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Contents lists available at ScienceDirect

Seminars in Orthodontics
journal homepage:

A three-dimensional perspective on Brodie Bite’s diagnosis, planning,

treatment alternatives, and complications
Carol Weinstein a, Miguel Hirschhaut b, Patricia Vergara c, Angelica de la Hoz Chois d,
Carlos Flores-Mir e,f,*
a
Private practice limited to Orthodontics in Santiago de Chile, Chile
b
Universidad Central de Venezuela, Caracas, Venezuela
c
Private practice limited to Orthodontics in Cartagena, Colombia
d
Private practice limited to Orthodontics in Barranquilla, Colombia
e
Graduate Orthodontic Program, Department of Dentistry, University of Alberta, Edmonton, Canada
f
Part-time Private Practice limited to Orthodontics, Edmonton, Alberta, Canada

A R T I C L E I N F O A B S T R A C T

Keywords: This narrative review describes the different diagnostic, prognostic, management aspects and complications of the
Brodie bite Brodie Bite. A current literature review was completed to identify relevant case reports, case series, and reviews
Three-dimensional approach about the Brodie Bite. Brodie Bite cases, fortunately, are not frequent. A checklist for this malocclusion is pre-
TADS
sented. Additionally, a description of the advantages of an early diagnosis will be discussed to avoid its progres-
Fixed and functional appliances
Disocclusion
sion to a more complex clinical scenario. The importance of solving the Brodie Bite before correcting any other
simultaneous malocclusion problem is stressed. Emphasis is given on a three-dimensional diagnosis and planning.
Different management mechanics are presented - ranging from TADS to fixed and functional appliances. Alterna-
tive disocclusion methods are also discussed. It is noted that some cases benefit from a combined surgical ortho-
dontic correction. Finally, periodontal issues and difficulties are addressed.

Introduction in a forward-centred position to evaluate arch coordination, resulting

Scissor bite, a buccal crossbite, is an uncommon malocclusion
affecting between 1.0 % to 1.5 % of the population.1−3 Brodie first
described it in 1952.4 He defined this malocclusion as a “Brodie
bite” or “Brodie syndrome” when the mandibular teeth are partially
or wholly contained within the maxillary arch.5 Clinically, it is por-
trayed by the buccal surfaces of the lower posterior teeth being in
contact with the palatal surfaces of the upper posterior teeth, with
no adequate cusps-fissures contacts.6
The Brodie Bite is caused, seen from the frontal plane, by a transverse
occlusal discrepancy. A vertical component is also usually involved,
which is more pronounced the more severe the Brodie Bite. The sagittal
plane will mostly be an aggravating condition. The more sagittal (ante-
roposterior) the skeletal relationship, the greater the tendency and
severity of the Brodie Bite. Suppose a sagittal correction is required
because of an increased overjet. In that case, studying digital or plaster
models in a corrected anteroposterior position will enable a more accu-
rate assessment of the Brodie Bite. This is important because what may
appear to be a buccal crossbite may disappear when checking the casts
in a normal transverse relationship once the sagittal discrepancy is
corrected.
This malocclusion can occur in a skeletal presentation due to exces-
sive maxillary width, mandibular constriction, or a combination of both.
In a dentoalveolar depiction, it is characterized by abnormal buccolin-
gual inclinations of posterior teeth.6,7 Proper measurements to arrive at
an adequate diagnosis are the orientation of the alveolar processes at
the canine, premolar and molar levels. To attain that clinical evaluation,
study models, photographs, stereophotogrammetry, and 2D/3D radio-
graphic analysis allow us to differentiate between the skeletal and den-
toalveolar etiology of the Brodie Bite.8,9 The shape of the palatal vault
and the mid-palatal raphe should be examined as part of the diagnosis.8
The curves of Spee, Wilson, and occlusal canting must also be considered
since the vertical plane is compromised. When linked to skeletal imbal-
ances, it can be accompanied by different degrees of facial asymmetry.
Dentoalveolar compensations, which can occur both in the transverse
and vertical planes, should be considered.8 The Brodie Bite can also be
associated with other malocclusions such as mandibular rotation or lat-
eral shift, an occlusal plane and facial asymmetry inclination, deep

* Corresponding author at: Division of Orthodontics, Department of Dentistry, University of Alberta, College of Health Sciences. Faculty of Medicine and Dentistry. 5-
528 Edmonton Clinic Health Academy. Edmonton, AB, Canada, T6G 1C2
E-mail address: cf1@ualberta.ca (C. Flores-Mir).

https://doi.org/10.1053/j.sodo.2023.12.008

1073-8746/© 2023 Elsevier Inc. All rights reserved.

Please cite this article as: C. Weinstein et al., A three-dimensional perspective on Brodie Bite’s diagnosis, planning, treatment alternatives, and
complications, Seminars in Orthodontics (2023), https://doi.org/10.1053/j.sodo.2023.12.008
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C. Weinstein et al.
Fig. 1. A. Unilateral Brodie Bite shows asymmetric malocclusion. B. Bilateral
Brodie Bite shows symmetric malocclusion.
anterior and posterior bite, and unilateral chewing contralateral to the
scissor bite.10
Its etiology can be attributed to genetic factors and functional or
muscular imbalances. Fig. 1 shows that the Brodie Bite can be unilateral,
characterized by a flat and asymmetric palatal vault and often a cant to
the occlusal plane and lateral deviation or bilateral, where the palatal
vault is flat but symmetric, and the mandible may be functionally ret-
ruded.5 As the development of this malocclusion has yet to be fully
understood, its prevention and management are quite challenging.5 A
late diagnosis of Brodie Bite can increase treatment difficulty and, there-
fore, affect the prognosis.
As soon as a buccal crossbite is consolidated, its developmental effect
may cause important sequelae such as deep bite, overeruption of the
maxillary segment, lingually inclined mandibular posterior segments,
occlusal plane cant, asymmetry, limited lateral excursions, temporoman-
dibular disorder, growth interference, and periodontal problems.3 Adap-
tive remodeling of the temporomandibular joints can promote
asymmetrical mandibular growth, with less condyle and ramus height
on the scissor-bite side than on the opposite side. Efficient mastication is
impossible when the mandibular arch is telescoped within the maxillary
arch, and lateral excursive movements may be limited, potentially lead-
ing to temporomandibular dysfunction.10
If the problem is of dentoalveolar origin, without a severe skeletal
asymmetry, maxillary constriction plates, intermaxillary cross elastics,
"dragon helix appliance", and functional appliances have been sug-
gested.4 Temporary skeletal anchorage devices (TADs) are a valuable
option for treating transverse discrepancies since they avoid undesirable
secondary effects of anchorage teeth.11 The bilateral form is likely easier
to treat than the unilateral as most transversal-acting appliances are
bilateral, making applying forces only unilaterally challenging.12 Never-
theless, normal bone development can be resumed in patients with
growth potential when the transverse buccal crossbite is corrected.11
Brodie Bite development
During the eruption process of permanent teeth, sometimes one
tooth emerges into the oral cavity with an inadequate transverse inclina-
tion. Its etiology is attributed to heredity, lack of space or a muscular
imbalance. Such eruption direction can incorrectly guide teeth on the
other arch exacerbating the problem or a mandibular lateral shift to the
opposite side as a proprioceptive reaction of the occlusion to avoid a
strong premature contact. Consequently, the upper palatal cusps glide
gradually along the buccal lower cusps. This is explained by the fact that
these two surfaces have a very subtle curvature, and the movement does
not have a natural anatomical stop. Along with this displacement, extru-
sion of teeth occurs, generating an occlusal plane compromise. The
neighbouring teeth may also enter the cycle, which is how premolars
and second molars are progressively affected, increasing the number of
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teeth involved in this malocclusion.3 Although it might initially be a
transverse discrepancy with the fault in the maxilla or the mandible or
in both jaws, it becomes a vertical problem because the unopposed teeth
in each arch over-erupt, creating a situation in which the elongated pos-
terior teeth need to be intruded several millimetres and repositioned
laterally.12
Severity and timing of diagnosis
The demands for correcting severe buccal crossbites warrant early
intervention as soon as the malocclusion is identified. Buccal crossbites
are a developmental malocclusion that worsens with time.3 A typical
scenario is a buccal ectopic eruption of the maxillary molar at about age
6 years. Initially, the Brodie Bite mainly develops as a single tooth prob-
lem; however, if it remains untreated and eruption occurs, the neigh-
bouring teeth will be compromised. They will erupt similarly to the
affected segment.2 Additional functional problems might increase the
severity. An untreated unilateral Brodie Bite malocclusion will progres-
sively shift towards a more stable position with bilateral tooth contacts.
Potential effects on the health of the temporomandibular joints have
been reported. Although the crossbite might not cause pathosis, compro-
mised mastication could eventually lead to temporomandibular dysfunc-
tion.12 This abnormal pattern may produce a functional shift of the
mandible, resulting in the rest of the buccal segment erupting in a buccal
crossbite during the late transitional stage of dental development (10-12
years).5 Figs. 2 and 3 show two examples of single premolar scissor bites.
One was identified during the eruption of permanent teeth, and the
other when the full permanent dentition erupted. These two scenarios
represent the simplest version of this malocclusion.
The scissor bite does not self-correct and progressively worsens.
Simultaneously, these malposed teeth gradually migrate in the trans-
verse and vertical planes. Vertically, migrations will take place until
upper and lower teeth reach contact. Maxillary teeth continue to erupt
in excess and occlude on the buccal surfaces of the mandibular posterior
teeth (as noted earlier). Occlusion causes tipping of maxillary posterior
teeth buccally and mandibular posterior teeth lingually due to muscular
forces when chewing in this more comfortable position. If this condition
persists, mandibular posterior teeth can become completely tipped lin-
gually, and the alveolar bone may be severely affected.13 Therefore,
early detection of the Brodie Bite is very important since, most likely,
the anteroposterior extension of the problem is limited, as well as the
vertical alterations. Fig. 4 shows a 2-year period between the initial eval-
uation and when parents were willing to treat the malocclusion. An
increase in the vertical overlap of the upper right molar can be seen.
Clinical observations have determined that extrusion is found in low per-
centages of the cases that range between 5 and 20 % of the vertical
height of posterior teeth when the scissor bite is identified early. As the
patient ages, the vertical component increases as the extrusion can be
presented in as much as a 100 to 120 % overlap compared to the ideal
original vertical position.
It is important to note that the Brodie Bite often does not affect the
patient’s anterior aesthetics. For this reason, it can stay undiagnosed
until late in development,11 causing an untimely referral to the ortho-
dontist. The chief complaint may appear later and can be related to diffi-
culty chewing.2,5,10,14−16 Some patients are aware of facial asymmetry
and canting of the occlusal plane but are not concerned by those prob-
lems. They are mostly worried about impaired occlusion due to a poste-
rior scissor bite.11
Vertical component
One of the difficulties of Brodie Bite diagnosis is that part of the mal-
occlusion is hidden since, in important vertical migrations, the upper
arch extrusion generally hides the lower arch partially or completely.
Therefore, the degree of compromise of the mandible cannot be evalu-
ated sometimes. This explains why the upper arch is frequently blamed
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Fig. 2. Single premolar scissor bite identified during the eruption of permanent
teeth.
as the main cause of the problem. Today we know that by clinical obser-
vation of the gingival margins. We can determine how much each arch
is affected and ultimately dictate the treatment mechanics for each case.
Fig. 5 shows a scenario, in which each arch must be evaluated separately
with enough mouth opening to visualize the upper and lower teeth
completely. Three different vertical scenarios can occur. The first sce-
nario is the upper arch extrusion with relative normal levelling of the
lower arch. A second scenario will present a relatively levelled upper
arch with an extruded lower arch. Finally, both upper and lower arches
can be vertically over-erupted.
Transverse component
The maxillary arch width will determine the extent and speed at
which the vertical problem develops. If the dentoalveolar bone is in a
more buccal position, occlusion has a lower chance of naturally restrain-
ing the vertical migration of the segment involved in the Brodie Bite.
The wider the maxilla to the mandible, the higher the chance of develop-
ing a buccal crossbite with an important overlap percentage. The degree
of tooth buccal inclination is another aggravating factor. The greater the
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Fig. 3. Single premolar Brodie bite identified in full permanent dentition.
buccal tipping in the maxillary arch and lingual tipping in the mandibu-
lar arch, chances of extrusion are greater.Therefore, the severity of the
Brodie Bite will increase.
The Brodie Bite can also appear after rapid palatal expansion. Fre-
quently narrow deficient maxilla has buccally tipped upper first perma-
nent molars and lingualized lower first and second molars, especially in
the absence of clinical crossbites, as a dental compensation to the trans-
verse skeletal deficiency. When palatal expansion is done, an iatrogenic
Brodie Bite can easily develop because of the mentioned abnormal tor-
que in the molars. In these cases, compression mechanics need to be
applied to the upper posterior teeth and uprighting of lingualized lower
posterior teeth needs to be made.
Fig. 6 shows a bilateral Brodie Bite was developed after expansion,
more severe on the right than on the left side. Aligners were used to
decompensate the lower arch and correct buccal upper tipping.
Anterior ramps, lingual to the incisors, were used to disoclude the
molars. The buccal crossbite was corrected during the first stage of
treatment in nine months. Fig. 7 shows a failed skeletal expansion is
shown. Only the right side expanded. A unilateral Brodie Bite devel-
oped consequently.
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Fig. 4. A. Initial evaluation. B. 2 years later, when parents were willing to treat
the malocclusion. An increase in the vertical overlap of the upper right molar
can be seen.
Predisposing conditions
The Brodie Bite may be related to a Class II skeletal malocclusion.16
When all the teeth are involved in a Brodie Bite, the condition usually
results from a retrognathic mandible and is often related to what has
been defined as the Brodie’s Syndrome.11 A unilateral Brodie Bite can
inhibit mandibular advancement, contributing to an increasingly retro-
gnathic mandible.12 The more retrusive a mandible is, the narrower,
more anterior part of the lower arch will relate or coordinate with a
wider part of the upper arch favoring the development of a Brodie Bite.
Fig. 8 shows a patient presented with a skeletal surgical Class II with
mandibular asymmetry characterized by a right scissor bite. Occasion-
ally, when the anteroposterior correction is made, once the models are
brought into occlusion, a “False Brodie Bite” is evidenced. During
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Fig. 5. Case with significant vertical migration of the dentoalveolar segments.
Maxillary overgrowth almost completely hides the lower teeth.
adolescence, a nighttime splint was used for retention purposes to avoid
extrusion, dental compensations, canting of the occlusal plane and man-
dibular shift. At the same time, the patient finished active growth, which
would add difficulties to the future orthognathic surgery procedure.
Congenitally missing teeth may facilitate the development of a Bro-
die Bite. A case with two missing lower incisors allowed migrations of
posterior teeth that shifted the lower arch mesially, and the lower left
posterior teeth tipped lingually. Transverse interarch relationships
changed as sagittal interarch relationships were modified. Customized
mechanics began with maxillary arch constriction and mandibular pos-
terior segments uprighting. It was continued with intermaxillary elastics
and stainless-steel rectangular wires, which were used to upright the
lower left molars and eliminate the unilateral scissor bite. Finally, extru-
sion of the lower molars reduced the overbite and increased the lower
facial height.10
Macroesthetics vs. microesthetics
A clinical evaluation involves an extraoral as well as an intraoral
exam. The macroesthetics analysis during a facial exam occasionally
provides some diagnostic information when evaluating facial symmetry
and muscular development. Occlusal plane canting and asymmetric
smile are the most noticeable characteristics. However, sometimes, the
Brodie Bite stays unnoticed extraorally. The unilateral expression of a
Brodie Bite has a higher chance of facial esthetics involvement than the
bilateral form, where the face stays symmetric.
Fig. 6. A. Bilateral Brodie Bite was developed after expansion,
more severe on the right than on the left side. B. Aligners were
used to decompensate the lower arch and correct buccal upper
tipping. Anterior ramps, lingual to the incisors, were used to
disoclude the molars. C. The buccal crossbite was corrected
during the first stage of treatment in nine months.
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Fig. 9 shows a patient was diagnosed early with a skeletal Class II
facial pattern with bilateral buccal crossbites. Clear aligner treatment
was chosen to correct the malocclusion. A symmetrical midline was
noted. After six months into treatment, the Brodie Bite was corrected.
The patient’s arch form and alignment were improved, even though the
skeletal problem was left for a later surgical correction once growth was
finished.
The microesthetic evaluation generally provides more information
on this syndrome. Some anatomical factors such as dental midline evalu-
ation, leveling of the gingival margins, and buccal/lingual tipping will
help diagnose this malocclusion and determine which arch is more com-
promised and the treatment strategy to be used. Identifying functional
mandibular shifts also provides important diagnostic information in the
transverse plane since it influences facial asymmetry.5,11 A typical uni-
lateral Brodie Bite description will include canting of the occlusal plane
down on the affected side and a mandibular deviation to the opposite
side on closure resulting in a degree of dental midline shift.5 Fig. 10
shows a diagrammatic representation presents a normal scenario and
changes a unilateral Brodie Bite generates.
Fig. 8. A. patient presented with a right scissor bite B. Skeletal Class II with
mandibular asymmetry. C. A “False Brodie Bite” is evidenced when an antero-
posterior correction is made by bringing the models into occlusion. D. A night-
time splint was used during adolescence for retention purposes to avoid
extrusion, dental compensations, canting of the occlusal plane and mandibular
shift, while the patient waits for a surgical correction.
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Fig. 7. A. Initial records. B. Failed skeletal expansion. Only the
right side expanded. A unilateral Brodie Bite developed conse-
quently.
Assessment and checklist
With the purpose of doing a complete evaluation of the different
variations of Brodie Bites and affected segments, the use of a Brodie
Bite Checklist is suggested in this article for extraoral, intraoral,
functional, and radiographic characteristics. The aspects of the clini-
cal exam that can be affected in a unilateral Brodie Bite are listed in
Table 1 & Fig. 11. As noted, the facial exam in many patients does
not suggest this malocclusion. This checklist covers the transverse
and vertical planes of space during the intraoral exam. Dental mid-
line relationships and inclinations must be recorded in the trans-
verse plane. Occlusal-gingival tooth positions must be observed
vertically. By looking at the gingival shape and contour, a
Fig. 9. A. Patient was diagnosed early with a skeletal Class II facial pattern with
bilateral buccal crossbites and symmetrical midlines. B. Clear aligner treatment
was chosen to correct the malocclusion. C. The Brodie Bite was corrected in six
months. Arch form and alignment improved. The skeletal correction was left for
a later surgical procedure.
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Fig. 11. Diagram of extraoral and characteristics of a right Brodie Bite.

in the radiographic exam. In the panoramic radiographic film, since

Fig. 10. A. Diagram of a normal scenario with centered midlines, leveled occlu-
sal plane and arch coordination. B. Representation of a right unilateral Brodie
Bite generates, aside from the buccal crossbite, canting of the occlusal plane and
midline deviation to the normal side.
periodontal assessment of the situation in the frontal plane helps
identify the most affected arch. The functional component is regis-
tered by diagnosing the mandibular deviation and joint and mastica-
tory issues. The condylar size and articular spaces must be observed
Table 1
Brodie Bite Checklist noting extraoral, intraoral, functional, and radiographic
characteristics to be considered. (Modified from J Clin Orthod MS 23193
accepted for publication)
Extraoral
it is taken with a bite-raising ramp in the front, the Brodie side will
appear with less interocclusal space than the non-Brodie side due to
the overeruption of teeth. At the same time, a normal occlusal vertical
relationship on the non-affected side explains the fact that the distance
of mandibular teeth will be closer to the mandibular border.
Figs. 12−15 show an interesting case is presented to showcase the
use of this tool. The clinical analysis of this treatment followed the
guidelines presented in the checklist. The patient came in with a left uni-
lateral Brodie Bite. The extraoral picture presents a slightly noticeable
occlusal cant at the level of the upper canines, higher on the right side.
In the intraoral exam, the gingival margins were vertically affected on
the Brodie Bite side. Both upper and lower teeth were extruded, and the
gingival margins were, therefore, at a more occlusal level than the
neighbouring teeth. Extrusion is evidenced in the panoramic film show-
ing a smaller interocclusal space on the Brodie Bite side. In the trans-
verse plane, upper teeth were inclined buccally and lower teeth

Normal Side Brodie Side

Chin Deviation
Asymmetric Smile: Higher Asymmetric Smile: Lower Commissure
Commissure

Intraoral

Normal Side Brodie Side

Lower Midline Deviation Upper Midline Deviation

Vertical Plane: Leveled
Leveled alveolar bone
Leveled gingival contours
Less gingival display
Transverse plane: Normal
inclinations
Functional Analysis
Normal Side
Normal position
Upper midline deviation due to
accommodating position
Upper Extrusion (Greater display generates
canting of occlusal plane)
Lower Extrusion (Hidden lower teeth)
Extruded maxillary and mandibular alveolar
process
More occlusal maxillary and mandibular gingi-
val contours
Greater gingival display
Upper buccal inclination
Lower lingual inclination
Brodie Side
Anterior joint displacement
Premature contacts
Chewing difficulty

Radiographic Analysis

Normal Side Brodie Side

TMJ Images
Normal condylar size
Reduced posterior joint space
Panoramic Film
Wider interocclusal space
Apices closer to mandibular
border
Larger condyle in case of hyperplasia
Even joint spaces of forward condylar position
Chewing difficulty
Narrower interocclusal space (extrusion)
Fig. 12. Patient with a left unilateral Brodie Bite. The extraoral picture presents
Apices distant from mandibular border
a slightly noticeable occlusal cant at the level of the upper canines, higher on the
right side.

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Fig. 13. A. Initial lateral right and left intraoral images. B. Gingival contours
were traced to visualize their vertical migration on the Brodie bite side. Both
upper and lower teeth were extruded, and therefore the gingival margins are at
a more occlusal level compared to the contralateral teeth.
Fig. 14. A. Initial occlusal upper and lower intraoral images. B. Gingival con-
tours were traced in green to visualize the non-affected arch form. Blue arrows
represent upper buccal and lower lingual inclinations in the transverse plane.
Fig. 15. A. Initial panoramic film taken routinely with upper and lower teeth
separated. B. Teeth and interocclusal space tracing shows teeth are extruded.
There is a smaller interocclusal space on the Brodie bite side.
lingually. The scissor bite was corrected with TADS and occlusal ramps
on the non-affected side. A single central upper TAD was used in the pal-
ate for transverse and vertical correction of the left upper molars. In the
mandible, an interradicular TAD was used with the same objective. The
Brodie Bite correction was accomplished in 6 months. To achieve the
complete solution of the case, lower teeth were controlled from incisor
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Fig. 16. A. Occlusal views of treatment mechanics with TADS and occlusal
ramps on the non-affected side. B. Diagram (courtesy of Dr. Viviane Tinoco) rep-
resents a single central upper TAD used in the palate for transverse and vertical
correction of the left upper molars. In the mandible, an interradicular TAD was
used with the same objective.
protrusion with buccal shelf TADs. Lower space was opened with coils
to restore a congenitally missing lower incisor. This was the third ortho-
dontic treatment for the patient, and a lower premolar had been previ-
ously removed. A decision was made to reopen the space with nitinol
coils as well. Figs. 16−20 show the finished case with a well-balanced
face, centered midlines, and a transverse and vertical correction of the
Brodie Bite. The patient was referred to the restorative dentist for lower
implant placement.
Transverse analysis available approaches
From the frontal view, information can be acquired from transverse
cuts from a cone-beam computed tomography reconstruction. The trans-
verse meausurements from Tamburino et al. can be helpful.17,18 In this
appraisal, the maxillary transverse measurement at the level of the fur-
cation of the first permanent molar should be 5mm wider compared to
the lower first permanent molar measurement at the Wala ridge. If a
skeletal transverse Brodie Bite discrepancy is present, it will most likely
reveal an augmented maxillary width greater than 5 mm. This exam
helps differentiate dentoalveolar compensations from the presence of a
skeletal component. Fig. 21 shows a case where the lower distance mea-
surement is 54 mm. The expected upper measurement should be
59 mm, but the patient measurement was 64 mm. A skeletal maxillary
transverse excess in width of 5 mm is present.
Andrews’s element III analysis is a clinical transverse skeletal usefull
measurement.19 The distance from palatal cusps of the upper first per-
manent molars is supposed to be equivalent to the distance between the
central fossae of the lower first permanent molars considering an opti-
mum axial inclination. In the lower arch, the lingual inclination needs to
be determined by measuring the distance between the central fossa of
the right and left lower first permanent molars. In a second step the
Fig. 17. Lower teeth were controlled from incisor protrusion with buccal shelf
TADs to achieve the complete solution of the case. Implants were treatment
planned for reconstruction of the congenitally missing lower incisor and previ-
ously extracted premolar.
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Fig. 19. A. Before and B. after extraoral views with centred midlines and cant
correction of occlusal planes.
Fig. 20. A. Before and B. after lateral intraoral views with the Brodie bite solved
and cant correction of occlusal planes.
Fig. 21. Transverse analysis with cone beam CT. The lower distance measures
54 mm. The expected upper measurement should have been 59 mm, but the
actual measurement was 64 mm. A skeletal maxillary transverse excess of 5 mm
was identified. (previously published in J Clin Orthod MS 23193 accepted for
publication − reproduction authorized by J Clin Orthod editor).
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Fig. 18. The finished case shows Brodie bite correction, cen-
tered midlines, leveled occlusal planes and spaces for future
restorative work.
measurement must be corrected if tooth inclinations are not ideal. This
is done by measuring the horizontal distance of a vertical imaginary line
at the Wala ridge to the FA point in the crown of the lower first perma-
nent molars. A lower first permanent molar with normal inclination will
be separated 2 mm lingual to this vertical reference. Depending on the
severity, the lower first permanent molars on the Brodie side are
expected to be lingually inclined with values greater than 2 mm. If a
molar is inclined -4 mm from FA point to the imaginary vertical line.
Then 2 mm should be added to the original measurement since this is
the amount of molar uprighting required. Upper first permanent molars
are usually inclined buccally in a Brodie Bite with an increased trans-
verse dimension. The correction is to narrow the upper arch, by inclining
the maxillary molars in a palatal direction. The amount of mm of move-
ment of the affected palatal cusp needs to be subtracted from the initial
distance between the right and left palatal cusps of the maxillary first
permanent molars. The final difference between the upper and lower
corrected measurements will provide the skeletal transverse diagnosis.
In Fig. 22, Andrew’s transverse appraisalof element III revealed a
maxillary excess of 4,5 mm. The lower first permanent molars on the left
side were lingually inclined, a torque correction of 2 mm to the buccal
was planned. In the maxillary molars, a correction of 2 mm towards the
palate was made for the upper arch measurement. In summary, the ini-
tial measurement in the maxilla from palatal cusp to palatal cusp was
46 mm. After the correction of the left molar, it became 44 mm. In the
mandibular arch, the fossa-to-fossa measurement was 37.5 mm. After
correcting the lower first left permanent molars, the measurement
should increase to 39.5 mm. Therefor, a difference of 44 -
39.5 = 4.5 mm. of maxillary transverse excess was determined.
Management alternatives
Three different diagnostic possibilities for upper positions and two
mandibular scenarios will determine treatment mechanics. The simplest
upper situation is the bodily extrusion of the Brodie side. A second sce-
nario includes extrusion and buccal inclination. A third situation
includes the affected segments’ upper extrusion and lingual crown incli-
nation. The lower arch will always present lingual inclination. The sim-
plest scenario is pure lingual inclination, while the more complex
scenario has both lingual inclination as well as extrusion of mandibular
teeth. These two situations will match the three different maxillary sce-
narios. Table 2 summarizes proposed management alternatives in the lit-
erature.
Biomechanical considerations
A non-surgical approach is feasible when the problem is caused
mainly by buccolingual tipping of the dentition rather than an underly-
ing skeletal problem. The plan includes mandibular arch expansion
through molar uprighting and maxillary arch constriction through molar
decompensation.12 In some cases, orthognathic surgery or functional
appliances can be used depending on the patient’s discrepancy and
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Fig. 22. Andrew’s transverse analysis of element III. On the Brodie side, a torque correction of 2 mm. to the buccal of the lower molars was considered. Therefore, the
initial fossa-to-fossa measurement increases from 37.5 mm to 39.5 mm. A torque correction of 2 mm towards the palate was made in the upper arch. So, the initial mea-
surement from the palatal cusp to the palatal cusp decreases from 46 mm. to 44 mm. Hence, a difference of 44 - 39.5 = 4.5 mm. of maxillary transverse excess was
determined. (previously published in J Clin Orthod MS 23193 accepted for publication − reproduction authorized by J Clin Orthod editor).

Table 2
Summary of proposed Brodie Bite management alternatives depicted in the literature.

Author Journal Article Type Dentition Disocclusion Technique Advantage Disadvantage /

Shortcomes

King et al. AJODO, April 2004 Case Report Permanent A full-coverage maxillary Midsymphyseal osteotomy Full correction Surgery was required
splint and mandibular distraction achived. with the extra cost
osteogenesis. and morbidity
involving surgery.
Yun et al. AJODO, December Case Report Permanent Was achieved through Fixed appliances with finger Non-surgical conserva- Method for single
2007 molar intrusion with the spring using indirect tive treatment with tooth or two teeth.
spring. anchorage from a minis- excellent occlusal The cost of the tad
crew. results. and fabrication of
screw.
Imada et al. Journal of Cranioman- Case Report Primary Upper fixed constriction None Conservative early None noted.
dibular Practice, orthodontic appliance approach. Allowing
April 2008 reduced his upper dental normalization of
arch width. A lingual growth.
arch appliance with a
finger spring was placed
to expand his lower den-
tal arch laterally.
Chugh et al. AJODO, May, 2010 Case Report Permanent A maxillary removable 0.40” expanded arch in round Non-surgical conserva- Required use of High-
plate. tubes in lower molar tive approach pull headgear and
bands. Combined with crosselastics.
crossbite elastics. Using a
high pull headgear as
anchorage.
Jung. AJODO, April 2011. Case Report Permanent Posterior biteblock. Upper molar intrusion against Non-surgical conserva- Facial profile convex
upper buccal and palatal tive option. after treatment.
tads. Lower molar upright-
ing against vestibular inter-
radicular tads.
Park et al. International Journal Case Report Permanent Series of aligners Aligner allows disoclussion. Conservative Single molar correc-
of Orthodontics, approach. tion.
Summer 2011.
Pinho JCO, September 2011. Case series Primary in 3 cases, Screw incorporated into Posterior Bite Block Conservative early None noted.
permanent in one posterior cemented bite approach. Allowing
case. block expansion appli- normalization of
ance, intraarch elastics growth.
to cemented button,
crossbite elastics.
Suda et al. AJODO, January Case Report Permanent dentition. None. Throught orthog- Posterior mandibular subapi- Improved facial Surgical Costs and
2012. nathic surgery bone seg- cal osteotomy to correct appearance. morbidity.
ments were moved. mandibular right premo-
lars and molars. That were
moved by using a lingual

(continued)

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Table 2 (Continued)

Author Journal Article Type Dentition Disocclusion Technique Advantage Disadvantage /

Shortcomes

arch appliance after the

subapical osteotomy. Le
Fort I osteotomy and sagit-
tal split ramus osteotomy
to correct the patien facial
asymmetry
Reddy et al. JCO, May, 2012. None Transpalatal bar with elasto- Cost effective and effi- Single tooth tech-
merics. cient, simple and nique.
less technique sensi-
tive than other
methods.
Kalia et al. JCO, September 2012 . Case Report Permanent Composite turbos on lower Use of palatal tads in the Conservative non-sur- Facial profile presents
first molars upper and in the lower gical approach. convexity due to
buccal interradicular tads mandibular defi-
with elastomerics. ciency.
Hua et al. AJODO, December, Case Report Permanent dentition. Posterior biteplane incor- Slow contraction maxillary Conservative non-sur- Facial profile not
2012. porated into constriction device plus fixed applian- gical approach. improved after
appliance. ces. treatment.
Shimazaki et al. Angle Orthodontist, Case Report Permanent Presurgical orthodontic Le Fort I osteotomy combined Facial esthetics Facial appearance is
Febraury 2014. occlusal resin build ups with mid-alveolar improvement and excellent. No short-
osteotomy occlusal correction comes noted.
Surgical costs and
morbidity
associated
Ishihara et al. AJODO, April, 2014. Case Report Permanent dentition None First, the mandibular poste- Non-surgical conserva-
rior teeth were labially tive option.
expanded with a lingual
arch appliance. Upper pre-
molar extractions. Use of
palatal tad to intrude and
bring palatally molars in
scissor bite.
Li et al. JCO, April 2014. Case Report Permanent Posterior bite plate Maxillary constriction spring Conservative non-sur- Facial profile presents
incorporated into posterior gical approach. convexity due to
bite plate. After nine mandibular defi-
months of constriction. ciency.
Lower .018" × .025" stain-
less steel archwire with
cross-elastics on left side
for uprighting the first
molar.
Sakamoto et al. Bull Tokyo Dent Col- Case Report Permanent Quadhelix in the upper Corticotomy followed by Satisfactory case reso- Extra costs and mor-
lege, April, 2016. arch to eliminate rapid mandibular lution. Correcting bidity associated
mechanical obstruction expansion arch forms and the with corticotomy.
to mandibular expan- scissor bite.
sion.
Kumar-Sharma et al. International journal Case series Permanent dentition. Anterior biteplane. Transpalatal arch Conservative non-sur- No facial profile
of orthodontics, gical approach for shown. Incomplete
December 2016 individual teeth records
Du et al. JCO, Febraury, 2018. Case Report Permanent Upper removable bite Miniscrew in lower arch with Conservative early Facial profile presents
plate. elastomerics. approach. convexity due to
mandibular
deficiency
Song et al. AJODO, September Case Report Permanent Andressen activator Fixed appliances with upper Non-surgical conserva- Despite the pro-
2018 premolar extractions. tive treatment with longued treatment
Andressen activator excellent occlusal of 3 years. Facial
results. post treatment
changes favorable.
Lee et al. AJODO, October 2018 Case Report Permanent Glass ionomer bite turbos Buccal shelf, elastomeric Non-surgical, conser- None noted, facial post
bonded on occlusal sur- chains anchored to buccal vative management treatment changes
faces of the maxillary left shelf tads extended to lin- favorable.
molars. Latter anterior gual buttons bonded on the
bite turbo lingually inclined mandib-
ular molars. Cross elastics
added as secondary
uprighting mechanics. Lat-
ter infracigomatic tads for
Class II correction and
upper anterior retraction.
Nakamura et al. Angle Orthodontist, Case Report Permanent Anterior bite block Fixed appliances. A lower lin- Non-surgical, conser- None noted besides
March, 2019. gual arch with anterior and vative approach. the cost associated
posterior palatal minis- with upper premo-
crews were used to lar extractions and
improve the bilateral placement of 6

(continued)

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Table 2 (Continued)

Author Journal Article Type Dentition Disocclusion Technique Advantage Disadvantage /

Shortcomes

scissors bite. Upper and miniscrews (2 pala-

lower anterior miniscrews tal), 4 anterior inter-
were used to address ante- radicular (two
rior deep bite. upper and 2 lower).
Facial post treat-
ment changes favor-
able.
Baik et al. AJODO, July, 2019 Case Report Permanent Bite plate Buccal and palatal tads, lower Non-surgical conserva- Post treatment profile
lingual arch with extension tive treatment still has mandibular
for lower molar uprighting. deficiency.
Left side upper and lower
premolar extractions
Simsuchin et al. Children, August, Case Report Primary Modified Frankell III. Modified Frankel III appli- Conservative early None noted.
2021. ance to induce mandible to approach. Allowing
move backwards and normalization of
relieve an occlusion dis- growth.
crepancy of the dental
arch. Functional dental
rehabilitation with resin
and myofunctional exer-
cises with a PFA which was
modified from an oral
screen appliance.
Araujo et al. AJODO CC, December, Case series Mixed dentition. Vacuum retainer and func- A combination of lip bumper, Conservative manage- Treatment length asso-
2021 tional appliances. FR-2 appliance, cross elas- ment of patients ciated to treatment
tics, fixed functional and starting early in starting in mixed
later full braces used. development dentition. Several
phases of treatment.
Yasir International Ortho- Case Report Permanent Glass ionomer bite turbos Tads, crossbite elastics, fixed Conservative non-sur- None. Excellent facial
dontist, September appliances gical approach. balance post treat-
2022 ment.
Venugopal et al. JCO, April, 2023 Case Report Permanent Premolar bite blocks Fixed appliances,buccal shelf Non-surgical conserva- Profile improved but
tads, transpalatal arch, tive management of surgery what have
intrusion arch a severe given more length
malocclusion to lower jaw.

skeletal maturity.10 Myofunctional therapy and oral screens were used
in a reported case.20
Different orthodontic treatment methods are suggested for correcting
scissor bites. Among them: maxillary constriction plates, intermaxillary
elastics, quad-helix, transpalatal arch, fixed bonded bi-helix appliances,
extractions, lip bumper, mandibular lingual holding arches, Frankel
functional (FR-2) appliances, distraction osteogenesis procedures,
orthognathic surgery. These treatments can improve masticatory func-
tion, esthetics, occlusion, and overall periodontal condition.12
Non-skeletally supported management alternatives
Appliances that work with a functional component, such as lip bum-
per and Frankel 2, are a choice when a tongue or muscular imbalance is
identified. Functional mandibular appliances help reduce the transverse
discrepancy when the mandible is positioned forward.3 The Frankel 2
appliance has the advantage that it can be customized either for bilateral
or unilateral treatments. Lip bumpers address the tongue versus the
cheek functional equilibrium. In a growing patient, an orthopedic appli-
ance can be used to advance the mandible, followed by fixed mechano-
therapy to finish the occlusion on the corrected skeletal bases.10
Treatment selection becomes a personal decision by the orthodontist,
and each procedure has pros and cons.3,13,15 Some management strate-
gies might be considered non-invasive alternatives to surgical treatment;
their limitations include excessive extrusive force requirements on the
anchor teeth and a need for patient compliance. To avoid these dental
side effects in scissor bite correction, temporary anchorage devices
(TADs) have begun to be used in recent years.13 When the Brodie Bite is
identified early when the eruption occurs, simple fixed appliance
mechanics can be used for correction.
Fig. 23 shows a simple power arm extension was added to the first
molar to pull the premolar in the scissor bite palatally. Just 1.5 months
was enough to correct the problem. Fig. 24 shows a minor raise in the
bite with occlusal bite turbos on the day of appliance placement. The
Brodie Bite was corrected during the levelling and aligning process.
Arch constriction in the upper arch is also possible when treating
Brodie Bite patients.14 Intra-arch medium to heavy rubber bands,
changed daily, can be used to collapse two single teeth buccally dis-
placed in opposite quadrants in the upper arch, bringing them into align-
ment. This approach will likely work better for two upper second molars
than multiple teeth or a posterior buccal segment.21
Some published examples are briefly discussed here. A maxillary
constriction spring was incorporated into a posterior bite plate. After
nine months of constriction. The lower arch was worked up to
.018" × .025" stainless steel archwire with cross-elastics on the left side
for uprighting the first molar.22 An intra-arch elastomeric chain extend-
ing twice its length to correct a buccally displaced upper second molar
with the help of a transpalatal arch as anchorage has been published as
a valid approach.23 Another reported alternative is a slow maxillary con-
traction appliance followed by fixed appliance treatment. This strategy
was used in a child with a maxillary asymmetric dentition 10 mm wider
than normal for his age.24 Another option is a constricting spring.10 The
use of a hyrax expander in an open position to produce palatal constric-
tion by narrowing the maxilla bilaterally has a higher risk of creating a
contralateral posterior crossbite on the non-affected side. To avoid this
undesired effect, the lab prepares an appliance with an expansion screw
which is narrowed gradually as treatment progresses. Special care to
strengthen the non-Brodie side anchorage is important. The anterior sec-
tion can be included with the non-Brodie side, covering it with more
acrylic than in the compromised side where the constriction is desired.14

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Different rubber band mechanics have been proposed for Brodie Bite
correction: including intermaxillary cross elastics, multibracket applian-
ces, transpalatal arches and lingual arches with intramaxillary elastics.
These mechanics can generate extrusive forces on the second molars in
both arches, possibly inducing an undesirable reduction in the overbite,
clockwise rotation of the mandible, and premature contacts. This situa-
tion is especially undesirable in high-angle cases.15,16 To avoid increas-
ing lower facial height, it is important to maintain the vertical height of
teeth by using devices with a relatively intrusive effect.2 Rubber bands,
especially cross intermaxillary elastics, can be used as a complementary
mechanism for skeletal anchorage.5 Unfortunately, intermaxillary elas-
tics depend on excellent patient cooperation for a successful
treatment.15,16
Skeletally supported management alternatives
Skeletal anchorage is an effective, non-compliant correction for Bro-
die Bite, which can be obtained with minimum undesirable side
effects.15,16 Currently, it is considered the gold standard in related treat-
ment mechanics. Adequate selection of anatomical insertion sites, length
of screws and physical characteristics need to be considered to avoid
temporary anchorage device failure. As most Brodie Bites require a mix-
ture of vertical and transverse corrections, successful intrusive move-
ments of large segments must be considered. Applying adequate force
when activating skeletal anchorage is a must.25
12
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Fig. 23. A. Occlusal and lateral views of a second left premolar
erupting in buccal crossbite. B. A simple power arm extension
was added to the first molar to pull the premolar palatally. C.
In 1.5 months, the abnormal position was corrected.
Fig. 24. A. Occlusal and lateral views of a first right premolar
erupting in buccal crossbite B. Bite turbos were placed on the
day of appliance placement to raise the occlusion. C. The Bro-
die Bite was corrected during the levelling and aligning stage.
Fig. 25 shows a diagram of the different biomechanical approaches
for the upper arch. In the first scenario, when the extrusion is pure, with-
out any inclinations, two TADs should be placed. One in a buccal posi-
tion and the other one in a palatal position.13 Upon activation, the
resultant intrusive force should pass through the center of resistance of
the tooth. Elastic chains must be engaged from both buccal and palatal
attachments to the TADS. To secure the elastic chains, a wire through
the contact point connecting two adjacent molars in buccal crossbites
was placed with cured composite on the occlusal surfaces. In this way
two teeth can be intruded with two TAD.15 The second scenario requires
extrusion in addition to buccal tooth inclination. One TAD located in the
palate will probably be enough to add both a palatal and intrusive com-
ponent to achieve the correction. Finally, a third scenario is character-
ized by a molar in an extruded as well as a lingually inclined position. In
this case, mechanics for correction require two steps. First a TAD needs
to be placed buccally to upright the tooth and position it in the center of
the bone. During a second stage a TAD needs to be placed in the palate
to proceed with bodily intrusion with a vertical vector along the center
of resistance.
Fig. 26 shows a diagram of the different biomechanical approaches
for the lower arch. Mechanics in the lower arch have less variability
since teeth involved in the Brodie Bite are always expected to be lin-
gually inclined. The difference is whether they are leveled to the occlu-
sal plane or extruded. For pure lingual inclination correction, the head
of the TAD needs to be at the level of the occlusal plane so that the vector
of movement produces verticalization of the tooth. Variations can be
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made in the length of the buccal-shelf screw. A longer TAD is suggested
so that the head of the screw is closer to the wire level or to approximate
FA point of the anatomical crown. Therefore, the intrusive vector is
smaller. If teeth are lingually inclined and extruded, then the head of the
TAD needs to be below the occlusal plane. For an activation vector to
have both a verticalizing and intrusive component TADS can be placed
in an interradicular position.
There are biomechanical differences between using an interradicular
compared to an extra radicular mandibular buccal shelf mini-screw in
the lower arch for Brodie Bite correction. There are more benefits favor-
ing a mandibular buccal shelf bone screw compared with interradicular
bone screw. The possibility of a prominent head that can retain elasto-
meric chains, which can efficiently upright a mandibular segment is an
advantage. If anatomy permits, an extra-alveolar TAD can be placed up
to 10 mm to the buccal aspect of the lingually tipped molars. This
13
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Seminars in Orthodontics 00 (2023) 1−19
Fig. 25. There are three different biomechanical approaches
for the upper arch in a unilateral Brodie bite. The blue lines
represent the occlusal plane. A. Pure extrusion. B two TADs
should be placed, one in a buccal position and the other in a
palatal position. The resultant intrusive force should pass
through the center of resistance. Elastic chains must be
engaged from buccal and palatal attachments to the TADs. C.
Extrusion and buccal tooth inclination. D. One TAD in the pal-
ate adds a palatal and intrusive component to achieve the cor-
rection. E. Extrusion and lingual tooth inclination. F.
Mechanics for correction require two steps. A Buccal TAD is
used to upright the tooth and position it in the center of the
bone. G. A TAD is added in the second stage in the palate to
proceed with bodily intrusion with a vertical vector along the
center of resistance. (Modified from J Clin Orthod MS 23193
accepted for publication).
position is beneficial since it can provide adequate space to upright the
entire buccal segment with one bone screw. Conversely, inter-radicular
TADs quickly interfere with the nearby teeth’ movement, and frequent
replacement is necessary.5 When indicated, the extra radicular mini-
screw can be placed with the head close to the occlusal plane and in a
buccal position relative to the center of rotation of the molar root. This
is advantageous for the inclination correction of the molar since a more
buccal and less intrusive force is generated compared with a TAD in an
interradicular position.26 The clinician can screw the buccal shelf TAD
deeper when a more intrusive force component is needed.
Figs. 27 and 28 shows a unilateral Brodie Bite on the left side. An
upper anterior bite plate was used as a disocclusion strategy to raise the
bite. Mini-screws were placed for Brodie Bite correction. This was
accomplished in 6 months. Fig. 29 shows TADs that were initially placed
too close to the affected teeth; therefore, they had to be repositioned.
Fig. 26. Diagram of the different biomechanical approaches
for the lower arch. The blue lines represent the occlusal plane.
Lower teeth can be A. Lingually inclined. B. The TAD should be
placed at the level of the occlusal plane to generate a verticaliz-
ing vector to C. successfully level the molar. The other possibil-
ity is D. lingually inclined and extruded teeth. E. The TAD
should be placed below the level of the occlusal plane to gener-
ate a verticalizing and intrusive vector to F. successfully level
the molar. (Modified from J Clin Orthod MS 23193 accepted
for publication).
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Figs. 30 and 31 show the rest of the treatment involved solving the den-
tal Class II with infrazygomatic TADs and detailing and finishing proce-
dures. The total treatment time was 35 months.
The extraction of a single tooth in a scissor bite with replacement by
an adjacent tooth or by future implant placement is considered a viable
treatment alternative.2 Fig. 32 presents this type of case with the Brodie
Bite involving only one tooth. The tooth was severely lingualized, with a
significant degree of tooth mobility. It failed to upright with a TAD. A
decision was made to extract it and replace it with a future implant.
Additional management strategies have been published in the litera-
ture underlying these principles. Fixed appliances with a finger spring
using indirect anchorage from a mini-screw.27 A screw was incorporated
into a posterior cemented bite block expansion appliance in conjunction
Fig. 28. Left side Brodie bite. Longitudinal cone-beam cuts on the teeth’ long
axis to visualize compromised teeth’ position and bone support. (previously pub-
lished in J Clin Orthod MS 23193 accepted for publication − reproduction
authorized by J Clin Orthod editor).
14
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Fig. 27. Pretreatment facial and intraoral photos. (previously
published in J Clin Orthod MS 23193 accepted for publication
− reproduction authorized by J Clin Orthod editor).
with intra-arch elastics to cemented buttons and crossbite elastics.28
Fixed appliances and a lower lingual arch with anterior and posterior
palatal mini-screws were used to improve bilateral scissors bite. Upper
and lower anterior mini-screws were also used to address anterior deep
bite.29 A strategy combining fixed appliances with upper premolar
extractions and an Andressen activator was also reported.30 Finally,
fixed orthodontic appliances, TADS and crossbite elastics were used
simultaneously.31
Disocclusion strategy
Mechanics for Brodie Bite cases are generally planned to address the
scissor bite during the first 7-8 months of treatment and continue the
case with the other required corrections. Sometimes an extreme vertical
overlap on the affected side makes it impossible to place orthodontic
Fig. 29. A. TADs were placed too close to the teeth, which limited the amount of
tooth movement. An upper bite plate was used to disoclude the bite. B. Both
TADs had to be moved for further movement: buccally in the lower arch and pal-
atally in the upper arch. (previously published in J Clin Orthod MS 23193
accepted for publication − reproduction authorized by J Clin Orthod editor).
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C. Weinstein et al.
attachments on the facial surfaces of the mandibular teeth.13 Therefore,
Brodie Bite treatment generally requires disarticulating upper and lower
teeth to correct the buccal crossbite free of interferences and occlusal
trauma. The patient will have a Brodie and a non-Brodie side in a unilat-
eral buccal crossbite. The occlusion on the non-Brodie side can be per-
fectly normal and not affected. The disocclusion strategy should be as
minimal as required to avoid altering the correct occlusion of the non-
involved side.
Temporary bite raising during fixed orthodontic treatment is com-
monly obtained through removable occlusal appliances. However,
patient cooperation is required since full-time use of the bite plate is
required for approximately 7 to 9 months.12 Most frequently, the bite is
Fig. 31. The left side corrected Brodie Bite. Upper and lower longitudinal cone-
beam cuts on the long axis of the involved teeth are presented to visualize the
buccal and palatal bone after the correction. (previously published in J Clin
Orthod MS 23193 accepted for publication − reproduction authorized by J Clin
Orthod editor)
15
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Fig. 30. Posttreatment facial and intraoral photos. (previously
published in J Clin Orthod MS 23193 accepted for publication
− reproduction authorized by J Clin Orthod editor)
raised on the normal side. Creating enough clearance to upright lin-
gually inclined and sometimes extruded lower posterior teeth with elas-
tic traction to mini-screws correcting the scissor bite.2,13,32
Unfortunately, undesired intrusion may occur during scissor bite correc-
tion, generating problems (to be discussed in the complications section).
The disocclusion can be done with several different treatment strategies,
as seen in Table 2.
Appliances to be used are an acrylic bite plate or a vacuum appliance
stabilizing normal occlusal contacts in the upper and lower arches. Other
appliances to open the bite are acetate plates with bite blocks on the side
without scissor bite or modified Hawley bite plate appliances. The use of
anterior bite planes as a simple method to disarticulate arches has also
been proposed.33
Upper palatal and lower lingual bonded bite turbos can also be used
on compromised teeth, contributing to raising the bite and helping with
the intrusion while the transverse correction is taking place. Bonding
with resin, the occlusal surface of the opposite side to provide the
Fig. 32. A. Brodie Bite involving only one tooth. B. The tooth was severely lin-
gualized, with a significant degree of tooth mobility. It failed to upright with a
TAD. A decision was made to extract it and replace it with a future implant.
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necessary clearance has also been described.16 Ideally, the disarticulat-
ing strategy covers most teeth instead of loading a few with masticatory
forces. The goal is to prevent occlusal interferences when the mandibu-
lar posterior teeth are being moved buccally and simultaneously avoid
unwanted extrusion of the maxillary posterior teeth. Glass ionomer bite
turbos bonded on occlusal surfaces of the maxillary molars, and later
anterior bite turbos have been used as well for treating a Brodie Bite.34
Figs. 33 and 34 show the treatment mechanics to solve the case pre-
sented in Fig. 5, where bite turbos were bonded on the affected side,
both in the upper and lower arch. Vertical compromise on the Brodie
side was so severe that upper extrusion completely covered the lower
teeth. This bite-raising strategy helped both intrusion and inclination
correction free of occlusal trauma. Upper teeth were moved lingually to
a TAD in the palate, and lower molars were activated as a segment to a
buccal shelf screw.
Aligners have also been used for disocclusion in situations of one
molar correction.35 Aligners can be an effective alternative to correct
scissor bites, particularly if the patient refuses to use conventional fixed
appliances. Anterior bite ramps are incorporated during the virtual plan-
ning as a bite-raising alternative. The problem is that aligners do not lift
the bite while not in the mouth. Fig. 35 shows another alternative is to
bond permanent bite ramps and design the plastic on top of them.
Surgical treatment options
It is important to consider surgery as a reasonable alternative to more
complex Brodie Bite cases. Sometimes the surgery addresses other skele-
tal problems, but sometimes it is part of the Brodie Bite problem. Differ-
ent surgical treatment options for Brodie Bites depend mostly on the
patient’s age. Until recently, a mandibular transverse deficiency was
Fig. 34. A. Schematic representation of the treatment mechanics. B. Upper teeth
were moved lingually by elastic activation to a TAD in the palate.
16
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Seminars in Orthodontics 00 (2023) 1−19
Fig. 33. A. Treatment mechanics used to solve the case pre-
sented in Fig. 5. B. Schematic representation of the treatment
mechanics. C. Bite turbos were bonded, both in the upper and
lower arch, on the affected side. D. Lower molars were acti-
vated as a segment to a buccal shelf screw. This bite-raising
strategy helped both intrusion and inclination correction free
of occlusal trauma.
almost always treated with dental compensations. However, research
has shown an inherent instability when intercanine width is expanded
dentally. Similarly, intermolar width might be unstable if expanded
excessively during orthodontic treatment. During distraction osteogene-
sis, a transverse skeletal deficiency can be treated with mandibular wid-
ening when a true skeletal discrepancy is present.36
A combination of orthognathic surgery and orthodontic treatment is
sometimes used to address the mandibular and facial asymmetries. This
approach uses a 3-piece Le Fort I surgery to address the unilateral poste-
rior scissors bite. Occasionally combined with a midline split for maxil-
lary constriction and a bilateral sagittal ramus osteotomy or mandibular
symphyseal distraction.2,11,37 Upper segmental osteotomies can be
designed, as well as subapical mandibular surgery to relocate the
affected segments.14 A scissors bite involving many teeth and a large
vertical overlap is very difficult to correct exclusively with orthodontic
therapy, especially for non-growing patients. However, surgical options
are often rejected by patients.11
Different surgical approaches have been suggested in reported Brodie
Bite cases. An extensive maxillary surgical case was treated with a 3-
piece Le Fort I osteotomy. The inter-molar maxillary width was reduced
bilaterally during surgery. While maintaining the intercanine distance.
The posterior segments were also managed vertically, solving the over-
eruption problem with segmental intrusion.7 Corticotomies followed by
rapid mandibular expansion to obtain inter-arch coordination were pro-
posed.38 Posterior mandibular subapical osteotomy was utilized to cor-
rect mandibular right premolars and molars on a Brodie Bite pattern.
Teeth were moved by using a lingual arch appliance after the subapical
Fig. 35. A. Permanent bite ramps are bonded to upper incisors to ensure a bite-
opening strategy while aligners are not in the mouth. B. The plastic is designed
to fit and the plastic on top of them.
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Fig. 37. A. Canted occlusal plane before Brodie Bite correction. B. Levelled
occlusal plane after scissor bite treatment.
osteotomy. Le Fort I osteotomy and sagittal split ramus osteotomy were
then used to correct the patient’s facial asymmetry.38
Figs. 36−39 shows a case with a skeletal Class II with a unilateral
right Brodie Bite which affected premolars and molars. For the scissor
bite correction, upper right TADS were used both in a buccal and palatal
position. Initially, the upper molars were only activated to the palatal
TAD for the buccal inclination correction. The buccal screw was also
activated for a purely intrusive vector applied to the whole segment.
The upper wire was then segmented both for intrusion and correction of
the occlusal plane canting. An acrylic removable appliance was used for
bite opening in the lower arch. The lower arch was only treated with
fixed appliances. The lingualized teeth were bonded upside down to pro-
duce positive torque values. The Brodie Bite was solved in nine months.
The patient went thereafter through orthognathic surgery for the skele-
tal Class II correction. Total treatment time was 3 years.
Stability
Once the Brodie Bite is corrected, the lingual incline of the buccal
cusp of the maxillary teeth and the lingual incline of the lingual cusp of
17
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Seminars in Orthodontics 00 (2023) 1−19
Fig. 36. A. Case (Courtesy of Dr. Macarena Alvarado) with a
skeletal Class II and a unilateral right Brodie Bite affected pre-
molars and molars. B. An acrylic removable appliance was
used for bite opening in the lower arch. For the scissor bite
correction, upper right TADS were used both in a buccal and
palatal position. Initially, the upper molars were only activated
to the palatal TAD for the buccal inclination correction. C. The
buccal screw was used when a purely intrusive vector to the
whole segment was activated. The lower arch was only treated
with fixed appliances. Brackets in the lingualized teeth were
bonded upside down to produce positive torque values.
the mandibular teeth should occlude properly. Therefore, this relation
itself functions as a retainer to prevent relapse.15 However, Brodie Bite’s
treatment stability may be compromised when treatment involves dental
expansion. For this reason, it is important to evaluate if the Brodie Bite
was originally mostly a skeletal and/or a dentoalveolar component.
Clinicians are frequently faced with the dilemma of either treating the
skeletal base or a dental compensation. It has been shown that the
expansion of basal bone relative to alveolar bone is critical in establish-
ing long-term stability.13 Stability issues are mostly related to other
problems associated with the Brodie Bite.
Treatment mechanics can also be a threat to stability. One of the
complications associated with molar intrusion facilitated with tempo-
rary skeletal anchorage devices is that intruded posterior teeth may con-
sequently experience a relapse rate as high as 30 %. Therefore, if
possible, overcorrection of molar intrusion is necessary to achieve a
proper result.13
Another important aspect of stability is to evaluate function in the
treatment result. The fact that the patient’s malocclusion is corrected
does not mean it is always accompanied by a functional masticatory
improvement. It is well known that orthodontic treatment morphologi-
cally rearranges the occlusion. However, obvious improvement in func-
tion does not occur instantly and sometimes requires specific further
treatment to avoid reverse masticatory cycles and dual bite.24 In some
instances, the asymmetric movement of the incisor paths and bilateral
condyles during lateral excursions disappeared after treatment provid-
ing instant functional improvement.15
Periodontal considerations
When the Brodie Bite is diagnosed early, periodontal consequences
are minimal and most likely addressed through orthodontic movements
Fig. 38. A. Pre-surgical Intraoral photos. B. Post-surgical
intraoral photos.
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C. Weinstein et al.
Fig. 39. Before and After images after orthognathic surgery for the skeletal Class
II correction. Total treatment time was 3 years.
with the help of craniofacial growth and additional natural tooth erup-
tion. At later ages, especially when craniofacial growth potential and
natural eruption processes are minimal, periodontal bone and soft tissue
defects may persist even after proper orthodontic movements. Hence, in
older patients with Brodie Bite malocclusion, interdisciplinary planning
and management with a periodontist is paramount.
It is important to note that, in general, periodontal conditions are not
affected in terms of inflammatory pathology; however, the typical bony
architecture is altered as extrusions and dental compensations are
expressed. As stated in this proposed checklist, periodontal anatomy will
become affected by the level of alveolar bone and gingival contours,
together with gum display. In the transverse plane, inclinations may also
affect the thickness of the buccal cortex and express gingival recession
in the most extreme cases, especially in the mandible.
Complications
Several associated complications with the Brodie Bite treatment have
been reported. A late diagnosis of this malocclusion may lead to compli-
cations such as mandibular development disorders, Class II malocclu-
sion, TMD, asymmetric growth and lateral deviations with functional
shifts.8,39 Dentoalveolar compensations in the vertical plane may cause
periodontal lesions and ulcers in the oral mucosa due to dental extru-
sions.8 Maxillary extruded teeth can impinge the mandibular
gingiva.5,10 Intrusion with heavy force can cause pulpal damage and
root resorption. The magnitude of force should be limited to 250 g per
molar to prevent root resorption.13
Anatomical considerations for TAD placement need to be addressed.
In the maxilla, caution must be exercised when placing mini-screws in
the posterior palate because the greater palatine nerve emerges from,
the greater palatal foramen medial to the third molars.16 When the alve-
olar bone is severely tilted buccally in the mandible, buccal insertion of
temporary skeletal anchorage devices may cause significant patient dis-
comfort. In addition, TADs placed in the mandible are known to have
higher failure rates. To avoid potential complications with TADs, a mod-
ified lingual holding arch for molar uprighting is a management alterna-
tive.13 Additionally, one unique unit of skeletal anchorage might not be
enough to correct a scissor bite involving a larger segment of teeth
(canine, premolars, and molars). In this case, the buccal shelf might be
located too posterior. More than one TAD, additional interradicular
TADS, or even a mixed solution might be reasonable.
The selection of the insertion site for mini-screws depends not only
on bone availability but the required movement direction should also be
considered. Initially, a 6 mm distance between the mandibular mini-
screw and the molar tube was described. Once the molar was uprighted,
it decreased to 0 mm.38 The amount of extrusion in the upper arch can
be so significant that there might be no space to fit a buccal shelf screw
since it would interfere with it during occlusion. An alternative is the
use of a lower interradicular screw. Another option is to solve the upper
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Seminars in Orthodontics 00 (2023) 1−19
extrusion initially. Later, begin with lower corrective mechanics in a sec-
ond stage when space is available.
Iatrogenic open bites can appear after the use of intermaxillary elas-
tics as an undesired effect of treatment mechanics. This might be a sig-
nificant problem in high-angle cases.15,16 Open bites could also appear
because of the mouth opening strategy or insufficient intrusion of the
Brodie segments. If there is insufficient intrusion of the Brodie segment,
it is sometimes better to further intrude molars on the affected side.5 If
the lateral open bite is on the contralateral side, a careful analysis of the
bite raising mechanics needs to be made. Bite opening in the anterior
region sometimes appears inevitably. Vertical control of the mandibular
molars cannot be done while simultaneously uprighting them. Mastica-
tory muscle exercises are an important adjunctive treatment to correct
and maintain an open bite.12
The non-Brodie side, which generally has a good occlusion, is consid-
ered the anchorage zone to correct the affected teeth. Unfortunately, it
can get compromised because of the correction. The planned disocclu-
sion strategy can generate undesirable intrusive movements and inclina-
tions. Then they need to be fixed as a newly created problem. Especially
with fixed strategies such as bite turbos, an undesired open bite or cant-
ing of the occlusal plane may appear, extending treatment time and diffi-
culty. To avoid this complication, ideally, the appliance used for
correction stabilizes the complete arch rather than just a group of teeth.
If few teeth are used to raise the entire dentition, such as with composite
turbos, it is better if those teeth are part of the Brodie Bite side as they
are generally over erupted.16 When a unilateral buccal crossbite is pres-
ent, the biomechanics of appliance selection is a concern. The expansion
has its effect on both sides. It is not simple to expand just one side of the
mandibular arch. To control this side effect, it is necessary to minimize
it. By creating an acrylic indentation or addition of composite on the
opposing arch or using elastics.3
Surgical complications are traditional problems that may arise
because of orthognathic surgery. These include non-union of bone seg-
ments, post-surgical infections, condylar resorption, facial sensitivity
issues, devitalized teeth, and tooth loss. In the case of mandibular mid-
line distraction to widen the lower arch, tooth loss is a possible
complication.40
Conclusions
The Brodie Bite is a malocclusion that presents different degrees of
severity. It can be skeletal, as well as dentoalveolar, and bilateral or uni-
lateral. Usually, it should be treated before any other malocclusion com-
ponent. Early diagnosis and management will reduce the complexity of
orthodontic mechanics and improve the overall prognosis. Efficient
treatment strategies need to be individualized depending on vertical and
transverse components. Ideally, the current standard of care is using
skeletal anchorage with a disocclusion strategy, stabilizing the teeth not
involved in the Boride Bite. Complications are related to the timing of
diagnosis, compensations, TAD mechanics and the development of unde-
sired open bites. Generally, the Brodie Bite treatment is stable and
presents a good long-term prognosis when addressed correctly
Declaration of Generative AI and AI-assisted technologies in the
writing process
While preparing this work, the author(s) did not use Generative AI or
AI-assisted technologies.
Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
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C. Weinstein et al.
CRediT authorship contribution statement
Carol Weinstein: Conceptualization, Data curation, Formal analysis,
Supervision, Writing − original draft, Writing − review & editing, Inves-
tigation, Project administration. Miguel Hirschhaut: Conceptualiza-
tion, Data curation, Formal analysis, Investigation, Project
administration, Writing − original draft, Writing − review & editing,
Supervision. Patricia Vergara: Investigation, Writing − review & edit-
ing. Angelica de la Hoz Chois: Investigation, Writing − review & edit-
ing. Carlos Flores-Mir: Conceptualization, Data curation, Formal
analysis, Investigation, Supervision, Writing − original draft, Writing −
review & editing.
Acknowledgements
Special thanks to Dr. Macarena Alvarado for providing us with a
case. Dr. Viviane Tinoco for providing us with a diagrammatic scheme.
Also, Dr. Nadia Araneda for helping us with the reference management.
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