Case report

Multidisciplinary management including endodontics,periodontics, orthodontics, anterior maxillary osteotomy andprosthetics in an adult case with a severe openbite

Naoto Suda *, Akiko Kawafuji, Keiji Moriyama

Maxillofacial Orthognathics, Department of Maxillofacial Reconstruction and Function, Division of Maxillofacial/Neck Reconstruction,

Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan

o r t h o d o n t i c w a v e s 6 8 ( 2 0 0 9 ) 4 2 – 4 9

a r t i c l e i n f o

Article history:

Received 25 August 2008

Received in revised form

7 October 2008

Accepted 14 October 2008

Published on line 29 November 2008

Keywords:

Multidisciplinary management

Anterior maxillary osteotomy

Openbite

a b s t r a c t

Adult patients frequently have periodontal problems, resulting in a loss of alveolar bone, the

migration and tipping of teeth, and interdental spaces. This case report describes the

orthognathic treatment of a 33-year-old adult female with a severe openbite. Her labial-

tipped maxillary central incisors were affected by severe periodontitis and treated by guided

tissue regeneration (GTR). After the presurgical orthodontics, an anterior maxillary osteot-

omy was performed and the anterior segment was moved distal and downward direction.

The patient achieved a stable and satisfactory occlusion after the prosthetic treatment. This

report describes multidisciplinary dental management including endodontics, periodontics,

orthodontics, oral surgery and prosthetics in an adult case with a severe openbite and

periodontitis, and highlights the importance of co-operation of interdisciplinary fields.

# 2008 Elsevier Ltd and the Japanese Orthodontic Society. All rights reserved.

avai lable at www.sc iencedi rec t .com

journal homepage: www.elsevier.com/locate/odw

1. Introduction

During the last three decades, remarkable advances have been

made in the management of periodontal problems [1]. Among

them, guided tissue regeneration (GTR) [2,3] and an applica-

tion of enamel matrix derivative (Emdogain gel1, Straumann,

Basel, Switzerland) [1] are known as successful interventions.

These advances lead the orthodontic treatment is no longer a

contraindication in cases with moderately severe period-

ontitis, and many adult patients are now treated orthodonti-

cally [4]. However, in cases, it is still difficult to establish a

proper anchorage due to the reduced periodontal support and

to promote bone resorption and apposition required for

normal tooth movement. Thus, careful treatment planning

and the co-operation of interdisciplinary fields are essential to

obtain a better outcome in these cases [5].

* Corresponding author. Tel.: +81 3 5803 5536; fax: +81 3 5803 5533.E-mail address: n-suda.mort@tmd.ac.jp (N. Suda).

1344-0241/$ – see front matter # 2008 Elsevier Ltd and the Japanesedoi:10.1016/j.odw.2008.10.002

The present adult case underwent multidisciplinary treat-

ment including endodontic and periodontic treatment, and

orthodontic treatment followed by an anterior maxillary

osteotomy. A prosthetic restoration of the maxillary incisors

and canines was also performed after the retention. This case

report discusses the difficulty in treating adult cases with a

severe openbite and periodontitis, and should help determin-

ing treatment planning in such cases.

2. History

A Japanese female was seen at our dental hospital at 33 years

and 3 months of age with a chief complaint of maxillary

protrusion and openbite. She had no systemic complication.

She showed a protrusion of the upper lip and retrognathic

Orthodontic Society. All rights reserved.

o r t h o d o n t i c w a v e s 6 8 ( 2 0 0 9 ) 4 2 – 4 9 43

mandible, resulting in a bird face profile (Fig. 1). She had a

tongue thrust and had sucked her thumb till 7 years of age. A

panoramic radiograph and dental X-rays showed extensive

apical periodontitis in the maxillary right incisors, which had

considerable mobility at this stage (Fig. 2). Dental calculi were

seen around roots of the mandibular incisors (Fig. 2). The

apical periodontitis was also seen along the roots of the left

mandibular first molar. Based on these examinations, it was

decided to treat her endodontically and periodontically before

the orthodontic treatment. Scaling and root plaining were

performed in the incisors of both arches, and root canal

treatment was conducted in the right and left maxillary

incisors. A flap operation was carried out in the right maxillary

incisor, followed by the insertion of a resorbable membrane

for GTR.

Fig. 1 – Frontal and lateral facial photographs before (upper pane

years and 7 months of age) the treatment.

At 15 months after her first visit (9 months after the

endodontic and periodontic treatments), an improvement of

the apical periodontitis of the maxillary right central incisor

was seen (Fig. 3). The tooth mobility was reduced; however,

the bone support was not enough. The root surfaces of the

mandibular incisors became smooth after scaling and root

plaining, but the alveolar bone height was not a satisfied

condition (Fig. 3). She had a severe openbite with interdental

spaces between the canines, while her premolars and the

molars of both arches had occlusal contact and showed a Class

I relationship (Fig. 4). Her teeth, especially the maxillary

incisors, were small. A lateral cephalogram showed a long

vertical height with a short ramus (Fig. 3). A narrowed airway

was also noted. A cephalometric analysis showed that SNB

was quite smaller than the Japanese norm (Table 1). The

ls; 33 years and 3 months of age) and after (lower panels; 39

Fig. 2 – Panoramic radiograph and dental X-rays before endodontic and periodontic treatments. Asterisks denote the severe

apical periodontitis around the maxillary right central incisor.

o r t h o d o n t i c w a v e s 6 8 ( 2 0 0 9 ) 4 2 – 4 944

incisors were significantly proclined in both arches. The gonial

angle was large, resulting in a steep mandibular plane.

3. Treatment plan and progress

The treatment objectives were to obtain occlusal contact in the

anterior teeth and close interdental spaces in both arches.

Labial tipping of the anterior teeth in both arches had to be

improved and the lingual movement of the maxillary incisors

was required. However, we planned not to move them

aggressively by the fixed appliance but by the intermittent

force of the removable appliance. Also, her tongue habit had to

be corrected for a favorable tooth movement and the

maintenance of a stable occlusion. Excess orthodontic tooth

movement had to be avoided, since the bone support of the

maxillary incisors, especially the right incisor, was still not

enough (Fig. 3). Thus, an anterior maxillary osteotomy was

planned to correct her skeletal openbite. After the orthodontic

treatment, a prosthetic restoration of the maxillary anterior

teeth was planned to stabilize these teeth and also to correct

the unfavorable anterior tooth size ratio between both arches.

She was given a tongue crib to eliminate her tongue thrust

(Fig. 5). The labial tipped-maxillary incisors were moved

lingually with the intermittent force via the labial wire of the

appliance. After the appliance had been used for nine months,

an edgewise multibracket appliance (MBA) was placed in both

arches. The brace was not placed on the maxillary right central

Fig. 3 – Cephalograms, panoramic radiograph and dental X-rays at nine months after endodontic and periodontic

treatments.

o r t h o d o n t i c w a v e s 6 8 ( 2 0 0 9 ) 4 2 – 4 9 45

incisor to prevent further mobility and the loss of the tooth

support. Thirteen months after the placement of the MBA,

interdental spaces in the maxillary arch were collected between

lateral incisors and canines on both sides (Fig. 6). After the 22

months of presurgical orthodontics using the tongue crib and

MBA, an anterior maxillary osteotomy was performed. The

anterior segment wasmoved downwardandbackwardby3 mm

and 4 mm, respectively. Postsurgical orthodontics was per-

formed for 15 months and the MBA was removed from both

arches at 37 years and 7 months of age (Fig. 7).

Fig. 4 – Oral photographs before the orthodontic treatment (34 years and 6 months of age).

Fig. 5 – Oral photographs with a tongue crib.

o r t h o d o n t i c w a v e s 6 8 ( 2 0 0 9 ) 4 2 – 4 946

Retention was carried out using removable retainers for 12

months. Prosthetic treatment was performed between both

maxillary canines to stabilize the anterior teeth and to correct

the disharmonized tooth size ratio (Fig. 8). A stable and

functional occlusion was obtained and oral photographs at

two years after the active treatment (39 years and 7 months)

were shown in Fig. 9. Her profile was slightly improved (Fig. 1).

The bone support for the maxillary right central incisor was

Table 1 – Analytical measurements (8).

Angle Japanesenorm � SD [10]

Pretreatme(34y 6mo)

SNA 82.3 � 3.5 81.0

SNB 78.9 � 3.5 67.8

ANB 3.4 � 1.8 13.2

U-1 to FH plane 111.1 � 5.5 123.4

L-1 to mandibular plane 96.3 � 5.8 114.8

Mandibular plane 28.8 � 5.2 46.5

Gonial 122.2 � 4.4 133.4

S, sella turcica; N, nasion; A, point A; SNA, angle between SN and NA; B

central incisor; U-1 to FH plane, angle between U-1 and FH (Frankfort h

mandibular plane, angle between L-1 and mandibular plane; Mandibular

between mandibular plane and ramus plane.

increased compared with the pretreatment condition (Fig. 9).

The significant change of the bone support was not seen along

the other teeth and the apical periodontitis was still seen along

the roots of the left mandibular first molar. The labial-tipped

incisors in both arches were significantly moved lingually,

mainly during the presurgical orthodontic treatment (Fig. 10

and Table 1). The maxillary incisors were slightly extruded

after the treatment. Depending on the prognosis of the

nt After the presurgicalorthodontics (36y 4mo)

After prosthetictreatment (39y 7mo)

81.0 79.3

67.9 67.9

13.1 11.4

91.5 85.5

101.1 97.6

46.5 46.5

133.4 133.4

, Point B; SNB, angle between SN and NB; U-1, long axis of maxillary

orizontal) plane; L-1, long axis of mandibular central incisor; L-1 to

plane, angle between mandibular plane and FH plane; Gonial, angle

Fig. 7 – Oral photographs after the active treatment (37 years and 7 months of age).

Fig. 6 – Oral photographs immediately before the surgery (36 years and 4 months of age).

o r t h o d o n t i c w a v e s 6 8 ( 2 0 0 9 ) 4 2 – 4 9 47

periodontitis in the mandibular left first molar, extraction of

the first molar followed by a transplantation of the third

molar, or root canal treatment of the mandibular left first

molar, was going to be decided.

Fig. 8 – Oral photographs after the prosthetic r

4. Discussion

The severe open bite in this Japanese female included a short

mandibular ramus and steep mandibular plane (Figs. 3 and

estoration (39 years and 7 months of age).

Fig. 9 – Cephalograms, panoramic radiograph and dental X-rays after the prosthetic restoration.

o r t h o d o n t i c w a v e s 6 8 ( 2 0 0 9 ) 4 2 – 4 948

10). The exact etiology of this skeletal openbite is unknown.

However, the thumb sucking in her youth (until 7 years old)

might have been a factor and her tongue thrust would have

maintained this severe malocclusion for over 25 years.

In GTR, resorbable membranes are placed over the denuded

root surface in such a way that the epithelium and the gingival

connective tissue are prevented from making contact with the

root during healing [2,3]. Restitution of the attachment

apparatus can be accomplished by using this method, which

becomes a successful treatment modality for the periodontal

reconstruction in many practices. In the present case, an

apparent improvement was not obtained solely with GTR.

Fig. 10 – Superimposed cephalometric tracings.

Pretreatment at 34 years and 6 months of age (—), after the

presurgical orthodontics at 36 years and 4 months of age

(– � –), after the prosthetic treatment (two years after the

active treatment) at 39 years and 7 months of age (- - -).

o r t h o d o n t i c w a v e s 6 8 ( 2 0 0 9 ) 4 2 – 4 9 49

Careful root canal treatment and scaling would have been also

effective in improving the periodontal condition of the

maxillary right incisor.

Anterior maxillary osteotomy was originally applied to

cases of maxillary excess [6]. Furthermore, it is also applicable

to patients with severe open and deep bites having vertical

disharmony of both jaws [7,8], as in the present case. After all

the multidisciplinary treatments including surgical interven-

tion to the patient, her retrognathic bird face was scarcely

improved (Fig. 1). This esthetic problem might have been more

improved if the surgical mandibular advancement was

applied. Another advantage of mandibular advancement is

that it can widen narrowed airways [9]. However, the present

patient did not have any esthetic complaint. Also, she did not

snore or suffer from sleep apnea at all. Considering these

factors and the pretreatment Class I molar relationship, an

anterior maxillary osteotomy was performed.

For treatment alternatives, an anterior mandibular osteot-

omy together with an anterior maxillary osteotomy was

considered to correct her skeletal openbite. However, surgical

intervention for the mandibular anterior segment was likely to

worsen the periodontal condition of the mandible. Thus, an

anterior maxillary osteotomy was planned solely. Genioplasty

to improve the shape of her chin was also considered.

However, she did not expect her facial appearance to be

improved by the treatment. If she complains about her

retrognathic appearance in the future, genioplasty will be

considered.

The prognosis of the periodontal tissues in the maxillary

incisors had a great impact on the occlusion in this case. To

obtain a better prognosis, excess tooth movement was avoided

and surgical intervention was performed. Also, only inter-

mittent force was applied from the labial wire of the tongue crib

to the maxillary right central incisor and a brace was not placed

all during the treatment. The active orthodontic treatment was

performed carefully and slowly. Consequently, it took 22 and 15

months for the presurgical and postsurgical orthodontics,

respectively. The prosthetic restoration between both maxillary

canines did not make contact with the mandibular incisors to

reduce the occlusal force between anterior teeth of both arches.

(Fig. 9). Stable occlusion was still seen after the restoration,

however, it is essential to keep a careful and long term

observation on her dentition and occlusion.

In short, multidisciplinary management including endo-

dontics, periodontics, orthodontics, oral surgery (anterior

maxillary osteotomy) and prosthetics was performed in the

case of a 33-year-old female with a severe openbite and

periodontitis. The co-operation of interdisciplinary fields and

careful treatment planning were required, and functional

occlusion was achieved after all these treatments.

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