Management of Deep Bite

School of Dental Sciences Bharatpur, Chitwan, Nepal
Management Of Deep Bite
Presented by : Guided by-

Dr Ajay Chhetri (MDS 2nd Y)
Prof Dr Basanta Kumar Shrestha
Dr Madhurendra Prasad Sah
Dr Rockey Shrivastava
Department of Orthodontics and Dentofacial Orthopedics-

1
CMC-SODS first batch 2078
Contents
1. Introduction
2. Classification
3. Prevalence
4. Diagnosis
5. Treatment Considerations
6. Management
7. Retention
8. Conclusion
2
Introduction

3
Introduction
(Strang;1950)
4
Overbite
Author Value
Proffit (2007) 1-2 mm
Bishara (2001) 3 mm

5
Zones (Nanda 1981)

6
Cover bite
• This condition was first recorded in the german literature in 1912 by

Mayrhofer et al. as Deckbiss.

7
Closed bite
(Moyers et al, 1988)

8
Classification

9
Origin
Deep bite
Skeletal deep Dental deep

bite bite
10
Skeletal deep bite
• Schudy;1965.
• A > I + II + III + IV
• (Anti clockwise rotation)
• A < I + II + III + IV
• (Clockwise rotation)
Schudy, The Rotation Of The Mandible Resulting From Growth: Its Implications In Orthodontic Treatment Angle Orthod (1965) 35 (1): 36–50
11
12
Rotation (Bjork 1983)

13
14
For an average individual with normal vertical facial proportions -
• -15 degree internal forward rotation from age 4 to adult life (25% -
matrix rotation and 75% - intramatrix rotation)
• 11 to 12 degrees of external, backward rotation
Producing the 3 to 4 degree decrease in mandibular plane

angle.

15
• So excessive forward rotation of mandible due to an increased
internal rotation and a decreased external compensation.
• Short LAFH, horizontal palatal plane, "square jaw" type, with a low
MPA and a square gonial angle.
• A deep bite malocclusion and crowded incisors is seen.

16
(Bjork & Skieller;1983) Short face

17
Dental deep bite
• Deep bite
Over-eruption Infra occlusion

of anteriors of posteriors

18
Function
TRUE PSEUDO
Infraocclusion of the posterior Overeruption of the anterior teeth
segments
Class II div II Class II div I

Near flat curve of spee Excessive
Large interocclusal clearance Normal or small

19
Extent
INCOMPLETE COMPLETE

20
Ackerly;1977 classification of traumatic overlap
Incisor relationship
I Lower incisor impinge into palatal mucosa
II Lower incisors incisal edge occlude into palatal gingival

sulci of max teeth
III Both maxillary and mandibular incisors incline lingually

with impingement of gingival tissues of each other.
IV Mandibular incisors move or extrude into the abraded
lingual surfaces of maxillary anterior teeth.
Varshini et al. Deep Bite- An Overview European Journal of Molecular & Clinical Medicine Volume 07, Issue 08, 2020
21
Prevalance

22
Lombardo G. et al. Worldwide prevalence of malocclusion in the different stages of dentition: A systematic review and meta-analysisEuropean Journal of Paediatric Dentistry
vol. 21/2-2020

23
vol. 21/2-2020

24
vol. 21/2-2020

25
26
27
28
R.Yadav; B. K.Shrestha; N. Yadav; P.Basel (2018). Prevalence of Dental Deep bite in Nepalese Adolescents of Kathmandu Valley. Journal of Institute of
Medicine, 41.

29
Medicine, 41. Department of Orthodontics and Dentofacial Orthopedics-
30
Medicine, 41.

31
Medicine, 41.
32
Severity of deep bite
Grade ((Brunelle et al, Amount

1988 -NHANES III)
Moderate 3-4 mm
Severe 5-7 mm
Extreme >7 mm

33
overbite Amount
Mild 3-4 mm
Moderate 5-7 mm
Severe >7 mm

34
NHANES III;1989-1994

35
Iotn Nature of deep bite Grade Treatment
(IOTN) need
1. Greater than or equal to 2 Mild
3.5 mm
2. Complete on gingival or 3 Moderate
palatal tissue but no
trauma
3. Complete overbite with 4 Severe
gingival or palatal
trauma.
PETER H. BROOK AND WILLIAM C. SHAW The development of an index of orthodontic treatment priority European journal of orthodontics 11 (1989) 309-320
36
Etiology

37
Etiology
• Hereditary
• Skeletal
• Dental
• Muscular
• Habits

38
Diagnosis

39
Features
Clinical
1. Reduced lower facial height.
2. Deep mentolabial sulcus.
3. Over closure of lips.
4. Trauma to the palate.

40
Features
Intra oral
1. Freeway space – Increased
2. Curve of spee - Increased
3. Lateral tongue thrust
4. Palatal vault - flat & traumatic

41
Skeletal deep bite
 Characterized by -
• Patient exhibits a horizontal growth pattern.
• Anterior facial height is reduced.
• Reduced freeway space.
• A cephalometric examination reveals that most of the horizontal
cephalometric planes such as mandibular plane, F.H. Plane, S.N.
Plane etc are parallel to each other.

42
Cephalometric parameters to determine
growth pattern

43
• The most reliable parameters in assessing Horizontal growth pattern
were SN-GoGn (95%) and Jarabak ratio (92.5%) followed by Facial axis
(70%) and Y axis (67.5%) and the least reliable parameter was FMA
(55%).
Rizwan M, Mascarenhas R, Hussain A. Reliability of the existing vertical dysplasia indicators in assessing a definitive growth pattern. Rev Latinoam
Ortodon Odontop. 2011 Dec;16:1-5

44
45
Occlusal plane angle

46
Cephalometric findings
Cephalometric Characteristics
1. Decreased anterior total facial height.
2. Decreased ramus height.

3. Decreased corpus length.
4. Mandibular buccal infra occlusion.

47
Features
Functional
Mandible cannot be opened to an appreciable
degree
Temporomandibular joint dysfunction
Degrading periodontal condition
Attrition

48
Management

49
Methods
• Extrusion of posteriors.
• Intrusion of anteriors.
• Relative intrusion and extrusion.
• Proclination of anteriors.
• By uprighting or distalizing the molars
• Surgical management.

50
Treatment considerations

51
Estimated skeletal growth potential and
growth direction
Easier to accomplish and the more stable when performed on
growing patient
(Simons et al,1973; Bell et al,1984)

52
Esthetic Consideration
• Patient’s soft tissue drape is the first step

53
A) Interlabial gap
• 2 to 3 mm of interlabial gap

54
B) Incision - stomion distance
• 3 to 4 mm incision - stomion distance is esthetically
pleasing

55
C) Smile line
• Average incisor exposure is almost 2/3rd of upper incisor.
• Most pleasing smiles – without gingival exposure (Male) &
1-2 mm of gingival exposure (Female).
Maulik and Nanda (2007)

56
• Proffit rightly emphasized, a person's interaction with the society
involves much more time spent in talking to others compared to the
time one smiles.
• It is better to have some gumminess during the shorter episodes of

smile rather than have insufficient incisor show during much longer
episodes of talking.

57
D) Lip length
• Lip growth continues till about 16-17 years in females and
18-19 years in male.
Mammandras AH. Linear changes of the maxillary and mandibular lips. Am J Orthod Dentofacial Orthop. 1988 ;94 :405-41058
• Short upper lip - intrusion of upper incisors

Crown Width to height ratio

59
Functional considerations
• Condyle assumes a new position
• Soft tissue and hard tissue equilibrium

60
Skeletal consideration
• Vertical dimension
• Upper to lower face height of 45%: 55% is optimal

61
Dental
• 4.0 mm upper incisor intrusion can be accomplished without any
significant root resorption.
• Persons who show signs of root resorption before the start of the
treatment, or those who have history of allergies/asthma are likely
to show more root resorption during incisor intrusion.

62
Occlusal plane
• Flat occlusal plane
• Step type of occlusal plane

63
Interocclusal space
• Normal interocclusal space is between 2 to 4 mm
• The correction of a deep overbite by extruding posterior

teeth to encroach on this space should be avoided
(Moyers, 1988)

64
DIFFERENT AGE GROUPS

65
Primary dentition
• Rarely treated
• Typically postponed until the mixed dentition

66
Mixed Dentition
• Skeletal bases are class I with normal incisor angulation – Wait and
watch
• Utility arch that incorporates molar and incisor teeth
• Deepbites with anterior vertical maxillary excess showing gummy
smiles - high pull headgears

67
Early Mixed Dentition
• Class II div I growing patients intrusion or prevention of excessive
eruption of the lower incisors is achieved by leveling out an
excessive curve of Spee with the continuous arch wire mechanics
from molar to incisors.

68
Early permanent dentition
• In the absence of growth, absolute intrusion is required
• In moderate cases a flat maxillary bite plane is used in conjunction
with full-banded therapy

69
Adults
• In adult patient showing excessive deep overbite of 100 % or more,
with accompanying - High smile line, decreased Vertical facial
height, Alveolar problems.
• Orthognathic correction of the problem.

70
Appliances and
Techniques

71
Removable
• The bite plane elevates molars but has no anterior intrusive effect.
(Strang;1958)

72
Removable
Myofunctional appliance
• Deep bite due to developing class II div I pattern -
Activator and bionator

73
Removable
Headgears
• High pull headgear
• Cervical headgear

74
Intrusion of anteriors
Burstone (1977) has outlined 6 principles that must be considered in
incisor or canine intrusion mechanics
1.Force levels – optimal magnitude, constant delivery and low load
deflections.
Burstone CR. Deep overbite correction by intrusion. American journal of orthodontics. 1977 Jul 1;72(1):1-22
75

76
2. Use of the single point contact in the anterior region

77
3. Selection of the point of force application with respect to the centre
of resistance of the teeth to be intruded

78
4. Selective intrusion based on anterior tooth geometry

79
5. Posterior anchorage to control over the reactive units

80
6. Control over undesirable extrusive effects on the posterior teeth.

81
Method for intrusion
• With continuous archwires that bypass the premolar

(and frequently the canine) teeth

82
Method
• With segmented archwires (so that there is no

connection along the arch between the anterior and
posterior segments) and an auxiliary depressing
arch.

83
• Anchor bend.
• Mulligan’s intrusion arch.
• Burstone’s intrusion arch.
• Utility arch.
• Three piece intrusion arch.
• K- SIR APPLIANCE
• Connecticut intrusion arch

84
Anchor bend

85
Mulligan’s intrusion arch

86
Burstone’s intrusion arch

87
Burstone’s intrusion arch

88
School of Dental Sciences Bharatpur, Chitwan, Nepal
Management Of Deep Bite
Presented by : Guided by-

Dr Ajay Chhetri (MDS 2nd Y)
Prof Dr Basanta Kumar Shrestha
Dr Madhurendra Prasad Sah
Dr Rockey Shrivastava

89
Contents
1. Introduction✓
2. Classification✓
3. Prevalence✓
4. Diagnosis✓
5. Treatment Considerations✓
6. Management
7. Retention
8. Conclusion
9. References
90
Utility arch
• Given by Robert Ricketts in 1976.

91
• Dimension in an 0.018" slot
Non heat treated blue elgiloy

0.016" x 0.016" or 0.016" x 0.022”(mandible)
0.016" x 0.022” (maxilla)
• Dimension in an 0.022" slot
Blue elgiloy 0.019" x 0.019”

92
Utility arch

93
Activation

94
95
Three piece intrusion arch

96
Three piece intrusion arch

97
98
K- SIR APPLIANCE
• K-SIR (Kalra Simultaneous Intrusion and Retraction)

• It is a continuous .019" × .025" TMA archwire with closed 7mm ×
2mm U-loops at the extraction sites
99
Kalra V, Simultaneous intrusion and retraction of the Anterior teeth. J. Clin. Orthod 1998;35(9),535-540)
100
101
102
103
104
Connecticut intrusion arch
• The CTA is fabricated from a nickel titanium alloy.

• It incorporates the characteristics of utility arch as well as those of the
conventional intrusion arch.
• Two wire size are available 0.016” x 0.022” and 0.17” x 0.25” niti.

105
Connecticut intrusion arch

106
107
Relative intrusion & extrusion

108
Relative intrusion & extrusion
Drawback:
• Extrusion is more easily accomplished while obtaining minimal
anterior intrusion.
• No definite control over mechanics.
(Woods;1988)

109
Intrusion with Miniscrews

110
UPPER INCISORS INTRUSION USING
MINISCREWS
• In a patient with a gummy smile or over - erupted upper incisors,
additional miniscrews can be placed in the upper anterior region to
produce a vector of force that counteracts occlusal plane rotation and
preserves anterior torque.
• These miniscrews can be placed between either the central and

lateral incisors or the lateral incisors and canines.
Jung MH, Kim TW. Biomechanical considerations in treatment with Miniscrew Anchorage. Part-I The sagittal plane. JCO.
2008;42(2):79-83.

111
112
UPPER INCISOR INTRUSION USING
MINISCREWS
Vela-Hernández et al. One versus two anterior miniscrews for correcting upper incisor overbite and angulation: a retrospective comparative study Progress in
Orthodontics (2020) 21:34

113
Vela-Hernández et al. One versus two anterior miniscrews for correcting upper incisor overbite and angulation: a retrospective comparative study Progress in
Orthodontics (2020) 21:34

114
Surgical Treatment

115
Envelop of discrepancy
Maxilla Mandible
117
Retention and
stability

118
Factors affecting retention
• Age.
• Facial type.
• Molar extrusion/ Incisor intrusion.
• Interincisal angle.
(Nanda;2010)

119
Retention
• Finishing arch wires should have appropriate bends
• A potential bite plate into the retainer
• Hawley retainer with a slight acrylic coverage on the gingival one
third of the lingual of incisors

120
Conclusion
• Deep overbite is a common malocclusion in adults and children.
• During treatment planning, considerations should be given to the

soft tissue, skeletal pattern, stability, occlusal plane, interocclusal
space, treatment time and age of the patient.
• It should be decided which method will be more beneficial or which

will improve the patients facial appearance and functional efficacy

121
References
1. C sreedhar, Sreenivas Baratam, Deep overbite—A review, Annals and
Essences of Dentistry, Vol I issue 1 July – September 2009
2. Schudy, The Rotation Of The Mandible Resulting From Growth: Its
Implications In Orthodontic Treatment Angle Orthod (1965) 35 (1): 36–50
3. Amarnath B.C, Prashanth C.S, Dharma R.M, Clinical Overview of Deep Bite
Management, Int Journal of contemporary dentistry, November, 2010, 1(2)
4. Varshini et al. Deep Bite- An Overview European Journal of Molecular &
Clinical Medicine Volume 07, Issue 08, 2020
5. Lombardo G. et al. Worldwide prevalence of malocclusion in the different
stages of dentition: A systematic review and meta-analysisEuropean Journal
of Paediatric Dentistry vol. 21/2-2020
122
References
6. R.Yadav, B. K.Shrestha, N.Yadav, P.Basel (2018). Prevalence of Dental Deep bite
in Nepalese Adolescents of Kathmandu Valley. Journal of Institute of Medicine
7. PETER H. BROOK AND WILLIAM C. SHAW The development of an index of
orthodontic treatment priority European journal of orthodontics 11 (1989) 309-
320
8. Burstone CR. Deep overbite correction by intrusion. American journal of
orthodontics. 1977 Jul 1;72(1):1-22
9. Kalra V, Simultaneous intrusion and retraction of the Anterior teeth. J. Clin.
Orthod 1998;35(9),535-540)
10. Philippe J. Treatment of deep bite with bonded bite planes J Clin. Orthod
1996; 30: 396 – 400

123
References
11. Philippe J. Treatment of deep bite with bonded bite planes J Clin.
Orthod 1996; 30: 396 – 400
12.Nanda R. Differential Diagnosis and treatment of excessive
overbite. DCNA 1981;25:61-83.
13.Nanda R. Connecticut intrusion arch, JCO, 1998 ,35:12:708-715
14.Jung MH, Kim TW. Biomechanical considerations in treatment with
Miniscrew Anchorage. Part-I The sagittal plane. JCO. 2008;42(2):79-83.
15.Vela-Hernández et al. One versus two anterior miniscrews for
correcting upper incisor overbite and angulation: a retrospective
comparative study Progress in Orthodontics (2020) 21:34
124
125

Management of Deep Bite

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School of Dental Sciences Bharatpur, Chitwan, Nepal

Management Of Deep Bite

Presented by : Guided by-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

• This condition was first recorded in the german literature in 1912 by

Department of Orthodontics and Dentofacial Orthopedics-

(Moyers et al, 1988)

Department of Orthodontics and Dentofacial Orthopedics-

Skeletal deep Dental deep

Department of Orthodontics and Dentofacial Orthopedics-

Producing the 3 to 4 degree decrease in mandibular plane

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Over-eruption Infra occlusion

Department of Orthodontics and Dentofacial Orthopedics-

Class II div II Class II div I

Large interocclusal clearance Normal or small

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

I Lower incisor impinge into palatal mucosa

II Lower incisors incisal edge occlude into palatal gingival

III Both maxillary and mandibular incisors incline lingually

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Grade ((Brunelle et al, Amount

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

2. Decreased ramus height.

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

• It is better to have some gumminess during the shorter episodes of

Department of Orthodontics and Dentofacial Orthopedics-

• Short upper lip - intrusion of upper incisors

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-

Department of Orthodontics and Dentofacial Orthopedics-