Documente Academic
Documente Profesional
Documente Cultură
Introduction: This study was a cephalometric evaluation of the growth changes in untreated subjects with min-
imal overbite at 4 time points during 4 developmental stages from the early mixed dentition to the permanent
dentition, as well as from the prepubertal phase to young adulthood. Methods: A sample of 24 untreated sub-
jects with minimal overbite (\1.5 mm) was selected retrospectively from the University of Michigan Growth Study
and the Denver Child Growth Study. The sample was followed longitudinally from about 9 years of age through
17 years of age. Dentofacial changes at the 4 times (T1-T4), dened by the cervical vertebral maturation method,
were analyzed on lateral cephalograms. Nonparametric statistical analysis was used for comparisons. Results:
Overbite on average increased by 2.3 mm during the overall observation period. Improvement occurred during
the prepubertal interval (T1-T2; 2.4 mm), whereas no signicant changes occurred in the pubertal and
postpubertal stages. From prepubertal ages to young adulthood, the open-bite tendency improved in 91% of
the subjects, with self-correction in 75%. Logistic regression analysis on the cephalometric variables at T1
with the value of overbite at T4 did not show a statistically signicant correlation. Conclusions: Subjects with
an open-bite tendency show improvement of their occlusal condition during the prepubertal stage, but there is
no signicant improvement after this. These results provide useful indications for appropriate orthodontic
treatment timing for patients with an open-bite tendency. (Am J Orthod Dentofacial Orthop 2014;145:28-35)
O
pen bite is an occlusal trait characterized by a sucking habits and facial hyperdivergent characteristics
lack of vertical overlap of the incisors.1 A reduced have been shown to be signicant risk factors for
depth of the bite can be associated with skeletal anterior open bite in the mixed dentition.7 Patients
hyperdivergence, otherwise referred to as long-face syn- with open bite mainly seek treatment on esthetic
drome or high-angle disharmony.2,3 The incidence of grounds, but there can be functional problems such as
anterior open bite varies according to age and ethnic difculty incising food and speech problems such as
group.4 In the United States, the reported incidence in lisping associated with this malocclusion.4
children is 3.5%, with the prevalence decreasing during There is no generally accepted method to identify a
adolescence.5 Anterior open bite is more common in Af- patient with an open-bite tendency.8 Various cephalo-
ricans and Afro-Caribbeans (5%-10%).5,6 Prolonged metric characteristics have been ascribed to patients
with an anterior open bite or an open-bite tendency,
a
Orthodontist, Discipline of Orthodontics, Faculty of Dentistry, University of including a large mandibular plane angle, increased total
Sydney, Surry Hills, New South Wales, Australia. and lower anterior face height, decreased posterior face
b
Research professor, Department of Orthodontics, University of Florence, Flor-
ence, Italy; Thomas M. Graber Visiting Scholar, Department of Orthodontics height, increased gonial angle, short ramus, low
and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor. posterior-to-anterior face height ratio, and large ante-
rior dentoalveolar heights in both jaws.2,8-10
c
Professor and chair, Discipline of Orthodontics, Faculty of Dentistry, University
of Sydney, Surry Hills, New South Wales, Australia.
d
Thomas M. and Doris Graber Endowed Professor of Dentistry, Department of Klocke et al,8 among others, stated that there is gen-
Orthodontics and Pediatric Dentistry, School of Dentistry; research professor, eral agreement that patients with anterior open bite or
Center for Human Growth and Development, University of Michigan, Ann Arbor; an open bite tendency are among the most challenging
private practice, Ann Arbor, Mich.
y
Deceased. to treat. Relapse is a common nding after open-bite
All authors have completed and submitted the ICMJE Form for Disclosure of Po- correction with both orthodontic treatment11 and surgi-
tential Conicts of Interest, and none were reported. cal orthodontic therapy.12 Despite the difculty that this
Address correspondence to: M. Ali Darendeliler, Discipline of Orthodontics, Fac-
ulty of Dentistry, University of Sydney, Level 2, 2 Chalmers St, Surry Hills NSW type of malocclusion poses for clinicians, few studies
2010, Australia; e-mail, adarende@mail.usyd.edu.au. have analyzed changes in the depth of the bite in sub-
Submitted, December 2011; revised and accepted, September 2013. jects with an open-bite tendency during growth. Studies
0889-5406/$36.00
Copyright 2014 by the American Association of Orthodontists. have described the development of normal overbite and
http://dx.doi.org/10.1016/j.ajodo.2013.09.013 its variations during the mixed and permanent
28
Phelan et al 29
American Journal of Orthodontics and Dentofacial Orthopedics January 2014 Vol 145 Issue 1
30 Phelan et al
Fig 1. Schematic representation of the stages of the cervical vertebral maturation method.
McNamara28 was used, generating 29 variables: 9 The errors for linear measurements ranged from 0.2
angular, 19 linear, and 1 ratio for each tracing. mm (overjet) to 0.8 mm (Pg to nasion perpendicular);
Four serial cephalograms for each subject were traced the errors for angular measurements varied from 0.4
at the same time. Fiducial markers were placed in the (ANB) to 1.6 (interincisal angle).
maxilla and the mandible on the rst tracing and then The assessment of the stages in cervical vertebral
transferred to the second, third, and fourth tracings in maturation on the lateral cephalograms of each subject
each subject's cephalometric series, based on superim- was performed by 1 investigator (A.C.P.) and then veri-
positions of internal maxillary or mandibular structures. ed by an expert examiner (T.B.).24 Any disagreements
The maxillae were superimposed along the palatal plane were resolved to the satisfaction of both observers.
by registering on the bony internal details of the maxilla
superior to the incisors and the superior and inferior sur-
Statistical analysis
faces of the hard palate. Fiducial markers were placed in
the anterior and posterior parts of the maxilla along the Descriptive statistics of the craniofacial measure-
palatal plane. This superimposition describes the move- ments in the open-bite sample at all 4 observation pe-
ment of the maxillary dentition. riods were calculated, as well as the between-stage
The mandibles were superimposed on the outline of changes (T2-T1, T3-T2, T4-T3, and the overall T4-
the mandibular canal, the anterior contour of the chin, T1). The Kolmogorov-Smirnov test showed a lack of
and the bony structures of the symphysis.27,28 A normal distribution for several measurements in the
ducial marker was placed in the center of the study. Therefore, comparisons of the values of the
symphysis and another in the body of the mandible cephalometric variables at the 4 time periods were
near the gonial angle. This superimposition describes carried out with nonparametric statistics with the
the movement of the mandibular dentition relative to Friedman test (analysis of variance on ranks for
the mandible. repeated measures) followed by Tukey post hoc tests
The magnication of the 2 data sets was different, (SigmaStat 3.5).
with the lateral cephalograms from the University of Prevalence rates for the following changes in overbite
Michigan study having a magnication of 12.9% and were calculated at T2, T3, and T4 with respect to the
those from the Denver study at 4%. Therefore, the lateral initial values at T1, and they were expressed in terms
cephalograms from the 2 studies were corrected to an of the numbers of subjects showing the change during
8% enlargement factor. specic time intervals (T1-T2, T1-T3, and T1-T4):
The power of the study when assessing cumulative improvement in overbite equal to or greater than 11.5
treatment changes (T1-T4) was calculated on the basis mm (more positive change), improvement in overbite
of an effect size equal to 129 (SigmaStat 3.5; Systat Soft- equal to or greater than 10.5 mm (more positive
ware, Point Richmond, Calif). The power of our study change), or worsening in overbite equal to or less than
with a sample size of 24 subjects was 0.93 at an 0.5 mm (more negative change).
alpha 5 0.05. The prevalence rates of subjects showing correction
A total of 42 lateral cephalograms randomly chosen of open bite at T2, T3, and T4 were calculated. Correc-
from all observations were retraced and redigitized to tion of open bite was assessed when the overbite value
calculate the method error with Dahlberg's formula.30 was greater than 1.5 mm at the specic time point.
January 2014 Vol 145 Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Phelan et al 31
Logistic regression on the cephalometric variables mandibular plane. The variables N-ANS, ANS-Me,
at T1, with the value of overbite at T4 (classied as N-Me, S-Go, Co-Go, and S-Go/N-Me exhibited signi-
self-corrected when overbite was greater than 1.5 cant increases during the prepubertal, pubertal, and
mm vs not corrected when overbite was still less overall growth intervals, with the exception of ANS-Me
than 1.5 mm) as the dependent variable, was performed at the prepubertal interval and S-Go/N-Me at the puber-
(stepwise method, with P to enter \0.05 and P to tal interval. N-Me also increased signicantly in the
remove .0.1). The basic idea of the stepwise method postpubertal T3 to T4 interval. The gonial angle (Ar-
is to add variables (with P values smaller than 0.05) GoiMe) exhibited a signicant decrease during all
one at a time as long as these additions improve the growth intervals.
model the most. After a variable has been added, all ef- For interdental relationships, a signicant decrease in
fects in the current model are checked to see whether any overjet was detected during the overall observation in-
of them should be removed (with P values greater than terval T1 to T4 (1 mm). Overbite showed a signicant
0.1). Then the process continues until the model cannot increase during the prepubertal growth interval (2.4 mm)
be further improved. The aim of logistic regression was and an insignicant change during the pubertal and
to identify T1 predictive variables for favorable or unfa- postpubertal growth intervals; this contributed to a sig-
vorable individual outcomes in overbite. Logistic regres- nicant increase during the overall observation interval
sion was carried out with statistical software (version (2.3 mm). The molar relationship had a signicant in-
17.0; SPSS, Chicago, Ill). crease during the overall interval (1.1 mm).
For the maxillary dentoalveolar relationships, signif-
icant vertical alveolar growth of the central incisors was
RESULTS
found during all growth intervals.31 The maxillary rst
Descriptive statistics for the cephalometric measure- molars moved downward signicantly at all observation
ments at the 4 observation periods and the statistical intervals. There were signicant decreases in the central
comparisons among the stages are reported in Table I. incisor to Frankfort horizontal angulation between T1
No signicant growth changes were detected in the and T2 (2.1 ) and during the overall observation inter-
cranial base angle. val T1 to T4 (3.1 ).
For maxillary skeletal size and position, SNA For the mandibular dentoalveolar relationships, the
increased signicantly during the overall observation in- central incisors showed vertical alveolar growth during
terval T1 to T4 (1.2 ). Point A to nasion perpendicular the prepubertal, pubertal, and overall observation inter-
increased during the overall observation interval (0.4 vals (5.8 mm). A signicant increase in the vertical alve-
mm), but this difference was not statistically signicant. olar growth of the mandibular rst molars was also
Co-Point A increased signicantly at all growth inter- detected during the prepubertal, pubertal, and overall
vals except the postpubertal T3-T4 interval. observation intervals (5.2 mm).
For mandibular skeletal size and position, SNB The analysis of the prevalence rates of open-bite sub-
increased signicantly during the overall observation in- jects showing either improvement or worsening in over-
terval T1 to T4 (2.0 ). Pogonion to nasion perpendicular bite during the growth intervals (Table II) showed that no
increased signicantly during this interval (2.5 mm), subject worsened during the prepubertal T1 to T2 inter-
whereas Co-Gn increased signicantly at all growth in- val, and 83% of the subjects had an improvement in
tervals. overbite greater than or equal to 1.5 mm. When the pu-
For the sagittal skeletal relationships, the ANB angle bertal T2 to T3 interval was included in the observation
decreased signicantly during the overall observation interval (T1-T3), the prevalence rate for subjects
interval T1 to T4 (0.9 ), whereas the Wits appraisal showing improvement in open bite greater than or equal
increased signicantly during this period (1.8 mm). Sig- to 0.5 mm was 92%; 71% of the subjects showed
nicant increments in the maxillomandibular differen- improvement greater than or equal to 1.5 mm.
tial were found during the pubertal and overall growth The analysis of the overall observation interval T1 to
intervals. T4 indicated that 92% of the subjects who started the
For the vertical skeletal relationships, no signicant observation interval with an open bite had an improve-
growth changes were detected in the inclination of the ment in overbite greater than or equal to 0.5 mm when
palatal plane relative to the Frankfort horizontal, they were examined in young adulthood. Seventy-one
whereas the inclination of the mandibular plane to the percent of the subjects showed an improvement in over-
Frankfort horizontal decreased signicantly during the bite greater than or equal to 1.5 mm during the overall
overall growth interval (2.3 ). These changes also are observation interval, but only 4% had worsening in the
reected in the inclination of the palatal plane to the vertical overlap of the incisors. With regard to the
American Journal of Orthodontics and Dentofacial Orthopedics January 2014 Vol 145 Issue 1
32 Phelan et al
Table I. Descriptive statistics for the cephalometric measurements at the 4 observation periods
T1 T2 T3 T4 Growth changes and statistical comparisons
*P \0.05.
correction of open bite (overbite .1.5 mm), 75% of the followed longitudinally from about 9 years of age until
subjects achieved open-bite correction at T2; this young adulthood. The pertinent features of this study
correction was maintained at T4. compared with previous investigations of the change in
Logistic regression on the cephalometric variables at overbite are (1) specic focus on subjects with an open-
T1 with the value of overbite at T4 (classied as self- bite tendency irrespective of their sagittal relationships;
corrected when overbite was .1.5 mm vs not (2) longitudinal study with an adequate sample size (prior
corrected when overbite was still \1.5 mm) as the investigations were semilongitudinal,19 or the subjects
dependent variable indicated no statistically signicant with minimal overbite or open bite were a subsample of
relationships. larger longitudinal studies on overbite changes15,18,19);
and (3) classication of growth intervals with a biologic
indicator of skeletal maturity.24 The cervical vertebral
DISCUSSION maturation method enables changes in overbite to be
We evaluated the growth changes in orthodontically evaluated in relation to skeletal maturity rather than
untreated subjects with minimal overbite (#1.5 mm) only chronologic age intervals.
January 2014 Vol 145 Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Phelan et al 33
American Journal of Orthodontics and Dentofacial Orthopedics January 2014 Vol 145 Issue 1
34 Phelan et al
open-bite tendency was self-correcting in 75% of the 4. Burford D, Noar JH. The causes, diagnosis and treatment of ante-
subjects by the pubertal period. These results suggest rior open bite. Dent Update 2003;30:235-41.
5. Kelly JE, Harvey CR. An assessment of the occlusion of the teeth of
that early treatment is not advisable for patients with
youths 12-17 years. DHEW Publication No (HRA) 77-1644. Wash-
an open-bite tendency in the prepubertal period ington, DC: National Center for Health Statistics; 1977.
because most self-correct without intervention. The 6. Noar JH, Portnoy S. Dental status of children in a primary and sec-
ndings of Hellman40 also support this recommenda- ondary school in rural Zambia. Int Dent J 1991;41:142-8.
tion: he found an equivalent rate of correction with un- 7. Cozza P, Baccetti T, Franchi L, Mucedero M, Polimenie A. Sucking
habits and facial hyperdivergency as risk factors for anterior open
treated open-bite patients as those who had received
bite in the mixed dentition. Am J Orthod Dentofacial Orthop 2005;
early treatment to correct the open bite. 128:517-9.
The cervical vertebral maturation method has been 8. Klocke A, Nanda RS, Kahl-Nieke B. Anterior open bite in the
used previously in appraisals of treatment timing for an deciduous dentition: longitudinal follow-up and craniofacial
orthopedic approach to treatment in patients with an growth considerations. Am J Orthod Dentofacial Orthop 2002;
122:353-8.
increased vertical dimension.24,38 The results indicated
9. Ceylan I, Eroz B. The effect of overbite on the maxillary and
that a signicantly more favorable effect can be mandibular morphology. Angle Orthod 2001;71:110-5.
obtained when expansion and vertical-pull chincup 10. Betzanberger D, Ruf S, Pancherz H. The compensatory mechanism
treatment are used at the peak in mandibular growth in high-angle malocclusions: a comparison of subjects in the
(CS 3) compared with treatment at an earlier maturational mixed and permanent dentition. Angle Orthod 1999;69:27-32.
11. Lopez-Gavito G, Wallen TR, Little RM, Joondeph DR. Anterior
stage (CS 1).24,38 Our results also support the treatment
open-bite malocclusion: a longitudinal 10-year post-retention
timing recommendation, and it is therefore advisable to evaluation of orthodontically treated patients. Am J Orthod
wait until the pubertal growth spurt before undertaking 1985;87:175-86.
treatment in subjects with an open-bite tendency. How- 12. Fisher K, von Konow L, Brattstr om V. Open bite: stability after bi-
ever, to strengthen this recommendation, a longitudinal maxillary surgery2 year treatment outcomes in 58 patients. Eur J
Orthod 2000;22:711-8.
growth study in subjects with severe open bite is required.
13. Baume LJ. Physiological tooth migration and its signicance for
the development of the occlusion. J Dent Res 1950;29:123-32.
CONCLUSIONS 14. Bjork A. Variability and age changes in overjet and overbite. Am J
Orthod 1953;39:779-801.
This longitudinal study on dentofacial growth
15. Moorrees CFA. The dentition of the growing child. Cambridge,
changes in subjects with an open-bite tendency showed Mass: Harvard University Press; 1959.
the following. 16. Fleming HB. An investigation of the vertical overbite during the
eruption of the permanent dentition. Angle Orthod 1961;31:
1. Overbite increased on average by 2.3 mm during the 53-62.
overall observation interval T1 to T4. The improve- 17. Moyers RE, van der Linden FPGM, Riolo ML, McNamara JA Jr.
ment occurred during the prepubertal interval T1 to Standards of human occlusal development. Monograph 5. Cranio-
T2 (2.4 mm), whereas no signicant change facial Growth Series. Ann Arbor: Center for Human Growth and
Development; University of Michigan; 1976.
occurred in the pubertal and postpubertal stages.
18. Bishara SE, Jakobsen JR. Changes in overbite and face height from
2. From prepubertal ages to young adulthood, an 5 to 45 years of age in normal subjects. Angle Orthod 1998;68:
open-bite tendency improves in 91% of the subjects 209-16.
and self-corrects in 75% of the subjects. 19. Bergersen E. A longitudinal study of anterior vertical overbite from
3. There are no predictive variables at T1 for favorable eight to twenty years of age. Angle Orthod 1988;58:237-56.
20. Worms FW, Meskin LH, Isaacson RJ. Open-bite. Am J Orthod 1959;
or unfavorable outcomes in overbite.
59:589-95.
4. The growth changes in such patients provide indica- 21. Gu Y, McNamara JA Jr. Mandibular growth changes and cervical
tions for timing of orthodontic treatment. It is vertebral maturation. Angle Orthod 2007;77:947-53.
advisable to wait until the pubertal growth spurt 22. Franchi L, Baccetti T, McNamara JA Jr. Thin-plate spline analysis
before undertaking treatment in subjects with an of mandibular growth. Angle Orthod 2001;71:83-9.
23. Stahl F, Baccetti T, Franchi L, McNamara JA Jr. Longitudinal
open-bite tendency.
growth changes in untreated subjects with Class II Division 1
malocclusion. Am J Orthod Dentofacial Orthop 2008;134:125-37.
REFERENCES 24. Baccetti T, Franchi L, McNamara JA Jr. The cervical vertebral
maturation (CVM) method for the assessment of optimal treatment
1. Daskalogiannakis J. Glossary of orthodontic terms. Chicago: Quin- timing in dentofacial orthopedics. Semin Orthod 2005;11:119-29.
tessence; 2000. p. 187-8. 25. Steiner CC. Cephalometrics for you and me. Am J Orthod 1953;39:
2. Schendel SA, Eisenfeld J, Bell WH, Epker BN, Mishelevich OJ. The 729-55.
long face syndrome: vertical maxillary excess. Am J Orthod 1976; 26. Jacobson A. The Wits appraisal of jaw disharmony. Am J Orthod
70:398-408. 1975;67:125-38.
3. Schudy FF. Vertical growth versus anteroposterior growth as 27. Ricketts RM. Perspectives in the clinical application of cephalomet-
related to function and treatment. Angle Orthod 1964;34:75-93. rics. The rst fty years. Angle Orthod 1981;51:115-50.
January 2014 Vol 145 Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Phelan et al 35
28. McNamara JA Jr. A method of cephalometric evaluation. Am J Or- 35. Bjork A, Skieller V. Normal and abnormal growth of the mandible:
thod 1984;86:449-69. a synthesis of longitudinal cephalometric implant studies over a
29. Cohen J. A power primer. Psychol Bull 1992;112:155-9. period of 25 years. Eur J Orthod 1983;5:1-46.
30. Dahlberg G. Statistical methods for medical and biological stu- 36. Bjork A, Skieller V. Facial development and tooth eruption. An
dents. New York: Interscience Publications; 1940. implant study at the age of puberty. Am J Orthod 1972;62:339-83.
31. Enlow DH. Handbook of facial growth. 3rd ed. Philadelphia: W.B. 37. Baccetti T, Franchi L, McNamara JA Jr. Longitudinal growth
Saunders; 1990. p. 120. changes in subjects with deepbite. Am J Orthod Dentofacial Or-
32. Jonsson T, Arnlaugsson S, Saemundsson SR, Magnusson TE. thop 2011;140:202-9.
Development of occlusal traits and dental arch space from adoles- 38. Baccetti T, Franchi L, Schulz SO, McNamara JA Jr. Treatment
cence to adulthood: a 25-year follow-up study of 245 untreated timing for an orthopedic approach to patients with increased ver-
subjects. Am J Orthod Dentofacial Orthop 2009;135:456-62. tical dimension. Am J Orthod Dentofacial Orthop 2008;133:
33. Steedle JR, Proft WR. The pattern and control of eruptive tooth 58-64.
movement. Am J Orthod 1985;87:56-66. 39. Subtelny JD, Sakuda M. Open-bite: diagnosis and treatment. Am J
34. Proft WR, Fields HW, Sarver DM. Contemporary orthodontics. 4th Orthod 1964;50:337-58.
ed. St Louis: Mosby; 2000. 40. Hellman M. Open bite. Int J Orthod 1931;17:421.
American Journal of Orthodontics and Dentofacial Orthopedics January 2014 Vol 145 Issue 1