version 3.0.43).28 The mean difference
tested for was 1.5 mm. A more liberal standard deviation
of the mean difference that was reported by Erverdi
et al29 was used (s 5 2.5 mm), with type I error of
0.05 and power of 80%. The estimated sample size
was 24 subjects.
An initial sample of 28 patients with skeletal anterior
open bite was selected according to the following
criteria.
1. Patients with Angle Class I or Class II malocclusion,
permanent dentition with anterior open bite
(dened by cephalometric overbite measurement
of at least
3 mm and a maximum of
8 mm),
and age between 19 and 28 years.
2. Maxillary posterior vertical dentoalveolar excess ac-
cording to the analysis of Burstone et al.30 It was
measured as the length of a perpendicular line
from the maxillary rst molar mesiobuccal cusp tip
to the palatal plane (female, mean is 23 mm [SD,
1.3 mm]; male, mean is 26.2 mm [SD, 2 mm]).
3. Acceptable or orthodontically correctable incisor-lip
relationship.
All subjects were treated by the same orthodontist
(E.S.M.) at the Department of Orthodontics, Faculty of
Dentistry, Alexandria University in Egypt. Written
informed consent was obtained from each subject before
the study. Approval regarding the ethical concerns of
this study was obtained from the ethical committee of
the Faculty of Dentistry at Alexandria University.
The clinical technique used was described in more
detail in a preliminary report.31 In brief summary, treat-
ment was conducted with the standard edgewise tech-
nique using 0.022 3 0.028-in conventional brackets.
Orthodontic leveling was carried out in 3 independent
segments for the maxillary arch (1 anterior and 2
posterior).
When the maxillary segments were leveled with a
0.019 3 0.025-in stainless steel segment, the patients
received a double transpalatal arch fabricated from
1.2-mm stainless steel round wire to counteract the
buccal tipping of the molars during intrusion. It was
placed 4 mm from the palate to create sufcient room
to accommodate the posterior impaction (Fig 1, A).
July 2016  Vol 150  Issue 1
80 Marzouk and Kassem

Fig 1. A, Double transpalatal arch; B, schematic illustration of the intrusion mechanics; C-E, pano-
ramic, lateral, and posteroanterior cephalometric radiographs after placement of the miniplates and
double transpalatal arch before intrusion. Red arrows show the direction of force application.

The patients were then referred for the surgical place-
ment of the miniplates. All patients had titanium
I-shaped multipurpose miniplates (Gebr uder Martin,
Tuttlingen, Germany) xed with 3 bone screws
(Gebruder Martin) 7 mm in length to the contour of
the lower surface of each zygomatic buttress by the
same surgeon. Maxillary posterior intrusion was started
4 weeks after the surgical procedure.
A nickel-titanium coil spring (GAC, Bohemia, NY) was
attached from the exposed hook of the miniplate to the
rst molar to deliver an intrusive force of 450 g per side
(Fig 1, B-E). The intrusion force was stopped when the
anterior overbite reached 1 to 2 mm.
Before starting the maxillary posterior intrusion, the
mandibular arch was stabilized by a continuous
0.019 3 0.025-in stainless steel archwire bypassing
the mandibular incisors to prevent the compensatory
eruption of the mandibular molars during intrusion of
the maxillary posterior teeth.
Throughout the treatment, the patients were in-
structed to perform tongue exercises using orthodon-
tic intermaxillary rubber bands; the bands were placed
on the tip of the tongue to bring it to the level of the
incisive papilla.32 These exercises were repeated at
least 4 or 5 times per day, aiming to reeducate the
tongue posture in these open-bite patients.
After the completion of intrusion, the maxillary mo-
lars were ligature-tied to the miniplates, which remained
until the end of active treatment. The subjects were eval-
uated for the need for extractions to correct mandibular
anterior crowding, overjet, or reduced interincisal angle.
Extraction of 4 rst premolars was deemed necessary in
all subjects. The patients were referred for the extrac-
tions. The mandibular incisors were bonded. Both arches
were releveled to 0.019 3 0.025-in stainless steel wires,
and the remaining spaces were closed.
The retention protocol included maxillary and
mandibular Hawley retainers to be worn full time during
the day except at mealtimes and toothbrushing during
the rst year after treatment. A maxillary Hawley retainer
with a posterior bite plane was to be worn during the
night to prevent overeruption of the posterior dentition.
For the second year of retention, the patients were in-
structed to wear the maxillary Hawley retainer with the
posterior bite plane with the traditional mandibular
Hawley retainer only at night. During the third and

July 2016  Vol 150  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Marzouk and Kassem 81

Table I. Skeletal, dental, and soft tissue measurements used in the lateral cephalometric analysis
Measurement Denition
Skeletal measurements
SNA ( ) Anteroposterior position of maxillary base to the anterior cranial base
SNB ( ) Anteroposterior position of mandibular base to the anterior cranial base
ANB ( ) Anteroposterior relationship of maxillary base to mandibular base
ANS-Me (mm) Lower anterior facial height, the measurement between anterior nasal spine (ANS) and menton (Me)
N-Me (mm) Total anterior facial height, the measurement between nasion (N) and Me
SN-MP ( ) Mandibular plane angle, the angle between mandibular plane, gonion (Go)-Me and anterior cranial base
plane (SN)
SN-Pog ( ) Angle between SN and N-pogonion (Pog)
VP-Pog (mm) Distance between the vertical reference plane and Pog
N-S-Gn ( ) Angle between SN and gnathion (Gn)
Dental measurements
U6-PP (mm) Maxillary posterior dentoalveolar height, the perpendicular distance between the mesial cusp of the
maxillary rst molar and the palatal plane
U1-FHP ( ) Angle between the long axis of the most anterior maxillary central incisor and the constructed Frankfort
horizontal plane
L1-FHP ( ) Angle between the long axis of the most anterior mandibular central incisor and the constructed Frankfort
horizontal plane
L1-MP ( ) Angle between the long axis of the most anterior mandibular central incisor and the mandibular plane
L1-MP (mm) Perpendicular distance between the most anterior mandibular central incisor tip and the mandibular plane
U1-FHP (mm) Perpendicular distance between the most anterior maxillary central incisor tip and the constructed Frankfort
horizontal plane
L6-MP (mm) Mandibular molar height, the perpendicular distance between the mesial cusp of the mandibular rst molar
and the mandibular plane
Overjet (mm) Horizontal distance between the incisal edges of the maxillary and mandibular central incisors,
perpendicular to the constructed Frankfort horizontal plane
Overbite (mm) Vertical distance between the incisal edges of the maxillary and mandibular central incisors, perpendicular
to the vertical reference plane (VP)
Soft tissue measurement
Soft tissue facial convexity The smaller angle formed by the intersection of the N0 -Sn line and the extension of the Pog'-Sn line at Sn
(N0 -Sn-Pog0 ) ( )

fourth years, the same appliances were used 1 night a
week. Additionally, the tongue exercises were reinforced
during the retention period.
Lateral cephalograms of the subjects were taken
before treatment (T1), immediately after treatment
(T2), 1 year posttreatment (T3), and 4 years posttreat-
ment (T4).
The lateral cephalometric radiographs were traced
through the midpoints between the right and left struc-
tures, and any magnication was corrected in the mea-
surements. Several angular and linear measurements
were obtained from lateral cephalograms to analyze the
skeletal, dental, and soft tissue changes (Table I; Fig 2).
A constructed Frankfort horizontal plane was drawn
with an inferior angle of 7 to the sella-nasion plane
from point S; a vertical line, drawn from point S at 90
to the constructed Frankfort horizontal plane, func-
tioned as the vertical plane of reference.33
Statistical analysis
To preserve reliability, all cephalometric measure-
ments and analyses were performed by the
same investigator (E.S.M.). To exclude the intraexaminer
error in the measurements, 10 randomly selected radio-
graphs were retraced 2 weeks after the rst measure-
ments by the same examiner. A paired t test and the
intraclass correlation coefcient were performed for
the rst and second measurements. The difference be-
tween the 2 sets of measurements was insignicant;
the paired t test and the intraclass correlation coefcient
were greater than 0.9.
The statistical analysis was accomplished using
the SPSS software (version 17; SPSS, Chicago, Ill).
Normal distribution of the sample data was
conrmed with the Kolmogorov-Smirnov test. Results
of this test demonstrated that all variables were nor-
mally distributed. A paired t test was used to
compare the variables at T1 and T2. Comparisons
among T2, T3, and T4 were done by repeated-
measures analysis of variance followed by a paired
t test. The Pearson correlation coefcient was used
to study the correlations between the variables. Com-
parisons of the treatment changes between Angle
Class I and Class II patients were performed using

American Journal of Orthodontics and Dentofacial Orthopedics July 2016  Vol 150  Issue 1
82 Marzouk and Kassem

Fig 2. Lateral cephalogram landmarks, reference planes, and main dental measurements. 1, U6-PP
(mm); 2, L6-MP (mm); 3, overjet; 4, overbite.

Table II. Demographic data of the study sample* and treatment duration
Treatment duration

Demographics Range Mean SD

Pretreatment age 19 y 4 mo-26 y 11 mo 22 y 5 mo 2y 4 mo
Duration of intrusion 5-10 mo 7.5 mo 2.3 mo
Total treatment duration (T1-T2) 24-28 mo 26.2 mo 1.98 mo
Duration between debonding and 1 year posttreatment (T2-T3) 12-14 mo 12.9 mo 0.89 mo
Duration between end of 1 year posttreatment to end of 4 years 36-41 mo 38.6 mo 2.11 mo
posttreatment (T3-T4)

*Study sample: 26 patients (15 women, 11 men). Angle classication: 16 Class I, 10 Class II.

independent-samples t tests. The signicance level
was set at P #0.05.
RESULTS
Table II shows the demographic data of the study
sample. Two of the original 28 patients were lost to
follow-up at T3; hence, 26 subjects were analyzed. Min-
imal mobility of the zygomatic miniplates was reported
in 3 patients, but it did not warrant removal.
The mean measurements and standard deviations for
the selected cephalometric variables at T1, T2, T3, and
T4 are shown in Table III. The mean differences of the
measurements between the various time intervals are
given in Table IV.
There were treatment and posttreatment changes in
molar intrusion and overbite. The maxillary molar was
intruded signicantly (P #0.01) by a mean of
3.04 mm (SD, 0.79 mm) during treatment and by
10.87% (SD, 2.46%) of the pretreatment molar height.
In addition, overbite was signicantly increased
(P #0.01) by a mean of 6.93 mm (SD, 1.99 mm) resulting
in a 1.6-fold increase (SD, 0.36-fold) (Tables IV and V).
No statistically signicant changes were found in
maxillary molar height or overbite during the rst year
posttreatment (T3-T2) or after 1 year to the end of
4 years posttreatment (T4-T3) (Fig 3).
The relapse rates of the intruded maxillary molars
were 10.20% (SD, 2.5%) in the rst year posttreatment
(T3-T2) and 13.37% (SD, 3.3%) at 4 years after treat-
ment (T4-T2); overbite relapsed by 8.19% (SD, 3.25%)
at T3-T2 and by 11.18% (SD, 4.11%) at T4-T2. The
changes in the rst year accounted for 76.29% and
73.2% of the relapses of molar intrusion and overbite,
respectively (Table V).
Moreover, the stability rates calculated as the relapse
rate subtracted from 100% were 89.8% and 86.63% for
molar intrusion, and 91.81% and 88.82% for overbite
correction after 1 year and 4 years posttreatment,
respectively.

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Marzouk and Kassem 83

Table III. Cephalometric variables at pretreatment (T1), posttreatment (T2), 1 year posttreatment (T3), and 4 years
posttreatment (T4)
T1 T2 T3 T4

Mean SD Mean SD Mean SD Mean SD

Skeletal measurements
SNA ( ) 81.86 2.59 80.20 2.62 80.31 2.60 80.42 2.69
SNB ( ) 75.00 3.21 77.18 3.23 76.96 3.29 76.79 3.34
ANB ( ) 6.86 1.13 3.02 1.11 3.35 1.14 3.63 1.15
ANS-Me (mm) 78.05 5.83 74.48 5.50 75.05 5.49 75.55 5.49
N-Me (mm) 124.68 6.14 121.05 5.69 121.61 5.76 122.11 5.76
SN-MP ( ) 49.05 3.90 46.91 3.89 47.19 3.91 47.43 3.93
SN-Pog ( ) 74.68 2.82 77.00 2.51 76.51 2.70 76.17 2.75
VP-Pog (mm) 45.00 6.09 47.45 6.06 46.67 6.09 46.05 6.09
N-S-Gn ( ) 77.09 3.01 74.86 2.67 75.39 2.83 75.69 2.89
Dental measurements
U6-PP (mm) 28.27 2.55 25.23 2.14 25.54 2.17 25.64 2.17
U1-FH ( ) 114.82 3.91 111.73 1.28 112.13 1.41 112.25 1.51
L1-FH ( ) 42.82 3.87 44.30 3.59 43.96 3.59 43.87 3.58
L1-MP ( ) 91.32 1.17 90.03 1.06 90.42 0.99 90.50 0.99
L1-MP (mm) 44.05 2.79 45.62 2.82 45.32 2.80 45.56 2.82
U1-FH (mm) 74.45 3.89 76.95 3.99 76.77 4.02 77.38 3.85
L6-MP (mm) 34.43 1.27 34.86 1.35 34.57 1.13 34.29 1.38
Overbite (mm)
4.75 2.27 2.18 0.48 1.61 0.42 1.41 0.39
Overjet (mm) 5.55 2.28 2.16 0.45 2.61 0.46 2.72 0.46
Soft tissue measurement
Soft tissue facial convexity N0 -Sn-Pog0 ( ) 25.91 3.24 23.55 2.43 23.90 2.42 24.09 2.44

When we evaluated the correlation between the
severity of the pretreatment condition (T1) and the total
amount of relapse (T4-T2), we found a statistically sig-
nicant positive correlation (r 5 0.543; P 5 0.009) be-
tween the pretreatment maxillary molar height and the
amount of molar intrusion relapse at 4 years posttreat-
ment. Similarly, the initial open-bite severity and the to-
tal amount of overbite relapse were signicantly
correlated (r 5 0.392; P 5 0.035) (Table VI).
As for the correlation between the magnitude of
treatment correction (T2-T1) and the degree of relapse
4 years after treatment (T4-T2), there was a statistically
signicant strong negative correlation (r 5
0.856;
P 5 0.001) between the extent of molar intrusion and
its amount of total relapse. A similar but weak correla-
tion was found for overbite treatment correction and
its total amount of relapse (r 5
0.314; P 5 0.046)
(Table VI).
In addition, there was a moderate positive correlation
(P \0.05) between the amount of molar intrusion and
overbite correction when we investigated the correla-
tions between the treatment changes of the variables
(T2-T1) (Table VII).
There were treatment and posttreatment changes of
the other cephalometric variables. During treatment,
there was a statistically signicant decrease (P #0.01)
in the SN-MP angle by 2.13 (SD, 0.21 ), the N-S-Gn
angle by 2.23 (SD, 0.37 ), and the lower anterior facial
height by 3.57 mm (SD, 1.15 mm). The SNB angle, SN-
Pog angle, and vertical reference plane-pogonion dis-
tance increased signicantly (P #0.01) by 2.18 (SD,
0.40 ), 2.32 (SD, 0.48 ), and 2.45 mm (SD,
0.05 mm), respectively, followed by a signicant
decrease (P #0.01) in the ANB angle by 3.84 (SD,
0.70 ).
Dentally, overjet was reduced by 3.39 mm (SD,
2.04 mm) (P #0.01), and there was signicant extrusion
of the maxillary incisors by 2.5 mm (SD,
0.11 mm) (P #0.01). There was no signicant change
in the distance between the mesial cusp of the mandib-
ular rst molar and the mandibular plane. The soft tissue
facial convexity decreased by 2.36 (SD, 0.92 ) (P #0.01)
(Table IV).
No signicant changes were seen in any parameters
during the rst year posttreatment (T3-T2) or after
1 year to the end of 4 years posttreatment (T4-T3),
yet when analyzing the total retention period (T4-T2),
there were a signicant increase (P #0.05) in the ANB
angle by 0.61 (SD, 0.10 ) and decreases (P #0.05) in
the vertical reference plane-pogonion distance by
1.40 mm (SD, 5.42 mm) and the SN-Pog angle by
0.83 (SD, 1.96 ), respectively. There were no statisti-
cally signicant differences in the other variables
(Table IV).

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84 Marzouk and Kassem

Table IV. Mean differences in cephalometric measurements between the time intervals
T2-T1 T3-T2 T4-T3 T4-T2

Mean SD P Mean SD P Mean SD P Mean SD P

Skeletal measurements
SNA ( )
1.66 0.45 * 0.11 0.18 NS 0.11 1.97 NS 0.22 2.01 NS
SNB ( ) 2.18 0.40 y
0.22 0.09 NS
0.17 2.36 NS
0.39 2.35 NS
ANB ( )
3.84 0.70 y 0.33 0.16 NS 0.28 0.10 NS 0.61 0.10 *
ANS-Me (mm)
3.57 1.15 y 0.57 0.18 NS 0.50 5.15 NS 1.07 5.21 NS
N-Me (mm)
3.64 1.06 y 0.57 0.18 NS 0.50 4.64 NS 1.07 4.67 NS
SN-MP ( )
2.13 0.21 y 0.27 0.05 NS 0.24 3.55 NS 0.51 3.55 NS
SN-Pog ( ) 2.32 0.48 y
0.49 0.22 NS
0.34 2.03 NS
0.83 1.96 *
VP-Pog (mm) 2.45 0.05 y
0.77 0.05 NS
0.63 5.44 NS
1.40 5.42 *
N-S-Gn ( )
2.23 0.37 y 0.53 0.20 NS 0.30 2.57 NS 0.83 2.52 NS
Dental measurements
U6-PP (mm)
3.04 0.79 y 0.31 0.07 NS 0.10 2.04 NS 0.41 2.03 NS
U1-FH ( )
3.09 3.19 y 0.41 0.42 NS 0.11 1.42 NS 0.52 1.46 NS
L1-FH ( ) 1.48 0.59 *
0.33 0.09 NS
0.09 3.30 NS
0.42 3.28 NS
L1-MP ( )
1.29 0.50 * 0.40 0.10 NS 0.08 0.99 NS 0.48 1.02 NS
L1-MP (mm) 1.57 0.07 NS
0.30 0.05 NS 0.24 1.88 NS
0.06 1.89 NS
U1-FH (mm) 2.5 0.11 y
0.18 0.035 NS 0.61 2.725 NS 0.43 2.708 NS
L6-MP (mm) 0.43 0.53 NS
0.29 0.49 NS
0.29 0.49 NS
0.57 0.53 NS
Overbite (mm) 6.93 1.99 y
0.57 0.09 NS
0.20 0.38 NS
0.77 0.43 NS
Overjet (mm)
3.39 2.04 y 0.46 0.05 NS 0.11 0.48 NS 0.56 0.48 NS
Soft tissue measurement
Soft tissue facial convexity N0 -Sn-Pog0 ( )
2.36 0.92 y 0.36 0.11 NS 0.18 2.09 NS 0.54 2.09 NS
Negative values represent decreases during treatment; positive values represent increases during treatment.
T2-T1, Changes produced by treatment; T3-T2, changes during the rst year posttreatment; T4-T3, changes after the rst year to the end of 4 years
posttreatment; T4-T2, changes during the entire 4 years posttreatment; NS, not signicant.
*
P #0.05; yP #0.01.

Table V. Maxillary molar (U6) height and overbite: percentages of correction of the pretreatment values and percent-
ages of relapse at 1 and 4 years posttreatment
Treatment change from
pretreatment measurement (%) One-year posttreatment Four years posttreatment
([T2-T1]/T1) relapse (%) ([T3-T2]/[T2-T1]) relapse (%) ([T4-T2]/[T2-T1])

Variable Mean SD Mean SD Mean SD

U6-PP (mm) 10.87 2.46 10.20 2.5 13.37 3.30
Overbite (mm) 161.16 36.38 8.19 3.25 11.18 4.11

Regarding the correlations between the changes of
cephalometric variables induced by treatment (T2-T1),
the treatment changes of the SN-Pog, SN-MP, and
SNB angles were all highly correlated (P \0.01) with
the change in overbite. In addition, a strong negative
correlation (P \0.01) existed between the SNB and
SN-MP angles. Moreover, the SN-Pog angle was highly
correlated (P \0.01) with the anterior movement of
hard tissue pogonion as shown by the vertical plane-
to-pogonion measurement (mm) as well as with the
change in the SNB angle (Table VII).
Comparison between treatment changes in Angle
Class I and Class II patients showed no statistically sig-
nicant difference between these groups in maxillary
and mandibular molar heights and overbite. Maxillary
incisor height showed a minimal mean difference of
0.13 mm (P 5 0.03) (Table VIII).
DISCUSSION
The treatment of skeletal anterior open bite in adults
classically involved a combination of surgical and ortho-
dontic treatment, which provided satisfactory results
and long-term stability.2,12-14 With the advent of
zygomatic miniplates, absolute molar intrusion was
made possible in skeletal anterior open-bite patients.
Because of the conservative surgical procedure required
for miniplate placement, it offered a more appealing op-
tion for most patients who refuse orthognathic surgery.

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Marzouk and Kassem
Fig 3. Changes in the vertical distance between the
maxillary rst molar cusp tip and the palatal plane (U6-
PP) and changes in overbite from T1 to T4. T1, Pretreat-
ment; T2, posttreatment; T3, 1 year posttreatment; T4,
4 years posttreatment. **P #0.01.
However, there are few studies on stability of anterior
open-bite correction in adults with zygomatic miniplate
anchorage. The available stability studies mostly have
short follow-up periods.19,22 Other studies had small
sample sizes,19,23 and 1 study was a case report.34 In
addition, the samples studied included both growing
and nongrowing subjects19,25 and both extraction and
nonextraction treatments,23 which are confounding var-
iables for the treatment results. Our series included only
adults, and all participants had 4 rst premolars ex-
tracted as part of their treatment; this added to the ho-
mogeneity of the sample.
Park et al35 recommended 10 to 20 g of force for the
intrusion of an incisor and 150 to 200 g of force to
intrude a multirooted tooth. Yao et al36 applied 150 to
200 g of force to overerupted maxillary rst molars
from the buccal and palatal aspects simultaneously. A
higher force magnitude of approximately 400 g of force
was used for en-masse intrusion of all maxillary teeth
distal to the canines.20,29,37 In our study, to determine
the amount of force to be applied to intrude the
posterior teeth, 150 g of force per molar and 75 g of
force per premolar were chosen; these added up to
450 g of intrusive force on the rst and second
premolars and molars.
American Journal of Orthodontics and Dentofacial Orthopedics
85
In this study, the anterior open bite was corrected
by a combination of mandibular rotation and maxillary
incisor extrusion. As the maxillary posterior teeth were
intruded, simultaneous changes followed; the mandible
rotated counterclockwise, closing the anterior open bite
and resulting in forward and upward movement of
Point B and pogonion; this in turn reduced the ANB
angle, the mandibular plane angle, and the anterior
facial height. This decreased the facial soft tissue con-
vexity, improving the patient's prole (Tables III
and IV).
The achieved amount of bite closure agreed with
some previous articles.11,20,21,24,29 Overbite correction
was mostly achieved by mandibular counterclockwise
rotation (Table VII). This agrees with the results of Lee
and Park22 and Baek et al.23 However, the amount of
overbite correction that was signicantly correlated
with the amount of posterior intrusion in this study dis-
agrees with the ndings of Baek et al,23 who attributed
more contribution of anterior extrusion to overbite
correction.
The maxillary molar intrusion observed agreed with
the studies of Erverdi et al,20,37 who reported a mean
molar intrusion of 3.6 mm, and Akan et al,38 who found
a mean intrusion of the maxillary rst molar of 3.37 mm.
However, the mean maxillary molar intrusion in our
study was greater than in several studies that reported
it to be 1.8 mm,39 1.99 mm,11 2.22 mm,22
2.3 mm,21,24,25 2.4 mm,23 and 2.6 mm.29 These differ-
ences can be attributed to the heterogeneity of the initial
maxillary molar heights of the samples. Hence, in our
study, the amount of molar intrusion, calculated as a
percentage of the initial pretreatment molar height,
was 10.87% (SD, 2.46%).
There was no statistically signicant change in either
maxillary molar height or overbite during retention. Lee
and Park22 reported a comparable relapse rate (10.36%)
for the intruded maxillary molars but a greater overbite
relapse (18.10%) after the 17.4-month retention period.
On the other hand, the relapse rates in this study were
smaller than in the study of Sugawara et al,19 who re-
ported approximately a 30% relapse rate of the intruded
molars 1 year after debonding; Baek et al,23 who noted a
maxillary rst molar relapse rate of 22.88% and an over-
bite relapse rate of 17.00% by the end of the 3-year
follow-up period; and Deguchi et al,24 who found
approximately a 21.7% maxillary molar relapse rate after
2 years of retention. The increased stability reported in
this study may be attributed to the stability of the maxil-
lary molar intrusion with a strict retention protocol and
maxillary incisor extrusion achieved during treatment
that remained relatively stable in the retention period,
in addition to the absence of compensatory mandibular
July 2016  Vol 150  Issue 1
86 Marzouk and Kassem

Table VI. Correlation between total amount of relapse (T4-T2) with pretreatment severity (T1) and treatment change
(T2-T1)
Variable 1 (T1) Variable 2 (T4-T2) r P value Signicance
Pretreatment measurements (T1) and total relapse (T4-T2)
U6-PP (mm) U6-PP (mm) 0.543 0.009 y
Overbite (mm) Overbite (mm) 0.392 0.035 *
Variable 1 (T2-T1) Variable 2 (T4-T2) r P value Signicance
Amount of correction (T2-T1) and total relapse (T4-T2)
U6-PP (mm) U6-PP (mm)
0.856 0.001 y
Overbite (mm) Overbite (mm)
0.314 0.046 *

T1, Pretreatment; T2-T1, changes produced by treatment; T4-T2, changes during 4 years posttreatment.
*
P #0.05; yP #0.01.

Table VII. Correlations between treatment changes of the cephalometric measurements (T2-T1)
Variables 1 T2-T1 Variables 2 T2-T1 r P value Signicance
Overbite (mm) SN-Pog ( ) 0.656 0.001 y
Overbite (mm) SN-MP ( )
0.741 0.001 y
Overbite (mm) SNB ( ) 0.772 0.001 y
U6-PP (mm) Overbite (mm) 0.556 0.039 *
SNB ( ) SN-Pog ( ) 0.711 0.001 y
SNB ( ) SN-MP ( )
0.878 0.0001 y
VP-Pog (mm) SN-Pog ( ) 0.757 0.001 y
VP-Pog (mm) SN-MP ( )
0.391 0.046 *
VP-Pog (mm) SNB ( ) 0.545 0.027 *

T2-T1, Changes produced by treatment.

*
P #0.05; yP #0.01.

Table VIII. Comparisons between treatment changes in Angle Class I and Class II patients
Variable U6-PP (mm) T2-T1 Overbite (mm) T2-T1 L6-MP (mm) T2-T1 U1-FH (mm) T2-T1

Class Class I Class II Class I Class II Class I Class II Class I Class II

Mean
3.00
3.14 6.70 7.43 0.50 0.33 2.41 2.54
SD 0.65 1.07 1.16 3.21 0.51 0.58 0.11 0.11
Mean difference 0.14
0.73 0.17
0.13
P value 0.75 0.58 0.72 0.03
Signicance NS NS NS *

T2-T1, changes produced by treatment; NS, not signicant.

*P #0.05.

extrusion during intrusion and after treatment, contrary
to that reported by Sugawara et al.19
In our study, the rst year accounted for 76.29% and
73.2% of the total relapses of molar intrusion and over-
bite, respectively. Baek et al23 reported that 80% of the
total relapse of the maxillary molars took place during
the rst year after treatment. This emphasizes the impor-
tance of applying effective posttreatment retention dur-
ing the rst year to minimize relapse and enhance the
long-term stability of the treatment.
The stability rates of open-bite correction in this
study were considered comparable with the rates re-
ported in various orthognathic surgical procedures for
anterior open-bite patients, ranging from 75% to
85%.12,14-16 This demonstrates that in addition to the
advantage of no major surgery, the combined usage
of zygomatic miniplate anchorage for molar intrusion
and rst premolar extractions can be considered a
stable method for correcting skeletal anterior open
bites.

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Marzouk and Kassem
The maxillary incisor extrusion was relatively stable
after debonding until the end of the 4-year follow-up.
Sugawara et al19 also reported nonsignicant changes
of the extruded incisors at 1 year after treatment. How-
ever, Schefer et al25 reported intrusion of the maxillary
incisors greater than 2 mm in 4% of the subjects after
1 year and 8% after 2 years. They believed that the inci-
sors that were elongated during treatment relapsed dur-
ing retention. Conversely, Baek et al23 reported extrusion
of the incisors during retention that may have helped to
maintain the corrected open bite.
Lee and Park22 and Baek et al23 found that the initial
overbite did not correlate with the overbite relapse. How-
ever, in this study, there was a signicant positive corre-
lation between the extent of the initial maxillary
posterior dentoalveolar height and the total amount of
relapse of the molar intrusion. A similar correlation was
found between the initial open-bite severity and the
amount of overbite relapse 4 years after treatment
(Table VI). Hence, it can be concluded that the greater
the pretreatment molar height and the amount of open
bite, the greater the amount of relapse to be expected.
On the other hand, the amounts of molar intrusion
and overbite improvement achieved from treatment
signicantly and negatively correlated with the degrees
of their relapse (Table VI). Similar correlations were
found by Lee and Park,22 whereas Baek et al23 reported
a signicant correlation for the change in overbite only.
Therefore, our results support the premises that the
initial open-bite severity and the amount of open-bite
correction play important roles in open-bite relapse.40-44
Hence, it is advisable to overcorrect the overbite to
counteract the inevitable relapse and to match the
overcorrection to the initial severity of the malocclusion.
The absence of signicant differences between the
treatment changes in the Angle Class I and Class II pa-
tients, except for a minimal difference in the maxillary
incisor height (Table VIII), indicates that the class of
the malocclusion was not a confounding variable.
CONCLUSIONS
1. The mean maxillary molar intrusion with zygomatic
miniplates was 3.04 mm associated with a mean
overbite closure of 6.93 mm.
2. The intruded maxillary molars relapsed by 10.2% in
the rst year and by 13.37% by 4 years after treat-
ment. Overbite relapse amounts were 8.19% and
11.18% at 1 year and 4 years posttreatment, respec-
tively.
3. The rst year after treatment accounted for 76.29%
and 73.2% of the total relapse of molar intrusion
and overbite, respectively.
American Journal of Orthodontics and Dentofacial Orthopedics
87
4. The amounts of total relapse of molar intrusion and
overbite were positively correlated with the amount
of pretreatment maxillary molar height and the
initial open-bite severity, respectively, but nega-
tively correlated with the amounts of molar intru-
sion and open-bite correction achieved by
treatment.
5. The stability of the open-bite patients in this study
was attributed to the stability of the maxillary molar
intrusion and the maxillary incisor extrusion.
ACKNOWLEDGMENTS
We thank Dr Mohamed M. Fata, professor of Cranio-
Maxillofacial and Plastic Surgery, Faculty of Dentistry
at Alexandria University, for surgical placement of the
miniplates.
REFERENCES
1. Subtelny JD, Sakuda M. Open-bite: diagnosis and treatment. Am J
Orthod 1964;50:337-58.
2. Epker BN, Fish L. Surgical-orthodontic correction of open-bite
deformity. Am J Orthod 1977;71:278-99.
3. Burford D, Noar JH. The causes, diagnosis and treatment of ante-
rior open bite. Dent Update 2003;30:235-41.
4. Cooke MS. Anterior open bite. Orthodontic aspectspart 1. Dent
Update 1980;7:475-6:478-81.
5. Cooke MS. Anterior open bite. Orthodontic aspectspart 2. Dent
Update 1981;8:33-41.
6. Ngan P, Fields HW. Open bite: a review of etiology and manage-
ment. Pediatr Dent 1997;19:91-8.
7. de Freitas MR, Beltr~ao RT, Janson G, Henriques JF, Chiqueto K.
Evaluation of root resorption after open bite treatment with and
without extractions. Am J Orthod Dentofacial Orthop 2007;132:
143.e15-22.
8. Nahoum HI, Horowitz SL, Benedicto EA. Varieties of anterior
open-bite. Am J Orthod 1972;61:486-92.
9. Kim YH. Anterior openbite and its treatment with multiloop edge-
wise archwire. Angle Orthod 1987;57:290-321.
10. K kkeles N, Acar A, Demirkaya AA, Evrenol B, Enacar A. Ceph-
ucu
alometric evaluation of open bite treatment with NiTi arch wires
and anterior elastics. Am J Orthod Dentofacial Orthop 1999;116:
555-62.
11. Sherwood KH, Burch JG, Thompson WJ. Closing anterior open
bites by intruding molars with titanium miniplate anchorage.
Am J Orthod Dentofacial Orthop 2002;122:593-600.
12. Hoppenreijs TJ, Freihofer HP, Stoelinga PJ, Tuinzing DB, van't
Hof MA, van der Linden FP, et al. Skeletal and dento-alveolar
stability of Le Fort I intrusion osteotomies and bimaxillary osteot-
omies in anterior open bite deformities. A retrospective three-
centre study. Int J Oral Maxillofac Surg 1997;26:161-75.
13. Proft WR, Bailey LJ, Phillips C, Turvey TA. Long-term stability of
surgical open-bite correction by Le Fort I osteotomy. Angle Orthod
2000;70:112-7.
14. Swinnen K, Politis C, Willems G, De Bruyne I, Fieuws S,
Heidbuchel K, et al. Skeletal and dento-alveolar stability after
surgical-orthodontic treatment of anterior open bite: a retrospec-
tive study. Eur J Orthod 2001;23:547-57.
July 2016  Vol 150  Issue 1
88
15. Ding Y, Xu TM, Lohrmann B, Gellrich NC, Schwestka-Polly R. Sta-
bility following combined orthodontic-surgical treatment for skel-
etal anterior open bitea cephalometric 15-year follow-up study. J
Orofac Orthop 2007;68:245-56.
16. Espeland L, Dowling PA, Mobarak KA, Stenvik A. Three-year stabil-
ity of open-bite correction by 1-piece maxillary osteotomy. Am J
Orthod Dentofacial Orthop 2008;134:60-6.
17. Greenlee GM, Huang GJ, Chen SS, Chen J, Koepsell T, Hujoel P.
Stability of treatment for anterior open-bite malocclusion: a
meta-analysis. Am J Orthod Dentofacial Orthop 2011;139:154-69.
18. Erverdi N, Tosun T, Keles A. A new anchorage site for the treatment
of anterior open bite: zygomatic anchorage case report. World J
Orthod 2002;43:l47-53.
19. Sugawara J, Baik UB, Umemori M, Takahashi I, Nagasaka H,
Kawamura H, et al. Treatment and posttreatment dentoalveolar
changes following intrusion of mandibular molars with applica-
tion of a skeletal anchorage system (SAS) for open bite correction.
Int J Adult Orthodon Orthognath Surg 2002;17:243-53.
20. Erverdi N, Usumez S, Solak A, Koldas T. Noncompliance open-bite
treatment with zygomatic anchorage. Angle Orthod 2007;77:
986-90.
21. Kuroda S, Sakai Y, Tamamura N, Deguchi T, Takano-Yamamoto T.
Treatment of severe anterior open bite with skeletal anchorage in
adults: comparison with orthognathic surgery outcomes. Am J Or-
thod Dentofacial Orthop 2007;132:599-605.
22. Lee HA, Park YC. Treatment and posttreatment changes following
intrusion of maxillary posterior teeth with miniscrew implants for
open bite correction. Korean J Orthod 2008;38:31-40.
23. Baek MS, Choi YJ, Yu HS, Lee KJ, Kwak J, Park YC. Long-term sta-
bility of anterior open-bite treatment by intrusion of maxillary pos-
terior teeth. Am J Orthod Dentofacial Orthop 2010;138:396.e1-9.
24. Deguchi T, Kurosaka H, Oikawa H, Kuroda S, Takahashi I,
Yamashiro T, et al. Comparison of orthodontic treatment out-
comes in adults with skeletal open bite between conventional
edgewise treatment and implant-anchored orthodontics. Am J Or-
thod Dentofacial Orthop 2011;139(Suppl):S60-8.
25. Schefer NR, Proft WR, Phillips C. Outcomes and stability in pa-
tients with anterior open bite and long anterior face height treated
with temporary anchorage devices and a maxillary intrusion splint.
Am J Orthod Dentofacial Orthop 2014;146:594-602.
26. Bondemark L, Holm AK, Hansen K, Axelsson S, Mohlin B,
Brattstrom V, et al. Long-term stability of orthodontic treatment
and patient satisfaction. A systematic review. Angle Orthod
2007;77:181-91.
27. Haralabakis N, Papadakis G. Relapse after orthodontics and or-
thognathic surgery. World J Orthod 2005;6:125-40.
July 2016  Vol 150  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Marzouk and Kassem
28. Dupont WD, Plummer WD Jr. Power and sample size calculations.
A review and computer program. Control Clin Trials 1990;11:
116-28.
29. Erverdi N, Keles A, Nanda R. The use of skeletal anchorage in open
bite treatment: a cephalometric evaluation. Angle Orthod 2004;
74:381-90.
30. Burstone CJ, James RB, Legan H, Murphy GA, Norton LA. Cepha-
lometrics for orthognathic surgery. J Oral Surg 1978;36:269-77.
31. Marzouk ES, Abdallah EM, El-Kenany WA. Molar intrusion in
open-bite adults using zygomatic miniplates. Int J Orthod Mil-
waukee 2015;26:47-54.
32. Giuca MR, Pasini M, Pagano A, Mummolo S, Vanni A. Longitudinal
study on a rehabilitative model for correction of atypical swallow-
ing. Eur J Paediatr Dent 2008;9:170-4.
33. Baumrind S, Miller D, Molthen R. The reliability of head lm mea-
surements. 3. Tracing superimposition. Am J Orthod 1976;70:
617-44.
34. Kuroda S, Katayama A, Takano-Yamamoto T. Severe anterior
open-bite case treated using titanium screw anchorage. Angle Or-
thod 2004;74:558-67.
35. Park YC, Lee SY, Kim DH, Jee SH. Intrusion of posterior teeth using
mini-screw implants. Am J Orthod Dentofacial Orthop 2003;123:
690-4.
36. Yao CC, Lee JJ, Chen HY, Chang ZC, Chang HF, Chen YJ. Maxillary
molar intrusion with xed appliances and mini-implant anchorage
studied in three dimensions. Angle Orthod 2005;75:754-60.
37. Erverdi N, Usumez S, Solak A. New generation open-bite treatment
with zygomatic anchorage. Angle Orthod 2006;76:519-26.
38. Akan S, Kocadereli I, Aktas A, Tasar F. Effects of maxillary molar
intrusion with zygomatic anchorage on the stomatognathic sys-
tem in anterior open bite patients. Eur J Orthod 2013;35:93-102.
39. Xun C, Zeng X, Wang X. Microscrew anchorage in skeletal anterior
open-bite treatment. Angle Orthod 2007;77:47-56.
40. Enacar A, Ugur T, Toroglu S. A method for correction of open bite.
J Clin Orthod 1996;30:43-8.
41. Huang GJ, Justus R, Kennedy DB, Kokich VG. Stability of anterior
openbite treated with crib therapy. Angle Orthod 1990;60:17-24.
42. Nahoum HI. Vertical proportions: a guide for prognosis and treat-
ment in anterior open-bite. Am J Orthod 1977;72:128-46.
43. Nielsen IL. Vertical malocclusions: etiology, development, diag-
nosis and some aspects of treatment. Angle Orthod 1991;61:
247-60.
44. de Freitas MR, Beltr~ao RT, Janson G, Henriques JF, Cancado RH.
Long-term stability of anterior open bite extraction treatment in
the permanent dentition. Am J Orthod Dentofacial Orthop 2004;
125:78-87.