Maxillary constriction is a common problem we face in orthodontics. In younger patients, rapid palatal expansion (RPE) works beautifully because the midpalatal suture is still immature and repairs predictably. But in adults, things get tricky. Conventional RPE is often insufficient, and that’s where miniscrew-assisted rapid palatal expansion (MARPE)comes in.
A recent study by Naveda et al. (2022) looked into how the midpalatal suture actually repairs in adults after MARPE. And the findings are important for how we plan retention and manage expectations in this age group.
🦴 Midpalatal Suture Repair (16 months post-MARPE)
Incomplete repair common in adults
Bone density ↓ (vs. pre-expansion):
Anterior: –34%
Median: –77%
Posterior: –52%
Anterior region always repaired (100%)
Middle third = weakest (57% unrepaired)
>50% repair in 81% of patients
📊 Repair Scoring (0–3 scale)
Score
Description
Frequency
0
No repair
0%
1
<50% repair
19%
2
>50% repair
38%
3
Complete repair
43%
🔑 Clinical Takeaways
✔ Expect slower & incomplete repair in adults ✔ Anterior + posterior heal better (vascular supply) ✔ Middle third caution → miniscrew zone, less vascularity ✔ Always reinforce retention
🔒 Retention Protocol
Maintain expander in situ: 12 months
After removal → place 0.8 mm stainless steel TPA
Monitor with CBCT + visual scoring
Inform patients: repair ≠ full ossification even after 16 months
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👉 Read the full interview in Dentowesome Monsoon 2025 | Issue No. 3 —
Anterior open bite has always been one of the most challenging malocclusions to treat. Patients often present with esthetic concerns, speech difficulties, and compromised function. While orthognathic surgery is a definitive option for severe skeletal open bites, not all patients are candidates—or willing—for surgery. Fortunately, nonsurgical strategies can offer promising results when case selection is appropriate.
🔍 Understanding the Problem
Open bite malocclusion can be dental or skeletal in origin:
Dental open bite: ▸ Normal craniofacial pattern ▸ Proclined incisors, under-erupted anterior teeth ▸ Often linked to habits like thumb/finger sucking
Skeletal open bite: ▸ Long face syndrome, ↑ mandibular plane angle, retrognathic mandible ▸ Greater vertical growth pattern ▸ More difficult to manage without surgery
Key Diagnostic Tools
UAFH : LAFH ratio (<0.65 → poor prognosis for orthodontics)
Extractions & retraction (first premolars) → “drawbridge effect” closes the bite by uprighting incisors.
Best suited for patients with: ✅ Proclined incisors ✅ Minimal gingival display ✅ ≤2–3 mm incisor show at rest
B. Skeletal Open Bite (Nonsurgical Options)
Skeletal open bite is much harder to correct nonsurgically than dental open bite. The central challenge lies in controlling vertical dimension—particularly by preventing or reducing molar eruption.
Posterior extractions preferred if needed (e.g., caries, premature contact, etc.)
👉 Clinical insight: For every 1 mm molar intrusion, you can achieve about 3 mm anterior bite closure through mandibular counterclockwise rotation.
Method
Key Points
High-pull headgear, lingual arches, bite blocks
Prevent molar eruption; maintain curve of Spee.
Implants / Miniplates
Posterior intrusion (3–5 mm possible); counterclockwise mandibular rotation.
Multiloop Edgewise Archwire (MEAW) Multilooped .016 × .022 SS wires + heavy anterior elastics
Molar intrusion + incisor extrusion; alters occlusal plane; mainly dentoalveolar effects. Not ideal in patients with already excessive dentoalveolar height.
Passive Posterior Biteblocks extend 3–4 mm beyond rest position
Inhibit molar eruption; Restrict buccal dentoalveolar eruption → allow mandibular autorotation forward, hence more effective in growing patients; can be spring-loaded or magnetic (more effective; ~3 mm improvement vs 1.3 mm for spring type)
Functional Appliances – Open bite is worsened by faulty orofacial muscle posture.
FR-4 (Frankel regulator): Alters dentoalveolar eruption, retracts incisors. Some evidence of forward mandibular rotation.
Bionator/Activator: Restricts maxillary molar eruption, mild decrease in facial height (~1.3 mm). Used mainly in Class II with mild anterior open bite, not severe skeletal cases.
Active Vertical Corrector (AVC) – using samarium cobalt magnets embedded in acrylic.
Magnetic molar intrusion; worn 12–24 hrs; ~3 mm bite closure avg, bulky (7 mm interocclusal opening needed)
Vertical Pull Chincup
Useful for patients with excessive vertical dimension and backward mandibular rotation tendencies. ↓ mandibular plane angle, restricts molar extrusion; compliance dependent.
Glossectomy
Only in true macroglossia cases. If tongue is normal in size but thrusting, it often adapts after bite closure → surgery not needed. If tongue is truly enlarged relative to oral cavity → partial glossectomy may improve stability.
🔄 The Retention Challenge
One of the biggest hurdles in open bite management is long-term stability.
Studies show relapse rates of 35–43%.
Relapse is often due to dentoalveolar rebound rather than skeletal relapse.
Retention strategies:
Long-term/fixed retainers
Retainers with occlusal coverage to limit molar eruption
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Anterior open bite is one of the trickiest malocclusions we deal with in orthodontics. It’s not just about teeth — skeletal, dental, functional, and even habitual factors play a role.
🔹 Traditional Approaches
For decades, open bites in adults were often corrected by:
Extruding anterior teeth orthodontically (which works dentoalveolarly but doesn’t do much for facial esthetics in skeletal cases).
Orthognathic surgery (Le Fort I osteotomy, sometimes two-jaw surgery) to reposition the maxilla.
These surgical approaches improve facial esthetics but come with a catch — relapse.
Denison et al. found a 21% relapse at 1-year post-surgery.
Proffit et al. reported 7–12% overbite reduction within 3 years after Le Fort I surgery.
🔹 The Game Changer: Skeletal Anchorage
With the introduction of absolute anchorage (miniscrews, miniplates), things got exciting. Now, orthodontists could correct open bites without surgery, by intruding the posterior teeth and letting the mandible autorotate upward and forward.
Kuroda et al.: Skeletal anchorage makes open-bite treatment simpler than surgery.
Sugawara et al.: Used miniplates to intrude mandibular molars; reported ~30% relapse after 1 year.
Lee & Park: Miniscrew intrusion of maxillary molars → only 10.4% relapse in molars and 18.1% relapse in overbite at 1 year.
🛠️ How Was Intrusion Done?
Two different miniscrew protocols were used:
1️⃣ Buccal + Palatal Screws
Screws placed between roots of 2nd premolar–1st molar and 1st–2nd molar.
Intrusive force applied with elastomeric chains after 1–2 weeks.
2️⃣ Buccal Screws Only
Screws placed on buccal side at the same sites.
Rigid transpalatal arch (TPA) added to prevent buccal tipping.
Interpretation: It’s not just teeth—it’s also muscles & soft tissue adaptation trying to return to “old balance.”
🔹 Role of Retention & Soft Tissue
Tongue posture, perioral muscles, and habits play a huge role.
Myofunctional therapy after treatment improves stability.
Standard retainers (lingual + circumferential) aren’t enough for intruded molars — because intrusion is inherently less stable than tipping or mesiodistal movement.
Authors suggest an “active retainer”: clear retainer with buccal buttons that can be hooked to miniscrews with elastics to hold molars in place.
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In this issue, Oral Pathologist Dr. Shivani Bhandari opens up about her inspiring path—from the first spark of ambition in her school days to navigating academic pressure, personal loss, and carving her own niche in the dental world.
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Practical advice on balancing studies, hobbies, and responsibilities.
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Managing skeletal anterior open bite (AOB) is one of the trickiest problems you’ll see in clinic. Decisions about which teeth to extract — or whether to extract at all — can change the vertical facial pattern, molar position, and ultimately whether the mandible rotates closed (helpful) or stays/re-rotates open (problematic). Understanding how extraction pattern, tooth movement, and growth stage interact helps you plan smarter treatments and set realistic expectations.
The study in one line
A prospective cephalometric study compared vertical/rotational changes in AOB patients treated with three extraction patterns: first premolars (E4), second premolars (E5), and first molars (E6) — and found that extraction choice (plus how posterior teeth move) influenced mandibular rotation.
1. Extraction Choice & Mandibular Rotation
Extraction Pattern
Skeletal Open Bite Involvement
Effect on Mandibular Rotation
1st Premolars (E4)
Anterior teeth only
No significant rotation.
2nd Premolars (E5)
Extends to posterior teeth
Closing rotation
1st Molars (E6)
Extends to posterior teeth
Greatest closing rotation
The logic behind those findings comes down to three biomechanical factors:
Where the extraction space is (anterior vs. posterior in the arch)
How molars move to close that space (translation vs. extrusion)
How that movement interacts with mandibular rotation mechanics
The more teeth you move forward, the harder it is to prevent some extrusion of molars during protraction (especially without TADs or intrusion mechanics).
This shorter movement path makes vertical control easier — fewer teeth to drag along, less tendency for extrusion.
Reduced extrusion allows the posterior occlusal contacts to move out of the “palatomandibular wedge” and encourages mandibular closing rotation (SN–GoGn, SGn–NBa decrease).
E6: Large forward movement of molars with minimal extrusion → maximum rotation.
Posterior occlusal “block” is eliminated quickly, and molars protract mostly horizontally rather than extruding.
With posterior teeth moving forward and out of the wedge, the mandible is free to rotate up and forward the most.
3. Cephalometric Change Patterns
Variable
E4
E5
E6
SN–GoGn
↔ (no change)
↓
↓↓ (largest decrease)
SGn–NBa
↔
↑
↑↑
ANS–Me / Na–Me
↑↑ (largest increase)
↑
↑ (smallest)
Upper Molar–Palatal Plane
↑↑
↑
↑
Lower Molar–Mand. Plane
↑↑ (largest)
↑
↑
4. Clinical Tips
For AOB limited to anterior teeth: First premolar extraction may not help rotation—consider vertical control strategies.
Use gable bends, TADs for anchorage/vertical control, intrusion mechanics if needed.
Avoid mechanics or auxiliaries that encourage molar extrusion during space closure.
For AOB involving posterior teeth: Second premolar or first molar extraction preferred to facilitate mandibular closing rotation.
Minimize posterior tooth extrusion during protraction to enhance rotation.
Treat after peak pubertal growth spurt – less natural extrusion tendency — greater chance of controlled molar protraction and closing rotation.
5. Pearls for exams & case presentations
When presenting a case, include: vertical pattern, extent of AOB, growth indicators (hand–wrist/CS stage), extraction rationale, and how you’ll control vertical molar movement.
Don’t equate “extraction = guaranteed closing rotation.” The pattern of tooth movement (extrusion vs. translation) and growth stage are decisive.
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