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Saudi Journal of Oral Sciences

REVIEW ARTICLE

Stability of anterior open bite correction treated

with posterior teeth intrusion using temporary
anchorage devices. A systematic review
Mohammed K. Al‑Dhubhani
Private Practice, Asser Province, KSA

Abstract
Anterior open bite (AOB) could be corrected by intrusion of the posterior teeth using temporary anchorage device (TAD). However,
stability of such approach is still not obvious. The aim of this paper is to systematically review the available scientific evidence
regarding the stability of AOB correction on treated with posterior teeth intrusion using TADs. Electronic databases and certain
orthodontic journals were searched. Randomized controlled trials (RCTs), nonRCTs (nRCTs), and retrospective studies (RTSs)
investigating the stability of AOB correction treated with intrusion of maxillary, mandibular posterior teeth or both using any
type of TAD were retrieved. Both reviewers were involved in data extraction and analysis, and any disagreements were resolved
by discussion. Three RTSs and one nRCT were recognized. Low level of scientific evidence was identified after assessment of the
risk of bias of the involved studies with no related RCT was performed. Although, overbite relapsed after debonding, positive
overbite is maintained in all 95 participants of the involved studies. Overbite relapse could not be explained by the relapse of
posterior teeth intrusion only. Weak scientific evidence supports that correction of the AOB by posterior teeth intrusion using
TAD is stable approach at the short and long term.

Key words: Miniplates, miniscrews, molar intrusion, open bite, orthodontic, systematic

Introduction adulthood and more recently intrusion of posterior teeth

Nonsurgical correction of anterior open bite  (AOB)
is usually a difficult task for any orthodontist mainly
because of high relapse tendency. Skeletal, dental,
respiratory, neurologic, or habitual factors are all
possible etiological factors.[1] The treatment of AOB
is usually aimed at obtaining an adequate amount
of overlap of the maxillary and mandibular anterior
teeth. Various treatment modalities were suggested
in the literature for the treatment of AOB, the typical
approach is orthodontic extrusion and retroclination of
the anterior teeth, however, such treatment aimed only
at camouflaging the underlying skeletal discrepancy.
More sophisticated treatment modality is a combination
of orthodontic and orthognathic surgical treatments in
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by means of temporary anchorage devices (TADs).[2‑4]
Several authors reported successful true maxillary molar
intrusion for the treatment of open bite, increased facial
height, and supraerupted maxillary molars.[5,6] Scheffler
et al.[7] found that a mean of 2.3 mm of true maxillary
molars could be obtained using TAD. However, molars
could be intruded up to 8 mm depending on their initial
position and treatment targets.[8]
Address for correspondence:
Dr. Mohammed K. Al‑Dhubhani, Private Practice,
Asser Province, KSA.
E‑mail: dr.mkm@hotmail.com
This is an open access journal, and articles are distributed under the terms
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License, which allows others to remix, tweak, and build upon the work
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DOI: Cite this article as: Al-Dhubhani MK. Stability of anterior open bite
10.4103/sjos.SJOralSci_21_18 correction treated with posterior teeth intrusion using temporary
anchorage devices. A systematic review. Saudi J Oral Sci 2018;5:69-74.

© 2018 Saudi Journal of Oral Sciences | Published by Wolters Kluwer - Medknow

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Al‑Dhubhani: Stability of open bite correction
Data regarding the stability of TAD‑assisted AOB
correction still are scarce in the literature. It has been
found that AOB relapsed by 11.2% over  4  years in a
sample of patients treated by zygomatic miniplates.[9]
When conventional mechanics for treatment of AOB
compared with TAD‑assisted correction, better stability
has been found in patients treated conventionally.[10] In
retrospective study, Baek et al.[11] evaluated the relapse
rate after 3 years of concluding treatment; 1.2 mm (17%)
of overbite reduction was noted and 80% of total
relapse occurs at the 1st year after treatment. Although
0.5–1.5  mm of molar intrusion relapse occurred, the
positive overbite maintained in a sample of 33 patients
and this could be explained by incisor extrusion after
treatment.[7]
Materials and Methods
The question this systematic review tried to answer is
“Does TAD‑assisted AOB correction is stable treatment
modality?” The treatment plan of included studies
should include utilization of any type of TAD to intrude
maxillary, mandibular posterior teeth, or both and has a
clear measure of overbite relapse after debonding. The
primary outcome was the amount of overbite relapse
after appliance debonding. The secondary outcome was
the amount of relapse of intruded posterior teeth.
Search strategy
A systematic search of articles published from January
2000 to October 2017 was performed to retrieve
randomized clinical trials  (RCTs), nonRCTs, and
retrospective studies  (RTS) investigated the stability
of TAD‑assisted AOB correction. Ovid MEDLINE,
PubMed, Embase, and the Cochrane Library databases
were systematically searched for related articles.
Independent search in selected orthodontic journals
(the American Journal of Orthodontics and Dentofacial
Orthopedics, Angle Orthodontist, European Journal
of Orthodontics, Journal of Clinical Orthodontics,
and Korean Journal of Orthodontics and Orthodontic
Waves) was also performed. Articles that do not
measure the posttreatment AOB change, case reports
and series, and animal experiments and studies that
involved patients in primary or mixed dentition stage or
patients with craniofacial deformities and non‑English
articles were all excluded from this review. The key
words used in the electronic search included “anterior
open bite,” “molar intrusion,” and “posterior teeth
intrusion,” which were crossed with “stability” and
“outcome” [Table 1].
S J Oral Sci Volume 5 Issue 2 70
Study selection and data collection
The titles and abstracts of all articles obtained through
the electronic searches were screened independently by
two reviewers (MK and RR). After reading abstracts and
removing the duplicates, a list of articles was generated
for full‑text screening by the same two reviewers.
A consensus was reached among the reviewers about
the articles that met the inclusion criteria.
Data were collected by the two reviewers (MK and RR)
on data forms containing the following items: Year of
publication, the design of study, material and methods,
sample size, type of TAD used, amount of AOB reduction
and amount of molar intrusion, follow‑up period,
amount of molar intrusion, and AOB relapse.
Risk of bias
A methodological quality scoring process was used to
identify which selected studies would be most valuable.
Methodological index for nonrandomized studies[12] was
applied to assess the quality of involved studies.
Results
Study selection
A total of 384 articles were recognized through electronic
searches. Sixty‑three duplicated articles were removed,
and another 315 articles were excluded depending on
their titles and abstracts. Thus, six articles remained for
full‑text screening. After full‑text screening, another
two articles were excluded because the full text of one
of them[13] is only available in the Korean language, and
the other one investigated the molar intrusion relapse
but not the overbite relapse.[14] Therefore, only four of
those met the inclusion criteria of this review [Figure 1].
Study characteristics
All included studies were retrospective except for
Marzouk and Kassem,[9] in which they performed a
prospective controlled trial. The sample size was relative
small in the studies maybe except for Scheffler et  al.
that involved 33 consecutive patients. However, the
long‑term follow‑up  (4  years) was only available for
25  patients. A  total of 95  patients were successfully
treated in all included studies with a wide age range
from 13 to 49 years, and various intrusion techniques
were used. The most common technique was buccal or
zygomatic TAD attached to the upper molars by mean of
Table 1: Search strategy
1. Anterior open bite or molar intrusion or posterior teeth intrusion
2. Stability or outcome
3. 1 and 2
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Al‑Dhubhani: Stability of open bite correction
power chains or coil springs[7,10,11] with transpalatal bar to
prevent buccal flaring of the molars. Scheffler et al.[7] used
miniplates for nearly half of the sample (14 patients) and
Marzouk and Kassem[9] used miniplates exclusively in
their trial. It should be noted that no study evaluated
the stability of AOB after intrusion of mandibular molars
with or without maxillary molars. Marzouk and Kassem[9]
was the only trial that specified the force magnitude for
molar intrusion (450 g/side). Follow‑up periods ranged
Figure 1: Flowchart of the study selection process
Figure 2: Characteristics of the involved studies
S J Oral Sci Volume 5 Issue 2 71
from 1 year[7,9,11] to 4 years.[9] All involved studies used
linear cephalometric values to measure the overbite
and posterior teeth intrusion. Maxillary first molar was
used as representative of the amount of posterior teeth
intrusion and subsequent relapse in all studies.[7,9‑11]
Detailed characteristics of the involved studies are
illustrated in Figure 2.
Risk of bias in the studies
Out of the four selected studies, only one was
prospective controlled trial [9], and the other three
studies were retrospective. [7,10,11] The total quality
scores of the included studies according to MINOR[12]
ranged from 5 out of 12 to 10 out of 24 that indicate
moderately to heavily biased studies. Comprehensive
quality assessment considering specific methodological
requirements is detailed in Table 2.
Results of the individual studies
Interestingly, no randomized clinical trial was performed
to assess the stability of TAD‑assisted AOB correction
perhaps due to new nature of such technique. In addition,
only one retrospective study[10] compared results of this
approach with other conventional methods of AOB
treatment  (i.e., combination of premolar extraction,
anterior elastics and either accentuated‑curve archwires
or the multiloop edgewise archwire technique (MEAW)
and high‑pull headgear). In this study, although more
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Al‑Dhubhani: Stability of open bite correction

Table 2: Studies quality assessment according to MINOR

Criteria
Clear aim
Inclusion of consecutive patients
Prospective data collection
Endpoints appropriate to the aim
Unbiased assessment of the endpoint
Follow‑up period appropriate
Follow‑up loss <5%
Prospective calculation of the study size
Adequate control group
Contemporary groups
Baseline equivalence of groups
Adequate statistical analyses
Total
Baek et al.[11] Deguchi et al.[10]
2 2
0 0
0 0
2 2
0 0
2 1
0 0
0 0
0 1
0 0
0 1
0 1
6 8
Scheffler et al.[7] Marzouk and Kassem[9]
2 2
0 1
0 1
2 2
0 0
1 2
0 0
0 2
0 0
0 0
0 0
0 0
5 10

AOB relapse after 2 years was reported in patient who
had TAD  (0.8  mm  ±  1.1) than conventional method
patient  (0.5  mm  ±  1.4), the difference was small and
insignificant clinically and statistically (P ≥ 0.05). Relapse
of posterior teeth intrusion was 0.5 mm ± 0.9 (P ≥ 0.05).
Baek et  al. [11] showed that AOB relapsed by
1.2  mm  ±  1.44 at the end of 3  years of retention.
However, most of the relapse  (82%) occurred in the
1st year posttreatment (P ≤ 0.05). Molar intrusion showed
small relapse (0.45 mm ± 0.46) at 3‑year follow‑up and
again most of the relapse (95%) occurred at the 1st year
of retention (P ≤ 0.05).
One of the RTS assessed in this review evaluated the
AOB and posterior teeth intrusion relapse at 1‑year and
2‑year follow‑up intervals.[7] At 1 year of retention, only
small relapse of AOB and posterior teeth intrusion was
noted (0.3 mm ± 0.8 and 0.5 mm ± 1.1, respectively).
Authors did not report whether such relapse was
statistically significant or not. However, they evaluated
the results of stability by percentage of patients who
had clinically significant changes (>2 mm). Only 2 out
25  patients  (8%) had more than 2  mm of overbite
relapse, and 4 patients (16%) had more than 2 mm of
maxillary molars reeruption (relapse).[7]
The last study involved in this review was the only
prospective trial with no control group. Marzouk and
Kassem[9] showed (0.57 mm ± 0.09) of overbite relapse
at 1 year of retention (P ≥ 0.05) and (0.31 mm ± 0.07)
posterior teeth intrusion relapse (P ≥ 0.05). At the 4th year of
retention, (0.77 mm ± 0.43 and 0.41 mm ± 2.03) of overbite
relapse and posterior teeth intrusion relapse was found,
respectively, which both were statistically insignificant.
Summary of results
Due to the heterogeneous variables in the involved
studies, a meta‑analysis was not possible. Large
differences concerning the selection criteria and size of
the samples were found. The samples studied comprised
both growing and nongrowing participants and both
extraction, nonextraction treatment approaches, wide
spectrum of participants age with different types of
malocclusions  (i.e., Class  I, Class  II, and crowding). In
addition, a different intrusion protocols with different
type of TAD, force magnitude, treatment duration, and
different retention protocols. Most importantly, the
different studies enrolled patients with different initial
AOB and maxillary molar alveolar heights.
Discussion
Several authors showed that intrusion of posterior
teeth mainly upper molars using TAD are an effective
strategy in the management of patients with dental or
skeletal AOB.[3,4,15] The mechanism behind this correction
believed to be due anticlockwise mandibular rotation.[16]
In this paper, we systematically investigated the available
scientific evidence regarding the stability of AOB treated
by means of posterior teeth intrusion with TAD.
Out of four studies included in this review, two studies
used miniscrews[10,11] one study used a combination
of miniscrews and miniplates[7] and one study used
miniplates exclusvily.[9] All miniscrews were placed by
orthodontists in contrast to miniplates that were placed
by oral surgeons.
One of the most stable results of overbite and molar
intrusion was reported by Scheffler et al.[7] who reported
less than half of millimeter of mean overbite relapse
either at the short‑term  (1‑year follow‑up) or the
long‑term  (≥2  years). Nevertheless, the initial AOB of
the patients in this study was the smallest (1.2 mm ± 1.7)
compared to other studies[9‑11] and even some patients
had a positive but shallow overbite (1.8 mm). In addition,

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Al‑Dhubhani: Stability of open bite correction
this was the only study that used bonded occlusal splint
covering the maxillary molars and premolars during
intrusion phase which may aid in stability by creating
better distribution of intrusive forces and in contrast
to other studies they first achieved the posterior teeth
intrusion before placement of fixed appliance.[7]
Marzouk and Kassem [9] also showed low relapse
rate for posterior teeth intrusion and overbite
(mean; 0.41 and 0.77  mm, respectively) compared
to Baek et al.[11] and Deguchi et al.[10] after 4 years of
debonding. It should be noted that unlike other studies
Scheffler et  al.[7] and Marzouk and Kassem[9] studies
used miniplates as anchorage tool for posterior teeth
intrusion and achieved the largest amount of molar
intrusion (3.04 mm ± 0.79)[9] compared to about 2 mm
of mean molar intrusion in other studies. Thus, it
could be speculated that the more the molar intrusion
during treatment, the more the stability of overbite
after treatment. Interestingly, although relapse of
molar intrusion seems to be comparable in all involved
studies in this review (ranged from 0.3 to 0.5  mm),
the overbite relapse showed large differences
(ranged from 0.3 to 1.2 mm) which may indicate that
molar reeruption  (relapse) is not the sole etiological
factor of overbite relapse posttreatment and another
factor such as compensating incisor extrusion, [7,9]
facial growth, and the treatment strategy itself may
contribute in the overbite maintenance.
Three studies[6,7,11] have followed the patients at two time
intervals, and most (80% to 95%) of the total relapse has
occurred at the 1st year out of treatment, and any further
relapse after that is small and insignificant clinically.
Moreover, when molar intrusion stability compared with
overbite stability, the former showed more stability after
the 1st year of follow‑up.[7,9‑11]
Deguchi et  al.[10] was the only comparative study in
this review where they compared the stability of AOB
correction treated with TAD or with conventional
methods. Patients treated without TAD had received
premolars extraction and combination of anterior
elastics and either accentuated curve of Spee archwires
or the MEAW and a high pull headgear. The results of
this study showed that AOB treated conventionally is
slightly more stable after 2  years of retention which
could be explained by the fact that patients with in TAD
group had more skeletal components of the AOB than
conventional method group. The authors recommended
applying of extra measures in AOB patients treated with
TAD such as the use of occlusal stops in the mandibular
molars, myofunctional therapy and keeping TAD during
retention period to maximize the stability.[10]
S J Oral Sci Volume 5 Issue 2 73
Baek et  al.[11] was among the first published articles
that assessed the AOB stability of patients treated by
maxillary molar intrusion in a small sample size of adult
patients (n = 9); The AOB was treated either by buccal
and lingual miniscrews or with buccal miniscrews and
transpalatal arch. This retrospective study showed the
higher relapse rate of AOB among all studies in this
review (1.2 mm ± 1.44) after 3 years of retention. While
one study[11] failed to find a correlation between initial
AOB severity and the amount of subsequent relapse,
another study[9] found a positive correlation and the
both studies[9,11] found a negative correlation between
the amount of overbite correction and posterior teeth
intrusion and the extent of subsequent relapse.
Regarding the retention protocol, two studies[7,11] used
a combination of fixed lingual retainers and removable
retainers while Marzouk and Kassem [9] used only
removable upper and lower retainers with posterior bite
plane. Deguchi et al.[10] gave no description of retention
protocol. Indefinite retention was recommended in all
those studies.[7,9,11]
Active retention in the form of elastics attached between
removable retainer and miniscrews in the first 6 months
of retention was prescribed in one study[7] that showed
low relapse rate of molar intrusion and overbite.
Limitations
Only four studies met the inclusion criteria of this review
with no RCTs. RCTs with proper randomization and
control groups are mandatory to compare the stability
of AOB treated by TAD with other treatment modality.
It is also interesting to compare the failure rate of AOB
after using different intrusion protocols. The absence
of control groups, small sample size, and confounding
factors are the most common disadvantages of the
involved studies. Only the 1st maxillary molar relapse was
measured in all studies; nevertheless, it is important to
investigate the effect of different posterior teeth relapse
on the relapse of the overbite.
Conclusion
Currently, there is weak evidence with low level of certainty
that correction of AOB by posterior teeth intrusion with
TAD is quite stable treatment strategy at the short‑ and
long‑term. Four years after debonding, overbite relapsed
by 0.3 to 1.2 mm and molar intrusion showed between 0.3
and 0.5 mm of relapse and most of this relapse occurred at
the 1st year after debonding. Thus, strict retention protocol
is highly recommended. Well‑conducted RCTs are urgently
needed to reach robust scientific evidence.
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Al‑Dhubhani: Stability of open bite correction
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Subtelny JD, Sakuda M. Open‑bite: Diagnosis and treatment. Am J Orthod
1964;50:337‑58.
2. Sperry  TP, Steinberg  MJ, Gans  BJ. Mandibular movement during
autorotation as a result of maxillary impaction surgery. Am J Orthod
1982;81:116‑23.
3. Kuroda S, Katayama A, Takano‑Yamamoto T. Severe anterior open‑bite case
treated using titanium screw anchorage. Angle Orthod 2004;74:558‑67.
4. Park HS, Jang BK, Kyung HM. Maxillary molar intrusion with micro‑implant
anchorage (MIA). Aust Orthod J 2005;21:129‑35.
5. Umemori  M, Sugawara  J, Mitani  H, Nagasaka  H, Kawamura  H. Skeletal
anchorage system for open‑bite correction. Am J Orthod Dentofacial
Orthop 1999;115:166‑74.
6. Akan S, Kocadereli I, Aktas A, Taşar F. Effects of maxillary molar intrusion
with zygomatic anchorage on the stomatognathic system in anterior open
bite patients. Eur J Orthod 2013;35:93‑102.
7. Scheffler NR, Proffit WR, Phillips C. Outcomes and stability in patients 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.
S J Oral Sci Volume 5 Issue 2 74
8. Kravitz ND, Kusnoto B, Tsay TP, Hohlt WF. The use of temporary anchorage
devices for molar intrusion. J Am Dent Assoc 2007;138:56‑64.
9. Marzouk  ES, Kassem  HE. Evaluation of long‑term stability of skeletal
anterior open bite correction in adults treated with maxillary posterior
segment intrusion using zygomatic miniplates. Am J Orthod Dentofacial
Orthop 2016;150:78‑88.
10. Deguchi T, Kurosaka H, Oikawa H, Kuroda S, Takahashi I, Yamashiro T, et al.
Comparison of orthodontic treatment outcomes in adults with skeletal open
bite between conventional edgewise treatment and implant‑anchored
orthodontics. Am J Orthod Dentofacial Orthop 2011;139:S60‑8.
11. Baek MS, Choi YJ, Yu HS, Lee KJ, Kwak J, Park YC, et al. Long‑term stability of
anterior open‑bite treatment by intrusion of maxillary posterior teeth. Am
J Orthod Dentofacial Orthop 2010;138:396.e1‑9.
12. Slim  K, Nini  E, Forestier  D, Kwiatkowski  F, Panis  Y, Chipponi  J, et  al.
Methodological index for non‑randomized studies (minors): Development
and validation of a new instrument. ANZ J Surg 2003;73:712‑6.
13. Han‑Ah L, Young‑Chel P. Treatment and posttreatment changes following
intrusion of maxillary posterior teeth with miniscrew implants for open
bite correction. Korean J Orthod 2008;38:31‑40.
14. 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 application of a skeletal anchorage
system  (SAS) for open bite correction. Int J Adult Orthodon Orthognath
Surg 2002;17:243‑53.
15. Xun C, Zeng X, Wang X. Microscrew anchorage in skeletal anterior open‑bite
treatment. Angle Orthod 2007;77:47‑56.
16. Alsafadi AS, Alabdullah MM, Saltaji H, Abdo A, Youssef M. Effect of molar
intrusion with temporary anchorage devices in patients with anterior open
bite: A systematic review. Prog Orthod 2016;17:9.
July‑December 2018