Submitted: 14 September, 2022 Accepted: 24 October, 2022 Published: 03 January, 2023 DOI:10.22514/jocpd.2022.

017

CASE REPORT

Combined orthopedic-orthodontic treatments of

adolescent skeletal open-bite with severe molar-incisor
hypomineralization: a case report and literature review
Jie Chen1 , Yuchan Xu1 , Weihua Guo1, *

1
State Key Laboratory of Oral Diseases, Abstract
Department of Pediatric Dentistry,
Orthodontics Faculty, National Clinical
The treatment of adolescent skeletal open-bite malocclusion with severe molar-incisor
Research Center for Oral Diseases, West hypomineralization (MIH) remains challenging. Though conducive to open-bite
China School of Stomatology, Sichuan treatment and endodontic management, early molar extraction may trigger a series
University, 610041 Chengdu, Sichuan, of negative impacts on occlusion and stomatognathic development. In addition,
China
molars’ crown restoration was shown to worsen open-bite malocclusion considering
*Correspondence the intrinsic vertical increment of hyperdivergent growth. This case report describes
[email protected] the successful multidisciplinary therapy combined with orthopedic and orthodontic
(Weihua Guo) treatment of a 10.2-year-old girl with mixed dentition, a protruding profile and skeletal
open-bite malocclusion with severe MIH and crowding. During the mixed and
early permanent dentition, function regulator-4 (FR-4), resin-bonding transpalatal arch
(TPA) and modified spring-loaded bite blocks were implemented to correct abnormal
swallowing and control the facial vertical growth. Radiographic results, including
the counterclockwise rotation of the occlusion plane, decreasing mandibular angle
and increasing posterior-anterior face height ratio accompanied by obvious mandibular
vertical growth, indicated that the performed orthopedic treatments efficiently controlled
hyperdivergent open-bite growth during puberty. After the maxillary and mandibular
second molars were occluded, all first permanent molars were extracted, and fixed
appliances combined with implant anchorage were used to correct malocclusion and
convex profile. Ultimately, a stable Class I functional occlusion and satisfying facial
improvement were achieved and maintained following a 2-year follow-up.

Keywords
Skeletal open bite; Early treatment; Orthodontic mini-implant; Molar-incisor hypomin-
eralization; First permanent molars extraction

1. Introduction dence to draw concrete conclusions about the most effective

early correction [5]. A lack of direct feedback loops to a patient
Following decay, molar-incisor hypomineralization (MIH) is during the long-term wearing of those passive devices often
a frequent compromising factor for the poor prognosis of leads to loss of patient compliance and uncertainty therapeutic
first permanent molars (FPMs), with a prevalence ranging outcomes. Here, we present an efficient strategy using ac-
from 10% to 27% [1]. The treatment approaches for MIH tive orthopedic modification and fixed appliance after FPMs
include filling, pre-formed crown restoration and even molar extraction to treat a girl with skeletal open-bite, protruding
extractions, especially for those with third molars and obvious incisors and severe MIH, which successfully achieved and
malocclusion [1]. Nevertheless, the potential of losing FPMs maintained a Class I canine and molar occlusion and aesthetic
negatively impacts occlusion development, chewing habits facial results following a 2-year follow-up.
and dentofacial symmetry, especially in the mixed dentition
stage [2]. Considering its controversial application, clini- 2. Case report
cal guidelines have primarily focused on the optimal FPMs
extraction time within different crowding malocclusions [3]. A 10.2-year-old girl without any general health problems
However, there is a lack of data to illustrate the influence of or menarche was referred by a general dentist regarding
vertical factors on this decision-making process for adolescent “open-bite and protruded incisors” during dental caries
skeletal open-bite malocclusion. Meanwhile, although early therapy (Fig. 1). The patient’s mother reported that the
orthopedic treatment is considered necessary for children and patient had mastication difficulties and disliked chewing
teenagers [4], a systematic review reported insufficient evi- any hard foods. She presented with a visceral swallowing

This is an open access article under the CC BY 4.0 license (https://creativecommons.org/licenses/by/4.0/).

J Clin Pediatr Dent. 2023 vol.47(1), 91-99 ©2023 The Author(s). Published by MRE Press. https://www.jocpd.com
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F I G U R E 1. Pretreatment photographs of facial, intraoral, panoramic and lateral records.

pattern, displayed as a forward movement of the tongue tip mixed dentition instead of one-phase therapy as orthodontic or
and pressure between the upper-lower incisors. Extraoral orthognathic treatment in permanent dentition. The 1-phase
examination showed partial long-face features with an objectives in mixed dentition with functional appliances were
increased lower facial height and a highly convex profile in to (1) cease visceral swallowing habit; (2) correct the anterior
the lateral aspect. Her temporomandibular joint examination open-bite; (3) continuously correct the skeletal discrepancy by
was normal. Intraorally, the patient presented with obvious controlling the mandibular vertical growth; and (4) perform
crown filling, bilateral Class Ⅱ molar relationship and anterior orofacial myofunctional training. Meanwhile, the 2-phase
open bite with mixed dentition. Notably, FPMs showed severe objectives with orthodontic braces in the permanent dentition
MIH with yellowish-brown crowns and occlusal breakdown were to (1) align, level and coordinate arches to achieve normal
even with large restorations. Further, hypomineralization overjet and overbite; (2) obtain functional occlusion; and
was visible on the central maxillary incisors, and she had (3) improve the soft tissue profile by implant anchorage to
an overjet of 4.1 mm and an overbite of −2.4 mm. The maximally retract the prominent incisor.
panoramic radiograph showed some teeth with restorations The patient maintained a high standard oral hygiene, and the
and incomplete treatments. Cephalometric analysis indicated glass ionomer restoration for FPMs was implemented when
a skeletal Class I open-bite malocclusion with hyperdivergent dentin hypersensitivity occurred. Importantly, professional
growth pattern (ANB = 3.7◦ , SGn-FH = 67.4◦ , and SN-MP = dental hygiene and specific prophylactic measures were per-
50.2◦ ) in a prepubertal growth spurt (CVMS I) and protruded formed before and throughout the orthodontic treatments. In
lower and upper incisors (U1-SN = 116.9◦ , FMIA = 51.2◦ ) the orthopedic phase, FR-4 was first used to guide somatic
(Table 1). swallowing and was worn daily for at least 10 hours. Open-
According to the treatment suggestion of MIH [6], mo- bite was corrected after 5 months of treatment, but the negative
lars were restored with a pre-formed metal crown to avoid swallowing habit persisted. Thus, orofacial myofunctional
continuous post-eruptive breakdown. The parents refused training with FR-4 was further emphasized until 18 months
this approach because of potential harm to the affected mo- because the overbite mildly relapsed, and her mother com-
lars and open bite correction. Considering the impact of plained about the patient’s gradual loss of compliance, long
open-bite malocclusion on socio-psychological and craniofa- facial appearance and protruding lower lip (Fig. 2). FR-4
cial development, the parents chose two-phase therapy as a increased overbite from -2.6 mm (0 M) to 0.8 mm (12 M)
combination with orthopedic and orthodontic treatments from in CVMS I, mainly through lingual inclination and eruption
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TA B L E 1. Cephalometric values of different treatment stages.

Measurement Pretreatment FR-4 mSLBB Posttreatment Norm Std Dev
Skeletal pattern
SNA (°) 73.7 73.2 75.5 76.2 83 4
SNB (°) 70.0 71.3 73.4 74.5 80 4
ANB (°) 3.7 1.9 2.2 1.7 3 2
SN-OP (°) 24.3 23.2 16.7 14.7 19 4
Go-Po (mm) 57.0 59 68.3 70.1 73 4
Go-Co (mm) 41.2 41.8 47.2 51.6 56 3
SN-MP (°) 50.2 45.0 45.2 44.4 30 6
Y-Axis (SGn-FH) 67.4 67.9 69.0 67.4 64 2
S-Go/N-Me (P-A Face Height) (%) 57.3 58.2 62.2 62.4 64 2
ANS-Me/Na-Me (%) 62.7 59.8 58.6 57.3 55 3
Wits (mm) 0.4 0.8 0.2 −0.8 0 2
APDI (°) 80.4 78.9 80.9 83.9 81 4
ODI (°) 65.0 68.1 71.0 70.8 73 5
Dental pattern
U1-L1 (Interincisal Angle) (°) 101.3 110.3 108.1 128.8 124 8
U1-SN (°) 116.9 108.5 113.5 109.2 106 6
FMIA (L1-FH) (°) 51.2 50.2 46.4 58.1 55 2
U1- Apo (°) 41.5 35.9 32.4 26.8 28 4
L1- APo (mm) 4.9 4.0 5.2 2.8 1 2
U1-PP (mm) 25.5 30.8 28.8 28.6 26 2
U6-PP (mm) 19.8 20.1 22.8 22.9 22 3
L1-MP (mm) 38.5 40.4 41.6 41.1 40 4
L6-MP (mm) 25.7 24.7 27.1 26.9 34 2
Overjet (mm) 3.9 2.8 3.4 3.7 2 1
Overbite (mm) −2.6 0.8 0.1 1.9 3 2
Profile
UL-EP (mm) 5.4 2.9 4.5 0.1 −1 1
LL-EP (mm) 9.1 5.3 6.4 1.1 1 2
Z-Angle (°) 44.1 63.6 52.7 68.2 77 5
FR-4: function regulator-4; mSLBB: modified spring-loaded bite blocks.

of the incisors: U1-SN decreased by 8.4◦ (from 116.9◦ to was alleviated at early permanent dentition (Fig. 3D), and
108.5◦ ), U1-PP increased by 5.3 mm (from 25.5 mm to 30.8 the patient’s compliance had improved. After 3 years of
mm) and L1-MP increased by 1.9 mm (from 38.5 mm to 40.4 orthopedic treatment, the second molars had occluded, but the
mm) (Supplementary Fig. 1; Table 1). open bite mildly relapsed with an obvious protruding lower lip
For more vertical control and to improve patient compli- (Fig. 3E). The panoramic radiograph showed that the crowns
ance, modified spring-loaded bite blocks (mSLBB) and resin of all third molars were almost completely developed, and
bonding-TPA were used (Fig. 3A– 3C). Compared with SLBB, cephalometric analysis indicated obvious vertical growth of the
the Adams clasp and tongue crib of mSLBB improved the re- mandible ramus in postpuberty (CVMS III) (Supplementary
tentive force and prevented visceral swallowing, respectively. Fig. 2). In contrast, mSLBB promoted the occlusal plane in
The vertical opening of mSLBB during occlusal reconstruc- a counterclockwise rotation (SN-OP decreased from 23.2◦ to
tion was approximately 3–4 mm beyond the resting position, 16.7◦ ), with a small increment in mandibular angle (SN-MP
thereby maintaining the forces between 300 and 400 g for changed from 45◦ to 45.2◦ ) and increased posterior-anterior
active myofunctional training. Principally, the total wearing face height ratio (from 58.2% to 62.2%) even with obvious
time was at least 4 hours a day (primarily used after three mandibular vertical growth as the length of Go-Co increased
meals and before bedtime), and it was re-activated every 6 by 5.4 mm (Supplementary Fig. 2; Table 1).
weeks. After 9 months of mSLBB treatment, the open bite Since the parents’ urgent wish was to keep more teeth intact,
94

extracting those FPMs with poor prognoses was the first choice excellent vertical control and facial aesthetics improvement for
instead of extracting the first permanent premolars. Next, hyperdivergent open-bite with bimaxillary protrusion (Fig. 7).
FPMs extraction and the fixed devices with temporary skeletal
anchorage devices (TSADs) were performed. Interestingly,
the open bite was significantly alleviated after FPMs extrac- 3. Discussion
tion (Fig. 4A). The 0.022-in slot fixed orthodontic device
(Damon Q brackets, high torque, Ormco, US) was bonded, Treatment of adolescent skeletal open-bite is controversial
and TSADs (SH1413-08 mm for maxillary dental arch, and and challenging. Much debate has centered on the treatment
SH1615-08 mm for mandibular dental arch, AbsoAnchor®, modalities between two-phase therapy, including early treat-
Korea) in the root apex of all first molars (Fig. 4B) were ment in deciduous or mixed dentition and one-phase therapy
simultaneously implanted. The teeth were well aligned by in permanent dentition [7]. Presently, there is a lack of strong
sequentially changing the sectioned nickel-titanium archwires scientific evidence to show the curative effectiveness and long-
(IMD, Shanghai, China). To avoid over-protrusion of the term stability of early treatment [7], and it was shown that
incisors, canine laceback with TSADs was applied in all four one-phase therapy was more “clinically stable” in the long-
quadrants from the initial alignment (partly shown as the lower term posttreatment period [7, 8]. However, several authors em-
dental arch in Fig. 4C). After 10 months, 0.018 × 0.025 SS phasized that patients with open bites should receive relevant
archwires with 100 g—9 mm nickel-titanium tension springs interventions, especially in children [4, 9]. Early treatment
were placed for anterior incisors’ retraction (Fig. 4D). In this is more likely to recover stomatognathic system function and
phase, transversely coordinating bimaxillary arches were nec- reduce treatment burden in the permanent dentition than pas-
essary to prevent posterior crossbite. After 14.5 months of sive self-correction [10]. Previously, FR-4 was used to correct
orthodontic treatment, TSADs in the left maxilla and right swallowing patterns and open-bite by over-eruption of incisors
mandible were loose, and the extraction space in the maxillary along with orofacial myofunctional training [11]. However,
dental arch was completely closed. Because of a small amount the effectiveness of these approaches remains controversial
of extraction space in the mandibular dental arch and the [12].
bilateral Class II canine and molar relationship, all TSADs The success of functional orthodontic treatment in children
were removed, and Class II elastic was applied with 3.5 oz 1/4e depends on many factors, among which patient compliance is
and 1/8e with 22 h/day to facilitate intercuspation (Fig. 4E). one of the most essential factors, especially when removable
Considering that Class II elastics might increase the ante- appliances are used [13]. It was shown that adolescents’ coop-
rior vertical dimension, we only used these elastics for three eration with wearing removable orthodontic devices gradually
months. After 24 months of orthodontic treatment, the patient decreased during long-term treatment [14]. According to the
was 15.3 years old, the fixed orthodontic appliances were servosystem theory, an increase in patients’ active feedback
removed, and vacuum-formed clear retainers were used for could increase positive reinforcements [15]. Thus, a lack of
retention in both arches. active feedback when wearing FR-4 could easily lead to relapse
A combination of orthopedic and orthodontic treatment, (Fig. 2).
together with the patient’s cooperation, permitted a satisfactory Spring-loaded bite-blocks are simple and effective for early
appearance with a slightly straight profile, a significant lower correction of skeletal open bite for mixed dentition [16]. As
lip retraction, a chin contour and no gummy smile. The a kind of modified bite block, some researchers have re-
maxillary and mandibular dental midlines coincided with the ported that the mechanism of Spring-loaded bite blocks is
facial midline. The bimaxillary arches were aligned, and based on inhibiting vertical development or intrusion of the
the second molars showed successful mesial migration. Bi- buccal dentoalveolar structures, thus producing counterclock-
lateral Class Ⅰ canine and molar relationship were achieved wise rotation of the mandible into a more horizontal growth
with normal overjet (3.7 mm) and overbite (1.9 mm). The direction rather than a vertical one [16, 17]. In this case,
temporomandibular joints were asymptomatic to palpation and mSLBB modified with a tongue crib and anatomic occlusal
movement. The lateral cephalogram revealed that vertical splint can directly feed the masticatory force back to improve
maintenance of the maxillary incisors after lingual retraction weak masticatory functions, promote adolescents’ long-term
(U1-PP changed from 28.8 mm to 28.6 mm while the U1- compliance and relieve anxiety about relapse. Although it may
SN decreased from 113.5◦ to 109.2◦ ) offered an effective exhibit some inhibition effects on the patient’s hyperdivergent
torque control by TSADs traction and high torque brackets. growth, a well-designed clinical trial with large sample size is
The posttreatment panoramic radiograph revealed good root required to validate the effectiveness and course of mSLBB on
parallelism and no root resorption, and all third permanent the skeletal changes.
molars showed satisfactory growth (Fig. 5). The goal of Open-bite extraction treatment has shown greater stability of
functional occlusion was also achieved as the bimaxillary oc- overbite than non-extraction treatment during the orthodontic
clusal surface presented with simultaneous centric contact and phase [18]. The extraction space offers more viable pos-
suitable anterior guidance during the mandible’s protrusive and sibilities for retraction and lingual tipping of incisors, for-
lateral excursive movements (Supplementary Fig. 3). The ward movement of molars and decreasing the posterior vertical
satisfying esthetic result and stable functional occlusion were height through the wedge effect (Fig. 4A), which reduced
consistent after a 2-year follow-up (Fig. 6). The craniofacial the clinically significant relapse of anterior open bite [8].
skeleton profile and cephalometric superimpositions results Extraction of FPMs is rarely preferred, but it is not advisable to
revealed that combined orthopedic-orthodontic treatments had extract a healthy premolar if FPMs on the same side have poor
 95

F I G U R E 2. Dental and facial images during FR-4 treatment.

F I G U R E 3. Orthopedic treatment with mSLBB. (A) Modified spring-loaded bite blocks (mSLBB). (B) Intraoral photographs
with mSLBB. (C) Resin bonding-TPA. (D) Intermediate records after 9 months of treatment with mSLBB. (E) Final records after
17 months of treatment using mSLBB.
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F I G U R E 4. Dental images of the orthodontic treatment. (A) Intraoral photographs after FPMs extraction. (B) Placement of
miniscrews. (C) Canine laceback with TSADs in the lower dental arch during alignment. (D) Space closure. (E) Final adjustment.

F I G U R E 5. Posttreatment records after orthodontic treatment.

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F I G U R E 6. Facial and intraoral photographs following the 2-year follow-up.

F I G U R E 7. Pretreatment and posttreatment comparison. (A) Craniofacial skeleton profile and (B) cephalometric
superimpositions of pretreatment and posttreatment. Here, “6” represents the first permanent molar, and “7” represents the second
permanent molar.
98

prognoses. However, this decision can be complicated by two design and manuscript review and editing. All authors read
important factors: (1) when to extract, and (2) how to close and approved the final manuscript.
the extraction space. It is generally accepted that FPMs can
influence occlusal stress distribution and displacement in the
human skull. Unless it could achieve spontaneous closure for E THICS APPROVAL AND CONSENT TO
mandibular second molars, the FPMs extraction time should be PA R TICIPATE
delayed until the second molars occlude, especially in hyperdi- The study was approved by the ethics committee of West
vergent patients with weakened masticatory functions. By this China Hospital of Stomatology (WCHSIRB-D-2017-073-R1)
stage, orthodontic intervention may not only prevent second and accepted by parents who chose modified spring-loaded
molars from mesial tipping and rotating but also continuously bite blocks appliance for the children. Parents gave written
promote more myofunctional training. Conversely, premature informed consent to participate in the study.
FPMs extraction accompanied by fixed appliances is bound
to weaken chewing habits, and postmature FPMs extraction
may increase the first molars’ hypersensitivity risk, producing ACK NOWLEDGMENT
inappropriate effects on stomatognathic system growth.
Not applicable.
In addition, it is recommended to pay more attention to the
mesial movement of second molars and the torque control of
maxillary incisors if more space is needed for the anterior arch F UNDING
after FPMs extraction. It is widely accepted that molar anchor-
age loss may easily happen in hyperdivergent skeletal patterns This research received no external funding.
as a relatively small cancellous bone density in the interradicu-
lar regions [19]. In this study, the young girl’s upper and lower
CONFLICT OF INTEREST
second molars exhibited obvious spontaneous mesial move-
ment during alignment, even with TSADs-laceback traction The authors declare no conflict of interest.
(Fig. 4C). Generally, the orthodontic mechanisms of open bite
in permanent dentition mainly include intrusion of the posterior
teeth, extrusion of the anterior teeth or a combination of both. S UP PLEMENTARY MATERIAL
Although simple extrusion of the anterior teeth can efficiently Supplementary material associated with this article can be
correct open-bite, it is usually criticized for being unstable found, in the online version, at https://oss.jocpd.com/
and compromising facial aesthetics with a gummy smile, es- files/article/1592085180828270592/attachment/
pecially in patients with an excessive anterior dentoalveolar Supplementary%20materials.pdf.
eruption height [17]. Thus, precautionary measures, including
high torque brackets and maxillary miniscrew placement at
a high level, were implemented in this patient to prevent R EF ERENCES
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