Contemporary Trends in Anterior Open Bite Treatment: An Umbrella Review
Fadi Haek, DMD, MSc *1, Olle Malmgren, DDS, PhD 2
*Correspondence to: Fadi Haek, Orthodontist, Dental Group Taby Centrum, Stockholm, Sweden.
Copyright.
© 2026 Fadi Haek, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 01 October 2026
Published: 05 October 2026
DOI: https://doi.org/10.5281/zenodo.23179304
Abstract
Background: Anterior open bite (AOB) is one of the most challenging malocclusions in orthodontics due to its multifactorial etiology and high relapse potential. Recent advances in skeletal anchorage systems and clear aligner therapy have expanded the range of treatment options available for both dental and skeletal open bite correction. However, contemporary evidence remains dispersed across different systematic reviews and meta-analyses.
Aim: To provide a comprehensive overview of current evidence regarding the effectiveness, skeletal and dental effects, long-term stability, and relapse patterns associated with contemporary treatment modalities for anterior open bite.
Materials and Methods: An umbrella review of systematic reviews and meta-analyses was undertaken and reported in accordance with the PRISMA 2020 statement. A structured search was performed in PubMed, Web of Science, and the Cochrane Library for systematic reviews and meta-analyses published between January 2020 and December 2025. Reviews evaluating clear aligner therapy (CAT), skeletal anchorage using temporary anchorage devices (TADs), orthognathic surgery, and relapse management were included. Methodological quality was assessed using the AMSTAR-2 tool.
Results: Eight systematic reviews and meta-analyses met the inclusion criteria. Clear aligner therapy demonstrated overbite improvements of approximately 2.7–3.5 mm, primarily through dentoalveolar changes with limited skeletal effects. Skeletal anchorage-supported molar intrusion achieved 1.7–2.2 mm of molar intrusion and 3–7 mm of overbite correction, accompanied by mandibular autorotation and reductions in lower anterior facial height. Post-treatment loss of correction was reported, although differences in outcome definitions and follow-up periods limited comparisons of stability. The available evidence did not establish long-term equivalence between skeletal anchorage-supported treatment and orthognathic surgery. AMSTAR-2 assessment classified two reviews as high quality, five as moderate quality, and one as low quality.
Conclusions: The included reviews suggest that clear aligner therapy achieves anterior open bite correction mainly through dentoalveolar changes, whereas skeletal anchorage-supported treatment involves posterior intrusion with accompanying mandibular autorotation. Heterogeneity and uncertainty in the evidence limit conclusions about comparative effectiveness and individual treatment predictability. Despite favorable treatment outcomes, relapse remains a significant concern, emphasizing the importance of long-term retention and follow-up. Further high-quality prospective studies are needed to clarify long-term stability and optimize evidence-based treatment strategies.
Keywords: Anterior open bite; orthodontics; temporary anchorage devices; skeletal anchorage; molar intrusion; clear aligner therapy; relapse; stability; umbrella review.
Introduction
Anterior open bite (AOB) is one of the most complex and relapse-prone malocclusions in orthodontics. It is defined by the absence of vertical overlap between the upper and lower anterior teeth, resulting in a visible gap upon occlusion (1,2). This condition frequently impairs oral functions such as incising, mastication, and speech, and also presents with esthetic concerns, including lip incompetence, a convex profile, and sometimes a gummy smile (3). Morphologically, AOB is often linked with a vertical skeletal pattern, characterized by increased lower anterior facial height, steep mandibular plane angles, short posterior facial height, and excessive dentoalveolar height of the maxillary molars (4,5). Functional habits such as thumb sucking and tongue thrust are commonly associated etiological factors, especially in younger patients (3).
For decades, orthodontists have employed a wide range of treatment modalities in an effort to manage AOB—particularly in growing individuals. Approaches have included high-pull headgear, functional appliances like the Bionator, chin cup therapy, bite-blocks, and appliances utilizing magnetic repulsion (6). Although some studies reported temporary improvements, systematic reviews and long-term studies have shown that these methods often fail to deliver stable outcomes, especially in cases involving significant skeletal discrepancies (7,8). Even in growing patients, the evidence remains inconclusive, and in adults—where growth modification is no longer viable—these traditional methods offer limited success.
Historically, orthognathic surgery, especially Le Fort I maxillary impaction, has been considered the gold standard for correcting moderate to severe skeletal AOB. Surgical repositioning of the maxilla can reliably reduce anterior facial height and induce secondary counterclockwise mandibular rotation.
However, surgery is associated with considerable financial, psychological, and physiological costs, making less invasive alternatives increasingly desirable (9).
The introduction of skeletal anchorage, particularly temporary anchorage devices (TADs), has brought a paradigm shift in AOB treatment. TADs enable controlled intrusion of posterior teeth, altering the occlusal plane and facilitating secondary mandibular autorotation—key mechanisms for reducing anterior facial height and closing the open bite without surgery (10). Numerous studies have demonstrated that this approach can improve both occlusal relationships and facial esthetics by enhancing lower facial harmony and chin projection (11).
The method of TAD placement may influence treatment efficiency and stability. Buccal insertion between molar roots may be associated with limited interradicular space, root proximity, soft-tissue irritation, and sinus perforation. In contrast, palatal placement generally offers favorable bone quality, minimal soft-tissue interference, and greater biomechanical flexibility (12). Consequently, several palatally anchored intrusion systems have been introduced for the management of anterior open bite. Among these, the Mousetrap appliance has gained increasing popularity as an efficient method for maxillary molar intrusion using palatal skeletal anchorage. By allowing controlled force application and minimizing undesirable tooth movements, such systems have expanded the possibilities for non-surgical correction of skeletal open bite and contributed to the growing role of skeletal anchorage in contemporary treatment protocols (13).
More recently, clear aligner therapy (CAT) has gained popularity in the treatment of anterior open bite. Advances in digital treatment planning, biomechanics, and aligner materials have expanded the possibilities for managing vertical discrepancies while maintaining high patient acceptance. Recent evidence suggests that CAT can effectively correct mild to moderate anterior open bites, primarily through dentoalveolar tooth movements, particularly incisor extrusion, while producing limited skeletal effects (14,15).
Clinical studies have further suggested that combining aligners with skeletal anchorage may enhance vertical control and facilitate more complex tooth movements. Such hybrid approaches have demonstrated improvements in overbite, overjet, facial proportions, and occlusal relationships while maintaining favorable esthetics throughout treatment (16–18).
Despite these advancements, relapse remains a major clinical concern. Intruded molars may partially re-erupt after treatment, and without appropriate retention protocols, treatment outcomes may deteriorate over time (19). Consequently, long-term stability remains a critical factor when evaluating different treatment modalities for AOB correction.
In recent years, a growing number of systematic reviews and meta-analyses have investigated various aspects of anterior open bite treatment, including clear aligner therapy, skeletal anchorage, orthognathic surgery, and relapse management.
However, these reviews address different patient populations, treatment modalities, outcomes, and follow-up periods, and may include overlapping primary studies. An umbrella review is therefore needed to examine their methodological quality and overlap, synthesize findings by clinical outcome, and clarify the limitations of comparisons between treatment approaches.
Aim
The aim of this umbrella review was to provide a comprehensive overview of contemporary evidence regarding the treatment of anterior open bite (AOB). Specifically, this review sought to evaluate the effectiveness, skeletal and dental effects, long-term stability, and relapse patterns associated with current treatment modalities, including clear aligner therapy (CAT), skeletal anchorage using temporary anchorage devices (TADs), and orthognathic surgery. The review also aimed to assess the methodological quality of the included reviews and the overlap of their primary studies, and to identify uncertainties in the evidence on treatment effects and stability.
The review question was: In patients with anterior open bite, what treatment-related changes in overbite, molar position, and skeletal measurements, and what post-treatment stability outcomes, are reported by systematic reviews of clear aligner therapy, skeletal anchorage-supported treatment, and orthognathic surgery?
Materials and Methods
Study Design
This study was conducted as an umbrella review and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) statement. The objective was to provide a comprehensive overview of contemporary evidence regarding anterior open bite (AOB) treatment by synthesizing findings from recently published systematic reviews and meta-analyses.
Search Strategy
A structured literature search was performed in PubMed, Web of Science, and the Cochrane Library. The search was limited to studies published between January 2020 and December 2025 in order to identify contemporary treatment approaches and emerging trends in anterior open bite management.
The search strategy combined terms related to anterior open bite, skeletal anchorage, temporary anchorage devices (TADs), molar intrusion, clear aligner therapy, orthognathic surgery, relapse, stability, systematic review, and meta-analysis.
In addition, reference lists of relevant reviews were manually screened to identify additional eligible publications.
Eligibility Criteria
The following inclusion criteria were applied:
The following were excluded:
Study Selection
Titles and abstracts were screened for relevance, followed by full-text assessment of potentially eligible publications. Eight systematic reviews and meta-analyses fulfilled the inclusion criteria and were included in the qualitative synthesis.
Methodological Quality Assessment
The methodological quality of the included systematic reviews and meta-analyses was assessed using the AMSTAR-2 (A MeaSurement Tool to Assess Systematic Reviews 2) checklist. Reviews were evaluated according to critical and non-critical domains, including protocol registration, comprehensiveness of the literature search, risk of bias assessment, appropriateness of meta-analytical methods, and consideration of publication bias. Based on the AMSTAR-2 criteria, reviews were categorized as high, moderate, low, or critically low quality. AMSTAR-2 assessments were performed independently by the authors and disagreements were resolved by consensus. The following AMSTAR-2 domains were considered particularly important: protocol registration, comprehensiveness of the literature search, risk of bias assessment, appropriateness of statistical methods, and assessment of publication bias. Overall confidence was classified as high when there were no or one non-critical weakness, moderate when there were multiple non-critical weaknesses but no critical flaws, low when there was one critical flaw, and critically low when there were more than one critical flaw.
Data Extraction and Synthesis
Data were extracted regarding study characteristics, treatment modality, patient population, treatment outcomes, skeletal and dental effects, relapse rates, and long-term stability.
Because the included reviews differed in methodology, outcome measures, and patient populations, no additional meta-analysis was performed. Findings were synthesized descriptively and organized according to the major treatment modalities identified in the literature:
To further characterize the evidence base, all unique primary studies identified through the citation matrix were classified according to patient maturity status. Studies were categorized as adult/non-growing, mixed adolescent–adult populations, or unclear when sufficient information regarding growth status was unavailable.
Results
Eight systematic reviews and meta-analyses fulfilled the inclusion criteria and were included in the qualitative synthesis. The main characteristics of the included reviews are summarized in Table 1
Methodological Quality
The methodological quality of the included reviews ranged from low to high. Two reviews were classified as high quality, five as moderate quality, and one as low quality according to AMSTAR-2 criteria (Table 2). Common methodological limitations included lack of protocol registration, incomplete reporting of excluded studies, and insufficient assessment of publication bias.
We extracted all the 112 original references (SPs) from each of the 8 included systematic reviews (SRs) and constructed a citation matrix including the SPs. After removing of deduplicates, 74 unique SPs remained, corresponding to 38 overlapping references, which represents 33.9% of all extracted studies. Table 3 summarizes the number of original and unique SPs per SR and the proportion of removed duplicates.
The degree of overlap among SRs was quantified using the Corrected Covered Area (CCA) according to Pieper et al. using the formula:
(???????? ⋅ ????????????) − ????????
with ???????? = 112, ???????? = 74, and ???????????? = 8, the calculated CCA was 7.34%. According to established interpretation thresholds (0–5% = slight; 6–10% = moderate; 11–15% = high; >15% = very high), this value indicates a moderate degree of overlap.
The number of newly identified unique primary studies varied across the included SRs (Table 3). However, these counts depend on the order in which the reviews were entered into the citation matrix. The lower number of newly identified studies in older reviews should therefore not be interpreted as evidence of less comprehensive coverage. The CCA provides an overall measure of overlap across the included reviews.
Population analysis of the unique primary studies demonstrated that most of the available evidence was derived from adult or non-growing patients. Twenty-eight studies were classified as confirmed adult/non-growing populations and an additional 15 studies were considered likely to represent predominantly adult samples. Nineteen studies included mixed adolescent–adult populations, while twelve studies could not be clearly classified. Overall, 28 of the 74 unique primary studies were classified as confirmed adult/non-growing populations, while a further 15 were considered likely to involve predominantly adult samples. The inclusion of mixed-age and unclassified populations limits the certainty with which the findings can be generalized to non-growing adults.
Clear Aligner Therapy (CAT)
Recent evidence suggests that clear aligners can effectively correct mild to moderate AOB in adults. Correa et al. (2025) conducted a systematic review and meta-analysis including 14 studies and reported a mean overbite improvement of 2.76 mm. This correction was primarily attributed to maxillary and mandibular incisor extrusion. Nshimiyimana et al. (2025) reported similar findings, demonstrating 3–3.5 mm of overbite improvement, predominantly through anterior dentoalveolar changes with minimal skeletal effects. Changes in mandibular plane angle were limited (approximately 0.4–0.9°), and lower anterior facial height remained stable or showed only minor increases.
Both reviews reported little evidence of clinically significant molar intrusion, indicating that CAT primarily achieves correction through dental rather than skeletal mechanisms.
Skeletal Anchorage and Molar Intrusion (TADs, MAFAs, and Miniplates)
Skeletal anchorage demonstrated substantial effects on both dental and skeletal components of AOB correction. Kwon et al. (2024), based on 15 included studies, reported an average overbite improvement of 3.88 mm and maxillary molar intrusion of 2.15 mm, accompanied by counterclockwise mandibular rotation and forward chin projection. Long-term follow-up data indicated a 19.9% reduction in overbite correction and a 22.9% relapse in molar intrusion.
González Espinosa et al. (2020) reported molar re-eruption corresponding to approximately 12% of the achieved maxillary intrusion and 27.2% of the achieved mandibular intrusion. The pooled change in overbite during follow-up was −1.23 mm (95% CI: −1.64 to −0.81), indicating loss of correction. These percentages describe molar re-eruption rather than the proportion of patients with recurrent anterior open bite.
Additional evidence was provided by Nshimiyimana et al. (2025), who found that miniscrew-anchored fixed appliances (MAFAs) produced 4–7 mm of overbite improvement, mandibular plane angle reductions of 1.1–3.3°, and reductions in lower anterior facial height ranging from 1.6 to 3.6 mm. Posterior intrusion may contribute to overbite correction through counterclockwise mandibular rotation; however, the relationship between the amount of intrusion and overbite improvement varies with patient characteristics and treatment mechanics
Burgos-Lancero et al. (2025) reported a pooled maxillary molar intrusion of 1.70 mm (95% CI: 0.53–2.87 mm), although substantial heterogeneity was observed (I² = 88.5%). The review also suggested that light forces, segmented mechanics, and appropriate TAD positioning were associated with favorable treatment outcomes and fewer complications.
Orthognathic Surgery
Orthognathic surgery remains an established treatment option for severe skeletal AOB. Malara et al. (2021) compared outcomes achieved with skeletal anchorage and orthognathic surgery and concluded that successful correction can be achieved using molar intrusion supported by skeletal anchorage. However, the available evidence was insufficient to determine whether long-term outcomes are equivalent to those obtained with orthognathic surgery. Orthognathic surgery remains a treatment option for severe skeletal discrepancies; however, the included evidence does not establish its comparative long-term effectiveness or stability relative to skeletal anchorage.
Relapse and Long-Term Stability
Relapse remains a significant concern across all treatment modalities. Alam and Alayyash (2024) evaluated various relapse management strategies and found that skeletal anchorage-based approaches demonstrated favorable stability outcomes, whereas orofacial myofunctional therapy showed less consistent effectiveness. Interpretation of the reported relapse outcomes requires consideration of the intervention, comparator, definition of relapse, and follow-up duration.
Discussion
The management of anterior open bite (AOB) has undergone substantial evolution in recent decades, driven by the development of temporary anchorage devices (TADs), skeletal anchorage systems, and the increasing use of clear aligner therapy (CAT). The growing body of evidence from recent systematic reviews provides a clearer understanding of the effectiveness, indications, biomechanical mechanisms, and long-term stability associated with contemporary treatment modalities.
An important finding of the present umbrella review was the overlap among the included systematic reviews. The calculated CCA of 7.34% indicated a moderate degree of overlap, suggesting that several reviews relied on some of the same primary studies. This overlap should be considered when interpreting the findings, as repeated inclusion of the same studies does not provide independent confirmation of the evidence.
The included evidence comprised adult/non-growing, mixed-age, and incompletely characterized populations. Applicability to adult anterior open bite treatment should therefore be interpreted cautiously, particularly for skeletal outcomes that may be influenced by residual growth.
Clear aligner therapy has emerged as a patient-friendly option for the treatment of mild to moderate dental anterior open bites. The systematic reviews by Correa et al. (21) and Nshimiyimana et al. (25) consistently demonstrated overbite improvements ranging from approximately 2.7 to 3.5 mm. However, these corrections were achieved primarily through dentoalveolar changes, particularly controlled extrusion of the anterior teeth, with limited evidence of clinically significant molar intrusion or skeletal modification. Consequently, CAT may be less suitable for patients requiring vertical maxillary control, mandibular autorotation, or correction of pronounced skeletal discrepancies. Nevertheless, the aesthetic advantages, digital treatment planning, patient comfort, and growing clinical experience with aligner systems continue to support their use in appropriately selected cases.
In contrast, skeletal anchorage represents one of the most significant advances in the nonsurgical correction of anterior open bite. Multiple systematic reviews and meta-analyses, including those by Kwon et al. (23), González Espinosa et al. (22), Nshimiyimana et al. (25), Burgos-Lancero et al. (26), and Ugolini et al. (19), demonstrated that TAD-supported molar intrusion was associated with reported changes of approximately 1.7–2.2 mm of maxillary molar intrusion and 3–7 mm of overbite improvement. Importantly, these treatment effects are accompanied by measurable skeletal changes, including reductions in mandibular plane angle, decreases in lower anterior facial height, and counterclockwise mandibular autorotation. These findings suggest that posterior intrusion contributes to overbite correction through mandibular autorotation, although heterogeneity among studies limits the predictability of individual treatment outcomes.
Further support for these findings was provided by Steele et al. (27), who directly compared Invisalign treatment with miniplate-supported posterior intrusion in adult patients with anterior open bite. The authors reported significant molar intrusion, reduction in lower anterior facial height, and counterclockwise mandibular autorotation in the skeletal anchorage group, whereas Invisalign treatment achieved open-bite correction primarily through incisor extrusion with minimal skeletal effects. These observations reinforce the concept that skeletal anchorage and clear aligner therapy achieve open-bite correction through fundamentally different biomechanical mechanisms.
From a biomechanical perspective, posterior molar intrusion reduces dentoalveolar height and facilitates counterclockwise mandibular rotation, contributing not only to open-bite closure but also to improvements in facial proportions and vertical skeletal relationships. Palatally anchored systems provide an alternative anchorage location for posterior intrusi on; however, the included reviews do not establish that these systems offer greater predict ability or fewer adverse effects than other anchorage approaches. Contemporary protocols utilizing anterior palatal anchorage, such as the Mousetrap appliance and related skeletal anchorage systems, exemplify the growing trend toward efficient and minimally invasive alternatives for the treatment of skeletal open bite.
Despite favorable treatment outcomes, relapse remains a significant clinical concern. González Espinosa et al. (22) reported molar re-eruption corresponding to approximately 12% of the achieved maxillary intrusion and 27.2% of the achieved mandibular intrusion. These figures describe loss of the achieved intrusion rather than the percentage of patients with recurrent anterior open bite. These findings emphasize the importance of long-term retention protocols and continued follow-up after active treatment. Evidence summarized by Burgos-Lancero et al. (26) suggests that light and well-controlled intrusive forces, adequate retention strategies, and careful biomechanical planning contribute to greater treatment stability. Furthermore, persistent etiological factors such as tongue posture, abnormal swallowing patterns, and vertical growth tendencies may increase the risk of relapse and should therefore be addressed as part of comprehensive treatment planning.
Orthognathic surgery continues to represent the gold standard for the correction of severe skeletal anterior open bite, particularly in patients presenting with significant vertical maxillary excess or complex dentofacial deformities.
Surgical correction provides substantial skeletal changes and has demonstrated favorable long-term stability. However, the invasiveness, cost, morbidity, and patient acceptance associated with surgical treatment limit its applicability. Malara et al. (24) reported that successful open-bite correction can be achieved with skeletal anchorage-supported molar intrusion; however, the available evidence was insufficient to establish equivalence in long-term outcomes with orthognathic surgery.
Overall, the contemporary literature demonstrates a clear movement toward individualized and minimally invasive treatment strategies for anterior open bite correction. Clear aligner therapy appears most suitable for mild to moderate dental open bites, whereas skeletal anchorage systems provide the vertical control necessary for moderate to severe cases with skeletal involvement. The combination of effective biomechanics, careful patient selection, and long-term retention remains essential for achieving stable outcomes. Future research should focus on high-quality prospective studies with standardized outcome measures and extended follow-up periods to further clarify long-term stability, relapse patterns, and the comparative effectiveness of emerging treatment modalities.
Limitations
This umbrella review has several limitations that should be considered when interpreting the findings. First, only systematic reviews and meta-analyses published between 2020 and 2025 were included, which may have resulted in the exclusion of relevant earlier evidence. However, this time restriction was intentionally applied to focus on contemporary treatment approaches and emerging trends in anterior open bite management.
Second, substantial heterogeneity existed among the included reviews regarding patient populations, treatment protocols, outcome measures, and follow-up periods. Variations in the definitions of treatment success, stability, and relapse limited direct comparisons between studies. Furthermore, several reviews reported relatively short follow-up periods, restricting the assessment of long-term stability.
No outcome-level assessment of the certainty of evidence was performed in this umbrella review. AMSTAR-2 evaluates the methodological quality of systematic reviews and does not replace an assessment of certainty for individual clinical outcomes. This limits the strength of the conclusions and clinical recommendations.
Overlap of primary studies across reviews means that agreement between review findings cannot be regarded as independent confirmation of treatment effects. Nevertheless, additional high-quality prospective studies and long-term investigations are needed to further clarify treatment stability and relapse patterns. The AMSTAR-2 assessment was performed by the review authors and was not externally validated. Furthermore, no quantitative re-analysis of primary study data was performed.
Conclusion
Clinical decision-making in anterior open bite treatment has shifted toward individualized, minimally invasive approaches. Clear aligner therapy is effective for mild to moderate dental open bites, producing 2.7–3.5 mm of overbite improvement primarily through controlled incisor extrusion. Its limited skeletal impact, however, restricts its use in more severe cases.
Skeletal anchorage-supported treatment was associated with reported molar intrusion of approximately 1.7–2.2 mm and overbite improvement of 3–7 mm, with accompanying mandibular autorotation. However, heterogeneity among studies limits the predictability of individual outcomes. Post-treatment loss of correction was reported, and long-term equivalence with orthognathic surgery has not been established.
Orthognathic surgery remains a treatment option for severe skeletal anterior open bite. However, the included evidence does not establish which treatment modality provides the greatest long-term stability. Retention and follow-up remain important, although the present review cannot determine the most effective retention strategy.
Overall, the included reviews suggest that clear aligners and skeletal anchorage achieve anterior open bite correction through different dentoalveolar mechanisms. Treatment selection should consider the severity of the skeletal discrepancy, growth status, and the limitations of the available evidence. Future high-quality prospective studies with long-term follow-up are needed to further clarify treatment stability and optimize evidence-based clinical decision-making.
References