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Deep bite: Treatment options and challenges

Joseph G. Ghafari, DMD, Anthony T. Macari, DDS, MS, and


Ramzi V. Haddad, DDS, MS
While deep overbite typically accompanies all classes of malocclusion, it
is singled out in this article as the prominent component of malocclusion.
We review the evidence-based treatment of deep overbite, mostly of lower
tier on the evidence hierarchy. Accordingly, challenges to treatment emerge
with the lack of rm guidelines for treatment. The main concerns relate to
long-term stability and facial esthetics. Treatment options in children focus
on possibilities of growth modication and avoidance of more severe
development of the condition. Camouage, surgical options, and compromised outcome are considered in the non-growing patient. We illustrate the
various treatment strategies, including maxillary incisor esthetic differential
extrusion, along with the side effects that may occur and ways to avoid them.
The need for structured controlled trials and associated formulation of
guidelines is demonstrated. (Semin Orthod 2013; 19:253266.) & 2013
Elsevier Inc. All rights reserved.

Introduction
eep overbite refers to the increase of overlap
of maxillary incisors over mandibular incisors beyond the normally reported coverage of 30
40%.1 Although many practitioners refer to the
overbite in millimeters, the percentage computation is more revealing because of the variation in
the crown height of the mandibular incisors. Also,
the inclination of both maxillary and mandibular
incisors impacts the amount of overbite, which
would decrease when these teeth are proclined
and increase when the incisors are retroclined.
When the mandibular incisors impinge on the
maxillary palatal mucosa behind the maxillary
incisors, the deep bite is severe, regardless of the
amount of virtual coverage of the mandibular
incisors by their antimeres. In addition to the
functional problems they cause, very deep impinging overbites2 can jeopardize the maxillary palatal

Division of Orthodontics and Dentofacial Orthopedics, American


University of Beirut, Beirut, Lebanon; Lebanese University, Beirut,
Lebanon; New York University, New York, NY; University of
Pennsylvania, Philadelphia, PA.
Address correspondence to Ramzi V. Haddad, DDS, MS Division
of Orthodontics and Dentofacial Orthopedics, American University of
Beirut Medical Center, P.O. Box 11-0236, Riad El-Solh, Beirut 1107
2020, Lebanon. E-mail: rh52@aub.edu.lb
& 2013 Elsevier Inc. All rights reserved.
1073-8746/13/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2013.07.005

mucosa and can in extreme situations lead to the


loss of maxillary incisors.
Like open bite, deep overbite exists with the
various malocclusions (Class I, II, and III), but
severity is mostly associated with skeletal hypodivergence typically found in Class II, division 2.
Accordingly, skeletal and dentoalveolar characteristics include shortened anterior lower face
height, at mandibular plane angle, more acute
gonial angle, parallel upper and lower occlusal
planes, and deep curve of Spee in the mandibular arch.3
Clinical observations indicate that maxillary
molars tend to be infracluded when a skeletal
dysplasia is present, in contrast to the overeruption of the incisors in dental deep bites.
While targeted research is still needed in this
diagnostic area, Janson et al.4 demonstrated in
a study of molar and incisor vertical dimension in
12-year-old children with excess, normal, and
short lower anterior face height (LFH) that
(1) the dentoalveolar heights are signicantly
different between faces with excessive, normal,
and short LFH, except for the lower posterior
dental height, which did not differ between
subjects with short and normal LFH; and (2) the
maxillary teeth present a higher correlation to
the upper/lower face height ratio than the
mandibular teeth, a higher percentage of this
ratio (44%) being explained by the maxillary and

Seminars in Orthodontics, Vol 19, No 4 (December), 2013: pp 253266

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Ghafari et al

mandibular incisors than by the maxillary and


mandibular molars (22%).
The etiology of deep bites, at least when contrasting the Class II, division 2 with the long face
syndrome, may be attributed to heredity5 and
development, but unlike open bite, it has not been
related to pathologic factors (e.g., blocked airways
leading to mouth breathing). In this context, the
opposite phenotypes differ in how the environment affects them. While environmental factors
such as respiratory mode and habits have not been
incriminated in the genesis of hypodivergence,
the prevalence of dental anomalies (missing
teeth5 and delayed dental development3)
associated with Class II, division 2 adds support,
albeit nonconclusive, to the concert of more
genetic control of this malocclusion. From this
perspective, treatment of deep bite may not
depend on intercepting the etiology as much as
avoiding the worsening of the condition during its
development. Nevertheless, the musculature
associated with mandibular function (masseter
and medial pterygoid) has been shown to have
different characteristics in hypodivergent versus
hyperdivergent facial patterns.6,7
The aim of this article is to review the
evidence-based treatment of deep overbite and
demonstrate that while challenges to orthodontic
treatment, mainly stability and esthetics, may lead
to compromises, problems exist even within
orthognathic therapy of this vertical dysplasia
that may also dictate less than ideal results. We do
not display the variety of options vastly described
in the literature, rather we focus on basic treatment principles.

State of evidence on treatment of deep


bite
Management of deep bite becomes more difcult with the existence of, or the increased
severity of, an underlying skeletal discrepancy
(hypodivergent skeletal pattern). Despite the
extensive amount of published articles, most of
the associated research remains at the lower tier
of the evidence scale, and this review reects the
variability of that level, highlighting the need for
further investigation.
Nonsurgical correction of a deep bite includes
molar extrusion, incisor intrusion, or a combination of both,8 with a general understanding
from the cumulative literature that intrusion

of teeth is more difcult to achieve than


extrusion.
(1) In growing patients, strategies can be employed
for deep bite correction that are not available
in adults: the extrusion of the buccal segments
can be compensated for by the vertical ramal
growth.9,10 Also, relative intrusion of incisors is
achieved, holding them in place while the
other teeth and the face are developing.
(2) Correction of a deep overbite in the late
mixed or early permanent dentition apparently is stable when compared to untreated
controls.11 However, deep bite correction in
the mixed dentition followed up into
retention of phase 2 treatment was mainly
due to a signicant proclination of the
incisors.12
(3) Treatment of deep bite at puberty in the
permanent dentition leads to signicantly
more favorable outcomes than treatment
before puberty in the mixed dentition.13
(4) The extrusion of the buccal segments in nongrowing patients will rotate the mandible in
a clockwise (backward) direction that might be
undesirable when the patient already presents
a hyperdivergent facial pattern. Such topography actually occurs more often than expected
reaching a ratio of 40%.14 In these instances,
labial tipping of the incisors, if indicated, can
simulate a decrease in overbite.1517
(5) Intrusion of incisors is not properly documented because frequent cephalographs,
needed for superimpositions, are not permitted by research review boards. Proclination of
incisors and extrusion of molars may be
misinterpreted as true intrusion in the absence
of convincing radiographic proof.8,1821
Intrusion without proclination can be
achieved by the application of intrusive
forces close to the center of resistance.22,23
(6) Intrusion constitutes a major risk for root
resorption, as much of the mechanical load is
applied on the apex.24,25
(7) While the range of intrusion is variable,
intrusion is more successful (potentially
more predictable) with the use of temporary
anchorage devices or osseointegrated
implants with no counteractive movements
in the molars.23,26
(8) Information on treatment and stability of
correction of Class II, division 2 are based on

Potential and Limitations of Vertical Correction

highly biased evidence27; however, guidelines for treatment are drawn on current
evidence until further research provides
more generalizable results.
(9) Randomized clinical trials (RCT) are needed
to understand the biological and mechanical
outcomes of intrusion, its optimal application with respect to function, periodontium
and esthetics, and whether intrusion mechanics produce a more stable overbite correction than other methods of leveling.
However, RCTs are difcult to conduct for
ethical, administrative, and nancial reasons.27

Treatment options
Mechanical considerations
Three main orthodontic mechanics constitute
the basis to correct a deep anterior overbite:
intrusion of the incisors, extrusion of posterior
teeth, and proclination of incisors. These
modalities are indicated separately or in combination depending on the diagnostic component
analysis. We discuss them briey with differentiation of their application in growing and
non-growing patients.

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Intrusion of incisors
In patients with deep bite and a normal or increased
lower facial height, the indication of intrusion of
maxillary and/or mandibular incisors encompasses
the following conditions: excessive distance between
the incisal edge (incision) and stomion, large
interlabial gap, and more occlusal level of central
incisors relative to lateral incisors. However, the
upper lip line during smile is a critical factor in
determining whether the maxillary incisors should
be intruded, rather than the molar teeth needing
extrusion. The lip line may actually intersect the
maxillary incisors, which paradoxically would need
to be extruded for better smile esthetics, while the
deep bite may otherwise dictate intrusion.
The intrusive force should be exerted through
the center of resistance of the incisors to avoid
their proclination.28 Different methods have
been developed to intrude incisors, basically
classied in continuous arches (Fig. 1) or
segmental techniques. Continuous arches
(usually including increased curves of Spee
and/or selective vertical steps) have been
described to result in molar extrusion29 and
incisor buccal tipping.30 Segmental techniques
include Ricketts' utility arch, Burstone's intrusive

Figure 1. (A) Front occlusal photograph of adult patient who had Class II, division 2 malocclusion with
supracluded maxillary central incisors. (B) Intrusive archwire anchored in the permanent rst molars resulted in
intrusion of the central incisors (note change in cervical level of central versus lateral incisors and in amount of
overbite).

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Ghafari et al

arch, and variations thereof.31 To minimize side


effects, the archwire is prevented from moving
forward and proclining the incisors by tying the
wire back. Adjunct appliances are used to control
molar extrusion, such as high-pull headgear,
against the permanent rst molars and larger
anchor units (e.g., palatal bar between right and
left posterior teeth).32,33 Buttressing posterior
anchorage is particularly required when a tendency to skeletal vertical hyperdivergence is
associated with the dentoalveolar deep bite.34
All types of advocated mechanics apply tip
back bends at the level of the molars to generate
the intrusive forces.3538 The methods differ with
the wire size and material, method of attachment
to the brackets, force amounts, and the inclusion
of torque within the force system.
The most important factors in the selection of
intrusive mechanics are the determination of
side effects and the adherence to the appropriate
physical principles (forces relative to centers of
resistance, computed moments, and controlled
anchorage). Rocking chair nickel-titanium
wires with pronounced curves of Spee have
been promoted as a means of reducing overbite
simultaneously by molar extrusion and incisor
intrusion. Because the wires are exible, they also
offer the prospect of full bracket engagement
early in the course of treatment.
Also advocated to intrude the maxillary incisors are high-pull headgears (e.g., J-hook headgear), which may be associated with heavier
forces than normal. Heavy forces increase the
risk of root resorption on the maxillary incisors,
which are actually more prone to this side
effect.39

Extrusion of posterior teeth


This movement is the most common method to
correct deep overbite, with 1-mm extrusion of
maxillary or mandibular posterior teeth effectively reducing the incisor overlap by 1.52.5 mm.
This modality is indicated in patients with a short
lower facial height, excessive curve of Spee, and
incisor display upon smiling ranging from normal to minimal.
Strategies employed to effect the extrusion
include the following:
(1) Altering bracket heights by placing the
anterior brackets at a more occlusal level.

(2)

(3)

(4)

(5)

However, this discrepancy is often adjusted


toward the end of treatment to line up the
marginal ridges.
Leveling the dental arches (essentially attening the curve of Spee) by using sequentially stronger archwires, and often reversing
the curve of Spee in the mandibular arch and
exaggerating it in the maxillary arch (at the
extreme, they resemble a rocking chair).
Including posterior teeth (second molars) in
the xed assembly, and when possible in the
initial arch leveling.
Increasing step bends progressively to the
occlusal level, from incisors, canines, premolars, to molars. These bends are mainly
indicated when the anterior and posterior
occlusal planes are at different levels, with a
minimal to moderate incisor display. Their use
must be controlled at times with anterior bite
plates to facilitate movement, but also minimize the expected slight intrusion of incisors.
Anterior bite plates. They may be removable
(Fig. 2) or xed. Their effect is mainly on the
mandibular arch, as they facilitate leveling of
the mandibular curve of Spee. They are very
effective in growing patients. When used along
xed appliances, particularly in the mandibular arch, the leveling is maintained with
stiffer wires. When used in conjunction with
posterior vertical elastics worn between maxillary and mandibular posterior teeth, these are
extruded faster. Patient compliance is critical
with removable appliances, whereby alternative xed devices have been designed for
non-cooperative patient particularly.
The xed auxiliaries40 include composite
platforms placed freehand or bite turbos
(prefabricated bracket-like platforms) bonded
on the palatal surfaces of maxillary incisors to
separate the posterior teeth (Fig. 2F). These
methods may interfere with speech and
comfortable chewing at rst, but patients
tend to adjust after a few days. They are
only useful when the overjet is not increased and the patient cannot bite posterior
to the xed bite plane, limiting their extension to approximately 34 mm in anteroposterior depth.
Platforms may be cemented or bonded on
selective posterior teeth (e.g., starting with
second molars) until the teeth anterior to the
covered teeth are extruded, usually with vertical

Potential and Limitations of Vertical Correction

257

Figure 2. (A and B) Pretreatment extraoral and intraoral photographs. Note severe depth of overbite, despite normal
lower face height. The lip line during smile underscores indication for extrusion of posterior teeth. (C) In the rst step,
only the maxillary arch and mandibular posterior teeth were banded/bonded. An anterior bite plate disoccluded the
posterior teeth while vertical elastics helped extrude the mandibular teeth, which were joined with segmental archwires.
(D and E) Posttreatment smile and occlusal photographs. (F) Another alternative of bite opening by extrusion of
posterior teeth: the bite plate is provided through platforms bonded on the palatal surfaces of the maxillary incisors.
Elatics between the maxillary and mandibular posterior teeth facilitate their extrusion.

elastics alone or together with vertical bends.


When the extruded teeth touch, the platforms
are removed and their supporting teeth in turn
extruded. Anchorage is reduced in the arch
where the teeth are intended to be extruded
(e.g., lighter wires are usedsee differential
extrusion in Section Esthetic considerations).
(6) When indicated, Class II elastics help extrude
mandibular molars, but may also extrude the
maxillary anterior teeth, requiring the inclusion of forces and moments to counteract this
side effect (e.g., increased maxillary curve of
Spee). While this control is needed, the
topography of the maxillary-mandibular relations is such that 1 mm of molar extrusion still
yields more bite opening even if accompanied
by 1 mm of incisor extrusion.

Proclination of incisors
The proclination of maxillary and mandibular
incisors decreases the amount of overbite,41 and
unlike the previous two options, it occurs as a side

effect of treatment. If indicated to remedy the


overbite, it should be part of a predetermined
treatment plan. Indications include malocclusion
with lingually tipped incisors, such as Class II,
division 2 or Class III.

Considerations in growing individuals


Most hypodivergent patterns at the age of 6 years
(58%) remain at 15 years of age42; yet 36% shift
closer to normal divergence and (unexpectedly)
4% to hyperdivergence. These results indicate
that a hypodivergent pattern persists through the
growth spurt in most subjects, but the data also
suggest that the capacity for some traits to change
is greater during childhood than adolescence.
Accordingly, early treatment should be contemplated while the malocclusion is developing.
Treatment usually aims at enhancing the
eruption of the posterior teeth, while maintaining the height of the incisors, especially if an
underlying skeletal hypodivergence exists. A
removable appliance with an anterior bite plate

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Ghafari et al

Figure 3. (AC) Pretreatment intraoral photographs of a 9-year-old girl. Note severe depth of overbite and severe
overjet. Imprint of mandibular incisors on palatal mucosa because of impinging incisors. (D and E) Frontal and
lateral view of maxillary removable retainer with anterior bite plate disocclusing the posterior teeth to allow their
eruption. Note hooks on labial bow used by the patient to stretch elastics for retraction of maxillary incisors and
overjet reduction. (F) Occlusal view illustrates amount of retraction of incisors in one month, between the prior
anterior position of the labial bow and the facial surfaces of the incisors. The acrylic touching the incisors was cut to
allow their retraction. (G) Frontal occlusal view at the end of early treatment (phase 1). The retainer was worn
subsequently for retention.

can achieve this objective (Fig. 3). The correction


of dentoalveolar deep bite increases the overjet,
demonstrating that an occlusal problem is not
limited to one plane of space. Retraction of the
incisors to reduce the overjet may be accomplished with the same appliance by stretching
elastics against those teeth.
Fixed appliances can be used to accomplish
the same objectives. Partial banding/bonding of

permanent rst molars and incisors is sufcient,


with the appropriate anchorage considerations,
as an intrusive arch will also promote extrusion
of the molars. True intrusion is difcult to achieve and is not as easily attainable as extrusion.
However, in a growing individual, stabilization of
the incisors is considered a relative intrusion
since their vertical movement is impeded relative
to the other teeth.43 Retention of an early

Potential and Limitations of Vertical Correction

259

Figure 4. (A) Pretreatment lateral cephalograph of a 23-year-old man with severe Class II, division 2 malocclusion
with severe hypodivergent pattern (nearly parallel maxillary and mandibular planes), characteristically reduced
lower face height relative to total face height (LFH/TFH: 48%), pouting lips, and deep mental sulcus. (B)
Following orthognathic surgery that involved downfracture of the maxilla, mandibular advancement, and vertical
augmentation genioplasty, the LFH/TFH is nearly normal (54%) and facial esthetics greatly improved.

overbite correction is necessary, usually with a


bite plate incorporated in the removable retainer
worn at night, especially if the problem is
associated with a skeletal hypodivergence.

Considerations in non-growing patients


With limited growth left in post-adolescence
spurt and practically none in adulthood, more
emphasis is assigned to adjunct orthognathic
surgery in the malocclusions with severe skeletal
dysplasias. Often such surgery requires mandibular advancement, but when the maxilla is
hypoplastic with reduced dentoalveolar heights,
maxillary downward movement is indicated, a
displacement that warrants special consideration
for long-term stability (Fig. 4). Proft et al.44 rank
this movement in the bottom third (one of the
lowest problematic) on the scale of stability and
predictability of the various surgical methods.
Obviously, the concept of camouage may be
applied, denoting an acceptable normalization of
occlusal relations with favorable esthetic results
both in the alignment of the teeth within the
arches and their environment (chin, lips, and
nose). While this principle often implies extraction
of teeth (usually premolars) in the context of the
correction of overjet or open bite, it would tilt more
often to nonextraction in the correction of the
deep bite (Fig. 5), mainly for mechanical reasons to
avoid worsening the deep bite. This realization

does not completely negate the possibility of


opening the bite under circumstances requiring
extraction (e.g., crowding).
The option for compromised results, with
minimal intervention for a specic target must be
properly weighed, particularly when an extensive
intervention involving the entire dentition would
likely lead to lengthy treatment, reduced esthetics, serious side effects (periodontal loss and
root resorption), or orthognathic surgery that
the patient originally rejected (Fig. 6).

Esthetic considerations
Although the increase in lower face height concomitant with bite opening is usually an esthetic
advantage in the treatment of deep overbite,
particularly when associated with skeletal hypodivergence, other esthetic considerations are
warranted. The most critical concerns relate to the
upper lip line in relation to the maxillary incisors
and the depth of the mental sulcus in relation to
the mandibular incisors.
Often, and particularly in association with a
decreased lower face height and in males, the
intrusion of incisors would be contraindicated
because of a low lip line during smile. In these
instances, the upper lip tends to be longer than
average, but this detail must be corroborated with
further research. In a growing child, appliances
may be used to favor extrusion of posterior teeth

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Ghafari et al

Figure 5. (AD) Pretreatment extraoral, intraoral, and cephalometric records of a 14-year, 8-month-old girl
demonstrate a typical Class II, division 2 malocclusion associated with facial convexity, decreased lower face height,
and retrognathic mandible but adequate chin form. (EH) Posttreatment records show successful resolution of the
malocclusion to neutroclusion with normal overjet and overbite, and improved prole and smile esthetics. While
only surgery would have ameliorated the chin to nose relationship, this feature is the main compromise in the
outcome, although the combination of mechanics and growth contributed to a more forward relation and
competence of the lower lip with upper lip.

and prevent the vertical position of the maxillary


incisors to be depressed. In adolescents and
adults, a viable approach is what we term Maxillary
Incisors Esthetic Differential Extrusion (MIEDE).
The method consists of disarticulating the posterior teeth to extrude them, forcing a separation
of the anterior maxillary and mandibular incisors
(Fig. 7). Afterwards, the maxillary incisors are
extruded. The process may be repeated until an
appropriate lip line to maxillary incisors
relationship is attained. Differential archwires
are used in this process, whereby a heavier
archwire is used in the anchoring arch and a
lighter one in the active quadrants. Bite elevation may be achieved with a removable (or
xed) bite plate and vertical elastics stretched
between the posterior teeth. Posterior xed
sequential platforms may be used to extrude

the posterior teeth, such as described in Section


Extrusion of posterior teeth. Sustained retention
is applied with an anterior bite plate worn at night.
The sagittal relationship between the jaws is
critical because bite opening increases the overjet.
Optimal results may be achieved if retroclination of
the maxillary incisors is recommended to remedy
this side effect. However, if the upper lip is in its
proper position and the only remaining orthodontic alternative is to procline the mandibular
incisors to bridge the overbite, deepening of the
mental sulcus may represent an esthetic compromise, assuming that the proclination of the lower
lip secondary to tooth proclination is acceptable.
Expectations in treatment of deep bite must
be realistic, as it is unlikely that a hypodivergent
pattern with a square face would be drastically
altered, much like a convex face with mandibular

Potential and Limitations of Vertical Correction

261

Figure 6. (AD) Pretreatment extraoral, cephalometric, and intraoral records of 21-year, 2-month-old woman
illustrating severe Class II malocclusion with impinging overbite. The severe convexity, mandibular retrognathism
and microgenia, proclination of incisors, and reduced lower face height required orthognathic surgery for optimal
esthetic and functional outcome. The patient rejected surgery and orthodontic alternatives would not produce
optimal outcome: distal movement of maxillary teeth would worsen overjet and facial convexity, and extraction of
maxillary and/or mandibular premolars would encounter difcult mechanics given the original bite depth and
hypodivergence. (E and F) A minimal compromised approach targeted the crowding of the maxillary anterior
teeth with xed appliances ending at the canines. A combination of minor enamel stripping to reduce tooth width
and attening the anterior arch curve while maintaining the original overbite answered the patient's chief
complaint of crowding.

retrognathism associated with Class II malocclusion would not look orthognathic despite the
correction to neutroclusion. Only surgery might
be expected to minimize the original phenotype.

Depending on the diagnostic features, the


clinician may end up selecting a compromise
alternative plan to the ideal approach in the
following ways:

Treatment challenges

 Addressing limited objectives to resolve a

Potential limitations in treatment outcome relate


to treatment planning, whether a specic plan is
actually achievable, or to treatment methods, in
essence technical and mechanical limitations.

specic patient complaint, reduce treatment


time, or avoid surgery (Fig. 6). In the latter
consideration, full treatment would disclose a
worse malocclusion that can only be resolved
through orthognathic surgery.

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Ghafari et al

Figure 7. Maxillary Incisors Esthetic Differential Extrusion (MIEDE) of maxillary incisors. The treatment rationale
is to change the cant of the maxillary occlusal plane by rotating it down anteriorly (A). The vertical dimesion is
increased by extrusion of the posterior segments using an anterior bite plate to disocclude the posterior teeth (B)
and maximizing their extrusion with vertical elastics stretched between the maxillary and mandibular molars and
premolars (C). The inclusion of second molars and rst premolars in elastic wear depends on the individual
situation. This movement is facilitated by using a very light wire in the mandibular arch (e.g., stainless steel 0.014 in
or nitinol 0.016 in). The effect of posterior extrusion is anterior bite opening (D), which allows the use of anterior
vertical elastics to extrude the maxillary incisors. To obtain this extrusion, anchorage is switched to the mandibular
arch by using a heavier rectangular archwire or 2 round wires (e.g., 0.018 0.014 in or 0.016 0.016 in) and a
lighter wire (e.g., SS 0.014 in or 0.016 in) in the maxillary arch. To avoid incisor retroclination during extrusion,
arch length is maintained through stops bent mesial to the rst premolars (not necessarily rst molars). The lighter
the wire, the more these stops are needed. Additional extrusion of the anterior teeth is obtained through a stepdown of the maxillary incisors in the archwire (E), when indicated. (F) Initial photograph of the patient whose
treatment is shown in (A)(E). (G) Increased appearance of incisors after their extrusion. (H and I) Initial and
progress smile photographs of another patient who had the MIEDE applied.

 Giving more weight to esthetic considerations




and awareness, sometimes at the expense of


evidence available for occlusal stability.
Minimizing the side effects of treatment such
as root resorption, periodontal complications,
or temporomandibular joint dysfunction.

While most of these choices might be patient


driven, certain limitations are necessary for more
objective reasons: the nature of the occlusion
(missing teeth and mutilated dentition),

compromised dental health (existing restorations/severe caries and root resorption), and
mechanical limitations (difcult space closure,
especially extraction spaces, and resistance to
intrusionmainly in adults).
Compliance is obviously a primary component
of success, particularly in children required to
wear a headgear, a functional appliance,
removable bite plates, or elastics. Growth direction and amount are also dening factors for
treatment success in children.

Potential and Limitations of Vertical Correction

The long-lasting challenge of deep overbite


correction is the stability of tooth movements,
particularly posterior teeth extrusion in severe
hypodivergent facies with hyperactive musculature. In a 10-year postretention study of deep
bite correction, Simon and Joondeph45 reported that proclination of mandibular incisors
and a clockwise rotation of the occlusal plane
during treatment were signicant relapse
factors. Binda et al.46 found the relapse of
overbite correction of Class II, division 2 to be
only at about 20% at 2-year postretention; this
percentage doubled at 15-year follow-up. The
authors further indicated that with large individual variations, the tendency for maxillary
incisor relapse was greater than that of the
molar correction. On the other hand, Burzin
and Nanda47 reported that the intrusion of
maxillary incisors was stable at long-term; their
results showing that an average incisor intrusion
of 2.3 mm relapsed an insignicant average
amount of 0.15 mm up to 2 years after treatment. The issue of stability remains controversial. In addition to variations in orthodontic
mechanics, variables such as amount of growth,
muscle strength, muscle adaptation, and the
original malocclusion are factors contributing
to the long-term stability, which require further
research.

Discussion
Research issues and challenges
Confounding the study of deep overbite is the
usual coexistence of a sagittal component
(mainly Class II), which may qualify the malocclusion as tting the study of the sagittal problem
more than the vertical problem. In this perspective, it may be useful in research to assign
severity scores to the malocclusion components
in each dimension and to classify predominantly
vertical malocclusions when the relative vertical
severity score is greater than the grades in the
other dimensions (sagittal and transverse).
Ideally, randomized clinical trials should be
conducted, but we suggest that even deep bite
phenotypes may not be grouped together simply
on the overlap between anterior teeth and
should at least be differentiated on the basis of
presence or absence of maxillary and mandibular
vertical skeletal hypoplasia. In its simplest form,

263

treatment of deep bite may be the strategy to


overcome vertical hypoplasia as the expression of
various etiologic and developmental factors, and
then retain it with the possible persistence of
these factors.
The evidence on amount of intrusion of
incisors versus extrusion of molars is difcult to
gauge because cephalometric records are scarce
and are often forbidden just for the purpose of
immediate post-intrusion evaluation. Long-term
post-treatment records often include additional
variables that mask the exclusive effect of the
intrusion mechanics. A meta-analysis48 aimed at
quantifying the amount of true incisor intrusion
determined on cephalometric superimpositions
yielded only four studies that met the inclusion
criteria. While true incisor intrusion is achievable
in both arches, the clinical signicance of the
magnitude of true intrusion as the sole treatment
option was questionable for patients with severe
deep bite. In non-growing patients, the segmented arch technique can produce 1.5 mm of
incisor intrusion in the maxillary arch and
1.9 mm in the mandibular arch.48
Tooth extrusion reects a basic form of tissue
engineering,49 facilitating bone formation and
corresponding movement of the periodontal
attachment apparatus. The biological changes
following intrusion are not as clearly dened,
which is again probably because intrusion is more
difcult to achieve, and as an orthopedic
movement, it aims at resorbing bone in a
direction (up or down) more restrained than
in other movements (e.g., mesial and distal)
where bone resorption occurs. Both animal and
clinical research22,50 has shown that intrusion of
incisors is possible with a controlled force system,
even in reduced periodontium, but is variable
(03.5 mm in adults22). Much work is required to
gauge the predictability of the movement under
various clinical conditions.
Research has not fully explored the overbite
malocclusion with attention to its variable components. The basic tenet remains that when
indicated, intrusion and/or proclination of
maxillary anterior teeth and extrusion of the
posterior teeth are applied and often maximized
to obtain a more optimal occlusion. Commensurate facial esthetics and long-term stability,
understandably connected with the original
severity of the problem, also require targeted
investigation. In this endeavor, the consideration

264

Ghafari et al

of deep bite as the biologic opposite of open bite


is a misguided conception, much like the thought
that Class III is the opposite of Class II. The
extreme poles reect totally different phenotypes
with differing etiologies, with research indicating
that more genetic components may be at play in
the deep bite (mainly Class II, division 2)5 and
Class III mandibular prognathism,51 while more
environmental factors would participate in the
evolution of open bite and distoclusion.

Guidelines for stability


Based on present evidence, a number of clinical
guidelines may be derived to foster stability:
(1) Treat a developing deep overbite early,
probably as soon as a worsening growth
pattern is recognized. The strategy is to
eliminate any known etiology and maintain
the bite open. In a Class II, division 2
malocclusion, the severe retroclination of
maxillary incisors would be addressed in a
timely manner consistent with the development of the roots to avoid dilacerations.
(2) Avoid extraction of premolars, particularly in
very deep bites, given the potential for
deepening of overbite, reopening of extraction spaces, and detrimental effects on facial
esthetics (upper lip retrusion and increased
nasolabial angle, particularly with thin upper
lip).27,52 Such side effects would favor nonextraction or if necessary extraction of more
posterior teeth (such as second molar and
distalization of teeth or second premolar and
minor retraction of the teeth mesial to it).
(3) Long-term retention, particularly if maxillary
incisor inclination has been compromised:
retroclined in the maxilla and proclined in
the mandible. The latter may lead to later
crowding without prolonged retention.27
(4) Enhance sustainability of the correction with the
mode of retention, such as the use of a bite plate
at least at night (particularly in growing patients)
to keep the molars elevated and the incisors at
the corrected height and inclination.27,53

Conclusion
While the centerpiece of this analysis is the deep
overbite, the skeletal components around it vary
in a myriad of arrangements, ranging from the
severe hypodivergent pattern with diminished

lower face height to even the high-angle skeletal pattern. Esthetic and mechanical considerations obviously vary in a parallel way,
disclosing potential for improvement but also
with many challenges, the most potent of which
are the stability of results in the severe malocclusions, and favorable facial esthetics. Often the
achievement of the latter requires long-term
retention. Existing protocols for treatment follow more generic than individual guidelines,
progressing to surgical considerations with
increased severity of an underlying hypodivergence. Most of the available publications
remain at the lower tier of the evidence scale, and
research at the various levels is indicated.

References
1. Moorrees CFA, Gron AM, Lebret LM, et al: Growth
studies of the dentition: a review. Am J Orthod 55:600616, 1963
2. Nasry HA, Barclay SC: Periodontal lesions associated with
deep traumatic overbite. Br Dent J 200:557-561, 2006
3. Ghafari J, Street KW: Dental development in children
with Class II, division 2 malocclusionFour types of the
malocclusion dened In: Davidovitch Z, Mah J eds.
Biological Mechanisms of Tooth Eruption, Resorption,
and Replacement by Implants. Boston, The Harvard
Society for the Advancement of Orthodontics 1998,
pp 8589-8596
4. Janson GR, Metaxas A, Woodside DG: Variation in
maxillary and mandibular molar and incisor vertical
dimension in 12-year-old subjects with excess, normal,
and short lower anterior face height. Am J Orthod
Dentofacial Orthop 106:409-418, 1994
5. Hartseld JK Jr.: Genetics and orthodontics In: Graber
LW, Vanarsdall RL, Vig KWL eds. Orthodontics: Current
Principles and Techniques 5th ed. St Louis, Elsevier
Mosby, 2011, pp 139-156
6. Al-Farra ET, Vandenborne K, Swift A, et al: Magnetic
resonance spectroscopy of the masseter muscle in
different facial morphological patterns. Am J Orthod
Dentofacial Orthop 120:427-434, 2001
7. Boom HP, Spronsen PH, Ginkel FC, et al: A comparison
of human jaw muscle cross-sectional area and volume in
long- and short-face subjects, using MRI. Arch Oral Biol
53:273-281, 2008
8. Parker CD, Nanda RS, Currier GF: Skeletal and dental
changes associated with the treatment of deep bite
malocclusion. Am J Orthod Dentofacial Orthop
107:382-393, 1995
9. Sankey WL, Buschang PH, English J, et al: Early treatment of vertical skeletal dysplasia: the hyperdivergent
phenotype. Am J Orthod Dentofacial Orthop 118:317327, 2000
10. Otto R, Anholm J, Engel G: A comparative analysis of
intrusion of incisor teeth achieved in adults and children

Potential and Limitations of Vertical Correction

11.

12.

13.

14.

15.

16.

17.
18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

according to facial type. Am J Orthod Dentofacial Orthop


77:437-446, 1980
Al-Buraiki H, Sadowsky C, Schneider B: The effectiveness
and long-term stability of overbite correction with incisor
intrusion mechanics. Am J Orthod Dentofacial Orthop
127:47-55, 2005
Franchi L, Baccetti T, Giuntini V, Masucci C, Vangelisti A,
Defraia E: Outcomes of two-phase orthodontic treatment
of deepbite malocclusions. Angle Orthod 81:945-952,
2011
Baccetti T, Franchi L, Giuntini V, Masucci C, Vangelisti A,
Defraia E: Early vs late orthodontic treatment of deepbite: a prospective clinical trial in growing subjects. Am J
Orthod Dentofacial Orthop 142:75-82, 2012
Betzenberger D, Ruf S, Pancherz H: The compensatory
mechanism in high-angle malocclusions: a comparison of
subjects in the mixed and permanent dentition. Angle
Orthod 69:27-32, 1999
Harrison JE, Shaw WC, Worthington HV, et al: Orthodontic treatment for prominent lower front teeth in
children. Cochrane Database Syst Rev: 18 [CD003452],
2007
Kim YH: Anterior openbite malocclusion: nature, diagnosis and treatment by means of multiloop edgewise
archwire technique. Angle Orthod 57:290-321, 1987
Worms F, Meskin LH, Isaacson RJ: Open bite. Am J
Orthod 59:589-595, 1971
Weiland FJ, Bantleon HP, Droschl H: Evaluation of
continuous arch and segmented arch leveling techniques
in adult patientsa clinical study. Am J Orthod Dentofacial Orthop 110:647-652, 1996
Hans M, Kishiyama C: Cephalometric evaluation of two
treatment strategies for deep overbite correction. Angle
Orthod 64:265-276, 1994
Noroozi H, Moeinzad H: Extrusion-based leveling with
segmented arch mechanics. Int J Adult Orthodon
Orthognath Surg 17:47-49, 2002
Van Steenbergen E, Burstone CJ, Prahl-Andersen B, et al:
The relation between the point of force application and
aring of the anterior segment. Angle Orthod 75:730735, 2005
Melsen B, Agerbaek N, Markenstam G: Intrusion of
incisors in adult patients with marginal bone loss. Am J
Orthod Dentofacial Orthop 96:232-241, 1989
Polat-zsoy , Arman-zrpc A, Vezirolu F, etinahin A: Comparison of the intrusive effects of miniscrews
and utility arches. Am J Orthod Dentofacial Orthop
139:526-532, 2011
McFadden WM, Engstrom C, Engstrom H, et al: A study
of the relationship between incisor intrusion and root
shortening. Am J Orthod Dentofacial Orthop 96:390-396,
1989
Upadhyay M, Yadav S, Nagaraj K, Patil S: Treatment
effects of mini-implants for en-masse retraction of
anterior teeth in bialveolar dental protrusion patients:
a randomized controlled trial. Am J Orthod Dentofacial
Orthop 134:18-29.e1, 2008
Ohnishi H, Yagi T, Yasuda Y, et al: A mini-implant for
orthodontic anchorage in a deep overbite case. Angle
Orthod 75:444-452, 2005
Millett DT, Cunningham SJ, O'Brien KD, et al: Treatment
and stability of Class II division 2 malocclusion in children

28.

29.
30.

31.

32.

33.

34.

35.

36.
37.

38.
39.

40.

41.

42.

43.

44.

45.
46.

265

and adolescents: a systematic review. Am J Orthod


Dentofacial Orthop 142:159-169, 2012
van Steenbergen E, Burstone CJ, Prahl-Andersen B, et al:
The relation between the point of force application and
aring of the anterior segment. Angle Orthod 75:730735, 2005
Cangialosi T: Skeletal morphologic features of anterior
open bite. Am J Orthod 85:28-36, 1984
Chang Y, Moon S: Cephalometric evaluation of the
anterior open bite treatment. Am J Orthod Dentofacial
Orthop 115:29-38, 1999
Cozza P, Mucedero M, Baccetti T, et al: Early orthodontic
treatment of skeletal open-bite malocclusion: a systematic
review. Angle Orthod 75:707-713, 2005
Kikuchi M, Higurashi N, Miyazaki S, et al: Facial pattern
categories of sleep breathing-disordered children using
Ricketts analysis. Psychiatry Clin Neurosci 56:329-330,
2002
Beane R: Nonsurgical management of the anterior open
bite: a review of the options. Semin Orthod 5:275-283,
1999
Burstone CJ, van Steenbergen E, Hanley KJ: Deep
overbite correction In: Burstone CJ eds. Modern Edgewise Mechanics. Glendora, California, Ormco Corp,
1995, pp 33-48
Shroff B, Yoon WM, Lindauer SJ, et al: Simultaneous
intrusion and retraction using a three-piece base arch.
Angle Orthod 67:455-461, 1997
Begg PR, Kesling PC: The differential force method of
orthodontic treatment. Am J Orthod 71:1-39, 1977
Ricketts RM, Bench RW, Hilgers JJ: Mandibular utility
arch. The basic arch in the light progressive technique.
Proc Found Orthod Res 120-125, 1972
Greig DG: Bioprogressive therapy: overbite reduction
with the lower utility arch. Br J Orthod 10:214-216, 1983
Ghafari J: Root resorption associated with orthognathic
surgery: modied denitions of the resorptive process In:
Davidovitch Z eds. Biological Mechanisms of Tooth
Eruption, Resorption, and Replacement by Implants.
Boston, Harvard Society for the Advancement of Orthodontics, 1995, pp 545-556
Dahl BL, Krogstad O, Karlsen K: An alternative treatment
in cases with advanced localized attrition. J Oral Rehabil
2:209-214, 1975
Ball JV, Hunt NP: The effect of Andresen, Harvold, and
Begg treatment on overbite and molar eruption. Eur J
Orthod 13:53-58, 1991
Buschang PH, Sankey W, English JP: Early treatment of
hyperdivergent open-bite malocclusions. Semin Orthod
8:130-140, 2002
Hering K, Ruf S, Pancherz H: Orthodontic treatment of
openbite and deepbite high-angle malocclusions. Angle
Orthod 69:470-477, 1999
Proft WR, Turvey TA, Phillips C: The hierarchy of
stability and predictability in orthognathic surgery with
rigid xation: an update and extension. Head Face Med
3:21, 2007
Simon M, Joondeph D: Changes in overbite. A ten years
post-retention study. Am J Orthod 64:349-367, 1973
Binda SK, Kuijpers-Jagtman AM, Maertens JK, et al: A
long-term cephalometric evaluation of treated Class II
division 2 malocclusions. Eur J Orthod 16:301-308, 1994

266

Ghafari et al

47. Burzin J, Nanda R: The stability of deep overbite


correction In: Nanda R, Burstone CJ eds. Retention
and Stability in Orthodontics. Philadelphia, Pa, W.B.
Saunders Co, 1993, pp 61-79
48. Ng J, Major P, Heo G, et al: True incisor intrusion
attained during orthodontic treatment: a systematic
review and meta-analysis. Am J Orthod Dentofacial
Orthop 128:212-219, 2005
49. Ghafari JG: Preprosthetic orthodontic tooth eruption In:
Baba NZ eds. Contemporary Restoration of Endodontically Treated Teeth: Evidenced Based Diagnosis and
Treatment Planning. Chicago, Quintessence Publishing
Co, 2012, pp 115-126

50. Melsen B, Agerbaek N, Eriksen J, et al: New attachment


through periodontal treatment and orthodontic intrusion. Am J Orthod Dentofacial Orthop 94:104-116, 1988
51. Ghafari J, Haddad R, Saadeh M: Evidence-based treatment of Class III malocclusion In: Huang G, Richmond S,
Vig K eds. Evidence-based Orthodontics. Wiley-Blackwell;
2011, pp 247-280
52. Stellzig A, Basdra EK, Kube C, Komposch G: Extraction
therapy in patients with Class II/2 malocclusion. J Orofac
Orthop 60:39-52, 1999
53. Devreese H, De Pauw G, Van Maele G, et al: Stability of
upper incisor inclination changes in Class II division 2
patients. Eur J Orthod 29:314-320, 2007