A cephlalometric study of 32 North American

patients with anterior open bite

black

Osmond G. Jones*
Washington, D.C.

The piirpose of this research project was,to investigate a group of 32 North American black patients
witti anterior opeti bite a,nd compare them to th& Noti, American black norms established by
Altemus and Drummond2 and to white populatiqn norms Mablished by Steiner.3 In addition, values
weke establitihed for blaCk patients bq use of ,the overbite depth indicator of Kim. The method
involved the tracing of Ia~eral e&ptialdmetric radiugraphs of 32 patients with anterior open bite using
the analyses of Ttieed,*,Steiner,3 and Kim. The resulting angles were added and the means and
standard deviations calculated. 0r1 the basis. of the criteria us&d for this study, the significant findings
were as follows: (1) the maxilla was normally positioned to the cranial base; (2) the upper and lower
incisors w&e procumberit with an acute interi,ncisal reltitionship; (3) the mandibular position tended
to be retrllsive to the cranial base; (4) the lower facial height was greater and the mandibular plane
angle (GoGn-SN) was smaller than white population standards; and (5) the overbite depth indicator
of Kim4 was smaller for this group than for the white population studied. (AM J ORTHOD DENTOFAC
ORTHOP

1$89;95:289-96.)

he patient with an anteridr open bite has

one of the most difficult orthodontic problems to correct. The cause of the anterior open bite may be both
complex and difficult to establish tind yet is critical iri
developing a treatment iegimen -that will produce St&bility and satisfactory cosmetic results. Although normal faces are different for the vtious racial groups,
cephalonietric stand&rds are available for both blacks
and whites..f However, our knowledge largely represents the white population.
The treatment of patients .with anterior open bite
raises as many problems as determining the calfse.
HellmanS (in 1931) and Nahouri-~~-~(in 1974) found as
many successes;as there were failures in the treatment
of open bite cases. In 1969, Richardson, stated that
the prognosis for these cases was -either good or poor.
In 197 1, Kim4 reported that the state of cephalometric
analysis and knowledge of the subject was inadequate
to diagnose an open bit& or deep bite tendency.
The purpose of this study was to evaluate the cephalometric feitures of a group of North American black
patients with anterior oijen bite. These data were COTpared to standards established for both white and black
racial groups with the hope that these findings would
be useful in differential diagnosis and treatment planning for orthodontic patients.

*Assistant Professor,
Orthodontics.

Howard

University

College of Dentistry,

Department

METHOD

This research involved the use of lateral cephalometric radiographs of 32 black patients, aged 8 to 39
years, with clinically diagnosed anterior open bite. The
group was divided into 25 female and seven male subjects. Tracings were made of x-ray films and landmarks
were identified by use of the analyses of Steiner,3
Tweed, and Kima (Figs. 1 through 3). The occlusal
planes (Fig. i) and the A-B plane (Fig. 3) were drawn.
Total facial height and lower facial height were measured according to Richardson, and Nahoum69 (Fig.
2), ahd the relevant angles for the Steiner and Tweed
analyses were recorded. The sample was divided further
into skeletal and dental groups by arbitrarily usihg
GoGn-SN angle of 32.5 as a division. Anterior skeletal
open bites were classified above this division.
Tracings were done with a hard pencil on 0.003
matte acetate tracing paper and measurements were obtained using cephalometric tracing equipment. * The
data were presented in tabular form and the mean,
range, and standard deviation were calculated.
RESULTS

Tables I through V include data collected without

dividing the sample into skeletal and dental anterior
open biteS; Tables VI and VII divide the sample into
skeletal and dental anterior open bites.
A comparison (Table I) between the present

of
*Unitek

Corporation.

Monrovia,

Calif.

289

290

Am. J. Orthod.

Jones

Dentofac. Orthop.
April 1989

KEY
S N a
SN=
60.
Gn=
A =

nidpoint
oi Pituitary
Foisa
Naiion
Cranial
base
plane
Gonion
Gnathion
Point
of greatest
convexity
the
anterior
of thr
maxilla
B = Point
of greatest
convexity
the
anterior
of the
mandible

on
on

Fig. 1. Steiners analysis.

study and norms established by Altemu? showed the

following:
i . The open bite patients did not demonstrate SNA
angles that weie significantly different from
black norms.
2. The SNB valueS usually w&e less than the black
norms.
3. SND angle was greater in open bite cases, but
was considerably less in those identified ai skeletal open bites.
4. The upper and lower incisors were more procumbent with open bite cases and the interincisal
angle was significantly smiller than the norm.
5. Open bite patients had larg& GoGn-SN angles.
Standard deviations for the norms established. by
Altemus were riot available and prevented statiStica
comparison with the figures from the open bite values.
In comparing these findings to the Tweed* norms
established by &ummond* (Table II), the FMA and
IMPA angles were not found to be significantly different
from the norm. The open bite FMA angle was larger
and IMPA angle was smaller than the black norms.
When the black open bite cases were compared with

the white open bite cases (Table III), it was seen that
both racial groups had $NA values similar to their respective notis. However, SNBs and interincisal angles
were smaller and GoGn-SN values were larger than
normal. The white data had larger GoGn-SN values.
Table IV shows that the mean open bite FMA angle
was smaller for the black subjects than that for white
subjects.
Both open bite racial groups had increased lower
facial height, but overall black subjects had the larger
value. The overbite depth indicator (ODI) was lower
for black subjects than for white subjects (Table V).
The sample was divided into two groups fo; the
iteine? analysis (Table VI). Group I (skeletal open bite)
had GoGn-SN angle above 32.5 and group II (dental
open bite) had a GoGil-SN angle below this point.
There were differences between the groups. The
skeletal type showed no maxillary protrusion (SNA,
85 = norm). The mandible @ND, 74.9) displayed
downward and backward rotation or retrusion. Ttie skeletal group also had maxillary incisal procumbency
(&NA, 25.5), but this was less than the dental group
(I-NA, 27;3). The dental types exhibited maxillary and

Volume 95
Number

Cephdometric

study of black patients with anterior

open bite

291

KEY
ANS= Anterior
nasal
spine
PNS= Posterior
nasal
spine
ANS-PNS
= Palatal
plane

Ii

- Nanton

N-N=
Total
facial
height
N-ANSUpper
f&J81
height
ANSM=
Lower
facial
height
LA = Long
axis
6f the
lower
Incisor
Frankfurt
Plrne
= Llna
irola
the
upper
border
of the
external
auditory
nertus
to the
lower
border
ofthe
orbit
Mandibular
Pi@no
= Line
tangential
tti the
lower
border
of the
mandible

Fig. 2. Tweeds analysis.

Table

I. Comparison of normal and open bite data by use of Steiners analysis

Black norm (Altemus)

SNA

SNB
ANB
SND
LNA
A-NA
LT
T-NB
T-NB
GoGn-SN

Black open bite (present srudyj

Mean

SD (2)

Mean

SD (2)

85.50
81.00
4.50
77.00
23.00
7.00 mm
119.00
34.00
10.00 mm
32.50

85.70
79.00Q
5.72
78.60
26.03
8.25 mm
111.10
37.90
ll.OOmm
35.60

4.79
4.78
3.57
5.31
7.50
2.97
11.57
7.82
3.36
5.72

mandibular protrusion (SNA, 87; SNB, 83, respectively) and had a greater procumbency than the norm
for the maxillary incisors (A-NA, 27.3).
Patients with skeletal open bite exhibited a greater
lower incisor procumbency (T-NB, 38.5) than those

with dental open bite, and had a more acute interincisal

angle (A-T, 110.8) than either skeletal (black patients,
1-T, 119; white patients A-T, 120) or dental Q-T,
1i2.20) norms.
Comparison of group I and group 11 for the Tweed

Am. J. Orrhod. Dentofac.

292 Jones

Orthop.
April

KEY
A-B
c!DI

Plane
from
= The
1.
2.

1989

a,
d.

= Line
Joining
points
A (L B
Steiners
analysis
sti.
of the
angie formed by8
The Hondibular
&d
A&B Planer
The Fr.arikfUrt
and Pdlat?l
Planes

Fig. 3. Kims analysis (overbite depth indicator [ODI]).

Table

II. Comparison of normal and open bite data by use of Tweeds analysis
Black

FMA
IMPA
FMIA

norm (Drummomf)

Black

Mean

SD (2)

Mean

;0.6&
100.00
49.40

4.70
5.00
5.70

31.56
99.50
49.20

analyses indicated that Fh4A angle was larger for patients with skeletal open bite and the IMPA angle was
larger for patients with dental open bite (Table VII).
(This implied that the skeletal group showed downward
and backward rotation of the mandible.) The dental
group generally had significantly lowerincisal procumbency. Upper facial heights were lower for skeletal open
bite cases than for the dental cases.
For Kims overbite depth indicator,4 the skeletal
group had a smaller ODI than the dental group. Both
groups were below the white norm of 74.50.
Dl!$ZUSSlON

Table I compares the normal data established by

Altemus with the open bite data for the Steineti analysis established by the current study. All the normal

open bite (present

study)
SD(*)
6.67
7.90
9.70

values were within one standard deviation of the means

for the open bite values in the study. A statistical comparison was not possible since standard deviations for
the normal means were not available. Instead, the clinical significance of the data was compared.
The relationship of .-point A (see Fig. 1) on the
maxilla to the cranial base (asindicated by angle SNA)
did not change significantly from the normal mean.
Similar findings were reported by Hapak13 in a study
of 52 white patients in 1964. The relationship of the
mandible to the cranial base as shown by the SNB angle
indicated that the mandible rotated downward and backward. This was contradicted by the SND mean value,
which increased. The increase was attributed to the
inclusion of both skeletal and dental open bite cases in
the groups used for the study. When including the SND

Volume 9s
Number

Cephnlometric

study

of black

patients

with

anterior

open

bite

293

Table III. Comparison of black and white open bite data by use of Steiners analysis
Black

SNA
SNB
ANB
AT
GoGn-\SN

open bite (present

study)

White open bite (Hapak)*

Mean

SD (?I

Mean

85.65
79.90
5.72
111.10
35.60

4.79
4.78
3.57
11.57
5.72

80. IO
75.90
4.20
120.00
38.56

SD (*i
3.23
3.79
2.88
10.49
7.19

___*Other

data unavailable.

Table IV. Comparison of black and white open bite data by use of Tweeds analysis
Black

FMA
IMPA
FMIA

open bite (present

study)

White open bite (Hapak)

Mean

SD (2)

Mean

31.56
99.50
49.20

6.67
7.90
9.70

33.40

SD (2)
Unavailable
Unavailable

Table V. Comparison of black and white data: Overbite depth indicator (ODI) and upper facial height/total
facial height (IJFH/TFH) by use of Kims analysis
Black

ODI
UFHiTFH
*Norm

UFHITFH

unavailable

open bite (present

study)

White

Mean

SD (2)

Mean

66.14
40.90%

6.78
3.58

14.50
42.80%

for black

data
SD (?)
6.07 norm (Kim4)
Open bite (Hapal?)*

subjects.

values for the dental open bites, the mean value for
SND angle would be elevated because the skeletal relationships were closer to the norm.
The values for the relationship of the upper incisor
to the maxillary I-NA angle and millimeter measurement indicated that the upper incisors were noticeably
more procumbent in open bite cases. This was reported
in previous studies such as the one by Hapak13 in 1964.
The diminished interincisal angle also indicated that the
incisors were more procumbent. The angle made by
the lower incisor and the mandible (T-NB) showed a
marked procumbency of the lower incisors.
The mandibular plane angle (GoGn-SN) showed an
increase above t.he normal mean. Mizrahi,14 Hellman,
Nahoum,6- and others. indicated in their studies that
the mandibular plane angle increased in open bite cases.
Table II shows the findings of the present study for
the TweedI analysis. The results were unexpected.

Compared with the norms established by Drummond

(Table II), the angle between the Frankfort plane and
the mandibular plane (FMA) increased significantly at
the 0.01 level. The IMPA and FMIA angles showed no
significant difference from the norms. This was somewhat surprising since a review of the literature had
indicated that changes in the lower incisor angulation
should have been expected.
In a comparison between black and white patients
with anterior open bite (Tables III and IV), significant
numerical differences were noted. Both groups also
exhibited the same trends. For example, both had SNA
values that were virtually the same as normal and SNB
angle was reduced in both groups. The data for white
patients were taken from research by Hapak in 1964
on an open bite sample of 52 cases. The article did not
specify whether the group was skeletal or dental in
nature.

Am. J. Orthod. Dentofac.

294 Jones

Orrhop.
April 1989

Table VI. Comparison of group I skeletal and group II dental data by use of Steiners analysis
Skeletal

open bite, group

(present study)

Mean
SNA
SNB
ANB
SND
I-NA
A-NA
1T
T-NB
T-NB
GoGn-SN

Dental

SD ()

85.00
78.70
6.30
74.90
25.50
7.90 mm
110.80
38.50
11.80 mm
38.30

4.10
3.96
3.10
4.72
7.60
2.80
10.37
7.70
3.26
3.79

open bite, group

(present studyJ

II

Mean

SD (2)

87.30
83.00
5.60
79.30
27.30
9.20 mm
112.20
36.10
9.00 mm
28.70

3.50
3.00
2.29
3.30
7.60
3.50
14.90
9.19
2.69
3.57

Table VIIA. Comparison of group I skeletal and group II dental data by use of Tweeds analysis and

Kims ODI
Group I open bite
(present study)

Tweeds analysis
FMA
IMPA
FMIA
Kims overbite depth indicator
ODI

Table VIIB. UFH/TFH

Group II open bite

(present study)

Mean

SD (2)

Mean

SD (2)

33.30
99.10
47.71

5.50
7.20
9.10

27.50
100.60
53.00

7.70
9.78
10.60

65.50

6.60

67.80

7.20

(ODI)

data (mean f SD)

Group I open bite
(present study)

UFIWTFH

40.40%

Steiners data3 for the two races were compared in

Table III and the differences were significant at the 0.05
level. The differences in the SNA, SNB, and 1: T values
were significant at the 0.001 level. The GoGn-SN angle
of 38.56 t 7.19 in white dental open bite subjects
was higher than that of black subjects-35.6
? 5.72;
it was approximately the same as that for black subjects
in the skeletal group-38.3
+ 3.79. This was an
unusual finding; possibly Hapak13 studied a group of
predominantly skeletal open bite patients. This might
explain the similarity between the races in the skeletal
cases.
Only angle FMA was available for racial compar-

Group II open bite

(present study)

3.90

42.20%

2.20

isons with the Tweed analysis (Table IV) and a statistical comparison was not possible because of incomplete data.
Table V indicates that the black open bite patients
had longer, lower faces than the white patients. This
was an expected finding since studies on normal patients
by Altemus already has displayed this trend.
The black patient sample evaluated in this study
showed the following:
1. Upper facial height to total facial height40.9 -+ 3.58
2. Kims overbite

depth indicator (OD1)466.14 f 6.78; the norm established by Kim

Volume 95
Number 4

Cephalometric

on 119 white patients was 74.5 + 6.07. The

difference between these two figures was significant at the 0.001 level.
Throughout the literature it had been stated that
open bite patients had significantly larger GoGn-SN
angles than the norm (32.5) established by Altemus (Hellmaqs Nahoum,6-9 and Mizrahi14). Nahoum6-9 stated that there were two types of open bite
cases-namely,
skeletal (group I) and dental (group
II). The mean mandibular plane angle (GoGn-SN) produced by this study, although larger than the norm, was
not as large as, might have been expected. It was believed that the cases included both skeletal and dental
types. An effort was made to identify the two groups
by dividing the cases into one group (group I, skeletal),
which had GoGn-SN angles higher than the norm
(32.5, Altemus), and another group (group II, dental)
with GoGn-SN angles 32.5 and below. The mandibular
plane angle (GoGn-SN, 32.5) was taken from the
norms established for blacks by Altemus (Table I).
In Table VI the two groups were compared and
Students t test applied to check the numerical differences for statistical significance. The difference between the SNA values for both groups (skeletal and
dental) was not significant at the 0.1 level, nor was
there much difference between the overall figure for
open bites for 1:his study and the norm established by
Altemus. Therefore it seemed that the SNA angle was
not significantly changed by the open bite condition.
This was also a finding of Hapak in his study of 52
open bite white patients.
The SNB values for the two groups (skeletal and
dental) were significantly different at the 0.01 level.
The skeletal open bite group I had a reduced SNB angle.
The dental open1bite group II displayed little difference
from the norm. while the skeletal group had a significantly reduced SNB angle. The ANB difference between the two groups was not statistically significant
at the 0.1 level. It can be concluded that skeletal open
bite cases had significantly reduced SNB and SND angles. This was caused by backward and downward rotation of the mandible.
The position of the upper incisors in relation to the
NA line was more procumbent; the difference between
the two groups was statistically significant and the dental open bite group showed greater procumbency. This
was not unexpected since increased procumbency of
the incisors was necessary to produce an opening in an
otherwise skeletally normal face and dentition.
The interincisal angle showed no statistically significant differenfze between the two groups; the angle
was more acute than the norm in both groups. It was
expected that the interincisal angle would have been

study of black patients with anterior

open bite

295

even more acute in dental open bite cases. Skeletal open

bites caused by what Schudy has described as a hyperdivergent skeletal pattern would need less dental
procumbency to produce an open bite.
The lower incisor position (T-NB) for both groups
showed no statistical difference between the groups.
Both had greater procumbency than the norm.
The data for the Tweed analysis for both groups
were compared in Table VII. Of the three parameters,
only one-the FMA angle-showed
a significant difference between the groups at the 0.1 level. This was
expected since the basis on which the two groups
were differentiated was a GoGn-SN angle above
normal and GoGn-SN below normal, normal taken to
be 32.5.
The ratio of upper facial height to total facial height
showed no significant difference between the groups at
the 0.1 level. This was a particularly surprising finding
because one of the points emphasized in the literature
by Mizrahi14 was that skeletal open bite patients had
greater facial heights. The reason the two groups
showed little difference may have been the sample size.
More studies need to be undertaken on open bite cases.
It is possible that the extremes within the two groups
caused the values to average out. The values produced
by the two groups from Kims ODP were not statistically different at the 0.1 level.
CONCLUSIONS

The following conclusions were drawn from this

study.
1. Black anterior open bite patients had SNA angles
close to the norm; SNB angles were less than the norm.
Interincisal angles were more acute than normal and
both upper and lower incisors were more procumbent
than the norm.
2. Dental anterior open bite cases (group II) had
maxillary protrusion and a greater upper incisal procumbency. However, skeletal open bite patients (group
I) showed backward and downward rotation of the
mandible, greater lower incisal procumbency, and
GoGn-SN values above the norm.
3. A comparison of anterior open bite data for black
and white subjects showed that black subjects had longer lower facial heights and white subjects had numerically larger GoGn-SN values.
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Reprint

requests

to:

Dr. Osmond G. Jones

Department
of Orthodontics
College of Dentistry
Howard University
600 W Street, NW
Washington,
DC 20059