J Oral Maxillofac Surg

xx:xxx, 2010

Evaluation of Skeletal Stability After

Surgical–Orthodontic Correction of
Skeletal Open Bite With Mandibular
Counterclockwise Rotation Using
Modified Inverted L Osteotomy
Zaher Aymach, DDS, DOrtho,* Hitoshi Nei, DDS, PhD,†
Hiroshi Kawamura, DDS, PhD,‡ and Joseph Van Sickels, DDS§

Purpose: To evaluate the surgical– orthodontic stability of treating skeletal open bite patients with
mandibular ramus osteotomies using a modified inverted L osteotomy (M-ILO) and counterclockwise
rotation of the mandible stabilized with rigid fixation.
Patients and Methods: In a retrospective review, 12 patients with skeletal open bites (8 females, 4
males) who received mandibular M-ILO in the period 2004-2007 at Tohoku University Hospital were
studied. Lateral cephalograms were taken immediately before surgery (T1), immediately after surgery
(T2), and at 1 yr after surgery (T3). Cephalometric analysis for point B, pogonion, menton, and
mandibular plane angle was obtained at the designated time intervals.
Results: Mandibular counterclockwise rotation showed stability for point B, pogonion, and menton
referred to X-Y coordinate, and for mandibular plane angle. The mean value for each variable was
compared between T2 and T3. No statistically significant change was observed for all variables.
Conclusions: With a well-positioned maxilla, skeletal open bite can be successfully treated using
M-ILO. Mandibular counterclockwise rotation showed stability at 1 yr after surgery.
© 2010 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights
reserved.
J Oral Maxillofac Surg xx:xxx, 2010

Numerous surgical procedures have been proposed
to correct a skeletal open bite. Mandibular common
osteotomies include a sagittal split ramus osteotomy
(SSRO), intraoral vertical ramus osteotomy, and in-
verted L osteotomy (ILO). These ramus procedures,
however, have not been uniformly successful due to a
relapse in both the horizontal and the vertical dimen-
sions. Although the potential for relapse of various
mandibular ramus osteotomies is a subject of much
controversy, factors such as proper surgical tech-
nique, rigid fixation, and temporomandibular joint
(TMJ) were shown to have a great impact on confer-
ring stability.1-3 However, much concern of relapse
remains when correction of the skeletal open bite is
attempted.4,5 For that reason, a maxillary impaction is
usually recommended because of greater stability.6,7
Although more stable, a maxillary impaction may not
give the best functional or esthetic results for an
individual patient. Therefore, limiting the surgery on
the mandible and closing the open bite with a coun-
terclockwise rotation will be required. SSRO, as the
most widely used mandibular procedure, was shown

*PhD candidate, Department of Maxillofacial Surgery, Graduate
School of Dentistry, Tohoku University, Sendai, Japan.
†Assistant Researcher, Department of Maxillofacial Surgery,
Graduate School of Dentistry, Tohoku University, Sendai, Japan.
‡Professor and Chairman, Department of Maxillofacial Surgery,
Graduate School of Dentistry, Tohoku University, Sendai, Japan.
§Professor and Assistant Dean, Department of Oral and Maxillo-
facial Surgery, College of Dentistry, the University of Kentucky,
Lexington, KY.
Address correspondence and reprint requests to Dr Aymach:
Tohoku University, Graduate School of Dentistry, Department of
Maxillofacial Surgery, 4-1 Seiryo-machi, Aoba-ku, Sendai 980 – 8575,
Miyagi, Japan; e-mail: zeimich@hotmail.com
© 2010 American Association of Oral and Maxillofacial Surgeons. Published
by Elsevier Inc. All rights reserved.
0278-2391/10/xx0x-0$36.00/0
doi:10.1016/j.joms.2010.05.020

1
2 SKELETAL STABILITY AFTER SURGICAL–ORTHODONTIC CORRECTION OF SKELETAL OPEN BITE
in most recent studies to be a relatively stable proce-
dure for counterclockwise rotation when applying
rigid fixation and eliminating TMJ pathology.8-11
In our institution, we have used an alternative os-
teotomy technique for correcting anterior open bites,
limiting the surgery to the mandible. ILO, with a
modification that brings its horizontal osteotomy be-
low the level of mandibular nerve entrance, allows
the distal segment to perform a counterclockwise
rotation with the stylomandibular and sphenomandib-
ular ligaments preserved and attached to the condylar
segment (Figs 1, 2).
The attempt to treat a skeletal open bite using an
ILO with stable results was originally described by
Dattilo et al in 1985.12 The method was applied as an
extraoral approach with no rigid fixation. Rigid fixa-
tion with ILO was described by Van Sickels et al13
using plates and a transbuccal approach after setting
FIGURE 1. Inverted L osteotomy. A, Original design; B, modified
ILO.
Aymach et al. Skeletal Stability After Surgical–Orthodontic Cor-
rection of Skeletal Open Bite. J Oral Maxillofac Surg 2010.
back mandibular prognathism. McMillan et al14 men-
tioned the use of ILO as a surgical option for mandib-
ular advancement, particularly where the risk of man-
dibular nerve injury is unacceptable. Later on, Muto et
al15 described a design for ILO that provides good
visibility, greater bony overlap, and rigid fixation to
correct mandibular prognathism. Although these
studies allowed more applicability for ILO to treat a
variety of deformity patterns, most of them had not
evaluated skeletal stability after application. To date,
there is no work investigating the skeletal stability of
open bite skeletal deformities treated by ILO with an
intraoral approach and rigid fixation.
The purpose of this study was to evaluate the skel-
etal stability after correction of skeletal open bite by
mandibular counterclockwise rotation using a modi-
fied intraoral inverted L osteotomy (M-ILO) with rigid
fixation (Fig 3).
Patients and Methods
This retrospective study is exempted from IRB
approval of the human studies committee. The
study included 12 patients (8 females, 4 males) with
skeletal open bite who had undergone mandibular
M-ILO at Tohoku University Hospital between 2004
and 2007. The group’s mean age was 24 yr, 8 mo,
ranging from 18 to 39 yr (Table 1). Patients for this
study met the following inclusion criteria: 1) all had
a lack of anterior teeth overlap with a skeletal
pattern of open bite (Go-Me-SN ⬎ 33°⫾ 3 upper
facial height [UFH]/lower facial height [LFH] index
⬍ 0.8 ⫾ 0.05, Go angle ⬎ 134° ⫾ 6, Y-axis angle ⬎
70° ⫾ 5); 2) the mean ANB was 0.9 ⫾ 3 including
skeletal Class I, and Class II and III tendency pat-
terns; 3) all the maxillas were confirmed to be well
positioned by clinical and cephalometric examina-
tions and none were actively growing at the time of
surgery; 4) all received preoperative and postoper-
ative orthodontic treatment; 5) all were operated
on by 1 surgeon using a single jaw procedure (M-
ILO); and, finally, 6) fixation with a titanium lock-
ing miniplate was performed without bone graft-
ing. Individuals with craniofacial anomalies,
asymmetries, syndromes, or history of trauma were
excluded from the study.
SURGICAL TECHNIQUE OF M-ILO
Preoperatively, the anatomy of the mandibular ra-
mus area, the mandibular foramen, and canal position
was evaluated using digital orthopantomographs and
computed tomography.
INCISION
After local anesthetic and epinephrine injection, a
30-mm-long incision is made starting approximately
AYMACH ET AL 3

FIGURE 2. Drawings illustrate different osteotomy lines with relation to stylomandibular and sphenomandibular ligaments. A, Original
SSRO; B, Original ILO; C, Modified ILO.
Aymach et al. Skeletal Stability After Surgical–Orthodontic Correction of Skeletal Open Bite. J Oral Maxillofac Surg 2010.

15 mm proximal to the mandibular second molar and HORIZONTAL OSTEOTOMY

extending down to the periosteum. A mucoperiosteal
flap is then elevated proximally and laterally to ex-
pose the anterior, lateral, and partially medial ramus
aspects.
VERTICAL OSTEOTOMY
By using an oscillating saw, the osteotomy runs
vertically 5 to 7 mm anterior to the ramus posterior
border and moves steadily downward to meet the
lower border just anterior to the mandibular angle
(Fig 4 displays a model simulation).
By using a reciprocating saw, the osteotomy cuts
horizontally below the level of mandibular foramen. It
starts posteriorly by cutting through the outer cortex
in the area where the nerve course passes through
until the osteotomy is 7 mm from the ramus anterior
border to include the inner cortex and complete the
osteotomy.
SPLITTING
Splitting progresses with an osteotome placed in
the osteotomy site at the anterior ramus and sup-
4 SKELETAL STABILITY AFTER SURGICAL–ORTHODONTIC CORRECTION OF SKELETAL OPEN BITE

FIGURE 3. A representative tracing displays mandibular counter-

clockwise rotation after M-ILO. (Dotted line), initial; (solid line), follow-
ing rotation; (blue circle), the center of rotation; (arrow), the direction.
Aymach et al. Skeletal Stability After Surgical–Orthodontic Correc-
tion of Skeletal Open Bite. J Oral Maxillofac Surg 2010.

ported with an additional curved osteotome placed in

the vertical cut to help split the rest of the horizontal
osteotomy, particularly the area near the mandibular
nerve entrance.

FIXATION
After maxillomandibular fixation, condyles are seated
and intersegmental bony prematurities are reduced.
Then, fixation takes place at the ramus anterior aspect
using an L-shaped titanium locking miniplate with
monocortical screws. Maxillomandibular fixation is then
released and replaced with light elastic.
FIGURE 4. Model simulation of M-ILO with fixation technique. A,
Lingual view with relation to mandibular nerve entrance; B, anterior view
Cephalometric Landmarks (fixation plates).
and Analysis Aymach et al. Skeletal Stability After Surgical–Orthodontic Correction of
Cephalometric radiographs were obtained at the Skeletal Open Bite. J Oral Maxillofac Surg 2010.
teeth in centric occlusion, with the lips relaxed and
the head in a natural position, and assessed at the

Table 1. BASIC PATIENT DATA

Case Number Diagnoses Age (yr) Gender ANB (°) Overjet (mm) Overbite (mm)

1 Skeletal Class I 28 F 2 1.5 ⫺3

2 Skeletal Class I 39 F 3 2.5 ⫺1.5
3 Skeletal Class I 19 F 3 3 ⫺5
4 Skeletal Class III 20 M 0 ⫺1 ⫺3.5
5 Skeletal Class III 22 M ⫺2 ⫺2.5 ⫺5
6 Skeletal Class III 25 F 0 0 ⫺2
7 Skeletal Class III 18 F ⫺4 0 ⫺0.5
8 Skeletal Class III 29 M ⫺3 ⫺3 ⫺4.5
9 Skeletal Class III 30 F ⫺2 ⫺4 ⫺3
10 Skeletal Class II 21 F 4 3 ⫺1
11 Skeletal Class II 23 F 5 4 ⫺4
12 Skeletal Class II 24 M 4.5 3.5 ⫺3.5
Aymach et al. Skeletal Stability After Surgical–Orthodontic Correction of Skeletal Open Bite. J Oral Maxillofac Surg 2010.
AYMACH ET AL 5

Table 2. CEPHALOMETRIC LANDMARKS WITH THEIR DEFINITIONS

Point Definition

N ⫽ Nasion The most anterior point of the frontonasal suture in the midsagittal plane
Or ⫽ Orbital The lowest point of the bony orbit (if the orbital rims overlapped, the lowest point on the average
outline is considered)
P ⫽ Porion The top of the external auditory meatus
S ⫽ Midpoint of sella The center of sella turcica
B ⫽ Point B The deepest point on the outer contour of the mandibular alveolar process between infradental
and pogonion
Pogonion The most anterior point of the bony chin in the midsagittal plane
Menton The most inferior point of the outline of the symphysis in the midsagittal plane
Go= ⫽ Gonion dash The most posterio-inferior point on the mandibular lower border just anterior to the designated
osteotomy line
Aymach et al. Skeletal Stability After Surgical–Orthodontic Correction of Skeletal Open Bite. J Oral Maxillofac Surg 2010.

following 3 intervals: before surgery (T1), immedi- position of the landmarks were noted relative to the
ately after surgery (T2), and at 1 yr after surgery (T3). coordinate system X-Y.
The following cephalometric points were identified:
midpoint of sella (S), nasion (N), orbital (Or), porion
Results
(P), point (B), pogonion (Pog), menton (Me), and
gonion dash (Go=) (Tables 2 and 3). For analysis, the The mean values of the variables at (T1), (T2), and
X-Y coordinate axis was constructed. This coordinate (T3) are presented in Tables 4 and 5. The mean
system has its origin at Pog and its X axis is parallel to changes that occurred after surgery (T3-T2) were
the Frankfort plane. The vertical line was perpendic- (⫺0.4 mm vertical, 0.2 mm horizontal) for pogonion,
ular to this line through Pog as the Y vertical axis (Fig (⫺0.3 mm vertical, 0.1 mm horizontal) for menton,
5). A 0.3-mm pencil was used to minimize errors in (⫺0.8 vertical mm, 0.4 mm horizontal) for point B,
locating cephalometric landmarks on tracing paper.
These serial cephalograms were identified twice by
the same examiner, and, if the difference between the
2 values of any point or angle exceeded 0.5 mm or 1°,
respectively, the point or angle was registered a third
time. The third registration was compared with the
others. The mean value was taken from the 2 closest
values, while the outlier was excluded from the data.
Tracing replication was a good means to reduce the
bias of identification of cephalometric points.
Lateral cephalometric tracings were superimposed
to calculate surgical changes right after surgery (T2-
T1) and at 1 yr after surgery (T3-T2). Changes in the

Table 3. DEFINITION OF LINEAR PLANES

AND ANGLES

Plane/Angle Definition

SN Anterior cranial baseline

FH Frankfort horizontal plane, drawn from
the point orbital to porion
N-B Line joining nasion and point B
N-Pog Line joining nasion and pogonion
Go=-Me Mandibular plane
(Go=-Me-SN) This angle is constructed from SN and
the intersection of the mandibular FIGURE 5. Cephalometric landmarks, linear and angular mea-
plane line Go=-Me surements used in this study.
Aymach et al. Skeletal Stability After Surgical–Orthodontic Cor- Aymach et al. Skeletal Stability After Surgical–Orthodontic Cor-
rection of Skeletal Open Bite. J Oral Maxillofac Surg 2010. rection of Skeletal Open Bite. J Oral Maxillofac Surg 2010.
6 SKELETAL STABILITY AFTER SURGICAL–ORTHODONTIC CORRECTION OF SKELETAL OPEN BITE

Table 4. VALUES OF THE SELECTED CEPHALOMETRIC VARIABLES FOR THE PATIENTS TREATED WITH M-ILO (mm)

T1 T2 T3
Variable Mean SD Mean SD Mean SD

Point B
V 10.8 1.6 14.9 2 14.1 2
H ⫺2.9 1.2 ⫺4.5 1.6 ⫺4.8 1.5
Pog
V 0 0 4 1 3.6 1
H 0 0 ⫺1.2 2.4 ⫺1 2.4
Me
V ⫺8.5 1.4 ⫺4.7 1.7 ⫺5 1.7
H ⫺4.6 2.3 ⫺5.6 1.6 ⫺4.5 1.6
Aymach et al. Skeletal Stability After Surgical–Orthodontic Correction of Skeletal Open Bite. J Oral Maxillofac Surg 2010.

and (⫹0.56°) for mandibular plane angle (Tables 6
and 7). To determine how significant these changes
are, 7 separate t tests were carried out. For each test,
the mean value of the variable right after surgery was
compared with its mean value at 1 yr after surgery.
There was no statistically significant evidence that the
mean value of all the variables was altered at least 1 yr
after surgery (P ⬎ .05) (Figs 6, 7).
Discussion
The complex nature of the open bite deformities
presents a number of problems and options for the
surgeon. A major concern continues to be the stability
of the changes after orthognathic surgery procedures
to close an open bite, particularly with a mandibular-
dependent surgery. Although some reports men-
tioned that closing an open bite or decreasing the
mandibular plane with SSRO increases the risk of
relapse up to 33%,16-18 recent studies suggest that
solely SSRO applied with some modifications is a
relatively stable procedure for correcting open bites
with the presence of rigid fixation and absence of TMJ
pathology.9-11 Such modifications included using a
short sagittal splitting line (Epker-Hunsuck modifica-
tion) that can help free the distal segment from the
stylomandibular ligament.10 Other suggestions can
be to develop a green-stick fracture or osteotomy
on the internal ramus aspect belonging to the distal
segment, to reduce the tension on the sphenoman-
dibular ligament, or even to detach the ligament
from the Lingula.8
The M-ILO, as an alternative osteotomy tech-
nique, helps to move the mandible counterclock-
wise effectively with little interference from the
mandibular ligaments and noticeably negating the
need of further stripping on the distal segment after
rotation, thus maximizing blood supply to the bony
segments.
Fixation of M-ILO is performed intraorally using
an L-shaped locking miniplate and monocortical
screws applied on the ramus anterior aspect. The
downward level of the horizontal cut helps in seat-
ing and controlling the condylar segment. This
abandons the use of condylar positional plates as-
sociated with the original ILO that showed a poor
control over the condylar segment during fixa-
tion.13,14 After M-ILO, the patient is kept on a soft
diet for 4 to 6 weeks and wears light elastics.
Nerve damage and numbness after ramus osteoto-
mies are considered a critical complication. The orig-
inal ILO is believed to reduce the incidence of neu-
Table 6. VALUES FOR THE SELECTED
CEPHALOMETRIC VARIABLES (mm) OF THE
SURGICAL MOVEMENT (T2-T1) AND THE CHANGE
AFTER SURGERY (T3-T2)
T2-T1 T3-T2
Variable Mean SD Mean SD

Point B
V 4.1 1 ⫺0.8 0.3
Table 5. VALUES FOR THE VARIABLE OF H ⫺1.8 2.4 0.4 0.4
MANDIBULAR PLANE ANGLE Go=-Me-SN(°) Pog
V 4 1 ⫺0.4 0.2
T1 T2 T3 H ⫺1 2.4 0.2 0.1
Variable Mean SD Mean SD Mean SD Me
V 3.8 1.1 ⫺0.3 1.6
Go=-Me-SN 38.4 3.8 35.6 4.2 36.1 3.7 H ⫺0.9 0.2 0.1 0.1
Aymach et al. Skeletal Stability After Surgical–Orthodontic Cor- Aymach et al. Skeletal Stability After Surgical–Orthodontic Cor-
rection of Skeletal Open Bite. J Oral Maxillofac Surg 2010. rection of Skeletal Open Bite. J Oral Maxillofac Surg 2010.
AYMACH ET AL
Table 7. VALUES OF THE MANDIBULAR PLANE
ANGLE Go=-Me-SN (°) OF THE SURGICAL
MOVEMENT (T2-T1) AND THE CHANGE AFTER
SURGERY (T3-T2)
T2-T1 T3-T2
Variable Mean SD Mean SD
Go=-Me-SN 3.1 1.5 ⫺0.6 1.2
Aymach et al. Skeletal Stability After Surgical–Orthodontic Cor-
rection of Skeletal Open Bite. J Oral Maxillofac Surg 2010.
rosensory defect.19 This defect, which was attributed
to the deep dissection carried on the ramus medial
aspect,13 showed significant recovery postoperatively
compared with SSRO.19,20 For the M-ILO, there is an
increased risk of injury to the nerve as the lateral hori-
zontal osteotomy cuts in the proximity of the nerve
course. Therefore, ascertaining the nerve entrance
location and course via computed tomographic
scan, obtaining proper technique skills, and main-
taining limited soft tissue dissection on the ramus
medial aspect will all have a great impact on reduc-
ing nerve injury. Clinically, our patients operated
with M-ILO were less likely to develop a neurosen-
sory defect, and if developed, more rapidly recov-
ered than our patients operated with SSRO. Among
the patients included in this study, only 2 cases showed
a partial defect that took no longer than 2 mo to recover
on performing the 2-point discrimination test.
For any skeletal deformity, skeletal as well as
dentoalveolar stability is of high concern for main-
taining good results, especially with cases of open
bite. Thus, observing tongue activity and position
and obtaining proper anterior teeth overlap orth-
odontically are helpful tools in maintaining stable
results.6,21
FIGURE 6. Diagram representing the changes immediately after surgery (T2-T1) and at 1 yr after surgery (T3-T2) for the vertical and
horizontal values of B, Pog, and Me points.
Aymach et al. Skeletal Stability After Surgical–Orthodontic Correction of Skeletal Open Bite. J Oral Maxillofac Surg 2010.
7
Our extended clinical contemplation to M-ILO
suggests that for those cases of open bite with
severe skeletal pattern or accompanying craniofa-
cial anomalies, maxillary posterior impaction may
be included in the treatment plan. Moreover, we
practice M-ILO for open bites accompanying small
to moderate skeletal sagittal discrepancies that can
be fixed without requiring bone grafting because
intersegmental bony prematurities are often seen
particularly at the posterior area. Therefore, when a
large amount of advancement will follow closing an
open bite, or in the lack of intersegmental bony
contacts with a gap formed over 5 mm, bone graft-
ing (ie, harvested from anterior symphysis cortex)
should be considered. We had not reported a case of
plating failure or infection that required early removal or
refixation. Regarding the TMJ issue, the initial clinical
data of our patients undergoing M-ILO had not recorded
a development of TMJ symptoms, if any, to be consid-
ered much more severe than at the time before surgery,
although further investigation will be required to reach
a conclusion.
Using M-ILO when indicated, limiting surgery to 1
jaw will significantly reduce the financial impact to
the patient and can make an orthognathic treatment
plan affordable.
With the versatility of ILO application,22 our up-
coming studies will investigate the application of
M-ILO for lengthening short ramus as in asymmetry
cases or hemifacial microsomia by combining M-
ILO with SSRO. In addition, this study presents the
stability for a short-term follow-up; because of that,
a long-term evaluation of our open bite patients
with large sample size is needed.
The M-ILO was shown to be a good method for
treating skeletal open bite. It allows mandibular coun-
8 SKELETAL STABILITY AFTER SURGICAL–ORTHODONTIC CORRECTION OF SKELETAL OPEN BITE
FIGURE 7. Diagram representing the changes immediately after surgery (T2-T1) and at 1 yr after surgery (T3-T2) for the mandibular plane
angle Go=-Me-SN.
Aymach et al. Skeletal Stability After Surgical–Orthodontic Correction of Skeletal Open Bite. J Oral Maxillofac Surg 2010.
terclockwise rotation and easy fixation with stable
results at 1 yr after surgery.
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