CASE REPORT

Nonsurgical correction of a severe

anterior open bite with mandibular molar
intrusion using mini-implants and the
multiloop edgewise archwire technique
Benedito Viana Freitas,a Mayara Cristina Abas Fraza~o,b Luana Dias,b Pedro Ce
sar Fernandes dos Santos,c
Heloiza Viana Freitas,b and Jose A. Bosiod
S~ao Luis and Fortaleza, Brazil, and Baltimore, MD

This article reports the case of a 24-year-old man with a large anterior open bite, mild mandibular crowding,
increased overjet, no passive lip sealing, and Angle Class I malocclusion. The treatment results were achieved
by mandibular molar intrusion using 1.8 3 8.5-mm mini-implants (C-implants) inserted between the mandibular
first and second molars bilaterally. A 2.5-mm molar intrusion and open-bite closure occurred within 8 months.
The multiloop edgewise archwire technique helped to intrude the posterior teeth. Total treatment time was
20 months. Fifty months postretention records are also presented. The patient achieved a suitable occlusion
and satisfactory facial esthetics at the end of treatment and at the 50-month retention check. (Am J Orthod
Dentofacial Orthop 2018;153:577-87)

O
pen bite and facial disharmony along the vertical
plane are great challenges for orthodontists, pri-
marily because of difficulties associated with
known treatment techniques and the consequent insta-
bility of the correction, dependence on severity, etiology,
and time of treatment.1-3 These changes are caused by
the interaction of hereditary and environmental factors
during facial development.4
Various methods have already been established in the
literature to treat anterior open bite, such as posterior
tooth intrusion using passive and active bite-blocks, ver-
tical chincup appliances, fixed orthodontic therapy, and
anterior vertical elastics,5 which may cause incisor extru-
sion and increase gingival exposure.3,6 Tongue
reeducation has also been indicated as a decisive factor
a
b
Department of Orthodontics, Federal University of Maranh~ao, S~ao Luis, Brazil.
Private Practice, S~ao Luis, Brazil.
c
Department of Orthodontics, Federal University of Ceara, Fortaleza, Brazil.
d
Department of Orthodontics and Pediatric Dentistry, University of Maryland,
Baltimore, MD.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Supported by the American Association of Orthodontists and the American Asso-
ciation of Orthodontists Foundation.
Address correspondence to: Jose A. Bosio, University of Maryland, School of
Dentistry, 650 W. Baltimore St, #3205, Baltimore, MD, 21201; e-mail,
jbosio@umaryland.edu.
Submitted, July 2016; revised and accepted, December 2016.
0889-5406/$36.00
Ó 2018 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2016.12.032
in correction and treatment stability.7,8 However, these
traditional techniques cannot satisfactorily intrude
molars or extrude incisors, especially in adults.
Various functional or orthopedic approaches such as
the Thurow appliance can be used for children and ado-
lescents.9 For adults, only orthodontic movement, or-
thognathic surgery, or a combination of both
techniques is effective.10 Thus, maxillary repositioning
is often used to obtain jaw counterclockwise rotation
and reduction of anterior facial height in patients with
severe skeletal open bite.5
It is necessary to properly establish diagnosis and
treatment plans to apply the most appropriate treat-
ment.5 Orthognathic surgery offers significant improve-
ments for occlusion and facial esthetics, but it is invasive
surgery with resulting discomfort, postoperative risk, and
prolonged hospitalization.11 Patients who prefer not to
undergo surgery may opt for orthodontic camouflage
in which mini-implants and the multiloop edgewise
archwire (MEAW) technique can be used for molar intru-
sion and consequently closure of the open bite.12
The MEAW technique can promote molar uprighting,
improve inclination of the maxillary or mandibular
occlusal plane, and correct an anterior open bite.12
Mini-implants can be used for posterior tooth intrusion
and as a treatment option to correct an open bite
without anterior tooth extrusion or increase of the lower
third of the face.13-15
577
578 Freitas et al

Fig 1. Pretreatment extraoral and intraoral photographs.

The patient presented here shows the correction of an
anterior open bite and changes in facial esthetics with
mini-implants and the MEAW technique without surgi-
cal intervention.
DIAGNOSIS AND ETIOLOGY
A man (24 years 10 months of age) with a Class I
malocclusion was referred by his dentist brother (Figs 1
and 2). His chief complaint was a severe anterior open
bite, and he reported having had unsuccessful
traditional orthodontic treatment in the past. His
medical history was insignificant, and no family
members had the same open-bite condition. Despite
having a normal tongue size, he had difficulty in
speaking due to his anterior open bite.
The patient showed facial asymmetry on the right
side, lip incompetence, clockwise-rotated jaw, and a
convex profile. No jaw deviation was observed during
opening and closing movements (Fig 1). However, an
asymptomatic bilateral crepitus of the temporomandib-
ular joint was detected during the clinical examination,
and condyle malformation was observed on the pano-
ramic radiograph, suggesting a degenerative disease
associated with osteophyte formation (Fig 3).
The patient's oral hygiene was reasonable, with mild
crowding and supragingival calculus in the mandibular
anterior region. No decay or gingival inflammation was
detected. Open bite, overjet of 5 mm, tongue posture
at rest, and tongue trust pattern while swallowing
were also observed (Figs 1 and 2).

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Freitas et al 579

Fig 2. Pretreatment study models.

Fig 3. Pretreatment lateral cephalometric radiograph and tracing; panoramic radiograph with the
details of the bilateral condyles.

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580 Freitas et al

The cephalometric analysis showed mandibular

Table. Initial, final, and 50 months posttreatment
retrusion and maxillary protrusion associated with
cephalometric measurements
excessive vertical growth, causing a deficient maxillo-
mandibular relationship. The maxillary incisors were Standard After
proclined and protruded, whereas the mandibular inci- measure Initial Final 50 months
sors were protruded with a normal lingual inclination Maxillary
SNA ( ) 82 80 80 79
(Fig 3; Table). Co-A (mm) 85 98 99 99
A-Nperp (mm) 1 3 2 2
TREATMENT OBJECTIVES Mandibular
SNB ( ) 80 73 75 78
The treatment goal was to correct the patient's ante- Co-Gn (mm) 108 130 131 132.5
rior open bite and overjet, create passive lip sealing, and P-Nperp (mm) 2/14 18 15 15
improve facial esthetics, without extruding the maxillary /6-Go-Me (mm) 46.5 44 45
and mandibular incisors and increasing the gingival Growth pattern
smile. These goals would be significantly difficult to FMA ( ) 25 42 41 40
SN.Ocl ( ) 14 25 18 20
achieve if a nonsurgical approach was selected by the SN.GoGn ( ) 32 50 48 50
patient as the preferred treatment option. AFAI (mm) 62 92 89 92
Facial axis ( ) 90 79 79 79
TREATMENT ALTERNATIVES ODI ( ) 74.5 64 65 63
Maxillo mandibular ratio
Two treatment alternatives were presented. The first ANB ( ) 2 6 5 1
included orthognathic surgery associated with mandib- Wits (mm) 0 2 1.5 1
ular advancement and maxillary posterior impaction. APDI ( ) 81.5 77 80 79.5
This ideal treatment option would resolve the vertical Maxillary teeth
1.NA ( ) 22 34 27 30
problem, and orthodontic treatment would be required 1- NA (mm) 4 8 5 8
only for leveling and alignment. The second alternative 1.PP ( ) 112.1 124 118 118
involved orthodontic camouflage by the intrusion of 1-PP (mm) 33 43 42 44.5
the mandibular posterior teeth using mini-implants be- 6-PP (mm) 27.9 31 32 32
tween the first and second molars as anchorage unit. Mandibular teeth
1.NB ( ) 25 28 26 25
This alternative was a compromise by not solving the 1-NB (mm) 4 7 6 6
anterior vertical problem or the lip competence. Howev- IMPA ( ) 87 83 81 80
er, it would return the patient's optimal chewing func- 1-GoMe (mm) 48.3 51.5 53 55
tion. He categorically refused any surgical approach Soft tissue
and chose the second treatment option. Nasolabial angle ( ) 110 110 115 113
E-line (mm) 2 12 1 0

TREATMENT PROGRESS
A straight-wire orthodontic fixed appliance using the
Roth prescription on slot size 0.022 3 0.028-in was in-
serted in the maxillary arch. Leveling started with
0.014-in nickel-titanium (NiTi) and 0.016-in wires, fol-
lowed by 0.018, 0.020, and 0.019 3 0.025-in stainless
steel wires. Mini-implants (C-implants) measuring
1.8 3 8.5 mm were inserted between the maxillary first
and second molars bilaterally to aid the intrusion move-
ment. A stainless steel band was installed on the mandib-
ular right first molar, and a convertible tube was welded
to the band. The mandibular left first molar received a
bonded bracket. The purpose of inserting the devices in
a different manner on the right and left sides was to
ascertain whether any changes occurred in the degree
of intrusion. No such changes were observed. The
mandibular second molars received bonded single tubes.
Sectional bilateral passive stainless steel wires measuring
0.019 3 0.025-in were inserted into the 2 mandibular
LFH, lower facial height; ODI, overbite depth indicator; APDI,
anteroposterior dysplasia indicator.
molar tubes, and a NiTi closed-coil spring was placed
for intrusive force at first. Intrusive mechanics were
also achieved by using elastomeric chain from the
mini-implants to the segmental wire bonded to the
mandibular molar tubes. No lingual arch was used in
the mandibular teeth to prevent buccal inclination of
the molars. These arches could decrease the amount of
intrusion if inserted. Thus, as expected, intrusion of the
mandibular teeth occurred along with buccal inclination
of the mandibular molars. The open bite was closed
7 months after starting the intrusive mechanics (Fig 4).
Mandibular fixed appliances were bonded 4 months
after starting intrusion activation, and leveling started
with a 0.014-in NiTi wire followed by a 0.016-in NiTi
wire. The mandibular molars were not included in the
arch while the incisors, canines, and premolars were

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Freitas et al
Fig 4. Intraoral photographs during treatment, showing open bite gradually closing.
aligning. After initial alignment, a constricted 0.018-in
stainless steel archwire was inserted on top of the
0.016-in wire and connected to the molars to prevent
labial inclination of the incisors. Simultaneously, the
maxillary arch was treated with a MEAW archwire with
a reverse curve of Spee and 5/16-in, 4.5-oz intermaxil-
lary elastics from the first L loop to the mini-implants
bilaterally (Fig 4). Both procedures helped to close the
anterior open bite. These mechanics also allowed retrac-
tion of the maxillary teeth and anterior open bite closure,
achieved 7 months after mini-implant placement. The
arches were kept in place for another 8 months to stabi-
lize the correction and finalize the mandibular leveling.
Treatment time with fixed appliances was 20 months.
The mini-implant heads were removed, and their bodies
were kept embedded into the bone for 5 years in case
of open-bite recurrence. After treatment completion,
brackets were removed, and maxillary and mandibular
Hawley retainer instead of a fixed bondable retainer,
were the patient's tendency for calculus formation. Patient
rejected the choice to wear an Essix retainer (bite plate).
RESULTS
The patient was satisfied with his smile harmony and
facial appearance. The final photographs show good lip
competence, open-bite correction, and improvement of
the facial profile (Fig 5). The convexity observed in the
American Journal of Orthodontics and Dentofacial Orthopedics
581
profile was due to the patient's small jaw and its retro-
gnathic position. Intraoral photographs and study
models showed an Angle Class I bilateral canine relation-
ship as well as normal overbite and overjet (Figs 5 and 6).
Tooth intercuspation and root parallelism were adequate
(Figs 5 and 7).The cephalometric tracing and total
overlay showed a tendency toward mandibular rotation
in a counterclockwise direction and improvement in
the patient's facial profile (Fig 8). The maxillary incisor
inclination was normalized, and a slight retroclination
of the mandibular incisors was noted. A decreased pro-
jection of the lips shown by the Ricketts E-line and an
increased nasolabial angle were observed after treatment
(Table).
DISCUSSION
Corrective orthodontic treatments without surgery
aim to extrude the anterior and intrude the posteriors
teeth.16 Sometimes dental compensation may be insuf-
ficient to correct a malocclusion; thus, an ideal surgical
approach must consider the open-bite severity, skeletal
development phase, facial esthetics, patient's age, and
clinical judgment.11
Conventional mechanics, in addition to the limita-
tions, are slow and prevent creation of an efficient force
system with a sufficient anchorage unit capable of pre-
venting the extrusive component of the anterior teeth.3,4
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582 Freitas et al

Fig 5. Posttreatment intraoral and extraoral photographs.

Fig 6. Posttreatment dental study casts.

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Freitas et al 583

Fig 7. Posttreatment lateral cephalometric radiograph and tracing; panoramic radiograph.

Fig 8. Superimposed pretreatment and posttreatment cephalometric tracings: overall, maxillary, and
mandibular superimpositions. Black, initial; red, final.

American Journal of Orthodontics and Dentofacial Orthopedics April 2018  Vol 153  Issue 4
584 Freitas et al

Fig 9. Facial and intraoral photos after 50 months.

Fig 10. Dental casts after 50 months.

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Freitas et al
Fig 11. Postretenion lateral cephalometric radiograph and tracing; panoramic radiograph.
Molar intrusion can be used in cases of anterior open
bite to reduce posterior facial height in the lower third
of the face, allowing subsequent mandibular
counterclockwise rotation. However, molar intrusion is
classified as a complex orthodontic movement when
conventional anchoring methods are used.13 Conven-
tional mechanics typically use forces that depend on pa-
tient cooperation, such as high-pull headgear or
interdental elastics; these methods are not efficient in
young or adult patients.5
The MEAW technique was created and has been
effective to treat severe anterior open-bite malocclu-
sions. This technique corrects an occlusal plane inclina-
tion by positioning the incisors harmoniously after
posterior tooth intrusion and anterior tooth extru-
sion.4,16,17 However, the MEAW technique requires
extra skill training to apply the correct diagnosis,
construct loops correctly, and execute the technique
American Journal of Orthodontics and Dentofacial Orthopedics
585
ideally. It also requires the patient's cooperation with
intermaxillary elastics use. In this patient, the
mandibular molars were intruded using miniscrews as
the anchorage unit. The MEAW technique was used to
complete the correction of the anterior malocclusion.
Mini-implants, miniplates, and dental implants can
be used as absolute intraoral anchorage units for molar
intrusion to minimize unwanted side effects, such as the
patient's poor compliance.1-5 Mini-implants have addi-
tional advantages such as minimal cost, simple surgical
insertion and removal techniques, capability of insertion
in several areas of the alveolar process and basal bone
(including areas between roots), ease of cleansing,
improved orthodontic mechanics, and great patient
acceptance.2 Nonetheless, appropriate orthodontic
planning and management, selection of the ideal inser-
tion site following specific criteria, and performing an
ideal surgical approach are mandatory.6
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586
Fig 12. Superimposed pretreatment, posttreatment, and 50-month postretention cephalometric trac-
ings: overall, maxillary, and mandibular superimpositions. Black, pretreatment; red, posttreatment;
green, 50 months postretention.
Studies have shown that stability during the intrusion
movement can be increased using partial osseointegra-
tion miniscrews 1.8 mm in diameter and 8.5 mm in
length, called C-implants, when installed between the
mandibular first and second molars.18 C-implants
receive special pretreatment via aluminum oxide sand-
blasting and etching with microparticles to increase
the potential for osseointegration and augment their
resistance to rotational forces through the dynamic
application of heavy loads.18 In addition, angulating
miniscrews between 10 and 20 at insertion has been
recommended to prevent contact between the miniscrew
and tooth roots.2 This case presentation showed that
mini-implants served as auxiliaries to mandibular molar
intrusion by receiving intermaxillary elastics connected
to the first loops of the maxillary MEAW and direct
attachment to the molars being intruded to allow
mandible to rotate counterclockwise.19
Mini-implants were inserted only on the buccal side
of the maxillary arch. This procedure increases the ten-
dency toward buccal proclination of posterior teeth if
a transpalatal arch is not used to hold the transverse
dimension. Instead of using a transpalatal arch, a maxil-
lary round 0.018-in stainless steel arch was inserted
overlaying the round 0.016-in NiTi leveling archwire.
This overlaid arch had its cross-sectional dimensions
decreased by 2 cm bilaterally and its ends positioned
April 2018  Vol 153  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Freitas et al
on the crowns of the first molars, as recommended in
some studies.3,6,20 By using mini-implants only on the
buccal side and a constricted continuous archwire
should result in counterclockwise movement of the mo-
lars in both quadrants and, by the same principle, pro-
duce a pure intrusion force of the posterior maxillary
teeth, counterclockwise rotation of the jaw, and conse-
quent closure of posterior and anterior open bites.21
However, our results did not show jaw counterclockwise
rotation after molar intrusion. On the other hand, the
changes obtained with this technique provided better
functional and aesthetic results.
The stability of open bite treatment is another con-
stant challenge for orthodontists due to the great diffi-
culty in solving vertical problems and eliminating
tongue posture and trust habits.8 Patients treated with
orthognathic surgery have a recurrence rate equal to or
greater than that of orthodontic treatments associated
with skeletal anchorage; the latter is indicated more
often to be less invasive.14,20,21 No treatment for
tongue habits was conducted for this patient, with the
exception of fabricating a hole on the maxillary
retainer to orient tongue positioning and verbal
guidance about correct deglutition habits.
Disc displacement without reduction associated with
degenerative joint disease is another cause of increased
anterior and reduced posterior vertical dimensions.
Freitas et al
Ahn et al22 demonstrated that patients with disc
displacement without reduction have more sagittal and
vertical problems. Temporomandibular disc displace-
ment without reduction might have contributed to
causing anterior open-bite relapse (Figs 9-12). Our
patient initially had articular disc displacement without
reduction associated with degenerative joint disease,
history of locking and jaw joint crepitation, and wear
of the anterior portions of the condyles observed in
the initial panoramic radiograph (Fig 3). Nevertheless,
50 months after treatment completion, a tendency for
open bite was observed only on the left side (Figs 9
and 10). This small relapse might have been the result
of increased wear of the anterior portion of the
condyles evidenced in the postretention panoramic
radiograph (Fig 11). Thus, based on previous studies,
this patient continued to be monitored for condyle
degeneration and possible surgical interventions
for temporomandibular disc repositioning (Figs 11
and 12).23-25 Small dental rotation relapse was also
noted on mandibular central incisors, which has
maintained stable over retention period (Figs 9 and 10).
CONCLUSIONS
The use of mini-implants for posterior tooth intru-
sion was effective, and treatment time was reduced;
also, it enabled mandibular molar intrusion to close
the anterior open bite. The MEAW technique helped to
finalize and refine the open-bite closure and the tooth
uprighting.
ACKNOWLEDGMENT
We thank the American Association of Orthodontists
and the American Association of Orthodontists Founda-
tion for the financial support for this and previous
studies of the corresponding author.
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