TURKISH JOURNAL of

DOI: 10.5152/TurkJOrthod.2022.21053

Case Report

Management of Anterior Open Bite and Skeletal Class

II Hyperdivergent Patient with Clear Aligner Therapy
Sudha Gudhimella , Vaibhav Gandhi
1 1
, Nichole Leigh Schiro 2
, Nandakumar Janakiraman 1

Division of Orthodontics, University of Louisville School of Dentistry, Louisville, Kentucky, USA

1

Private Practice, Denver, Colorado, USA

2

Cite this article as: Gudhimella S, Gandhi V, Leigh Schiro N, Janakiraman N. Management of anterior open bite and skeletal class II hyperdivergent
patient with clear aligner therapy. Turk J Orthod. 2022;35(2):139-149.

Main Points 139

• This Invisalign case represents the biomechanical aspect to consider for the open bite and hyperdivergent case.
• An asymmetric mechanism is used to correct the anteroposterior discrepancy.
• Utilizing the advantages of the active biteblocks helped to maintain and improve the vertical molar positions.

ABSTRACT
In orthodontics, patients with hyperdivergent facial types or problems in the vertical dimension are often challenging to treat with
­predictable treatment results. Conventionally along with fixed appliances, a headgear, posterior bite block, extraction, temporary
­anchorage devices, or orthognathic surgery are preferable approaches to treat such patients. This case report illustrates a non-­extraction,
non-surgical orthodontic treatment of 5 mm anterior open bite in a non-growing adult patient, utilizing clear aligner therapy.
Keywords: Open bite, clear aligner therapy, molar intrusion, sagittal discrepancy

INTRODUCTION

The management of problems in the vertical dimension is often challenging to treat, and more importantly,
the stability of correction is unpredictable. Traditionally, these patients are treated with headgear, posterior bite
blocks, and extraction of premolar teeth, mini-implants-assisted molar intrusion, or orthognathic surgery.1 With
the introduction of mini-implants, the mild to moderate skeletal open bite cases can be treated predictably
with molar intrusion, as documented by numerous case reports.2,3 Buschang et al.4 documented favorable facial
changes in Class II retrognathic and hyperdivergent subjects after mini-implant-assisted molar intrusion.

Recently, clear aligners or aligners combined with mini-implant have shown some promising results in man-
aging mild to moderate skeletal Class II hyperdivergent cases.5-7 Most of the patients treated were mild cases
with incisor extrusion and minimal evidence of posterior teeth intrusion. However, recent retrospective studies
evaluated the dental and associated skeletal changes after clear aligner treatment.8,9 The open bite malocclusion
improved due to a combination of maxillary and mandibular molar intrusion and maxillary and mandibular inci-
sor extrusion.

Based on the current evidence, the clear aligners may be successful in managing patients with mild to moderate
skeletal open bite. Hence, the aim of this case report is to document the management of skeletal open bite in an
adult patient with clear aligner treatment.

Corresponding author: Vaibhav Gandhi, e-mail: [email protected] Received: April 19, 2021
© Copyright 2021 by Turkish Orthodontic Society - Available online at turkjorthod.org Accepted: August 20, 2021
 Gudhimella et al. Management of anterior open bite with clear aligners Turk J Orthod 2022; 35(2): 139-149

Diagnosis and Etiology extending from the upper second premolar on the left side to the
A 26-year-old female patient sought orthodontic treatment with first premolar of the right side. The model analysis revealed 6 mm
the chief complaint of anterior open bite and underbite. The of crowding in the upper arch with 2 mm of lower midline shift
patient was in good health, exhibited good oral hygiene, and toward the left side and flat curve of Spee (Figures 1 and 2).
had no harmful oral habits, caries, or periodontal problems that
contraindicated orthodontic treatment. There was no history of The cephalometric analysis revealed that the patient had a skel-
trauma to the oral region. etal Class II malocclusion (ANB = 7.9o, Wits appraisal = 4.7 mm)
with mild hyperdivergent growth pattern (Mandibular plane
The patient had a convex soft tissue profile with competent lips [MP] to SN = 34.5o) and upright upper and slightly proclined
and reverse smile arc on extraoral examination. Intraoral examina- lower incisors (U1-PP 102.4o, Incisor mandibular plane angle
tion showed a full step Class II molar relationship on the left side [IMPA] = 96.6o) (Table 1, Figure 3). No significant pathology was
and half-cusp Class II on the right side, with a narrow maxillary found in the panoramic radiograph (Figure 4). Based on clinical
arch. Overjet of 5 mm and 5 mm anterior open bite were observed and cephalometric findings, our diagnosis was skeletal Class II

140

Figure 1.  Pretreatment photographs

Figure 2.  Pretreatment dental casts

Turk J Orthod 2022; 35(2): 139-149 Gudhimella et al. Management of anterior open bite with clear aligners

Table 1.  Cephalometric measurements

Treatment Objective
The treatment objectives were (1) to correct the anterior open
Parameter Pretreatment Posttreatment Change
bite and achieve ideal overjet and overbite, (2) to achieve Class I
SNA (°) 84 83.4 −0.6 molar and canines bilaterally, (3) to improve or prevent worsen-
SNB (°) 76.2 76.8 0.6 ing of lower anterior facial height, and (4) to maintain the facial
ANB (°) 7.9 6.6 −1.3 balance, improve the soft tissue profile, and achieve a consonant
Wits appraisal (mm) 4.7 0.8 3.9 smile arc.
Angle of convexity (°) 15.6 14.7 0.9
N-A-Pog Treatment Alternatives
MP-SN (°) 34.5 33.1 −1.4 The patient was offered 3 treatment options which were: orthog-
nathic surgery, a non-surgical, non-extraction option with mini-
U1-PP (°) 102.4 97.7 −4.7
implant-assisted molar intrusion, and clear aligner.
IMPA 96.6 100.4 3.8
LAFH (ANS-Me) 70.7 70.5 −0.2
1. Orthognathic surgery: Bimaxillary surgery with Lefort 1 maxil-
U1-PP (mm) 30 33.6 3.6 lary posterior impaction and segmental osteotomy and bilat-
U6-PP (mm) 24.8 22.7 −2.1 eral sagittal split osteotomy of mandible with advancement
L1-MP (mm) 37.6 38.9 1.3 was recommended to the patient. This can lead to autorota-
tion of the mandible and correct the anterior open bite. The
L6-MP (mm) 33.1 32.7 −0.4
major advantage of this approach was predictability and
Ar-Go-Me (°) 127 122.9 4.1 shorter treatment duration. However, the comorbidities asso-
(gonial angle)
ciated with orthognathic surgery are a significant limitation.
U6-PP, Upper first molar to palatal plane; L1-MP, Lower incisor to mandibular
2. Non-extraction, non-surgical treatment with Temporary 141
plane; L6-MP, Lower first molar to mandibular plane.
Anchorage Device (TADs): Although the outcome of molar
intrusion using TADs is comparable with surgery, appropri-
due to retrognathic mandible and mild hyperdivergent growth ate biomechanical consideration is critical for the success of
pattern, Angle's Class II molar relation with increased overjet and the treatment. Numerous variables such as the number of
anterior open bite with convex soft tissue profile, and non-con- TADs, area of placement (buccal or palatal), type of anchor-
sonant smile arc. age should be considered in order to obtain optimum

Figure 3.  Pretreatment lateral cephalometric radiograph

 Gudhimella et al. Management of anterior open bite with clear aligners Turk J Orthod 2022; 35(2): 139-149

Figure 4.  Pretreatment panoramic radiograph

outcome and minimize the treatment time. Additionally, and Table 2). The rationale was to correct the anterior open bite
TAD failures can prolong the treatment time. with the combination of mandibular autorotation and upper
3. Non-extraction, non-surgical treatment with clear aligners: and lower anterior teeth extrusion. Initial Clincheck instructions
This was the most conservative approach for dentoalveolar included 5 mm rectangular vertical attachments on the occlusal
142 correction without any surgical intervention or TAD place- surface of maxillary and mandibular first and second molars to
ment. Molar intrusion and bite block effect produced by contact each other throughout treatment to get the posterior bite
aligners on posterior teeth may lead to autorotation of the block effect (Figures 6 and 7). A total of 43 sets of aligners, includ-
mandible and help with the anterior open bite correction. ing 3 overcorrection aligners, were staged in the initial ClinCheck
Also, upper and lower anterior uprighting and extrusion will approval. The patient was instructed to wear trays 20-22 hours a
help to close the bite further. day and change to the next set every 7 days. She was advised to
wear 1/4-inch, 4.5 oz Class II elastics with the initial trays.
All of these options were presented to the patient, and benefits
to risk assessment of each of the options were discussed. The At the end of the initial set of trays, the patient still had end-on
patient specifically demanded an aesthetic treatment approach molar on the right side and slight improvement on the left side,
using clear aligner therapy and did not want any surgical inter- premature contact at the upper left canine, and a large dark
vention or fixed orthodontic treatment. After the discussion with triangle between upper central incisors with 2 mm open bite.
the patient, she elected for clear aligner treatment, and written The first refinement was planned with instructions to expand
informed consent was obtained from the patient before begin- the upper arch and an Interproximal reduction (IPR) of 0.5 mm
ning the treatment. between upper central incisors to address premature contact
and black triangle (Figure 7, Table 3). Also, an IPR of 0.2 mm per
TREATMENT PROGRESS contact was planned between lower first premolar to premolar
to allow mesial movement of lower posterior teeth with class
In the first ClinCheck, a significant amount of upper and lower II elastics. To resolve issues with asymmetric molar relation-
molar intrusion and incisor extrusion was programmed (Figure 5 ship and lower midline, asymmetric Class II elastics (right side:

Figure 5.  Pretreatment ClinCheck images

Turk J Orthod 2022; 35(2): 139-149 Gudhimella et al. Management of anterior open bite with clear aligners

Table 2.  Programmed crown movement in the ClinCheck software

Programmed Crown Movement
Teeth UR8 UR7 UR6 UR5 UR4 UR3 UR2 UR1 UL1 UL2 UL3 UL4 UL5 UL6 UL7 UL8
Extrusion/ - 1.1 I 0.8 I 0.1 I 0.4 E 0.1 E 0.9 E 0.8 E 0.8 E 1.3 E 0.2 E 0 0 0.7 I 1.2 I 0.6 I
intrusion (mm)
Translation - 0.5 B 0.9 B 2.4 B 2.3 B 1.6 B 1.2 B 0.8 L 0 0.9 B 0.1 B 2.6 B 2.6 B 2.2 B 1.3 B 0.9 B
buccal/lingual
Translation - 0.1 D 0.2 D 0.2 D 0.4 D 0.5 D 1.0 D 0.9 D 0.6 D 0.4 D 0.4 D 0.2 D 0.1 M 0.1 D 0.1 D 0.4 D
mesial/distal
Rotation (°) - 12.1 D 13.7 D 5.3 D 3.1 M 29.9 D 2.7 D 28.6 M 15.1 M 15.8 M 0.3 D 3.8 M 4.1 D 9.6 D 4.5 D 1.6 D
Angulation (°) - 2.0 D 2.7 D 1.1 M 0.4 D 8.7 D 4.4 D 0.3 M 0.3 M 6.4 D 7.4 D 3.0 D 2.1 D 2.7 D 0.5 D 0.7 D
Inclination (°) - 1.0 L 0.2 L 7.1 B 10.4 B 7.1 B 2.6 B 5.0 B 5.9 B 3.0 B 0.1 B 13.4 B 8.6 B 5.3 B 0.4 L 2.4 L
Teeth LL8 LL7 LL6 LL5 LL4 LL3 LL2 LL1 LR1 LR2 LR3 LR4 LR5 LR6 LR7 LR8
Extrusion/ - 0.8 I 1.4 I 0.9 I 0 0.2 E 0.9 E 1.2 E 1.2 E 1.2 E 0.7 E 0.1 E 0.5 I 1.2 I 1.3 I -
intrusion (mm)
Translation - 3.4 L 1.6 L 0.1 B 0.4 B 0 0.6 B 0.8 B 0.6 B 0.3 B 0.1 L 0.8 B 1.5 B 1.5 B 1.8 B -
buccal/lingual
Translation - 0.5 D 0 0.1 M 0.2 M 0 0.1 M 0.1 D 0.4 M 0.5 M 0.2 M 0.2 M 0 0.2 D 0.1 M -
mesial/distal
Rotation (°) - 24.3 D 17.5 D 18.2 17.9 14.2 M 12.6 10.5 M 12.4 M 16.1 M 21.3 11.4 0.6 D 4.2 D 4.7 D -
D D M M D 143
Angulation (°) - 2.4 M 0.2 D 1.5 M 2.1 D 2.8 D 1.8 M 1.8 D 0.4 M 0.4 M 1.4 D 5.0 D 1.8 M 1.1 M 0.5 M -
Inclination (°) - 5.7 L 3.2 L 2.1 L 0.6 B 0.6 L 1.6 B 2.3 B 0.9 L 1.4 B 1.7 L 0.7 L 1.1 L 1.4 B 0.5 L -
UR, Upper right; UL, Upper left; LL, Lower left; LR, Lower right; I, Intrusion; E, Extrusion; B, Buccal; L, Lingual; M, Mesial; D, Distal.
Teeth with the significant intrusion or extrusion programmed in the ClinCheck are highlighted in this table. Alphabets used in Table 2 are tooth numbering.

3/16 inch, 4.5 oz; left side: 1/4 inch, 6 oz) were started through- increased the SNB angle, and decreased the lower anterior face
out the first and second refinements. The patient developed height and angle of convexity (Figures 8-13). Regional superim-
centric interferences after the first refinement aligners due to position of maxillary dentition showed intrusion and distaliza-
hanging premolar palatal cusps caused by insufficient expres- tion of maxillary molar. Maxillary and mandibular incisors were
sion of planned buccal root torque during dental expansion in extruded with the clear aligner treatment (Figure 14).
the upper arch. Additional buccal root torque was programmed
in the second refinement for upper premolars to address the DISCUSSION
occlusal interferences (Figure 7). Asymmetric Class II elastics led
to the significant forward movement of the left posterior seg- Management of skeletal open bite malocclusion in adults is
ment assisted by IPR space in the lower arch and flaring of lower often challenging with conventional treatment options. Mild to
anteriors. As a result, a bilateral Class I molar relationship with 2 moderate open bite cases in Class II hyperdivergent and retrog-
mm overbite was obtained in the second refinement. The final nathic patients can be successfully treated with mini-implants.
series of 30 aligners were used to achieve good posterior inter- Umemori et al.10 used mini plates for the intrusion of mandibu-
cuspation and to improve the occlusion (Figure 7). lar posterior teeth, whereas Erverdi et al.11 and Sherwood et al.12
documented the correction of an open bite by the intrusion
In the retention phase, the patient was asked to wear Essix of maxillary molars with mini-implants placed in the infrazy-
retainers full time for the first 6 months, followed by Hawley’s gomatic region.
retainers with posterior bite block. A total of 117 trays were used
in 3 refinements to finish the case (Figure 7). The patient’s com- Recently, the clear aligners have become popular, and clinicians
pliance was exemplary during the entire treatment duration. The are attempting to treat the open bite cases with aligners either
overall treatment time was 3 years, and all the treatment objec- in conjunction with mini-implants or standalone with aligners.13
tives were fulfilled without any complication. Normal overjet However, the comprehensive orthodontic treatment mechanics
and overbite were achieved with Angle's Class I molar relation- are generally extrusive for posterior teeth, leading to an increase
ship while maintaining the facial balance. Soft tissue profile was in the mandibular plane angle, worsening the facial profile, and
improved, and a consonant smile arc was achieved (Figures 8-14). decreasing the overbite. To counteract these side effects, exten-
sive extrusion of anterior teeth needs to be done to improve the
There was a 1 mm intrusion of maxillary molars and slight intru- overbite, comprising the long stability of attained results.
sion of mandibular molars, which caused the counterclock-
wise rotation of the mandible (Figures 6 and 7). This effect led On the contrary, beneficial results are reported with aligner treat-
to decreased Wits appraisal, increased the chin projection, ment of open bite subjects. Harris  et  al.8 observed the amount
 Gudhimella et al. Management of anterior open bite with clear aligners Turk J Orthod 2022; 35(2): 139-149

144

Figure 6.  Intraoral progress photographs

of molar intrusion of 0.47 ± 0.59 mm and a reduction in SN-MP based on the above study, the results are promising compared to
by 0.73 ± 0.94o, along with the decrease in SNB, Lower anterior comprehensive orthodontics. Mild to moderate open bite cases
facial height (LAFH), and favorable auto-rotation of the mandible. can be successfully corrected with clear aligner treatment, as doc-
Although the amount of intrusion of posterior teeth was minimal umented by numerous case reports.14 However, Garnett  et  al.15
Turk J Orthod 2022; 35(2): 139-149 Gudhimella et al. Management of anterior open bite with clear aligners

145

Figure 7. A-E.  ClinCheck progress images (A: pretreatment, B: first refinement, C: second refinement, D: third/final refinement, E: final results)

compared the anterior open bite treatment between fixed appli- The effectiveness of clear aligner treatment for various tooth
ances and clear aligner therapy, they did not find a significant movements has to be understood before treatment planning.
difference in outcome between the 2 groups. The evidence is This step is critical as overcorrections can be programmed in
controversial regarding the effectiveness of aligners for the treat- the ClinCheck to minimize the refinements, thereby increas-
ment of skeletal open bite. With the improvement in technology16 ing the efficiency of the appliance. In a recent study looking at
and greater biomechanical understanding and the expertise of the efficacy of tooth movement with Invisalign,16 they found
clinicians, complex vertical dimension malocclusion can be suc- improved accuracy compared to a decade back. This was
cessfully treated as documented in this report. made possible by introducing smart force features that include
 Gudhimella et al. Management of anterior open bite with clear aligners Turk J Orthod 2022; 35(2): 139-149

Table 3.  Arch measurements programmed in ClinCheck Refinement 1

Arch Width (mm)
Arch Teeth Initial, Stage 1 Align Final, Stage 40 Difference
Upper arch UR3-UL3 29.1 32 2.9
UR4-UL4 29.1 34.7 5.6
UR5-UL5 32.7 37.9 5.2
UR6-UL6 38.1 41.2 3.1
Lower arch LR3-LL3 25.4 25.5 0.1
LR4-LL4 27.8 28.9 1.1
LR5-LL5 31.5 33 1.5
LR6-LL6 37 37.1 0.1

146

Figure 8.  Final ClinCheck projection

Figure 9.  Posttreatment photographs

Turk J Orthod 2022; 35(2): 139-149 Gudhimella et al. Management of anterior open bite with clear aligners

147

Figure 10.  Posttreatment lateral cephalometric radiograph

Figure 11.  Posttreatment panoramic radiograph

optimized attachments, pressure zones, customized staging, and the occlusal surfaces. Also, the counterclockwise rotation of the
SmartTrack aligner material, allowing a better working range and mandibular due to molar intrusion will not interfere with the cor-
improved fit of trays. The accuracy was highest for buccolingual rection of the anterior open bite, as happens with the conven-
tipping (56%), whereas the intrusion of maxillary molar and inci- tional braces.17
sor was at least 35% and 33%, respectively. To offset the draw-
back, overcorrection can be planned for the molar intrusion. The patient in this report had a mild skeletal open bite with 5 mm
of overbite and an overjet of 8 mm. The treatment was planned
The clear aligners have a specific advantage for molar intru- as recommended by Buschang  et  al.4 who used mini-implants
sion. The occlusal forces can be applied simultaneously along for posterior teeth intrusion, leading to the autorotation of man-
with the desired tooth movement since aligners entirely cover dible, which aided in the correction of skeletal and dental class
 Gudhimella et al. Management of anterior open bite with clear aligners Turk J Orthod 2022; 35(2): 139-149

Figure 12.  Superimposed lateral cephalometric tracings

148

Figure 13.  Posttreatment dental casts

Figure 14.  Superimposed dental casts

Turk J Orthod 2022; 35(2): 139-149 Gudhimella et al. Management of anterior open bite with clear aligners

II relationships. However, we planned intrusion of maxillary and Declaration of Interests: The authors have no conflict of interest to declare.
mandibular posterior teeth using clear aligners by having pas-
sive bite blocks of 5 mm thickness. Maxillary molar intrusion of Funding: The authors declared that this study has received no financial
support.
1 mm and slight intrusion of lower molars were achieved due to
the bite block effect from raised clear aligner trays on posterior
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