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2012. Published by Oxford University Press on behalf of the European Orthodontic Society.
doi:10.1093/ejo/cjs079 All rights reserved. For permissions, please email: journals.permissions@oup.com
Advance Access publication 28 November 2012
Correspondance to: Jan C. Danz, Klinik für Kieferorthopädie, Zahnmedizinische Kliniken der Universität Bern,
Freiburgstrasse 7, CH-3010 Bern, Switzerland. E-mail: jan.danz@zmk.unibe.ch.
SUMMARY The purpose of this long-term follow-up study was twofold—firstly, to assess prevalence of
relapse after treatment of deep bite malocclusion and secondly, to identify risk factors that predispose
patients with deep bite malocclusion to relapse. Sixty-one former patients with overbite more than 50%
incisor overlap before treatment were successfully recalled. Clinical data, morphometrical measurements
on plaster casts before treatment, after treatment and at long-term follow-up, as well as cephalometric
measurements before and after treatment were collected. The median follow-up period was 11.9 years.
Patients were treated by various treatment modalities, and the majority of patients received at least a
lower fixed retainer and an upper removable bite plate during retention. Relapse was defined as increase
in incisor overlap from below 50% after treatment to equal or more than 50% incisor overlap at long-term
follow-up. Ten per cent of the patients showed relapse to equal or larger than 50% incisor overlap, and
their amount of overbite increase was low. Among all cases with deep bite at follow-up, gingival contact
and palatal impingement were more prevalent in partially corrected noncompliant cases than in relapse
cases. In this sample, prevalence and amount of relapse were too low to identify risk factors of relapse.
Introduction
Treatment of deep bite malocclusion is recommended
Deep bite, by definition increased overbite, is measured in order to reduce or prevent tissue trauma from tooth
as vertical overlap of the incisors perpendicular to the contact (Bjørnaas et al., 1994), facilitate possible future
occlusal plane absolutely in mm, relatively in percent- reconstructive dental work and reduce increased tooth wear
age of incisor overlap or qualitatively by describing the (Ritchard et al., 1992; Silness et al., 1993). Reoccurrence
contact of the lower incisors to the upper arch or palate. of malocclusion years after the end of treatment may lead
Most commonly, deep bite can be divided into dento- to patients seeking retreatment or questioning the benefit
alveolar origin (overeruption of teeth) and skeletal origin of their initial therapy. Therefore the long-term stability
(decreased lower face height, low mandibular plane angle) seems to be more important than the final result itself.
(Nielsen, 1991). Relapse is a dento-alveolar and skeletal change after
Deep bite prevalence varies from 8.4 to 51.5%, depend- orthodontic treatment towards the initial malocclusion,
ing on the threshold values applied, ethnic group and gen- and it is often encountered even in ideally treated cases
der (Tausche et al., 2004; Proffit et al., 2007; Lux et al., (Crum and Andreasen, 1974). These changes are attributed
2009; Thilander and Myrberg, 1973). Prevalence of palatal to a physiologic reestablishment of force equilibrium
non-traumatic tooth contact and palatal impingement was (Proffit et al., 2007), periodontal remodeling (Picton and
reported to vary from 5.9 to 15.9% (Tausche et al., 2004; Moss, 1973; Crum and Andreasen, 1974; Ackerman and
Lux et al., 2009). Angle classification (Angle, 1899) has Proffit, 1997), growth or normal/abnormal development
been associated with vertical and/or cephalometric patterns. (Bergersen, 1988; Forsberg et al., 1991; Iseri and Solow,
Class II malocclusion was shown (Lux et al., 2009) to be 1996). The loss of about one-third of the orthodontic
significantly associated with increased overbite compared treatment result during 10 years of follow-up and consistent
with class I malocclusion. Class II Division 2, with a preva- relapse of all malocclusion characteristics were reported by
lence of 5.3%, a less frequent malocclusion (Ingervall et al., some authors (Al Yami et al., 1999). Therefore, stability
1978), may be associated with a deep bite (Brezniak et al., of orthodontic result is one of the biggest challenges in
2002). A correlation of increased overbite with retrusive orthodontics.
incisors in Angle class I malocclusions as well as in Angle Increase in overbite after completion of treatment is
class II Division 2 malocclusions was described in the lit- regarded as relapse for dental deep bite cases. Several
erature (Simons and Joondeph, 1973). authors have described deep bite malocclusions as relapse
STABILITY AND RELAPSE AFTER ORTHODONTIC TREATMENT OF DEEP BITE CASES 523
prone (Rönnerman and Larsson, 1981; Berg, 1983; Binda relapse of deep bite to develop hypotheses for a future pro-
et al., 1994). In a study of Berg (Berg, 1983), relapse spective clinical trial.
reduced treatment effect by 18.8% on average in 26
patients with deep bite malocclusion after 5–9 years out
of retention. Relapse of deep bite was reported 10 years Material & Methods
after treatment in 23 consecutive patients to almost pre- The sample of the present retrospective study consisted
treatment levels, although Hawley plates as retention of patients treated at the Department of Orthodontics and
devices were used in most of the patients (Rönnerman and Dentofacial Orthopedics, University of Bern, Switzerland.
Larsson, 1981). Lapatki et al. (2004) investigated a sample No standardized treatment or retention protocols were used
The initial aim was to divide the sample into a relapse and
a non-relapse group and to identify risk factors predicting
the relapse of deep bite using a logistic regression model as
Figure 1 Flow chart of patient selection according to inclusion and shown in Figure 2. The threshold value was defined at initi-
exclusion criteria. Inclusion criteria OB > 50% at T1 was applied twice. ation of the study according to the inclusion criteria as 50%
The first time with pencil and ruler in the archive and a second time with a
digital sliding caliper. Finally the remaining deep bite cases were assigned
upper incisor overlap. The outcome variable ‘upper incisor
to the relapse group and the stable group. overlap at T3’ would have been used to test the hypothe-
sis that ‘there is no difference between the relapse and the
non-relapse group’. Given the small number of patients in
Measurements on dental casts the relapse group, a comparison of the groups or a logis-
tic regression analysis was not feasible. Therefore, only
Measurements on T1-T3 plaster models were carried out
descriptive analysis is presented in this article.
by one investigator (C), using a fine tip digital caliper
(150 mm ISO 9001 electronic caliper, Tesa Technology, Error of the method
Renens, Switzerland). The following measurements were
made: maxillary and mandibular intercanine width, maxil- The intracluster correlation coefficient (ICC) was used in
lary and mandibular intermolar width between the central order to assess the method error and specifically intra-exam-
fossae, incisor overjet, upper incisor overlap (percentage iner agreement. The ICC was calculated for all the variables
of the lower incisor overlap by the upper incisor, measured measured on 20 randomly selected dental casts and 20 ran-
perpendicular to the occlusal plane). domly selected cephalometric radiographs using the Stata 12.1
statistical package (Stat Corp, College Station, TX, USA).
Statistical Analysis
Results
Descriptive statistics were performed at T1, T2, and T3.
Medians were preferred to the means because of the The ICC ranged for both dental casts and measurements
higher robustness against outliers with small sample ranged from 0.94 to 0.99, indicating very low measurement
numbers. error/excellent intra-rater agreement.
STABILITY AND RELAPSE AFTER ORTHODONTIC TREATMENT OF DEEP BITE CASES 525
The median age was 12.5 and 11.5 years at T1, 17.1 and prevalence and degree of deep bite relapse were relatively
16.7 years at T2, and 29.2 and 26.9 years at T3 for the relapse small and clinically insignificant.
and the non-relapse group, respectively. The median active The low prevalence and amount of relapse may be attrib-
treatment duration was 3.2 years in the relapse group and uted to the relatively high median age at T2 (17 years) of our
3.6 years in the non-relapse group, while the median long- sample (Iseri and Solow, 1996). While it is not scientifically
term follow-up period was 13.4 years (range 10.7 years to 16.5 proven by longitudinal superimpositions, it is plausible that
years) and 11.7 (range 9.5 to 16.4 years), respectively. The more remaining growth in addition with anterior growth rota-
median long-term follow-up period of all cases was 11.9 years tion (Björk and Skieller, 1983) and without retention would
(range 9.5 years to 16.5 years). Clinical data, cast analysis, and experience increased relapse. A recent study compared facial
Table 1 Descriptive analysis for clinical, dental cast and cephalometric measurements stratified by stable and relapse group.
Stable Relapse
Table 1 (Continued)
Stable Relapse
Differences in numbers (N) are due to missing permanent canines or missing lateral cephalograms.
Figure 3 Long-term stable case. Angle class II Division 2, skeletal Figure 4 Relapse case with biggest incisor overlap at T3. Angle class II
class II, deep bite with palatal impingement, skeletal hypodivergency, Division 1, skeletal class II, deep bite with gingival incisor contact, skel-
moderate space deficency in the lower arch (left column). Correction with etal hypodivergency, spacing in the upper front (left column). Treatment
functional appliance and headgear, Goshgarian, multibracket appliance with a removable plate with a frontal bite plateau and headgear. The patient
segmented arch technique with base arch, upper retention plate, dental rejected fixed treatment despite slightly increased overjet, spacing in the
incisor contact (middle column). 10 years long term follow-up (right upper front and missing incisor contact. No fixed retainers were used after
column). treatment (middle column). 10 years later relapse of incisor overlap is appar-
ent but now seemingly stable with frontal dental contact and no complaints.
528 J. C. DANZ ET AL.
n % n %
Conclusions
1. The prevalence of vertical relapse in moderate deep bite
cases after a median post-treatment follow-up of 11.9
years was low (10.3%, relapse group N = 4).
2. The median deepening of incisor overlap in the relapse
group at long-term follow-up (median 13.4 years) was low
(6.7%, with a range from 3.2 to 19.8%).
3. It was not possible to identify important factors to pre-
dict relapse of deep bite malocclusion as prevalence and
Figure 7 Adult case with long-term stability. Angle class II Division 2, the amount of relapses were too low with respect to the
skeletal class II, deep bite with palatal impingement, skeletal hypodiver- sample, sample size, outcome, and retention procedures.
gency, maxillary and mandibular frontal crowding. Decompensation with 4. Deep bite at long-term follow-up was more likely due to
multibracket appliance segmented arch technique, base arch and palatal
power arms, extraction of third molars, surgery (sagittal split osteotomy partial correction at T2 (OB > 50% at T3, OB > 50% at
and genioplasty), retention with upper and lower fixed retainers and reten- T2, N = 7) than due to relapse (OB > 50% T3, OB < 50%
tion plate (middle column). Excellent stability 11 years after treatment at T2, N = 4).
(right colum).
5. Among all cases with deep bite at T3, gingival contact
and palatal impingement were more prevalent in partially
corrected noncompliant cases than in relapse cases.
discontinued treatment or in whom treatment had to be
stopped have a higher prevalence of gingival contact or
palatal impingement at T3. On the other hand, it might be References
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