orthodontic waves 68 (2009) 42–49

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Case report

Multidisciplinary management including endodontics,

periodontics, orthodontics, anterior maxillary osteotomy and
prosthetics 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

article info abstract

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
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.

1. Introduction The present adult case underwent multidisciplinary treat-

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].
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

* 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 Japanese Orthodontic Society. All rights reserved.
doi:10.1016/j.odw.2008.10.002
 orthodontic waves 68 (2009) 42–49 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.
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

Fig. 1 – Frontal and lateral facial photographs before (upper panels; 33 years and 3 months of age) and after (lower panels; 39
years and 7 months of age) the treatment.
44 orthodontic waves 68 (2009) 42–49

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.

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
 orthodontic waves 68 (2009) 42–49 45

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

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 was moved downward and backward by 3 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).
46 orthodontic waves 68 (2009) 42–49

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

Fig. 5 – Oral photographs with a tongue crib.

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
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

Table 1 – Analytical measurements (8).

Angle Japanese Pretreatment After the presurgical After prosthetic
norm  SD [10] (34y 6mo) orthodontics (36y 4mo) treatment (39y 7mo)

SNA 82.3  3.5 81.0 81.0 79.3

SNB 78.9  3.5 67.8 67.9 67.9
ANB 3.4  1.8 13.2 13.1 11.4
U-1 to FH plane 111.1  5.5 123.4 91.5 85.5
L-1 to mandibular plane 96.3  5.8 114.8 101.1 97.6
Mandibular plane 28.8  5.2 46.5 46.5 46.5
Gonial 122.2  4.4 133.4 133.4 133.4

S, sella turcica; N, nasion; A, point A; SNA, angle between SN and NA; B, Point B; SNB, angle between SN and NB; U-1, long axis of maxillary
central incisor; U-1 to FH plane, angle between U-1 and FH (Frankfort horizontal) plane; L-1, long axis of mandibular central incisor; L-1 to
mandibular plane, angle between L-1 and mandibular plane; Mandibular plane, angle between mandibular plane and FH plane; Gonial, angle
between mandibular plane and ramus plane.
 orthodontic waves 68 (2009) 42–49 47

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

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

periodontitis in the mandibular left first molar, extraction of 4. Discussion

the first molar followed by a transplantation of the third
molar, or root canal treatment of the mandibular left first The severe open bite in this Japanese female included a short
molar, was going to be decided. mandibular ramus and steep mandibular plane (Figs. 3 and

Fig. 8 – Oral photographs after the prosthetic restoration (39 years and 7 months of age).
48 orthodontic waves 68 (2009) 42–49

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

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.
 orthodontic waves 68 (2009) 42–49
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 (- - -).
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
49
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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