ORIGINAL ARTICLE

Longitudinal growth changes in subjects with

open-bite tendency: A retrospective study
Angie Phelan,a Lorenzo Franchi,b Tiziano Baccetti,y M. Ali Darendeliler,c and James A. McNamara Jrd
Surry Hills, New South Wales, Australia, Florence, Italy, and Ann Arbor, Mich

Introduction: This study was a cephalometric evaluation of the growth changes in untreated subjects with min-
imal overbite at 4 time points during 4 developmental stages from the early mixed dentition to the permanent
dentition, as well as from the prepubertal phase to young adulthood. Methods: A sample of 24 untreated sub-
jects with minimal overbite (\1.5 mm) was selected retrospectively from the University of Michigan Growth Study
and the Denver Child Growth Study. The sample was followed longitudinally from about 9 years of age through
17 years of age. Dentofacial changes at the 4 times (T1-T4), dened by the cervical vertebral maturation method,
were analyzed on lateral cephalograms. Nonparametric statistical analysis was used for comparisons. Results:
Overbite on average increased by 2.3 mm during the overall observation period. Improvement occurred during
the prepubertal interval (T1-T2; 2.4 mm), whereas no signicant changes occurred in the pubertal and
postpubertal stages. From prepubertal ages to young adulthood, the open-bite tendency improved in 91% of
the subjects, with self-correction in 75%. Logistic regression analysis on the cephalometric variables at T1
with the value of overbite at T4 did not show a statistically signicant correlation. Conclusions: Subjects with
an open-bite tendency show improvement of their occlusal condition during the prepubertal stage, but there is
no signicant improvement after this. These results provide useful indications for appropriate orthodontic
treatment timing for patients with an open-bite tendency. (Am J Orthod Dentofacial Orthop 2014;145:28-35)

O
pen bite is an occlusal trait characterized by a
lack of vertical overlap of the incisors.1 A reduced
depth of the bite can be associated with skeletal
hyperdivergence, otherwise referred to as long-face syn-
drome or high-angle disharmony.2,3 The incidence of
anterior open bite varies according to age and ethnic
group.4 In the United States, the reported incidence in
children is 3.5%, with the prevalence decreasing during
adolescence.5 Anterior open bite is more common in Af-
ricans and Afro-Caribbeans (5%-10%).5,6 Prolonged
a
Orthodontist, Discipline of Orthodontics, Faculty of Dentistry, University of
Sydney, Surry Hills, New South Wales, Australia.
b
Research professor, Department of Orthodontics, University of Florence, Flor-
ence, Italy; Thomas M. Graber Visiting Scholar, Department of Orthodontics
and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor.
c
Professor and chair, Discipline of Orthodontics, Faculty of Dentistry, University
of Sydney, Surry Hills, New South Wales, Australia.
d
Thomas M. and Doris Graber Endowed Professor of Dentistry, Department of
Orthodontics and Pediatric Dentistry, School of Dentistry; research professor,
Center for Human Growth and Development, University of Michigan, Ann Arbor;
private practice, Ann Arbor, Mich.
y
Deceased.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conicts of Interest, and none were reported.
Address correspondence to: M. Ali Darendeliler, Discipline of Orthodontics, Fac-
ulty of Dentistry, University of Sydney, Level 2, 2 Chalmers St, Surry Hills NSW
2010, Australia; e-mail, adarende@mail.usyd.edu.au.
Submitted, December 2011; revised and accepted, September 2013.
0889-5406/$36.00
Copyright 2014 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.09.013
28
sucking habits and facial hyperdivergent characteristics
have been shown to be signicant risk factors for
anterior open bite in the mixed dentition.7 Patients
with open bite mainly seek treatment on esthetic
grounds, but there can be functional problems such as
difculty incising food and speech problems such as
lisping associated with this malocclusion.4
There is no generally accepted method to identify a
patient with an open-bite tendency.8 Various cephalo-
metric characteristics have been ascribed to patients
with an anterior open bite or an open-bite tendency,
including a large mandibular plane angle, increased total
and lower anterior face height, decreased posterior face
height, increased gonial angle, short ramus, low
posterior-to-anterior face height ratio, and large ante-
rior dentoalveolar heights in both jaws.2,8-10
Klocke et al,8 among others, stated that there is gen-
eral agreement that patients with anterior open bite or
an open bite tendency are among the most challenging
to treat. Relapse is a common nding after open-bite
correction with both orthodontic treatment11 and surgi-
cal orthodontic therapy.12 Despite the difculty that this
type of malocclusion poses for clinicians, few studies
have analyzed changes in the depth of the bite in sub-
jects with an open-bite tendency during growth. Studies
have described the development of normal overbite and
its variations during the mixed and permanent
Phelan et al
dentitions,9,13-18 sometimes by analysis of small
subsamples with reduced overbite.14,18,19
Bergersen19 investigated the changes in overbite
from 8 to 20 years of age in subjects with increased over-
bite (.3 mm) and normal or decreased overbite (#3
mm). The general trend in this study for the normal or
decreased overbite group was about an even chance of
an overbite less than 3 mm remaining the same or get-
ting worse by 12 years of age. Bergersen wrote that if
a child starts with an overbite less than 3 mm at 8 years
of age, there is about 50% chance that it will be greater
than 3 mm at 12 years of age and an equal chance that it
will remain less than 3 mm at 12 years of age. Overbite
changes were suggested to be due to exfoliation and
eruption of teeth because open bite was found to in-
crease during the exchange of incisors and deciduous
molars at 8 to 11 years and to decrease during the erup-
tion of the second and third molars between 13 and 20
years of age. Unfortunately, Bergersen's study did not
include any open-bite subjects (overbite \1 mm), and
it also was semilongitudinal, because annual consecu-
tive observations were not available for all subjects
from the ages of 8 through 20 years.
A longitudinal cephalometric study of subjects with
anterior open bite in the deciduous dentition was per-
formed by Klocke et al.8 They reported that although
only 1 subject had an open bite at 12 years of age, over-
bite remained reduced during the longitudinal follow-up.
These ndings were consistent with those reported by
Worms et al,20 who showed that 80% of early open bites
in a cross-sectional sample self-corrected. Although self-
correction of open bite has been reported, there is a
paucity of longitudinal research in this area. None of
the studies mentioned above included an assessment of
individual skeletal maturity, although this aspect is crucial
to longitudinal studies of growing subjects.21-23
The aim of this study was to provide a cephalometric
evaluation of the growth changes in untreated subjects
with minimal overbite at 4 time points during the devel-
opmental ages from the early mixed dentition to the per-
manent dentition, and from prepubertal phases to
young adulthood. The main features of this investiga-
tion were a specic focus on growth changes of un-
treated subjects with minimal overbite at the initial
observation (\1.5 mm), its longitudinal nature with
the same subjects evaluated at all time points, and the
use of a biologic indicator of skeletal maturity.
MATERIAL AND METHODS
The les of the University of Michigan Growth Study
(n 5 706) and the Denver Child Growth Study (n 5 155)
were searched for longitudinal records of untreated
American Journal of Orthodontics and Dentofacial Orthopedics
29
subjects with an open-bite tendency. High-quality
lateral cephalograms at 4 consecutive developmental in-
tervals (T1 through T4) corresponding to the different
stages in cervical vertebral maturation (CS 1-CS 6) had
to be available for all selected subjects.24 The stages of
cervical vertebral maturation are illustrated diagram-
matically in the Figure 1.
The rst observation (T1) corresponded to CS 1 or CS
2 (prepubertal); the second observation (T2) corre-
sponded to CS 2 or C3 (beginning of puberty); the third
observation (T3) corresponded to either CS 4 or CS 5
(postpubertal); and the fourth observation (T4) corre-
sponded to the appearance of CS 6 (young adulthood).
Longitudinal records for all subjects therefore covered
the entire circumpubertal period from the prepubertal
through the young adult stages of skeletal development.
All subjects were of European-American ancestry
(white), with no craniofacial abnormalities or tooth
anomalies (supernumeraries, congenitally missing teeth,
impacted canines).
Subjects were included according to the presence of
an overbite less than or equal to 1.5 mm and a Frankfort
horizontal to mandibular plane angle greater than 23 .
Both maxillary central incisors and all 4 mandibular in-
cisors had to be erupted fully at T1. Permanent incisors
were judged to be fully erupted when most of the
anatomic crown was exposed, as assessed radiographi-
cally and on dental casts, with the incisal edges of the
mandibular incisors at the same level. The sample con-
sisted of 24 subjects (14 boys, 10 girls). Mean age at
T1 was 8 years 9 months 6 11 months, with all subjects
in the early mixed dentition; at T2, their chronologic age
was 11 years 8 months 6 13 months, with subjects in
the late mixed or early permanent dentitions; at T3, their
age was 14 years 2 months 6 16 months, with all sub-
jects in the permanent dentition; and at T4, it was 16
years 8 months 6 28 months, with all subjects showing
permanent dentition. Class I occlusion was present in 10
subjects, Class II Division 1 malocclusion in 12 subjects,
and Class III malocclusion in 2 subjects. No data were
available on subjects from either growth study on digital
habits.
Cephalograms were traced by an investigator (A.C.P.)
and then veried for landmark location, anatomic con-
tours, and tracing superimpositions by a second investi-
gator (J.A.M.). Any disagreements were resolved by
retracing the landmark or structure to the satisfaction
of both observers. A customized digitization regimen
and analysis from Dentofacial Planner (Dentofacial Soft-
ware, Toronto, Ontario, Canada) was used for all cepha-
lograms examined in this study. The customized
cephalometric analysis containing measurements from
the analyses of Steiner,25 Jacobson,26 Ricketts,27 and
January 2014  Vol 145  Issue 1
30
Fig 1. Schematic representation of the stages of the cervical vertebral maturation method.
McNamara28 was used, generating 29 variables: 9
angular, 19 linear, and 1 ratio for each tracing.
Four serial cephalograms for each subject were traced
at the same time. Fiducial markers were placed in the
maxilla and the mandible on the rst tracing and then
transferred to the second, third, and fourth tracings in
each subject's cephalometric series, based on superim-
positions of internal maxillary or mandibular structures.
The maxillae were superimposed along the palatal plane
by registering on the bony internal details of the maxilla
superior to the incisors and the superior and inferior sur-
faces of the hard palate. Fiducial markers were placed in
the anterior and posterior parts of the maxilla along the
palatal plane. This superimposition describes the move-
ment of the maxillary dentition.
The mandibles were superimposed on the outline of
the mandibular canal, the anterior contour of the chin,
and the bony structures of the symphysis.27,28 A
ducial marker was placed in the center of the
symphysis and another in the body of the mandible
near the gonial angle. This superimposition describes
the movement of the mandibular dentition relative to
the mandible.
The magnication of the 2 data sets was different,
with the lateral cephalograms from the University of
Michigan study having a magnication of 12.9% and
those from the Denver study at 4%. Therefore, the lateral
cephalograms from the 2 studies were corrected to an
8% enlargement factor.
The power of the study when assessing cumulative
treatment changes (T1-T4) was calculated on the basis
of an effect size equal to 129 (SigmaStat 3.5; Systat Soft-
ware, Point Richmond, Calif). The power of our study
with a sample size of 24 subjects was 0.93 at an
alpha 5 0.05.
A total of 42 lateral cephalograms randomly chosen
from all observations were retraced and redigitized to
calculate the method error with Dahlberg's formula.30
January 2014  Vol 145  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Phelan et al
The errors for linear measurements ranged from 0.2
mm (overjet) to 0.8 mm (Pg to nasion perpendicular);
the errors for angular measurements varied from 0.4
(ANB) to 1.6 (interincisal angle).
The assessment of the stages in cervical vertebral
maturation on the lateral cephalograms of each subject
was performed by 1 investigator (A.C.P.) and then veri-
ed by an expert examiner (T.B.).24 Any disagreements
were resolved to the satisfaction of both observers.
Statistical analysis
Descriptive statistics of the craniofacial measure-
ments in the open-bite sample at all 4 observation pe-
riods were calculated, as well as the between-stage
changes (T2-T1, T3-T2, T4-T3, and the overall T4-
T1). The Kolmogorov-Smirnov test showed a lack of
normal distribution for several measurements in the
study. Therefore, comparisons of the values of the
cephalometric variables at the 4 time periods were
carried out with nonparametric statistics with the
Friedman test (analysis of variance on ranks for
repeated measures) followed by Tukey post hoc tests
(SigmaStat 3.5).
Prevalence rates for the following changes in overbite
were calculated at T2, T3, and T4 with respect to the
initial values at T1, and they were expressed in terms
of the numbers of subjects showing the change during
specic time intervals (T1-T2, T1-T3, and T1-T4):
improvement in overbite equal to or greater than 11.5
mm (more positive change), improvement in overbite
equal to or greater than 10.5 mm (more positive
change), or worsening in overbite equal to or less than
0.5 mm (more negative change).
The prevalence rates of subjects showing correction
of open bite at T2, T3, and T4 were calculated. Correc-
tion of open bite was assessed when the overbite value
was greater than 1.5 mm at the specic time point.
Phelan et al
Logistic regression on the cephalometric variables
at T1, with the value of overbite at T4 (classied as
self-corrected when overbite was greater than 1.5
mm vs not corrected when overbite was still less
than 1.5 mm) as the dependent variable, was performed
(stepwise method, with P to enter \0.05 and P to
remove .0.1). The basic idea of the stepwise method
is to add variables (with P values smaller than 0.05)
one at a time as long as these additions improve the
model the most. After a variable has been added, all ef-
fects in the current model are checked to see whether any
of them should be removed (with P values greater than
0.1). Then the process continues until the model cannot
be further improved. The aim of logistic regression was
to identify T1 predictive variables for favorable or unfa-
vorable individual outcomes in overbite. Logistic regres-
sion was carried out with statistical software (version
17.0; SPSS, Chicago, Ill).
RESULTS
Descriptive statistics for the cephalometric measure-
ments at the 4 observation periods and the statistical
comparisons among the stages are reported in Table I.
No signicant growth changes were detected in the
cranial base angle.
For maxillary skeletal size and position, SNA
increased signicantly during the overall observation in-
terval T1 to T4 (1.2 ). Point A to nasion perpendicular
increased during the overall observation interval (0.4
mm), but this difference was not statistically signicant.
Co-Point A increased signicantly at all growth inter-
vals except the postpubertal T3-T4 interval.
For mandibular skeletal size and position, SNB
increased signicantly during the overall observation in-
terval T1 to T4 (2.0 ). Pogonion to nasion perpendicular
increased signicantly during this interval (2.5 mm),
whereas Co-Gn increased signicantly at all growth in-
tervals.
For the sagittal skeletal relationships, the ANB angle
decreased signicantly during the overall observation
interval T1 to T4 (0.9 ), whereas the Wits appraisal
increased signicantly during this period (1.8 mm). Sig-
nicant increments in the maxillomandibular differen-
tial were found during the pubertal and overall growth
intervals.
For the vertical skeletal relationships, no signicant
growth changes were detected in the inclination of the
palatal plane relative to the Frankfort horizontal,
whereas the inclination of the mandibular plane to the
Frankfort horizontal decreased signicantly during the
overall growth interval (2.3 ). These changes also are
reected in the inclination of the palatal plane to the
American Journal of Orthodontics and Dentofacial Orthopedics
31
mandibular plane. The variables N-ANS, ANS-Me,
N-Me, S-Go, Co-Go, and S-Go/N-Me exhibited signi-
cant increases during the prepubertal, pubertal, and
overall growth intervals, with the exception of ANS-Me
at the prepubertal interval and S-Go/N-Me at the puber-
tal interval. N-Me also increased signicantly in the
postpubertal T3 to T4 interval. The gonial angle (Ar-
GoiMe) exhibited a signicant decrease during all
growth intervals.
For interdental relationships, a signicant decrease in
overjet was detected during the overall observation in-
terval T1 to T4 (1 mm). Overbite showed a signicant
increase during the prepubertal growth interval (2.4 mm)
and an insignicant change during the pubertal and
postpubertal growth intervals; this contributed to a sig-
nicant increase during the overall observation interval
(2.3 mm). The molar relationship had a signicant in-
crease during the overall interval (1.1 mm).
For the maxillary dentoalveolar relationships, signif-
icant vertical alveolar growth of the central incisors was
found during all growth intervals.31 The maxillary rst
molars moved downward signicantly at all observation
intervals. There were signicant decreases in the central
incisor to Frankfort horizontal angulation between T1
and T2 (2.1 ) and during the overall observation inter-
val T1 to T4 (3.1 ).
For the mandibular dentoalveolar relationships, the
central incisors showed vertical alveolar growth during
the prepubertal, pubertal, and overall observation inter-
vals (5.8 mm). A signicant increase in the vertical alve-
olar growth of the mandibular rst molars was also
detected during the prepubertal, pubertal, and overall
observation intervals (5.2 mm).
The analysis of the prevalence rates of open-bite sub-
jects showing either improvement or worsening in over-
bite during the growth intervals (Table II) showed that no
subject worsened during the prepubertal T1 to T2 inter-
val, and 83% of the subjects had an improvement in
overbite greater than or equal to 1.5 mm. When the pu-
bertal T2 to T3 interval was included in the observation
interval (T1-T3), the prevalence rate for subjects
showing improvement in open bite greater than or equal
to 0.5 mm was 92%; 71% of the subjects showed
improvement greater than or equal to 1.5 mm.
The analysis of the overall observation interval T1 to
T4 indicated that 92% of the subjects who started the
observation interval with an open bite had an improve-
ment in overbite greater than or equal to 0.5 mm when
they were examined in young adulthood. Seventy-one
percent of the subjects showed an improvement in over-
bite greater than or equal to 1.5 mm during the overall
observation interval, but only 4% had worsening in the
vertical overlap of the incisors. With regard to the
January 2014  Vol 145  Issue 1
32 Phelan et al

Table I. Descriptive statistics for the cephalometric measurements at the 4 observation periods
T1 T2 T3 T4 Growth changes and statistical comparisons

T1-T2 T2-T3 T3-T4 T1-T4

Measurement n 5 24 Mean SD Mean SD Mean SD Mean SD prepubertal pubertal postpubertal overall
Cranial base
NSBa ( ) 130.3 5.3 129.9 5.3 129.8 5.5 129.9 6.1 0.4 0.1 0.1 0.4
Maxillary skeletal
SNA ( ) 80.4 3.1 81.0 3.1 81.5 3.0 81.6 3.0 0.6 0.5 0.1 1.2*
Point A to nasion perpendicular (mm) 0.1 2.7 0.1 2.8 0.4 3.0 0.5 3.1 0.2 0.5 0.1 0.4
Co-Point A (mm) 87.5 6.5 91.8 6.8 95.8 6.9 97.6 7.4 4.3* 4.0* 1.8 10.1*
Mandibular skeletal
SNB ( ) 76.0 2.8 76.9 3.0 77.7 3.2 78.0 3.4 0.9 0.8 0.3 2.0*
Pg to nasion perpendicular (mm) 8.2 4.3 7.8 5.0 6.5 5.5 5.7 6.0 0.4 1.3 0.8 2.5*
Co-Gn (mm) 109.1 6.5 114.6 7.5 122.6 7.6 126.4 8.5 5.5* 8.0* 3.8* 17.3*
Maxillomandibular
ANB ( ) 4.5 1.9 4.1 1.7 3.8 2.0 3.6 2.0 0.4 0.3 0.2 0.9*
Wits (mm) 1.9 2.3 1.0 2.8 0.7 3.2 0.1 3.1 0.9 0.3 0.6 1.8*
Maxillomandibular differential (mm) 21.7 2.6 23.9 2.8 26.8 3.3 28.8 3.8 2.2 2.9* 2.0 7.1*
Vertical skeletal
Frankfort horizontal to palatal plane ( ) 2.9 2.4 2.0 2.9 1.8 3.1 2.0 3.2 0.9 0.2 0.2 0.9
Frankfort horizontal to mandibular plane ( ) 28.2 3.6 27.6 4.1 26.7 4.2 25.9 4.4 0.6 0.9 0.8 2.3*
Palatal plane to mandibular plane ( ) 25.3 4.9 25.6 5.6 25.0 5.9 23.8 6.0 0.3 0.6 1.2 1.5*
N-ANS (mm) 48.6 3.2 52.3 3.8 55.4 4.3 56.4 4.5 3.7* 3.1* 1.0 7.8*
ANS-Me (mm) 66.7 5.0 69.5 6.0 73.5 6.9 75.8 7.4 2.8 4.0* 2.3 9.1*
N-Me (mm) 112.8 6.8 119.4 8.4 126.5 9.6 129.8 10.2 6.6* 7.1* 3.3* 17.0*
S-Go (mm) 68.6 5.4 74.3 6.5 80.3 7.4 83.8 9.0 5.7* 6.0* 3.5 15.2*
S-Go/N-Me (%) 60.8 3.3 62.3 3.7 63.5 3.7 64.5 4.4 1.5* 1.2 1.0 3.7*
Co-Go (mm) 50.4 3.6 53.1 4.8 58.0 4.5 61.0 5.7 2.7* 4.9* 3.0 10.6*
ArGoiMe ( ) 130.4 3.8 128.6 3.7 126.9 4.2 125.1 4.9 1.8* 1.7* 1.8* 5.3*
Interdental
Overjet (mm) 6.2 2.2 6.0 1.9 5.6 1.8 5.2 1.9 0.2 0.4 0.4 1.0*
Overbite (mm) 0.0 1.5 2.4 2.1 2.4 2.0 2.3 2.2 2.4* 0.0 0.1 2.3*
Molar relationship (mm) 0.5 1.3 0.9 1.2 1.4 1.5 1.6 1.5 0.4 0.5 0.2 1.1*
Maxillary dentoalveolar
U1 to Frankfort horizontal ( ) 116.3 5.0 114.2 5.6 113.5 6.1 113.2 6.4 2.1* 0.7 0.3 3.1*
U1 vertical (mm) 22.4 2.0 24.6 2.3 25.9 2.4 26.7 2.6 2.2* 1.3* 0.8* 4.3*
U6 vertical (mm) 25.5 2.2 27.3 2.5 29.2 2.8 30.3 2.9 1.8* 1.9* 1.1* 4.8*
Mandibular dentoalveolar
L1 to mandibular plane ( ) 95.9 5.2 95.2 6.0 94.9 6.5 94.5 6.4 0.7 0.3 0.4 1.4
L1 vertical (mm) 30.8 2.6 33.0 3.2 35.2 3.6 36.6 4.0 2.2* 2.2* 1.4 5.8*
L6 vertical (mm) 28.9 3.1 30.6 3.5 32.9 3.6 34.1 4.0 1.7* 2.3* 1.2 5.2*

*P \0.05.

correction of open bite (overbite .1.5 mm), 75% of the
subjects achieved open-bite correction at T2; this
correction was maintained at T4.
Logistic regression on the cephalometric variables at
T1 with the value of overbite at T4 (classied as self-
corrected when overbite was .1.5 mm vs not
corrected when overbite was still \1.5 mm) as the
dependent variable indicated no statistically signicant
relationships.
DISCUSSION
We evaluated the growth changes in orthodontically
untreated subjects with minimal overbite (#1.5 mm)
followed longitudinally from about 9 years of age until
young adulthood. The pertinent features of this study
compared with previous investigations of the change in
overbite are (1) specic focus on subjects with an open-
bite tendency irrespective of their sagittal relationships;
(2) longitudinal study with an adequate sample size (prior
investigations were semilongitudinal,19 or the subjects
with minimal overbite or open bite were a subsample of
larger longitudinal studies on overbite changes15,18,19);
and (3) classication of growth intervals with a biologic
indicator of skeletal maturity.24 The cervical vertebral
maturation method enables changes in overbite to be
evaluated in relation to skeletal maturity rather than
only chronologic age intervals.

January 2014  Vol 145  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Phelan et al
Table II. Prevalence rates for subjects with open-bite
tendency showing improvement, worsening, or
correction of overbite
T1-T2 % T1-T3 % T1-T4 %
of subjects of subjects of subjects
Improvement $ 11.5 mm 83 71 71
(more positive change)
Improvement $ 10.5 mm 87.5 91.5 91.5
(more positive change)
Worsening # 0.5 mm 0 0 4 skeletal changes in the mandibular ramus and condylar
(more negative change)
Corrected (.1.5 mm) by end 75 (at T2) 75 (at T3) 75 (at T4)
of observation interval
The depth of the overbite showed a signicant
improvement from about 9 years of age to young adult-
hood. The average increase in overbite was 2.3 mm. The
trend for the increase in overbite with growth and age
has been demonstrated by most prior investiga-
tions.8,15,18,19 We focused specically on subjects with
minimal overbite. Prior investigations have described
the development of normal overbite and its variations
during the mixed and permanent dentitions,9,13-18 but
there has been limited analysis of subjects with a
reduced overbite.14,18,19 The inclusion criteria of an
overbite less than 1.5 mm reects an open-bite tendency
because it represents a difference of more than 2 SD
from the reported average overbite in subjects of a
similar age.16,19
A signicant increase in the vertical overlap of the in-
cisors in this sample occurred during the prepubertal
ages (average, 2.4 mm). Those who found a similar
change in overbite in previous studies have attributed
this change mainly to the exfoliation of the deciduous
dentition in the transition to the permanent denti-
tion.15,18,19,32 There was statistically signicant vertical
alveolar growth of the central incisors (maxillary
vertical, 2.2 mm; mandibular vertical, 2.2 mm) and
molars (maxillary vertical, 1.8 mm; mandibular vertical,
1.7 mm) during the prepubertal growth interval.31 Co-
Gn length also increased signicantly (2.7 mm) during
the same growth interval. The coordinated nature of
the eruption, the similar rates of vertical alveolar growth
in the anterior and posterior teeth, and the growth of the
jaws indicate that the improvement in overbite cannot
simply be attributed to incomplete incisor eruption.
The changes seen in this growth interval are typical of
the postfunctional stage of eruption, as the eruptive
mechanism of the teeth responded to changes in cranio-
facial dimensions.33 Previous studies have shown that
the rate of eruption parallels the rate of jaw growth;
therefore, it can be suggested that the improvement is
a reection of a favorable growth pattern.34-36
American Journal of Orthodontics and Dentofacial Orthopedics
33
After the prepubertal increase, there was an insignif-
icant change in overbite during the pubertal and postpu-
bertal growth intervals. Previous longitudinal studies in
subjects with deepbite37 and normal overbite14,19
reported decreases in overbite during adolescence and
young adulthood. These decreases were attributed to
the eruption of the second and third molars.19
The use of a biologic indicator of skeletal maturity to
dene growth intervals enables the identication of
regions.24 In our investigation, the amount of vertical
growth in the mandibular ramus, along with total
mandibular length, was statistically signicant during
these periods and was greatest at the pubertal interval
(T2-T3). Increased vertical growth of the mandibular
ramus with closure of the gonial angle and anterior
growth rotation of the mandible have been suggested
as fundamental parts of the correction mechanism for
skeletal hyperdivergence with orthopedic appliances.38
Therefore, favorable growth tendencies in the pubertal
and postpubertal periods might explain why there was
no signicant change in overbite in this study compared
with the ndings of previous investigators.14,19,37
We found that the open-bite tendency self-corrected
in 75% of the subjects at the end of the overall observa-
tion interval T1 to T4. This nding agrees with those of
Worms et al,20 who reported self-correction of 80% of
the anterior open bites from a 7-to-9-year-old to a
10-to-12-year-old sample. Klocke et al8 also found a
high rate of self-correction (93%) of anterior open bite
in the deciduous dentition from 5 to 12 years of age.
Although data on the occurrence of digital habits were
not available on the untreated subjects considered in
this study, cessation of a digit-sucking habit might
have contributed to the high self-correction rate given
the young ages of the subjects.8,39
There were no predictive variables at T1 for favorable
or unfavorable outcomes in overbite, as shown by logis-
tic regression analysis. This observation is in contrast to
the study of Baccetti et al37 in deepbite subjects; they
found that reduction in overbite was related to the initial
amount of maxillary incisor proclination. Deepbite sub-
jects with reduced inclination of the maxillary incisors at
9 years of age had the least reduction in overbite during
the subsequent developmental intervals.37
The results of this longitudinal growth study provide
some potential indications for treatment planning in
patients with an open-bite tendency in the mixed denti-
tion. The signicant improvement in depth of the bite
(2.4 mm) during the prepubertal period suggests that
a more realistic diagnostic evaluation and assessment
of the need for therapeutic correction would be ob-
tained in the pubertal period. In this investigation, the
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34
open-bite tendency was self-correcting in 75% of the
subjects by the pubertal period. These results suggest
that early treatment is not advisable for patients with
an open-bite tendency in the prepubertal period
because most self-correct without intervention. The
ndings of Hellman40 also support this recommenda-
tion: he found an equivalent rate of correction with un-
treated open-bite patients as those who had received
early treatment to correct the open bite.
The cervical vertebral maturation method has been
used previously in appraisals of treatment timing for an
orthopedic approach to treatment in patients with an
increased vertical dimension.24,38 The results indicated
that a signicantly more favorable effect can be
obtained when expansion and vertical-pull chincup
treatment are used at the peak in mandibular growth
(CS 3) compared with treatment at an earlier maturational
stage (CS 1).24,38 Our results also support the treatment
timing recommendation, and it is therefore advisable to
wait until the pubertal growth spurt before undertaking
treatment in subjects with an open-bite tendency. How-
ever, to strengthen this recommendation, a longitudinal
growth study in subjects with severe open bite is required.
CONCLUSIONS
This longitudinal study on dentofacial growth
changes in subjects with an open-bite tendency showed
the following.
1. Overbite increased on average by 2.3 mm during the
overall observation interval T1 to T4. The improve-
ment occurred during the prepubertal interval T1 to
T2 (2.4 mm), whereas no signicant change
occurred in the pubertal and postpubertal stages.
2. From prepubertal ages to young adulthood, an
open-bite tendency improves in 91% of the subjects
and self-corrects in 75% of the subjects.
3. There are no predictive variables at T1 for favorable
or unfavorable outcomes in overbite.
4. The growth changes in such patients provide indica-
tions for timing of orthodontic treatment. It is
advisable to wait until the pubertal growth spurt
before undertaking treatment in subjects with an
open-bite tendency.
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