CASE REPORT

Long-term stability of a Class III

malocclusion with severe anterior open
bite and bilateral posterior crossbite in a
hyperdivergent patient
Oscar Mario Antelo,a Thiago Martins Meira,a Dauro Douglas Oliveira,b Matheus Melo Pithon,c
and Orlando Motohiro Tanakaa
Curitiba, Belo Horizonte, Minas Gerais, and Bahia, Brazil

Anterior open bite malocclusion is generally associated with several causes. This case report describes the 2-
phase treatment of a 13-year-old boy with a Class III malocclusion, severe anterior open bite, and bilateral pos-
terior crossbite treated without surgical intervention. An orthopedic approach was performed in phase 1 with a
hyrax-type palatal expander, followed by maxillary protraction with a facemask for a 10-month period to promote
the correction of transverse and sagittal deviations. In phase 2, a comprehensive orthodontic approach using
fixed preadjusted appliances associated with intermaxillary elastics was performed. These approaches, com-
bined with good patient compliance, established a functional and esthetic occlusal relationship, normal overjet
and overbite, and a well-balanced facial appearance. The 4.5-year follow-up indicated that treatment results
were stable. (Am J Orthod Dentofacial Orthop 2020;157:408-21)

A
nterior open bite malocclusion represents one of Posterior crossbite can be of skeletal origin when a
the most challenging issues in orthodontics, and transverse skeletal deficiency of the maxilla is present,
relapse is prone to occur after treatment. or it can be of dental origin when an altered tooth posi-
Furthermore, treatment difficulty increases considerably tion in the palatal or buccal direction is present.4,5
when associated with a Class III malocclusion and bilat- Class III malocclusion etiology is multifactorial and
eral posterior crossbite. Anterior open bite etiology is occurs because of interactions involving heredity and
multifactorial, including unfavorable vertical growth environmental factors.6 Moreover, Class III malocclusion
pattern, mouth breathing, oral habits, and abnormal po- may present dental or skeletal implications.7 However,
sition and function of the tongue.1,2 The morphology of the Class III dental relationship can be treated orthodon-
an anterior open bite with a skeletal component includes tically with a good prognosis. Depending on its severity,
an open mandibular plane angle and an increase in ante- a skeletal Class III relationship is more difficult to treat
rior facial height, which primarily reflects the clockwise and tends to relapse and require, on several occasions,
rotation of the mandible and the vertical growth of the to perform orthodontic-surgical procedures for
maxilla.3 adequate correction.8 This problem is characterized by
the presence of one or a combination of the following
factors: maxillary retrognathism and mandibular prog-
a
Graduate Dentistry Program, School of Life Sciences, Pontifical Catholic Univer- nathism.9
sity of Paran
a, Curitiba, Brazil.
b
Department of Orthodontics, Pontifical Catholic University of Minas Gerais, Belo
This case report presents the clinical case of a
Horizonte, Minas Gerais, Brazil. 13-year-old boy with a Class III malocclusion, severe
c
Southwest Bahia State University, Jequi
e, Bahia, Brazil. anterior open bite, and bilateral posterior crossbite
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
treated without surgery over 2 phases of treatment us-
Address correspondence to: Orlando Motohiro Tanaka, Graduate Dentistry Pro- ing orthopedic and comprehensive orthodontic ap-
gram in Orthodontics, School of Life Sciences, Pontif
ıcia Universidade Cat
olica proaches.
do Paran
a, R. Imaculada Conceiç~ao, 1155, Curitiba 80215-901, Brazil; e-mail,
[email protected].
Submitted, revised, August 2018; accepted, October 2018. DIAGNOSIS AND ETIOLOGY
0889-5406/$36.00
Ó 2019 by the American Association of Orthodontists. All rights reserved. A 13-year-old boy arrived with his older sister to the
https://doi.org/10.1016/j.ajodo.2018.10.029 orthodontic consultation with the chief complaint of
408
Antelo et al 409

Fig 1. Pretreatment facial and intraoral photographs.

open and inverted bite. An extraoral evaluation showed a position of the tongue at rest and a tongue-thrust
hyperdivergent pattern of growth, symmetrical face, and swallowing pattern.
a straight profile with a relatively strong chin projection The panoramic radiograph indicated that the third
(Fig 1). molars were in development (Fig 3). Despite the dental
Intraorally, he exhibited a severe angle Class III Class III malocclusion presented (AoBo5 -7
), the lateral
malocclusion on both sides, bilateral posterior cross- cephalometric analysis indicated a skeletal Class I rela-
bite, and a 4.5-mm anterior open bite. The maxillary tionship (ANB 5 3
) with a marked hyperdivergent
arch presented an excess of space of 8 mm, and an growth pattern (SN-GoGn 5 42
; FMA 5 37
). The
excess of space of 3.5 mm was in the mandibular maxillary incisors were slightly proclined (U1-
arch (Fig 2). Maxillary and mandibular midlines were NA 5 24
), and the mandibular incisors were also pro-
coincident with his facial midline. No signs and symp- clined (L1-NB 5 30
) but uprighted considering the
toms of temporomandibular joint disorder were IMPA angle 5 80
. In the concave profile, the Z
observed. The patient exhibited a habit of anterior angle 5 70
(Table).

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410 Antelo et al

Fig 2. Pretreatment dental casts.

Fig 3. Pretreatment panoramic, lateral cephalometric radiograph, and tracing.

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Antelo et al 411

Table. Cephalometric measurements

Measurements Norms Pretreatment Progress Posttreatment Follow-up
SNA angle (
) 82 87 87 87 86
SNB angle (
) 80 84 82 82 82
ANB angle (
) 2 3 5 5 4
Ao-Bo (mm) 0 6 2* 7 2 1 0
1 6 2y
Facial angle (
) 87 91 90 91 91
Convexity (
) 0 6 12 8 7
FMA (
) 25 37 38 37 37
GoGn-SN (
) 32 42 44 43 44
y-axis (
) 59 62 63 62 62
1-NA (mm) 4 4 4 3 3
1-NA (
) 22 24 23 22 25
1-NB (mm) 4 7 6 7 7
1-NB (
) 25 30 28 24 23
IMPA 90 80 76 74 74
Interincisal angle (
) 132 124 127 133 134
Z angle (
) 75 74 76 78 81

*Denotes female; yDenotes male.

TREATMENT OBJECTIVES (3) Perform RME with an acrylic splint hyrax-type

The following treatment objectives were established: expander, followed by maxillary protraction with a
(1) correct bilateral posterior and anterior crossbite, (2) facemask. In phase 2, bond complete fixed appliances
correct the habit of anterior posture of the tongue at and use Class III and vertical elastics. Perform orofacial
rest and tongue-thrust swallowing, (3) correct anterior myofunctional therapy to correct the anterior posture
open bite (4) obtain Class I molar and canine relationship of the tongue at rest.
on both sides, (5) obtain normal overjet and overbite,
and (6) maintain facial profile. TREATMENT PLAN
The selected treatment approach was conservative,
TREATMENT ALTERNATIVES commensurate with the patient's young age and the par-
The following treatment alternatives were proposed: ents' wishes.
(1) Perform rapid maxillary expansion (RME) with a
banded hyrax palatal expander, followed by maxillary TREATMENT PROGRESS
protraction with a facemask. In phase 2, bond complete At phase 1 of treatment, an 11-mm opening hyrax-
fixed appliances and bilaterally insert miniplates in the type palatal expander with occlusal acrylic plate was
maxillary and mandibular bones to perform intrusion bonded in the maxillary arch to perform correction of
of the maxillary posterior teeth and intrusion and dis- the bilateral posterior crossbite, with hooks for maxillary
talization of the mandibular ones, thereby aiding open protraction. The hyrax-type expander was activated
bite closure and correction of the sagittal discrepancy. twice per day for 22 days, with 1 activation in the morn-
Perform orofacial myofunctional therapy to correct the ing and another at night. After 11 mm of expansion, the
anterior posture of the tongue at rest. patient was instructed to use a facemask for 14 hours per
(2) Perform RME with a banded hyrax expander, fol- day over a period of 10 months with 600 g of force per
lowed by maxillary protraction with a facemask and side to perform maxillary protraction for anterior cross-
placement of tongue spurs in the mandibular arch to bite correction (Fig 4).
control the anterior posture of the tongue at rest. In After 10 months, the hyrax-type expander was
phase 2, bond complete fixed appliances and bilaterally removed (Figs 4-6). At this point, the patient was at an
insert miniscrews between the maxillary and mandib- appropriate age to begin phase 2 treatment with
ular first and second molars, performing intrusion of comprehensive fixed appliances. Two weeks later, MBT
maxillary and mandibular posterior teeth to aid open 0.022 3 0.028-inch slot preajdusted fixed appliances
bite closure and use of Class III and vertical elastics. were bonded in the maxillary and mandibular dental

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412 Antelo et al

Fig 4. Final phase 1 facial and intraoral photographs.

arches. Aligning and leveling were performed using 0.016 Throughout the treatment process, the patient was
inch and 0.019 3 0.025-inch nickel titanium heat- instructed to place his tongue on the upper part of the
activated archwires. Subsequently, 0.019 3 0.025-inch palate to correct the anterior position of the tongue at
stainless steel archwires were placed in both dental arches rest and lingual interposition swallowing pattern, thus
to improve leveling and to close spaces by sliding me- establishing a suitable environment for closing the ante-
chanics (Fig 7). rior open bite, thereby enhancing the stability of results.
At this time, the maxillary incisors were reshaped with During the completion stage, a segmented 0.014-inch
composite resin to increase their mesiodistal size to stainless steel archwire extending from the maxillary
obtain adequate occlusion. Furthermore, Class III elastics right lateral incisor to the left lateral incisor was placed,
were used to maintain the sagittal correction achieved and all teeth were tied together. Furthermore, in the
during phase 1, whereas vertical elastics were used in mandibular arch, the 0.019 3 0.025-inch stainless steel
the anterior segment to achieve the correct overbite archwire remained for proper settling of dentition using
(Fig 7). vertical elastics in the premolar and canine areas (Fig 7).

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Antelo et al 413

Fig 5. Final phase 1 dental casts.

Fig 6. Final phase 1 panoramic, cephalometric radiograph, and tracing.

TREATMENT RESULTS appliances were removed (Fig 8). Teeth were well leveled
After 4 years and 10 months of treatment, corre- and aligned, and ideal overbite and overjet were estab-
sponding to 10 months for phase 1 and 4 years for phase lished with molars, premolars, and canines in a Class I
2, all treatment objectives were achieved, and the relationship (Fig 9).

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414 Antelo et al

Fig 7. Phase 2 treatment progress.

In phase 1, the transversal and sagittal discrep- was successfully treated over 2 phases of treatment
ancies were corrected (Figs 4-6). In phase 2, the that included orthopedics and orthodontics. Treating
vertical discrepancy of anterior open bite was anterior open bite malocclusion is challenging for any
adequately corrected, and the habits of anterior orthodontist, and relapse is common after treatment.10
posture of the tongue at rest and tongue-thrust swal- Moreover, treatment difficulty considerably increases
lowing were eradicated. Correction of the dental Class when it is associated with a Class III malocclusion and
III relationship performed in phase 1 was maintained bilateral posterior crossbite.
in phase 2 through the use of Class III elastics (Fig Correction of severe open bite has frequently
7). The favorable results obtained justify the adopted been obtained using a combination of orthodon-
treatment procedure decisions (Figs 8-10). tics and orthognatic surgery. Although this pro-
Furthermore, orthodontic records for the 3.5-year cedure has been proven successful, our patient
follow-up indicate that the treatment results remained and parents rejected it because of the treat-
stable (Figs 11-13; Table). ment's apparent aggressiveness and financial
At the 4.5-year follow-up appointment, the results of constraints.
treatment remained stable with good healthy peri- Treatment of Class III malocclusion in growing pa-
odontal tissues and a harmonious facial appearance tients involving RME followed by facemask protrac-
(Fig 14). The patient is in the postretention phase and tion therapy is commonly described in the
does not use the retainers since the finalization of the literature.11,12 In the present case report, an orthope-
second-year after treatment. (Fig 15). dic approach was applied to our 13-year-old patient
over 10 months for 14 hours per day, which achieved
DISCUSSION
dentoalveolar changes and, to a lesser extent, skeletal
The present case report shows a 13-year-old boy that changes.
presented with a Class III malocclusion, severe anterior According to Cordasco et al,13 skeletal modifications
open bite, and bilateral posterior crossbite. This patient induced by facemask therapy include forward

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Antelo et al 415

Fig 8. Posttreatment facial and intraoral photographs.

displacement of maxilla, backward displacement of involve rational and efficient mechanics in the control
mandible, clockwise rotation of the mandibular plane, of the vertical plane by intrusion of molars without
and counterclockwise rotation of the maxillary plane. extruding the incisors. This approach could, thereby,
Although such changes improve facial esthetic aspect improve the dentofacial esthetic of patients with skeletal
and correct the Class III relationship, this method could open bite tendency.16 In addition, Kuroda et al17 sug-
be worse for anterior open bite tendency, particularly in gested that it is more practical to treat anterior open
vertically growing patients (such as the patient featured bite malocclusion by intrusion of posterior teeth with
in the present study). To reduce the extrusive effect of temporary skeletal anchorage, rather than performing
this mechanic, a hyrax-type expander was designed surgery.
with an occlusal acrylic plate. The use of miniplates represents another option,
Several treatment modalities have been advocated to particularly for correcting skeletal anterior open bite
intercept and correct anterior open bite malocclusion, malocclusion,18,19 and little patient discomfort is asso-
each with varying degrees of success in terms of long- ciated with their placement, maintenance, and
term correction stability.14,15 Temporary skeletal removal.20 Regarding the patient featured in the pre-
anchorage devices are typically used for posterior teeth sent study, any type of treatment involving surgery
intrusion because they are minimally invasive and was unacceptable to the patient's family. For this

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416 Antelo et al

Fig 9. Posttreatment dental casts.

Fig 10. Posttreatment panoramic, lateral cephalometric radiograph, and tracing.

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Antelo et al 417

Fig 11. Follow-up facial and intraoral photographs after 3.5 years.

reason, the patient was treated using nonsurgical tech- and function. Fortunately, this type of approach was
niques in 2 phases of treatment that involved orthope- accepted by the parents.
dics and orthodontics. During phase 2 (using fixed appliances), the patient
Concerning the habit of anterior position of the was motivated and received orofacial myofunctional
tongue at rest and tongue-thrust swallowing presented therapy to acquire adequate tongue function and posi-
by our patient, it was indicated to place soldered tongue tion. Smithpeter and Covell23 stated that orofacial myo-
spurs in the maxillary arch. It has been well established functional therapy, in conjunction with orthodontic
that tongue spurs are an excellent device for intercepting treatment, is highly effective at keeping anterior open
and correcting anterior open bite caused by inadequate bites closed, compared with patients treated only with
tongue position and function.21 These spurs re-educate orthodontics. Moreover, we believe that the observed
the tongue by proprioceptive reflex, placing it in a supe- long-term stability of results in the present case likely
rior position in contact with the palate.22 Unfortunately, had a strong influence on correction of tongue function
the patient's family also rejected this option. Therefore, and position.
we performed myofunctional orofacial therapy to Performing such treatment in our 13-year-old pa-
improve and correct the inadequate tongue position tient with severe anterior open bite malocclusion

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418 Antelo et al

Fig 12. Follow-up dental casts.

Fig 13. Follow-up panoramic and lateral cephalometric radiographs. Superimposition of cephalometric
tracings: black, pretreatment; red, posttreatment; green, follow-up.

associated with a dental Class III relationship and bilat- to permanently deal with unfavorable vertical growth
eral posterior crossbite posed a significant challenge by using vertical and Class III-orientated elastics that
because of the vertical, sagittal, and transverse devia- could compromise the stability of the results in the
tions presented. During the entire treatment, we had short and long term. Although an open bite

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Antelo et al 419

Fig 14. Follow-up facial and intraoral photographs after 4.5 years.

malocclusion in patients with a vertical growth pattern routinely attended, and the use of buccal elastics was
often requires surgery, a more conservative approach superlative.
that respects the patient's choice should be consid- After 4 years and 10 months of orthopedic-
ered.24 orthodontic treatment and following confirmation
The overall superimposition demonstrates that the that the habit of anterior position of the tongue at
patient underwent a significant facial growth. rest and tongue-thrust swallowing were corrected,
Furthermore, the resulting observed mandible auto- the appliances were removed, and a removable wrap-
rotation was minimal, and the vertical dimension around Hawley-type retainer and fixed mandibular
was well controlled. Moreover, partial maxillary canine-to-canine retainer were placed. The patient
superimposition exhibited successful vertical control was instructed to continuously wear the retainers
of the maxillary molars and extrusion of the incisors for a period of 1 year and only at night thereafter.
that were initially above the maxillary plane of occlu- At the 4.5-year follow-up, the occlusion looked
sion. remarkable, and the patient was pleased with the sta-
This patient could have been satisfactorily treated bility of results in the long term. We strongly believe
using other modalities. Also, treatment duration was that the preserved stability was due above all to the
acceptable based on the high level of commitment of re-education in the function and position of the
the patient and his family. Appointments were tongue.

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420 Antelo et al

Fig 15. Profile superimpositions. Pretreatment, final phase 1, posttreatment, 3.5 years follow-up, and
4.5 years follow-up.

CONCLUSION 6. Toffol LD, Pavoni C, Baccetti T, Franchi L, Cozza P. Orthopedic

treatment outcomes in Class III malocclusion: a systematic review.
A Class III malocclusion associated with severe ante- Angle Orthod 2008;78:561-73.
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treatment without surgery. A functional occlusion, 8. Lin SS, Kerr WJS. Soft and hard tissue changes in Class III patients
treated by bimaxillary surgery. Eur J Orthod 1998;20:25-33.
harmonious profile, and patient satisfaction were
9. Cha KS. Skeletal changes of maxillary protraction in patients ex-
achieved. Also, negative tongue habit was eradicated, hibiting skeletal Class III malocclusion: a comparison of three skel-
and the patient retained stable results at the 4.5-year etal maturation groups. Angle Orthod 2003;73:26-35.
follow-up examination. 10. Kim YH. Anterior openbite and its treatment with multiloop edge-
wise archwire. Angle Orthod 1987;57:290-321.
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