European Journal of Orthodontics, 2021, 1–10

doi:10.1093/ejo/cjab011
Systematic Review

Systematic Review

Vertical stability of different orthognathic

treatments for correcting skeletal anterior open

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bite: a systematic review and meta-analysis
Mengqiao Wang#, Bowen Zhang#, Lan Li, Mingrui Zhai, Zhengyan Wang
and Fulan Wei
Department of Orthodontics, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong Univer-
sity and Shandong Key Laboratory of Oral Tissue Regeneration and Shandong Engineering Laboratory for Dental
Materials and Oral Tissue Regeneration, Jinan, China

Correspondence to: Fulan Wei, Department of Orthodontics, School and Hospital of Stomatology, Cheeloo College of Medi-
cine, Shandong University & Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory
for Dental Materials and Oral Tissue Regeneration, No. 44-1 Wenhua Road West, Jinan, Shandong 250012, China. E-mail:
[email protected]

Mengqiao Wang and Bowen Zhang contributed equally to this work and are cofirst authors.
#

Summary
Background:  Several orthognathic procedures have been applied to correct skeletal anterior open
bites (SAOB). Which method is most stable has been debated and no consensus has been reached
and there is no conclusive evidence for clinicians to use.
Objective:  To analyse whether maxillary, mandibular, or bimaxillary surgery provides a better stability.
Materials and methods:  A systematic search was conducted up to December 2020 using PubMed, EMBASE,
Medline, Scopus, Web of Science, Cochrane CENTRAL, and Google Scholar. We made direct comparisons
among the controlled trials and also made indirect comparisons via subgroup analysis on the aspects of
occlusional, skeletal, and dento-alveolar stability to assess the overall stability of each method.
Results:  Finally 16 cohort studies were identified. At the occlusional level, pooled change in overbite
was 0.21 mm in maxillary surgery, 0.37 mm in bimaxillary surgery, and −0.32 mm in mandibular
surgery. At the skeletal level, pooled sella–nasion–Point A  angle (SNA) was −0.12  degrees in
bimaxillary surgery, −0.37 degrees in maxillary surgery and −0.20 degrees in mandibular surgery.
The sella–nasion to palatal plane angle (SNPP) relapsed to a statistically significant degree in all
samples received single maxillary surgery. Relapse of the sella–nasion–Point B angle (SNB) was
0.47 degrees in mandibular setback, −1.8 degrees in mandibular advancement, and −0.48 degrees
in maxillary surgery. The Sella–Nasion to mandibular plane angle (SNMP) relapsed more in
procedures involving bilateral sagittal split osteotomy than in other procedures. As for dento-
alveolar changes, intrusion of molars and extrusion of incisors took place in most patients.
Conclusions:  Bimaxillary surgery produced the most beneficial post-operative increase in overbite,
maxillary surgery led to a lesser but still positive overbite change, and mandibular surgery correlated
with some extent of relapse. Skeletally, bimaxillary surgery was more stable than maxillary surgery
at both SNA and SNPP; SNB was more stable in mandibular setback than advancement; and
SNMP was unstable in both mandibular and bimaxillary surgeries versus maxillary surgery with
comparable surgical changes. Dento-alveolar compensation helped maintain a positive overbite.
Registration number:  CRD42020198088.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Orthodontic Society.
1
All rights reserved. For permissions, please email: [email protected]
2 European Journal of Orthodontics, 2021

Introduction Eligibility criteria

Selection criteria for this review are shown in Table 1 in reply to the
Rationale
question: ‘What is the vertical dental and skeletal stability (outcome)
Treatment and stability of skeletal anterior open bite (SAOB) are al-
of orthodontic–orthognathic treatment with different surgical pro-
ways challenging topics due mainly to multifactorial vertical relapse
cedures (interventions) for patients with skeletal anterior open bite
(1–5), which manifests as a decrease in overbite, eruption of molars,
(participants)?’
opening rotation of the maxilla and mandible, and an increase in facial
height (6, 7). For adult SAOB patients, who experience excessive ver-
tical growth and abnormal morphology characterized by shorter rami Study selection
and greater facial height (8, 9), orthodontic–orthognathic treatment is Articles were selected in two phases. In Phase 1, two authors (WMQ
considered to achieve optimal aesthetic and occlusal results and offer and ZBW) independently screened titles and abstracts of all articles.
greater long-term stability than non-surgical treatments (10, 11). In Phase 2, the same two reviewers independently assessed eligibility

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Several orthognathic procedures have been proposed to correct of studies enrolled in the full-text review; in the event of disagree-
SAOB, all of which could influence stability (2, 3, 11–16). These pro- ment, the third senior author (WFL) was consulted.
cedures include maxillary surgery, mandibular surgery, and a com-
bination of the two (bimaxillary surgery). Many researchers have Information sources and search strategy
attempted to confirm which is the most stable surgical procedure, a We performed an electronic search of literature published from 1
very controversial topic with no consensus. Bimaxillary surgery was January 2000 to 15 December 2020 in seven databases: PubMed,
reported to be less stable than either maxillary or mandibular surgery EMBASE, Medline, Scopus, Web of Science, Cochrane Central
alone (14, 17, 18), while Maia et  al. demonstrated no difference in Register of Controlled Trials (CENTRAL), and Google Scholar
long-term overbite change between maxillary surgery and bimaxillary to search grey literature. Medical Subject Heading (MeSH) terms
surgeries (1). Maxillary intervention, most commonly maxillary Le combined with free-text terms were used in the literature search
Fort I impaction, appeared to be more stable than mandibular surgery (Supplementary File 1). We manually searched the following jour-
(13, 19) and, therefore, has become the most frequently used orthog- nals for studies performed from January 2014 to December 2020:
nathic protocol for SAOB (18); however, relapse after this intervention American Journal of Orthodontics and Dentofacial Orthopedics
has also been reported (4). Meanwhile, some studies have suggested (AJODO), European Journal of Orthodontics, Journal of Dental
single mandibular surgery to be as least stable as maxillary impaction Research, and European Journal of Orthodontics, Progress in
and bimaxillary in correcting SAOB deformities (20), and results have Orthodontics, and The Angle Orthodontist.
been very favourable and clinically stable (21).
To our knowledge, no meta-analysis or systematic review has Data collection and data items
been conducted to assure the stability of different surgical proced- Two authors (WMQ and ZBW) independently extracted data from
ures for SAOB. Previous meta-analysis focussed on the differences in included studies using a pre-prepared data extraction form. The fol-
post-operative overbite stability between surgical and non-surgical lowing information was extracted from each study: general informa-
treatments (22). Given the persistent debates on the vertical sta- tion (first author, year of publication, and region), methods (study
bility of orthognathic treatments, clinicians lack clear informa- design and duration), participants information (sample size, age,
tion about which orthognathic surgery—maxillary, mandibular, or gender, preoperative overbite, type of malocclusion, and measure-
bimaxillary—can provide the greatest stability when used clinically. ment methods), and outcome measurements. Inconsistencies were
Consequently, a systematic review and meta-analysis is needed to resolved in consensus meetings and confirmed with the authors of
produce quantifiable results on the stability of orthognathic treat- the included studies when necessary.
ments and to provide evidence-based indications for clinical practice
and insights for further studies by evaluating current evidence.
Quality assessment
All studies recognized eligible for systematic review were assessed
Objectives
for risk of bias using the Risk Of Bias In Non-randomized Studies
The objectives of the present study were 1. to evaluate available evi- of Interventions (ROBINS-I) tool (23). The criteria take four main
dence on the vertical stability of orthognathic treatments—maxil- categories of bias into account: selection bias, performance bias,
lary, mandibular, and bimaxillary surgeries—for correcting SAOB measurement bias, and outcome reporting bias (attribution bias is
with at least a 6-month follow-up period, and 2. to identify which not included for studies with retrospective designs). The ROBINS-I
procedure could provide the best occlusional, skeletal, or dento- scale contains a total of seven measures: 1.  inclusion and exclu-
alveolar stability. sion criteria; 2.  random-sequence generation; 3.  standard surgery
in combination with rigid internal fixation (RIF); 4.  blinded as-
sessment; 5. validation of measurements; 6. statistical analysis; and
Materials and methods
7.  sufficiently long follow-up. Two reviewers (WMQ and ZBW)
Protocol and registration independently performed the assessment and attempted to resolve
This systematic review was prepared in accordance with the Preferred disagreements via discussion. If no consensus could be reached, the
Reporting Items for Systematic Reviews and Meta-Analyses third senior reviewer (WFL) became involved in the final decision.
(PRISMA) checklist. We registered the protocol of this systematic Overall risk of bias of the included articles was evaluated after
review and meta-analysis in the US National Institute of Health’s the assessment. Furthermore, we determined the quality of cumu-
(NIH; Bethesda, Maryland, USA) International Prospective Register lative evidence using the Grades of Recommendation, Assessment,
of Systematic Reviews (PROSPERO) research database (https:// Development and Evaluation (GRADE) system (24). Two authors
www.crd.york.ac.uk/prospero/; Trail Registration No. PROSPERO (WMQ and ZBW) evaluated the quality of evidence on five aspects:
CRD42020198088). risk of bias, indirectness, inconsistency, imprecision, and magnitude
M. Wang et al. 3

Table 1.  Eligibility criteria for study selection. SNMP: the angle between sella–nasion and mandibular plane; U1PP: the distance from the
edge of upper incisor perpendicularly to palatal plane; U6PP: the distance from the mesial cusp tip of upper first molar perpendicularly to
the palatal plane; L1MP: the distance from the edge of lower incisor to mandibular plane; L6MP: the distance from the mesial cusp tip of
lower first molar perpendicularly to the mandibular line.

Category Inclusion criteria Exclusion criteria

Study design Randomized controlled trials, controlled clinical trials, co- Case reports with ≤5 subjects, systematic reviews, opinion,
horts or philosophy articles without new data
Participants Patients after the stage of rapid growth with skeletal anterior Patients with systematic disease or craniofacial pathologies
open bite and in good general health requiring or anomalies potentially influencing stability or
surgical-orthodontic correction complicating treatment (periodontal disease, root
resorption, oral neoplasm, cleft lip or palate, trauma, and

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temporomandibular disorder).
Intervention Orthodontic–orthognathic treatment, of which surgical Surgery-first approach, isolated alveolar bone corticotomy
procedures include separated maxillary surgery, separated and isolated genioplasty, studies with no application of
mandibular surgery, and bimaxillary surgery Rigid Internal Fixation was excluded
Control Groups treated with different orthognathic treatments or Studies with no comparison of subjects before and after a
subjects treated with orthognathic surgery before versus after post-operative follow-up period >6 months.
a post-operative follow-up period >6 months
Outcome measures 1.Primary outcome: numerical change of overbite (mm),
frequency of relapse, or obvious overbite change (%)
2.Secondary outcome: measurements indicating vertical
skeletal and dento-alveolar stability, such as change of SNA
(°), SNPP (mm), SNB (°), SNMP (°), U1PP (mm), U6PP
(mm), L1MP (mm), and L6MP (mm)

of effect; and then classified it into four levels: high, moderate, low, Asia (China (25, 26), South Korea (12, 15)); 255 were from Europe
and very low. (Sweden (4), Finland (14), UK (33), Norway (18, 30), Italy (29),
Belgium (32)); and 71 were from the USA (21, 27, 28).
Summary measures and additional analysis The sample sizes of the studies ranged from 6 (13) to 72 (25)
of results participants, with mean age of included patients ranging from 19
(33) to 30.8 (16) years. Of all participants, 63.7 per cent were fe-
We conducted meta-analysis using Stata software version 15.1
male and 36.3 per cent were male. Initial mean open bite ranged
(StataCorp., College Station, Texas, USA). The pooled post-operative
from 1.9 (30) to 6.78 mm (12). Eight studies reported the type of
change (PC) was weighted by sample size. Forest plots and quantita-
antero-posterior relationship. Overall, 6.0 per cent of patients had
tive τ2, χ2, and I2 indices were used to indicate statistical heterogen-
eity. We applied the fixed-effects model if I2 <25 per cent; otherwise,
we applied the random-effects model. P < 0.05 was regarded to in-
dicate a statistically significant difference. When homogeneity was Records idenfied through
Identification

database searching
insufficient in the original data (I2 > 50 per cent), sensitivity analysis (n=1490)
was applied, and subgroup analyses of different orthognathic pro-
cedures (separated maxillary surgery, separated mandibular surgery,
and bimaxillary surgery) were performed to explain heterogeneity Records aer duplicates removed
(n=837)
and compare stability levels among these different procedures.

Records excluded based on title or

Screening

abstract (n=804)
Results Records screened
(n = 837)

Study selection Full-text arcles excluded, with

reasons (n=17)
The search strategy and results are detailed in Supplementary File Review arcle (n=1)
Sample size<5 (n=2)
1. The search of major databases was performed on 15 December Not SAOB paents (n=1)
Full-text arcles assessed No informaon on method
2020. Figure 1 shows the study flowchart. A total of 1490 articles for eligibility for fixaon or not RIF (n=9)
were retrieved by electronic search. We selected 34 recorded for full- (n=33) Post-operave period within
Eligibility

6 months (n=3)
text reading and assessment of eligibility. All publications found by No outcome data about
manual search were also among in the electronic search results. stability (n=1)

Ultimately, we included 16 records in the qualitative analysis Studies included in

qualitave synthesis Records not excluded from
and selected 12 for quantitative synthesis. The level of agreement quantative synthesis
(n=16)
between the two authors (WMQ and ZBW) in selecting studies for (meta-analysis) (n=4)
No usable data for quantave
full-text review was measured by k = 98.5 per cent. synthesis
Included

Studies included in
quantave synthesis
Study characteristics (meta-analysis)
(n=12)
All 16 studies were retrospective cohort studies. Data extraction re-
vealed that they included a total of 506 patients who underwent
orthognathic correction of SAOB. Of all patients, 180 were from Figure 1.  PRISMA diagram of the study identification process.
4 European Journal of Orthodontics, 2021

Class I malocclusion, 31.5 per cent had Class II malocclusion, and overbite changes in maxillary surgery (n = 114; PC = 0.21 degrees;
62.5 per cent had Class III malocclusion. 95 per cent CI, 0.06–0.37; I2  =  95.0 per cent, P  =  0) (4, 14, 18,
In terms of surgical procedures, 29.7 per cent of cases received 28–30), and the relapse rate for mandibular surgery had no hetero-
bimaxillary treatment (12–14, 25, 26, 29, 32), all of which consisted geneity (n = 79; PC = −0.32 degrees; 95 per cent CI, −0.61 to −0.02;
of Le Fort I  in combination with bilateral sagittal split osteotomy I2 = 0, P = 0.752) (13, 15, 21, 30, 31). One record was excluded by
(BSSO); 32.8 per cent of cases received a single mandibular oste- sensitivity analysis due to its high level of heterogeneity (27).
otomy (15, 21, 25, 27, 30, 31) performed via BSSO or modifications
thereof; and 36.3 per cent of subjects received a single maxillary Secondary outcomes
surgery (4, 13, 14, 18, 26, 28–30, 32) using Le Fort I osteotomy. For Figure 4 illustrates greater and lesser rates of relapse for each skel-
six cases in one study, specific surgical procedures were not reported etal measurement in all studies. Synthesized SNA had lower relapse
(1). Follow-up periods ranged from 8.3 (15) to 98 months (1); only in bimaxillary surgery (n = 61; PC = −0.12 degrees; 95 per cent CI,

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one study had a mean follow-up period of <12 months (15). Fifteen −0.42 to 0.17; I2 = 0, P = 0.444) (12, 14, 29) than in maxillary surgery
studies measured via cephalometric radiography; only one study (n = 74; PC = −0.37 degrees; 95 per cent CI, −0.56 to −0.17; I2 = 99.1
measured overbite clinically and on cast models (4). Detailed char- per cent, P = 0) (14, 28–30) and was even comparable to mandibular
acteristics are presented in Supplementary Table 1. surgery (n = 20; PC = −0.20 degrees; 95 per cent CI, −0.73 to 0.33),
which served as a non-maxillary surgical control (15). In terms of
Results of individual studies SNB, setback movement (n = 49; PC = 0.47 degrees; 95 per cent CI,
Table 2 summarizes the outcomes reported from the included studies, 0.17–0.78; I2 = 21.1 per cent, P = 0.281) (12, 15) was found to be as
classified by author (year), type of surgery, follow-up, measurements, stable as non-mandibular surgery (n = 24; PC = −0.95 degrees; 95 per
and significance (if evaluated). As Figure 2 and Supplementary Table cent CI, −1.48 to −0.42; I2 = 84.2 per cent, P = 0) (14, 28, 30). Obvious
2 illustrate, five studies directly compared stability among different relapse was observed in advanced movement (n = 39; PC = −1.80 de-
orthognathic surgeries, setting statistical significance at P < 0.05 (13, grees; 95 per cent CI, −2.25 to −1.35) (14, 30). As for SNMP, more re-
14, 25, 29, 30). lapse was observed in surgeries involving BSSO, whether mandibular
Two articles (14, 29) compared the stability of maxillary and or bimaxillary (n = 59; PC = 3.35 degrees; 95 per cent CI, 2.71–3.99;
bimaxillary surgeries. They reached no consensus on overbite relapse. I2  =  0, P  =  0.542) (14, 15, 30) than in maxillary surgery (n  =  54;
Although the difference was not statistically significant, both studies PC = 0.36 degrees; 95 per cent CI, −0.09 to 0.82; I2 = 42.0 per cent,
observed less change in maxillary measurements [sella–nasion–Point P = 0.178) (14, 28, 30). One study was excluded by sensitivity analysis
A angle (SNA); sella–nasion to palatal plane angle (SNPP)] in bimax- for its significant heterogeneity (27).
illary surgery. Mean change in SNPP after maxillary surgery was Pooled results of each dento-alveolar measurement presented
significant (>2  mm). The two studies also agreed that mandibular a tendency towards dento-alveolar compensation (Supplementary
parameters [sella–nasion–point B angle (SNB), sella–nasion to man- Figure 1): U1PP (n = 161; ES = 0.24 degrees; 95 per cent CI, 0.08–
dibular plane angle (SNMP)] relapsed less in maxillary surgery to 0.40; I2 = 79.0 per cent, P = 0) indicated vertical eruption of upper
a significant degree. Both articles observed dento-alveolar changes incisors (13, 14, 21, 27, 28, 32); U6PP (n = 132; ES = −0.49 degrees;
in incisor extrusion and molar intrusion in both surgeries, with no 95 per cent CI, −0.48 to −0.30; I2 = 89.6 per cent, P = 0) showed
intergroup differences. extrusive movement of the upper first molar (14, 21, 27, 32); L1MP
Two studies (13, 25) compared mandibular surgery with bimax- (n  =  64; ES  =  0.28  degrees; 95 per cent CI, −0.05 to 0.61; I2  =  0,
illary surgery. In terms of occlusion, mandibular surgery had a sig- P = 0.954) showed no heterogeneity for vertical eruption of lower in-
nificantly higher frequency of significant overbite decrease and a cisors; and L6MP (n = 95; ES = −0.06 degrees; 95 per cent CI, −0.38
significantly lower frequency of significant overbite increase; over- to 0.25; I2  =  83.7 per cent, P  =  0) (14, 21, 27, 28) indicated high
bite relapsed more often in mandibular surgery, although not to a heterogeneity in the upward-movement tendency of the lower first
significant degree. As for SNMP, both studies observed a higher fre- molar. We did not perform subgroup analysis of different surgeries
quency of significant increase and lower frequency of significant de- due to the limited number of studies.
crease in mandibular surgery (25). Dento-alveolar changes towards
compensation were also found in mandibular and bimaxillary sur-
Quality assessment
geries, with no intergroup differences (13).
Risk of bias within studies is detailed in Supplementary Table 3.
One article (30) compared maxillary and mandibular surgeries.
Most studies were deemed to have moderate (1, 4, 12, 15, 18, 25−27,
Although no statistical difference was found in overbite, the fre-
29, 30) or serious (4, 13, 14, 28, 31, 32) overall risk of bias. The risk
quency of no overlap significantly increased after mandibular
of biases in performance and reporting were low. Only one study in-
surgery. As for skeletal changes, SNB significantly relapsed in man-
cluded a blinded assessment of variables, although such assessment
dibular surgery, while there was no significant change in maxillary
is essential for reducing risk of bias during measurement. According
surgery. A  significantly greater SNMP relapse was observed after
to GRADE, we found the quality of evidence to be moderate to very
mandibular than after bimaxillary surgery. Remarkably, SNMP
low (Supplementary Table 4). The main factors decreasing the level
showed significantly relapse: 80 per cent of surgical correction after
of evidence were limitations of study design (observational studies),
mandibular surgery eventually reverted to its prior form.
inconsistency, and low magnitude of effects.

Synthesis of results
Primary outcome Discussion
Figure 3 presents the pooled overbite relapse rates of different sur- This study explored the post-operative stability of SAOB across
geries. The most beneficial overbite increases were in bimaxillary sur- three aspects: occlusional, skeletal, and dento-alveolar stability. The
gery (n = 69; PC = 0.37 degrees; 95 per cent CI, 0.18–0.57; I2 = 98.5 most beneficial overbite increase was found in bimaxillary surgery,
per cent, P  =  0) (12–14, 29). There were fewer but still positive there was less but still positive overbite change in maxillary surgery,
Table 2.  Data on occlusional, skeletal, and dento-alveolar stability from the included studies. Le Fort I: Le Fort I Osteotomy; BSSO: bilateral sagittal split osteotomy; SNMP: the angle between
sella–nasion to mandibular plane; L1-Me: Distance between the edge of lower incisor and menton point; FNO: Frequency of people with No vertical Overlap; FsOBd: Frequency of people with
significant postsurgical overbite decrease (≥ 2mm); FsOBi: Frequency of people with significant postsurgical overbite increase (≥ 2mm); FsSNMPi: Frequency of people with significant post-
surgical SNMP increase (≥ 2mm); FsSNMPd: Frequency of people with significant post-surgical SNMP decrease (≥ 2mm); T1:Measurement before follow-up; T2: Value at the end of follow-up;
NR: None related Report; NR: None significance (P ≥ 0.05).
M. Wang et al.

T1 T2 Difference Significance
Author (year)/surgery Follow-up (months) Variables Measurements M ± (SD) M ± (SD) M ± (SD) P-value

Bisase et al. (31)/BSSO 12 Occlusional OB (mm) 1.42 (0.51) 1.0 (0.6) −0.42 (0.51) 0.045
Espeland et al. (18)/Le Fort I 36 Occlusional OB (mm) NR NR 0.1 (0.4) NS
Fontes et al. (21)/BSSO 54 Occlusional OB (mm) 0.6 (1.0) 1.0 (1.0) NR NR
FNO (%) 25.8 9.7 NR NR
Skeletal SNA (°) 80.3 79.9 NR NR
SNB (°) 78.1 77 NR NR
Dento-alveolar U1PP (mm) 32.6 32.8 NR NR
U6PP (mm) 26.1 25.8 NR NR
L1MP (mm) 44 43.8 NR NR
L6MP (mm) 32.5 32.2 NR NR
Hull et al. (28)/Le Fort I 25 Occlusional OB (mm) 1.7 (0.6) 1.5 (0.8) −0.1 (1.1) NR
Skeletal SNA (°) 81.9 (6.4) 81.2 (6.3) −0.7 (1.1) NR
SNB (°) 78.1 (5.0) 77.4 (5.0) −0.7 (1.3) NR
SNMP (°) 35.6 (6.2) 36.4 (6.6) 0.8 (2.1) NR
Dento-alveolar U1PP (mm) 29.5 (3.2) 29.7 (2.6) 0.2 (1.0) NR
L1MP (mm) 30.1 (2.0) 30.4 (2.0) 0.3 (0.9) NR
L6MP (mm) 37.0 (2.9) 37.6 (2.9) 0.6 (0.6) NR
Iannetti et al. (29) (Bi)/Le Fort I+BSSO 24 Occlusional OB (mm) NR NR 0.875 (0.141) NR
Skeletal SNA (°) NR NR 0.055 (0.051) NR
SNB (°) NR NR −0.54 (0.305) NR
Iannetti et al. (29) (Max)/Le Fort I 24 Occlusional OB (mm) NR NR 0.4 (0.152) NR
Skeletal SNA (°) NR NR 0.1 (0.117) NR
SNB (°) NR NR 0.025 (0.072) NR
Ismail et al. (26) (Bi)/Le Fort I+BSSO 24 Occlusional FNO (%) 20.8 12.5 −8.3 NR
Ismail et al. (26) (Max)/Le Fort I 24 Occlusional FNO (%) 11.1 11.1 0 NR
Kwon et al. (15)/BSSO 8.3 Occlusional OB (mm) NR NR −0.2 (1.6) 0.519
Skeletal SNA (°) NR NR −0.2 (1.2) 0.461
SNB (°) NR NR 0.2 (1.3) 0.533
SNMP (°) NR NR 3.6 (2.9) <0.001
Kor et al. (12) (Bi1)/Le Fort I+BSSO 12 Occlusional OB (mm) NR NR 0.75 (0.70) NR
Skeletal SNA (°) NR NR −0.11 (0.75) NR
SNB (°) NR NR 0.45 (0.66) NR
Kor et al. (12) (Bi2)/Le Fort I+ BSSO 12 Occlusional OB (mm) NR NR 0.06 (0.93) NR
Skeletal SNA (°) NR NR −0.14 (1.07) NR
SNB (°) NR NR 0.79 (1.05) NR
Liu et al. (25) (Bi)/Le Fort I+BSSO 24 Occlusional FsOBd (%) 10 NR
FsOBi (%) 8 NR
Skeletal FsSNMPi (%) 19 NR
FsSNMPd (%) 6 NR
5

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 6

Table 2.  Continued

T1 T2 Difference Significance
Author (year)/surgery Follow-up (months) Variables Measurements M ± (SD) M ± (SD) M ± (SD) P-value

Liu et al. (25) (Mand)/BSSO 24 Occlusional FsOBd (%) 18 NR

FsOBi (%) 4 NR
Skeletal FsSNMPi (%) 25 NR
FsSNMPd (%) 7 NR
Maia et al. (1)/BSSO 24 Occlusional OB (mm) NR NR −0.83 (1.42) NR
Nina et al. (30) (Mande)/BSSO 36 Occlusional OB (mm) NR −0.2 −0.3 (1.3) NS
FNO (%) 37 58.3 21.3 NR
Skeletal SNB (°) NR 75.1 −1.2 (1.2) <0.05
SNMP (°) NR 43.4 3.5 (2.1) <0.05
FsSNMPi (%) 80 NR
FsSNMPd (%) 0 NR
Nina et al. (30) (Max)/Le Fort I 36 Occlusional OB (mm) NR 0.5 −0.2 (1.0) NS
FNO (%) 13.3 26 14 NR
Skeletal SNA (°) NR 78.5 −0.5 (0.7) NS
SNPP (°) NR 13.8 −0.7 (1.9) <0.05
SNB (°) NR 73.6 −0.1 (0.7) NS
SNMP (°) NR 41.1 0.0 (1.3) NS
FsSNMPi (%) 7 NR
FsSNMPd (%) 4 NR
Ooi et al. (13) (Bi)/Le Fort I+ BSSO 12 Occlusional OB (mm) 1.4 1.6 0.25 (0.80) NR
Dento-alveolar U1PP (mm) NR NR −0.56 (0.88) NR
L1–Me (mm) NR NR 0.03 (0.52) NR
Ooi et al. (13) (Mand)/BSSO 12 Occlusional OB (mm) 2.7 2.2 −0.48 (0.64) NR
Dento-alveolar U1PP (mm) NR NR −0.50 (0.86) NR
L1–Me (mm) NR NR −0.19 (0.53) NR
Silva et al. (4)/Le Fort I, Segmentated 30 Occlusional OB (mm) 2.6 (0.15) 1.65 (0.14) NR <0.001
Stansbury et al. (27)/BSSO 12 Occlusional OB (mm) 1.1 (1.1) 1.7 (0.7) 0.6 (1.2) 0.014
Skeletal SNMP (°) 38.5 (8.4) 38.6 (8.5) 0.1 (1.2) NS
Dento-alveolar U1PP (mm) 33.1 (4.5) 33.2 (4.4) 0.8 (1.4) 0.01
U6PP (mm) 27.3 (3.6) 27.5 (3.8) 0.2 (0.8) 0.17
L1MP (mm) 47.0 (6.9) 47.3 (6.8) 0.3 (1.1) 0.133
L6MP (mm) 35.9 (4.7) 35.7 (4.6) −0.3 (0.9) 0.063
Swinnen et al. (32)/Le Fort I or 12 Occlusional OB (mm) NR NR 0.5 (0.3) NS
Le Fort I+ BSSO Skeletal SNA (°) NR NR −0.7 (0.3) <0.05
SNPP (°) NR NR −1.5 (0.4) <0.0001
Dento-alveolar U1PP (mm) NR NR 0.1 (0.3) NS
U6PP (mm) NR NR −0.7 (0.3) <0.05
Teittinen et al. (14) (Bi)/Le Fort I+ BSSO 24 Occlusional OB (mm) 0.98 (1.53) 0.73 (0.93) −0.25 (1.33) 0.529
Skeletal SNA (°) 83.41 (5.23) 83.00 (4.67) −0.41 (2.12) 0.515
SNPP (°) 8.27 (3.91) 7.06 (4.14) −1.38 (2.34) 0.066
SNB (°) 81.39 (5.45) 78.25 (6.33) −3.15 (1.85) 0.001
SNMP (°) 37.48 (8.47) 41.25 (10.37) 3.60 (2.68) 0.001
European Journal of Orthodontics, 2021

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 M. Wang et al. 7

Significance
P-value

0.046
0.022
0.206
0.293
0.088
0.864
0.197
0.159
0.359
0.111
0.709
0.175
0.276
−0.47 (1.41)
−2.14 (3.31)
−1.02 (1.33)

−0.77 (1.42)

−0.61 (1.54)
−0.24 (0.86)

0.84 (2.17)
0.40 (1.24)

0.12 (2.38)
0.44 (1.01)

0.38 (0.75)
0.18 (1.66)
0.59 (1.40)
Difference
M ± (SD)

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81.24 (3.67)
35.84 (5.95)
33.19 (4.44)
24.50 (3.93)
43.31 (5.29)
31.84 (4.03)
32.41 (2.15)
23.13 (1.80)
41.90 (3.99)
31.67 (3.69)
1.85 (0.93)
84.71 (3.67)
7.45 (3.08)
M ± (SD)
T2

Figure 2. Direct comparison with controlled studies. Le Fort I: Le Fort

I  osteotomy; BSSO: bilateral sagittal split osteotomy; +: more increase in
85.18 (2.94)
9.59 (3.23)
82.26 (3.64)
34.17 (7.30)
32.80 (4.36)
25.27 (4.15)
43.19 (4.75)
32.45 (3.70)
31.97 (2.50)
23.37 (1.80)
41.52 (3.92)
31.48 (2.94)
1.23 (1.05)

overbite or less relapse; L1–Me: distance between edge of lower incisor and
M ± (SD)

menton point; FNO: Frequency of patients with No vertical Overlap; SNMP:

angle between sella–nasion and mandibular plane; NS: no significance (P ≥
T1

0.05).
Measurements

L1MP (mm)
L6MP (mm)
L1MP (mm)
L6MP (mm)

U1PP (mm)
U6PP (mm)
U1PP (mm)
U6PP (mm)

SNMP (°)
OB (mm)

SNPP (°)
SNA (°)

SNB (°)

Dento-alveolar
Dento-alveolar

Occlusional
Variables

Skeletal
Follow-up (months)

Figure 3.  Pooled changes in overbite after surgery.

42

and some extent of relapse occurred in mandibular surgery. As for

skeletal stability, bimaxillary surgery was more stable than maxil-
lary surgery in SNA and SNPP. When it came to mandibular skeletal
stability, SNB was highly stable in mandibular setback compared
with mandibular advancement; as for mandibular plane, counter-
Teittinen et al. (14) (Max)/Le Fort I

clockwise rotation in either mandibular or bimaxillary surgery was

unstable compared with autorotation in maxillary surgery with a
comparable amount of surgical correction. Furthermore, we verified
that dento-alveolar compensation played an important role in main-
Author (year)/surgery
Table 2.  Continued

taining positive overbite, regardless of orthognathic procedure.

To the best of authors’ knowledge, few meta-analysis and systematic
reviews have been conducted on the stability of orthognathic surgery in
correcting SAOB (33, 34), and none of them focus on the hierarchical
stability order of different orthognathic procedures. As current views
are too controversial to reach a consensus, although no high-quality
8 European Journal of Orthodontics, 2021

In terms of mandibular stability, the studies of Gaitan-Romero

et al. indicate more post-operative SNB relapse in individuals in skel-
etal Class II than in skeletal Class III (3, 19). Class II patients have
also been found more likely to suffer vertical relapse than Class III
patients after surgery (1, 15, 17). With the addition of different sur-
gical directions, we evaluated SNB in three subgroups: mandibular
setback (angle Class III), mandibular advancement, and auto-move-
ment in mandibular surgery. In line with the findings given above,
relapse of SNB happened the least in mandibular setback (angle
Class III) (12, 15) compared with the other two subgroups (14, 28).
As for SNMP, several investigations believe that the risk of re-

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lapse increases when open bite is closed by decreasing the SNMP
through BSSO procedure (39, 40) Similarly, we found maxillary
surgery compared with bimaxillary surgery or single mandibular
surgery based on direct and indirect evidence (13–15, 25, 28–30).
Considering that previous study revealed a correlation between re-
lapse and the amount of mandibular rotation during surgery (13,
15, 29), to avoid methodological bias, we divided studies into two
groups: surgical change of SNMP above 3  degrees (14, 27) and
below 3 degrees (15, 28). At a comparable level of surgical change,
the application of mandibular surgery was correlated with a larger
percentage of relapse (the percentage of mean relapse took in the
mean magnitude of surgical movement: 124 and 66.7 per cent, sep-
arately) than separated maxillary surgery (33.3 and 21.1 per cent,
separately).
In terms of dental-alveolar change, Espeland et  al. states that
post-operative incisor movements make a 50 per cent contribution
towards the correction of open bite (18). In addition, compensatory
Figure 4. Postoperative skeletal stability. (A) Pooled SNA relapse. (B)
post-operative eruption of anterior teeth has been observed in both
Cumulative SNB relapse. (C) Pooled SNMP relapse.
arches of SAOB patients (3, 32). In the current investigation, we also
found dento-alveolar changes to play an important role in prevent-
clinical trials have been conducted, a quantitative summary based on
ing overbite relapse. Our data indicated that extrusion of incisors
currently available evidence could still provide some implications for
and intrusion of molars occurred after surgery, while dental changes
clinical decision-making and insights for further research.
could not be differentiated between post-operative orthodontics
Before the advent of RIF, orthognathic surgery for SAOB was
and self-compensation. Espeland et al. revealed a discrepant vertical
considered unstable (11, 35). As RIF ensures more stability in orthog-
alternation between upper incisors and anterior nasal spine point
nathic surgery and has been routinely used therein (33, 36−38), we
and lower incisors and Menton point (Me) in the first 6  months
applied strict eligibility criteria to eliminate methodological hetero-
after surgery. Many patients wore appliances during this period,
geneity and enrolled only studies that applied.
so movement of incisors seems to be more closely correlated with
As for occlusional stability, both direct evidence from controlled
post-operative orthodontics (18). By contrast, Kor et al. reported an
studies (13, 25, 30) and indirect comparison by meta-analysis (2,
increase of overbite from 6 months to 1 year post-surgery (12). In
12−15, 18, 21, 28−30) illustrated that single mandibular surgery had
addition, clinical relapse of open bite was observed both in the first
some post-operative overbite relapse and was unstable compared
6 months post-surgery and during a 2.5-year follow-up period (4);
with bimaxillary and maxillary surgeries. Despite the obvious het-
this indicated that dental-alveolar compensation, whether originat-
erogeneity within studies of bimaxillary and maxillary surgeries, it
ing from orthodontics or self-compensation, could only partly coun-
should be noted that most of them tended towards positive change
teract the recurrence of open bite.
compared with mandibular surgery. This could be explained by the
elongation of the pterygomasseteric sling and elevator muscle after
mandibular surgery (4, 12).
In terms of the skeletal stability of maxillae, it is suggested that Limitations
vertical movement thereof, either superior repositioning of the pos- The results and conclusions of this investigation must be adopted
terior maxilla or downward movement of the anterior maxilla, poses with caution, taking the following limitations of study design,
the risk of undesirable reopening rotation after surgery (4, 14, 32). quality problems, and statistical methods into consideration:
By contrast, Proffit et al. (17) classified downward movement of the
maxilla as a problematic procedure, while finding maxillary upward 1. Regarding study design, there was no randomized clinical trial on
movement to be very stable. In this study, both direct and indirect the stability of orthodontic–orthognathic treatments in combin-
evidence proved that SNA and SNPP relapsed less in bimaxillary (12, ation with RIF in correcting SAOB. In addition, no study used 3D
14, 29) than in maxillary (14, 28, 29) surgery. SNA was considered techniques to assess post-operative stabilities.
to be highly stable in bimaxillary surgery, leading to comparable or 2. There was heterogeneity among included subjects, especially in
even fewer changes than non-maxillary surgical control (15). On the measurement and randomized selection. Therefore, we suggest
other hand, a statistically significant counterclockwise rotation of more rigorous design in future studies.
the PP plane was observed after surgery, especially in maxillary sur- 3. The mean change could only present the overall stability. In fact,
gery (14, 30, 32). significant relapse occurred only in a small portion of patients.
M. Wang et al. 9

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