THE RESTORATIVE MANAGEMENT OF

THE DEEP OVERBITE

H. P. Beddis, K. Durey, A. Alhilou and M. F. W. Y. Chan
BRITISH DENTAL JOURNAL VOLUME 217 NO. 9 NOV 7 2014

Presented by
Dr. S. Nithya
Post Graduate student
Department of Prosthodontics
 CONTENTS
 INTRODUCTION
 DEFINITION
 CLASSIFICATION OF TRAUMATIC OVERBITE
 FACTORS INVOLVED IN DEVELOPMENT OF TRAUMATIC OVERBITE
 MANAGEMENT
 CONCLUSION
 INTRODUCTION

A deep overbite is where the vertical overlap of the upper and

lower incisors exceeds half of the lower incisal tooth height.
Problems associated with the deep overbite can include soft tissue
trauma, lack of inter-occlusal space and tooth wear, all of which can present
significant challenges for the restorative dentist.
While management options very much depend on the nature of the
situation and patient’s symptoms, options may range from provision of a simple
removable appliance or splint and non-surgical periodontal therapy, to
multidisciplinary care involving orthodontics, orthognathic surgery and
restorative dentistry.
 Restorative management may involve an increase in the occlusal
vertical dimension (OVD) with fixed restorations or removable prostheses, and
careful assessment and treatment planning is essential.
This article discusses the etiology and restorative management
strategies for deep and traumatic overbites.
 DEFINITION
OVERBITE : (VERTICAL OVERLAP )
The vertical relationship of the incisal edges of the maxillary incisors
to the mandibular incisors when the teeth are in maximal intercuspal position.
(GPT 9)
DEEPBITE :
Where the overlap is greater than half of the lower incisor tooth height, the
overbite is considered to be increased or deep.

TRAUMATIC OVERBITE :
Traumatic overbite is where there is damage to the underlying periodontium
or the hard tissues of the teeth involved.
 AKERLY’S CLASSIFICATION OF TRAUMATIC OVERBITE

Classification Clinical presentation

CLASS I The lower incisors contact Discomfort or indentation/

the upper palatal mucosa, ulceration of the palatal
away from the palatal mucosa
gingival margins

CLASS II The lower incisors contact Inflammation due to food

the palatal gingival margins and foreign body impaction
into the gingival crevice of
the upper incisors
Classification Clinical Presentation
CLASS III The lower incisors contact the Inflammation and
palatal gingival margins and the recession of the
maxillary teeth contact the labial respective gingival
gingival margins margins

CLASS IV Wear faceting on the upper Loss of posterior

maxillary teeth and/or the labial support or a
surfaces of mandibular teeth parafunctional habit
 Progression from asymptomatic deepbite to symptomatic
traumatic overbite
 FACTORS INVOLVED :

PLAQUE ACCUMULATION

OCCLUSION OF INCISAL EDGES ONTO

THE GINGIVAL MARGINS

LOSS OF POSTERIOR OCCLUDING

UNITS

PARAFUNCTIONAL HABITS
 Progression from asymptomatic deepbite to symptomatic traumatic
overbite

 FACTORS INVOLVED :

 1. Inflammation Soft tissue

Poor plaque
of palatal trauma due to
control
gingiva deep-bite

Oral hygiene
Periodontal Food
efforts are
disease impaction
hindered
 3.
2. Occlusion of incisal edges onto the Loss of posterior occluding units
gingival margins

Traumatic stripping of gingiva Anterior posturing of mandible

Gingival inflammation overclosure

 Parafunctional habits
 4.

Worsen the symptoms of

soft tissue trauma
 Delivery of Restorative treatment
 FACTORS NEED TO BE CONSIDERED :

SOFT TISSUE TRAUMA

LACK OF INTER-OCCLUSAL SPACE

TOOTH WEAR
 Delivery of Restorative treatment

 FACTORS NEED TO BE CONSIDERED:

1. SOFT TISSUE TRAUMA

2.
LACK OF INTER-OCCLUSAL SPACE :
 3.
TOOTH WEAR :

Tooth reduction for restoration  pulpal damage , tooth preparation

with less retention and resistance
 MANAGEMENT

STABILISATION RESTORATIVE TREATMENT

1. PERIODONTAL 1. FIXED RESTORATIONS

THERAPY
2. REMOVABLE OPTIONS :
2. SPLINT THERAPY THE ONLAY DENTURE

3. ORTHODONTIC
TREATMENT
 STABILISATION
1. PERIODONTAL THERAPY
 STABILISATION
2. SPLINT THERAPY
 Initial step to palliate symptoms
 Protect mucosa and teeth
 SOFT AND HARD SPLINTS
 Polyvinyl material or Bilaminar material
 Disadvantage
 STABILISATION
3. ORTHODONTIC TREATMENT
 technically difficult and lengthy
 difficult to maintain even with long-term orthodontic retention
 Treating adult patients with lost teeth and compromised periodontium is challenging
 skeletal discrepancy  Multidisciplinary approach
 Restorative treatment
 Orthognathic surgery (considered in cases where
it is not possible to resolve the patient’s traumatic occlusion and
achieve a stable result with orthodontics alone)
 RESTORATIVE TREATMENT
 Involves increasing OVD (Occlusal vertical dimension)
 Changes to occlusion made in a controlled way
 Articulation of models is done to
 Assess the occlusal relationship
 Determine the increase in OVD needed

FIXED
RESTORATIVE TREATMENT
REMOVABLE
 FIXED RESTORATION

 A diagnostic wax-up at an increased OVD can help to plan the treatment

 Helps to develop features like stable occlusal stops and appropriate guidance

Dahl’s principle

 Once occlusal scheme has been planned on the articulator , it can be reproduced
in the definitive restorations

Extra coronal restorations

Fixed restoration
Composite build ups
 Case 1
Chronic periodontitis Tooth erosion and attrition Following stabilisation of the patient’s
periodontal condition, the incisal edges of the
upper anteriors were recontoured

Mucosal trauma Traumatic overbite composite bonding at an An upper soft night

increased OVD to restore the guard
worn upper and lower anterior
teeth
 REMOVABLE RESTORATION:
THE ONLAY DENTURE

Indication Advantage Disadvantage Co-Cr

framework to
Alleviate soft tissue
trauma
Shorter life due to wear overcome wear
Situation where
stable tooth-tooth No change in position Composite can
contact is esthetics
and height of teeth be placed over
impossible to the framework
develop Occlusal table can be to improve
modified
esthetics
 46 yr old patient,deep overbite ,left sided scissor Crowns on 16,11,21,24,25 CoCr upper partial onlay
bite with skeletal discrepancy, palatal soft tissue With rest seats and milled denture was fabricated at
trauma,tooth surface loss with parafunction guide planes an increased OVD

Veneers were placed on the 41,

The patient complained of sensitivity of the teeth and an 42, 43, 31, 32 and composite
inability to tolerate an upper partial denture bonding to the 12
SEQUENCING RESTORATIVE TREATMENT
 CONCLUSION
Deep overbite can present many clinical challenges. Treatment
should aim to improve occlusal stability, function and aesthetics. The initial aims
of treatment are to reduce soft tissue trauma and improve periodontal health.
Further restorative intervention may be required if there is continued trauma, tooth
wear or teeth have been lost.
Successful rehabilitation of these cases can be achieved with careful
planning and management of the occlusion .
Full mouth rehabilitation of the patient with
severely worn dentition : a case report

Mi-Young Song, DDS et al , J Adv Prosthodont 2010

 INTRODUCTION
The gradual wear of the occlusal surfaces of teeth is a normal
process during the lifetime of a patient. However, excessive occlusal wear can
result in pulpal pathology, occlusal disharmony, impaired function, and esthetic
disfigurement. Tooth wear can be classified as attrition, abrasion, and erosion
depending on its cause.
The severe wear of anterior teeth facilitates the loss of anterior
guidance, which protects the posterior teeth from wear during excursive
movement. The collapse of posterior teeth also results in the loss of normal
occlusal plane and the reduction of the vertical dimension.
 VERTICAL DIMENTION AT OCCLUSION
( VDO)

DEFINITION :
 The distance between two selected anatomic or marked points (usually one on
the tip of the nose and the other on the chin) when in maximal intercuspal
position
(GPT 9)
 The rehabilitation of the severely worn dentition using fixed or removable
prostheses is complex and among the most difficult cases to restore when the
space for restoration is not sufficient.
 Hence, assessment of the vertical dimension is important for the
management, and careful comprehensive treatment plan is required for each
individual case

 This case explains how a satisfactory clinical result was achieved by restoring
the vertical dimension with an improvement in esthetics and function.
 CASE REPORT
 PATIENT DETAILS :
 77 year Old woman
 Chief complaint : Could not eat anything because her teeth were worn too much
 Medical history : Had anticoagulant and analgesic agent due to HT and idiopathic
head ache
 The facial type of patient was square
 Her lip seemed to be under strong tension.
INTRA-ORAL EXAMINATION :

 Generalized loss of tooth substance

 more in maxillary left incisors and mandibular right
incisors
 Maxillary left canine and mandibular right canine
(had root canal treatments) were worn to gingival
level
 Anterior teeth had
1. Sharp enamel edges,
2. Dentinal craters
3. Attritional wear due to loss of posterior support
 Mandibular posterior teeth were missing
 The discrepancy between centric occlusion (CO) and maximum intercuspal
position (MIP) was found when she was guided to CR with bimanual technique.
 The patient did not have temporomandibular disorder history and soreness of
the mastication muscles
 In the transcranial view , any specific disorder was not found
 Determination of alteration in VDO :

1. Loss of posterior support

2. History of wear
3. Phonetic evaluation
4. Interocclusal rest space
5. Facial appearance
POSSIBLE CAUSES OF PATIENT’S WORN DENTITION :
1. Posterior interferences
2. Parafunction
3. Eating habit
4. Dental ignorance
 Treatment Options

1. Restoring mandibular edentulous posterior region with implants or

removable partial denture,
2. Full mouth rehabilitation with metal ceramic restoration with or
without crown lengthening procedure
 Treatment Procedure
 Casts were mounted on a semi-adjustable
articulator using a face-bow record
 An interocclusal record that was made with the
aid of a Lucia jig and polyvinylsiloxane occlusal
registration material
 The new VDO was set by 5 mm increase in the
incisal guidance pin of the articulator
 An occlusal splint was fabricated
 Offered bilateral contacts of all posterior teeth in
centric relation and anterior guidance in Occlusal overlay splint was delivered
excursive movements and monitored for 1
month to evaluate patient’s adaptation to
 The anterior guidance disoccluded the posterior the new VDO.
teeth in all jaw positions except centric relation
 CR record using Lucia jig and wax-rim was
taken
 Diagnostic wax-up was performed
 Autopolymerizing acrylic resin (ALIKETM;
GC America, ALSIP, USA) provisional crowns
were fabricated using a vacuum formed matrix
 mandibular provisional RPD was made to fit
provisional crowns
 The provisional fixed restorations were
cemented with temporary cement

Provisional restorations were placed after

trial period of removable
occlusal overlay splint
 For three months, interim restorations were used as a
guide for the definitive oral rehabilitation
 Improvement in mastication, speech, and facial
esthetics confirmed the patient’s tolerance to the new
mandibular position with the restored VDO
 The anterior guidance and posterior disocclusion on
excursive movements were established
 Adjusted occlusion was transferred to customized
anterior guide table, which was made with acrylic
resin(PATTERN RESIN)
 Final preparation was performed, and definitive Customized anterior guide was made utilizing
the duplicated
impressions were made with polyvinylsiloxane Provisional restoration casts.
impression material
 Bite registration
- was taken using provisional crown and occlusal registration
material (StoneBite; Dreve Dentamid GmbH, Unna, Germany)

 Porcelain fused to metal restorations were made using customized anterior

guide table .They were cemented with resin modified glass ionomer cement
 The amount of occlusal adjustment on the lingual surface of maxillary anterior
teeth was minimal (Because the patient’s anterior guidance table was used in the
production of definitive restoration)
 Definitive mandibular RPD was fabricated and delivered with minor occlusal
adjustment
 The prostheses were designed using mutually protected occlusion.
 Oral hygiene instructions and regular check-up were administered.

Definitive restoration
 DISCUSSION

 Turner’s classification and crown lengthening procedure

 Adhesive strategy is used more now-a-days
 Conventional treatment modality was chosen for this case which
includes
A trial overlay splint

Provisional restoration

Careful monitoring and

Definitive prosthesis
 Increase of VDO was determined by patient’s physiologic factor like
interocclusal rest space and speech.
 Trial period for the removable occlusal overlay splints was 1 month
and provisional restoration was 3 months.
 Depending on the patient’s situation and adaptation ability, the
interim period can be modified
 The rehabilitation using restoration of crowns and RPD providing
posterior support is affordable
 The education on wearing RPD is necessary
 CONCLUSION

Management of patients with a worn dentition is

complex and difficult. Accurate clinical and radiographic
examinations, a diagnostic wax-up, and determining OVD are crucial.
In this clinical report, raising vertical dimension of occlusion
using removable occlusal overlay splint and following fixed
provisional based on accurate diagnosis showed successful full mouth
rehabilitation for severely worn down dentition.
 REFERENCES
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College of Prosthodontists