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Deep bite: Treatment options and challenges

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


Ramzi V. Haddad, DDS, MS

While deep overbite typically accompanies all classes of malocclusion, it


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

Introduction mucosa and can in extreme situations lead to the


loss of maxillary incisors.
eep overbite refers to the increase of overlap
D of maxillary incisors over mandibular inci-
sors beyond the normally reported coverage of 30
Like open bite, deep overbite exists with the
various malocclusions (Class I, II, and III), but
severity is mostly associated with skeletal hypo-
40%.1 Although many practitioners refer to the
divergence typically found in Class II, division 2.
overbite in millimeters, the percentage compu-
Accordingly, skeletal and dentoalveolar charac-
tation is more revealing because of the variation in
teristics include shortened anterior lower face
the crown height of the mandibular incisors. Also,
height, at mandibular plane angle, more acute
the inclination of both maxillary and mandibular
gonial angle, parallel upper and lower occlusal
incisors impacts the amount of overbite, which
planes, and deep curve of Spee in the man-
would decrease when these teeth are proclined
dibular arch.3
and increase when the incisors are retroclined.
Clinical observations indicate that maxillary
When the mandibular incisors impinge on the
molars tend to be infracluded when a skeletal
maxillary palatal mucosa behind the maxillary
dysplasia is present, in contrast to the over-
incisors, the deep bite is severe, regardless of the
eruption of the incisors in dental deep bites.
amount of virtual coverage of the mandibular
While targeted research is still needed in this
incisors by their antimeres. In addition to the
diagnostic area, Janson et al.4 demonstrated in
functional problems they cause, very deep imping-
a study of molar and incisor vertical dimension in
ing overbites2 can jeopardize the maxillary palatal
12-year-old children with excess, normal, and
short lower anterior face height (LFH) that
Division of Orthodontics and Dentofacial Orthopedics, American
(1) the dentoalveolar heights are signicantly
University of Beirut, Beirut, Lebanon; Lebanese University, Beirut,
Lebanon; New York University, New York, NY; University of different between faces with excessive, normal,
Pennsylvania, Philadelphia, PA. and short LFH, except for the lower posterior
Address correspondence to Ramzi V. Haddad, DDS, MS Division dental height, which did not differ between
of Orthodontics and Dentofacial Orthopedics, American University of subjects with short and normal LFH; and (2) the
Beirut Medical Center, P.O. Box 11-0236, Riad El-Solh, Beirut 1107
2020, Lebanon. E-mail: rh52@aub.edu.lb
maxillary teeth present a higher correlation to
the upper/lower face height ratio than the
& 2013 Elsevier Inc. All rights reserved.
1073-8746/13/1801-$30.00/0 mandibular teeth, a higher percentage of this
http://dx.doi.org/10.1053/j.sodo.2013.07.005 ratio (44%) being explained by the maxillary and

Seminars in Orthodontics, Vol 19, No 4 (December), 2013: pp 253266 253


254 Ghafari et al

mandibular incisors than by the maxillary and of teeth is more difcult to achieve than
mandibular molars (22%). extrusion.
The etiology of deep bites, at least when con-
trasting the Class II, division 2 with the long face (1) In growing patients, strategies can be employed
syndrome, may be attributed to heredity5 and for deep bite correction that are not available
development, but unlike open bite, it has not been in adults: the extrusion of the buccal segments
related to pathologic factors (e.g., blocked airways can be compensated for by the vertical ramal
leading to mouth breathing). In this context, the growth.9,10 Also, relative intrusion of incisors is
opposite phenotypes differ in how the environ- achieved, holding them in place while the
ment affects them. While environmental factors other teeth and the face are developing.
such as respiratory mode and habits have not been (2) Correction of a deep overbite in the late
incriminated in the genesis of hypodivergence, mixed or early permanent dentition appa-
the prevalence of dental anomalies (missing rently is stable when compared to untreated
teeth5 and delayed dental development3) controls.11 However, deep bite correction in
associated with Class II, division 2 adds support, the mixed dentition followed up into
albeit nonconclusive, to the concert of more retention of phase 2 treatment was mainly
genetic control of this malocclusion. From this due to a signicant proclination of the
perspective, treatment of deep bite may not incisors.12
depend on intercepting the etiology as much as (3) Treatment of deep bite at puberty in the
avoiding the worsening of the condition during its permanent dentition leads to signicantly
development. Nevertheless, the musculature more favorable outcomes than treatment
associated with mandibular function (masseter before puberty in the mixed dentition.13
and medial pterygoid) has been shown to have (4) The extrusion of the buccal segments in non-
different characteristics in hypodivergent versus growing patients will rotate the mandible in
hyperdivergent facial patterns.6,7 a clockwise (backward) direction that might be
The aim of this article is to review the undesirable when the patient already presents
evidence-based treatment of deep overbite and a hyperdivergent facial pattern. Such topog-
demonstrate that while challenges to orthodontic raphy actually occurs more often than expected
treatment, mainly stability and esthetics, may lead reaching a ratio of 40%.14 In these instances,
to compromises, problems exist even within labial tipping of the incisors, if indicated, can
orthognathic therapy of this vertical dysplasia simulate a decrease in overbite.1517
that may also dictate less than ideal results. We do (5) Intrusion of incisors is not properly docu-
not display the variety of options vastly described mented because frequent cephalographs,
in the literature, rather we focus on basic treat- needed for superimpositions, are not permit-
ment principles. ted by research review boards. Proclination of
incisors and extrusion of molars may be
misinterpreted as true intrusion in the absence
State of evidence on treatment of deep
of convincing radiographic proof.8,1821
bite
Intrusion without proclination can be
Management of deep bite becomes more dif- achieved by the application of intrusive
cult with the existence of, or the increased forces close to the center of resistance.22,23
severity of, an underlying skeletal discrepancy (6) Intrusion constitutes a major risk for root
(hypodivergent skeletal pattern). Despite the resorption, as much of the mechanical load is
extensive amount of published articles, most of applied on the apex.24,25
the associated research remains at the lower tier (7) While the range of intrusion is variable,
of the evidence scale, and this review reects the intrusion is more successful (potentially
variability of that level, highlighting the need for more predictable) with the use of temporary
further investigation. anchorage devices or osseointegrated
Nonsurgical correction of a deep bite includes implants with no counteractive movements
molar extrusion, incisor intrusion, or a combi- in the molars.23,26
nation of both,8 with a general understanding (8) Information on treatment and stability of
from the cumulative literature that intrusion correction of Class II, division 2 are based on
Potential and Limitations of Vertical Correction 255

highly biased evidence27; however, guide- Intrusion of incisors


lines for treatment are drawn on current
In patients with deep bite and a normal or increased
evidence until further research provides
lower facial height, the indication of intrusion of
more generalizable results.
maxillary and/or mandibular incisors encompasses
(9) Randomized clinical trials (RCT) are needed
the following conditions: excessive distance between
to understand the biological and mechanical
the incisal edge (incision) and stomion, large
outcomes of intrusion, its optimal applica-
interlabial gap, and more occlusal level of central
tion with respect to function, periodontium
incisors relative to lateral incisors. However, the
and esthetics, and whether intrusion mecha-
upper lip line during smile is a critical factor in
nics produce a more stable overbite correc-
determining whether the maxillary incisors should
tion than other methods of leveling.
be intruded, rather than the molar teeth needing
However, RCTs are difcult to conduct for
extrusion. The lip line may actually intersect the
ethical, administrative, and nancial reasons.27
maxillary incisors, which paradoxically would need
to be extruded for better smile esthetics, while the
Treatment options deep bite may otherwise dictate intrusion.
The intrusive force should be exerted through
Mechanical considerations
the center of resistance of the incisors to avoid
Three main orthodontic mechanics constitute their proclination.28 Different methods have
the basis to correct a deep anterior overbite: been developed to intrude incisors, basically
intrusion of the incisors, extrusion of posterior classied in continuous arches (Fig. 1) or
teeth, and proclination of incisors. These segmental techniques. Continuous arches
modalities are indicated separately or in combi- (usually including increased curves of Spee
nation depending on the diagnostic component and/or selective vertical steps) have been
analysis. We discuss them briey with differ- described to result in molar extrusion29 and
entiation of their application in growing and incisor buccal tipping.30 Segmental techniques
non-growing patients. include Ricketts' utility arch, Burstone's intrusive

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

arch, and variations thereof.31 To minimize side However, this discrepancy is often adjusted
effects, the archwire is prevented from moving toward the end of treatment to line up the
forward and proclining the incisors by tying the marginal ridges.
wire back. Adjunct appliances are used to control (2) Leveling the dental arches (essentially at-
molar extrusion, such as high-pull headgear, tening the curve of Spee) by using sequen-
against the permanent rst molars and larger tially stronger archwires, and often reversing
anchor units (e.g., palatal bar between right and the curve of Spee in the mandibular arch and
left posterior teeth).32,33 Buttressing posterior exaggerating it in the maxillary arch (at the
anchorage is particularly required when a ten- extreme, they resemble a rocking chair).
dency to skeletal vertical hyperdivergence is (3) Including posterior teeth (second molars) in
associated with the dentoalveolar deep bite.34 the xed assembly, and when possible in the
All types of advocated mechanics apply tip initial arch leveling.
back bends at the level of the molars to generate (4) Increasing step bends progressively to the
the intrusive forces.3538 The methods differ with occlusal level, from incisors, canines, premo-
the wire size and material, method of attachment lars, to molars. These bends are mainly
to the brackets, force amounts, and the inclusion indicated when the anterior and posterior
of torque within the force system. occlusal planes are at different levels, with a
The most important factors in the selection of minimal to moderate incisor display. Their use
intrusive mechanics are the determination of must be controlled at times with anterior bite
side effects and the adherence to the appropriate plates to facilitate movement, but also mini-
physical principles (forces relative to centers of mize the expected slight intrusion of incisors.
resistance, computed moments, and controlled (5) Anterior bite plates. They may be removable
anchorage). Rocking chair nickel-titanium (Fig. 2) or xed. Their effect is mainly on the
wires with pronounced curves of Spee have mandibular arch, as they facilitate leveling of
been promoted as a means of reducing overbite the mandibular curve of Spee. They are very
simultaneously by molar extrusion and incisor effective in growing patients. When used along
intrusion. Because the wires are exible, they also xed appliances, particularly in the mandi-
offer the prospect of full bracket engagement bular arch, the leveling is maintained with
early in the course of treatment. stiffer wires. When used in conjunction with
Also advocated to intrude the maxillary inci- posterior vertical elastics worn between maxi-
sors are high-pull headgears (e.g., J-hook head- llary and mandibular posterior teeth, these are
gear), which may be associated with heavier extruded faster. Patient compliance is critical
forces than normal. Heavy forces increase the with removable appliances, whereby alter-
risk of root resorption on the maxillary incisors, native xed devices have been designed for
which are actually more prone to this side non-cooperative patient particularly.
effect.39 The xed auxiliaries40 include composite
platforms placed freehand or bite turbos
(prefabricated bracket-like platforms) bonded
Extrusion of posterior teeth
on the palatal surfaces of maxillary incisors to
This movement is the most common method to separate the posterior teeth (Fig. 2F). These
correct deep overbite, with 1-mm extrusion of methods may interfere with speech and
maxillary or mandibular posterior teeth effec- comfortable chewing at rst, but patients
tively reducing the incisor overlap by 1.52.5 mm. tend to adjust after a few days. They are
This modality is indicated in patients with a short only useful when the overjet is not incre-
lower facial height, excessive curve of Spee, and ased and the patient cannot bite posterior
incisor display upon smiling ranging from nor- to the xed bite plane, limiting their exten-
mal to minimal. sion to approximately 34 mm in antero-
Strategies employed to effect the extrusion posterior depth.
include the following: Platforms may be cemented or bonded on
selective posterior teeth (e.g., starting with
(1) Altering bracket heights by placing the second molars) until the teeth anterior to the
anterior brackets at a more occlusal level. covered teeth are extruded, usually with vertical
Potential and Limitations of Vertical Correction 257

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

elastics alone or together with vertical bends. effect of treatment. If indicated to remedy the
When the extruded teeth touch, the platforms overbite, it should be part of a predetermined
are removed and their supporting teeth in turn treatment plan. Indications include malocclusion
extruded. Anchorage is reduced in the arch with lingually tipped incisors, such as Class II,
where the teeth are intended to be extruded division 2 or Class III.
(e.g., lighter wires are usedsee differential
extrusion in Section Esthetic considerations).
Considerations in growing individuals
(6) When indicated, Class II elastics help extrude
mandibular molars, but may also extrude the Most hypodivergent patterns at the age of 6 years
maxillary anterior teeth, requiring the inclu- (58%) remain at 15 years of age42; yet 36% shift
sion of forces and moments to counteract this closer to normal divergence and (unexpectedly)
side effect (e.g., increased maxillary curve of 4% to hyperdivergence. These results indicate
Spee). While this control is needed, the that a hypodivergent pattern persists through the
topography of the maxillary-mandibular rela- growth spurt in most subjects, but the data also
tions is such that 1 mm of molar extrusion still suggest that the capacity for some traits to change
yields more bite opening even if accompanied is greater during childhood than adolescence.
by 1 mm of incisor extrusion. Accordingly, early treatment should be con-
templated while the malocclusion is developing.
Treatment usually aims at enhancing the
Proclination of incisors
eruption of the posterior teeth, while maintain-
The proclination of maxillary and mandibular ing the height of the incisors, especially if an
incisors decreases the amount of overbite,41 and underlying skeletal hypodivergence exists. A
unlike the previous two options, it occurs as a side removable appliance with an anterior bite plate
258 Ghafari et al

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

can achieve this objective (Fig. 3). The correction permanent rst molars and incisors is sufcient,
of dentoalveolar deep bite increases the overjet, with the appropriate anchorage considerations,
demonstrating that an occlusal problem is not as an intrusive arch will also promote extrusion
limited to one plane of space. Retraction of the of the molars. True intrusion is difcult to ach-
incisors to reduce the overjet may be accom- ieve and is not as easily attainable as extrusion.
plished with the same appliance by stretching However, in a growing individual, stabilization of
elastics against those teeth. the incisors is considered a relative intrusion
Fixed appliances can be used to accomplish since their vertical movement is impeded relative
the same objectives. Partial banding/bonding of to the other teeth.43 Retention of an early
Potential and Limitations of Vertical Correction 259

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

overbite correction is necessary, usually with a does not completely negate the possibility of
bite plate incorporated in the removable retainer opening the bite under circumstances requiring
worn at night, especially if the problem is extraction (e.g., crowding).
associated with a skeletal hypodivergence. The option for compromised results, with
minimal intervention for a specic target must be
properly weighed, particularly when an extensive
Considerations in non-growing patients
intervention involving the entire dentition would
With limited growth left in post-adolescence likely lead to lengthy treatment, reduced esthe-
spurt and practically none in adulthood, more tics, serious side effects (periodontal loss and
emphasis is assigned to adjunct orthognathic root resorption), or orthognathic surgery that
surgery in the malocclusions with severe skeletal the patient originally rejected (Fig. 6).
dysplasias. Often such surgery requires man-
dibular advancement, but when the maxilla is
Esthetic considerations
hypoplastic with reduced dentoalveolar heights,
maxillary downward movement is indicated, a Although the increase in lower face height con-
displacement that warrants special consideration comitant with bite opening is usually an esthetic
for long-term stability (Fig. 4). Proft et al.44 rank advantage in the treatment of deep overbite,
this movement in the bottom third (one of the particularly when associated with skeletal hypo-
lowest problematic) on the scale of stability and divergence, other esthetic considerations are
predictability of the various surgical methods. warranted. The most critical concerns relate to the
Obviously, the concept of camouage may be upper lip line in relation to the maxillary incisors
applied, denoting an acceptable normalization of and the depth of the mental sulcus in relation to
occlusal relations with favorable esthetic results the mandibular incisors.
both in the alignment of the teeth within the Often, and particularly in association with a
arches and their environment (chin, lips, and decreased lower face height and in males, the
nose). While this principle often implies extraction intrusion of incisors would be contraindicated
of teeth (usually premolars) in the context of the because of a low lip line during smile. In these
correction of overjet or open bite, it would tilt more instances, the upper lip tends to be longer than
often to nonextraction in the correction of the average, but this detail must be corroborated with
deep bite (Fig. 5), mainly for mechanical reasons to further research. In a growing child, appliances
avoid worsening the deep bite. This realization may be used to favor extrusion of posterior teeth
260 Ghafari et al

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

and prevent the vertical position of the maxillary the posterior teeth, such as described in Section
incisors to be depressed. In adolescents and Extrusion of posterior teeth. Sustained retention
adults, a viable approach is what we term Maxillary is applied with an anterior bite plate worn at night.
Incisors Esthetic Differential Extrusion (MIEDE). The sagittal relationship between the jaws is
The method consists of disarticulating the pos- critical because bite opening increases the overjet.
terior teeth to extrude them, forcing a separation Optimal results may be achieved if retroclination of
of the anterior maxillary and mandibular incisors the maxillary incisors is recommended to remedy
(Fig. 7). Afterwards, the maxillary incisors are this side effect. However, if the upper lip is in its
extruded. The process may be repeated until an proper position and the only remaining ortho-
appropriate lip line to maxillary incisors dontic alternative is to procline the mandibular
relationship is attained. Differential archwires incisors to bridge the overbite, deepening of the
are used in this process, whereby a heavier mental sulcus may represent an esthetic com-
archwire is used in the anchoring arch and a promise, assuming that the proclination of the lower
lighter one in the active quadrants. Bite ele- lip secondary to tooth proclination is acceptable.
vation may be achieved with a removable (or Expectations in treatment of deep bite must
xed) bite plate and vertical elastics stretched be realistic, as it is unlikely that a hypodivergent
between the posterior teeth. Posterior xed pattern with a square face would be drastically
sequential platforms may be used to extrude altered, much like a convex face with mandibular
Potential and Limitations of Vertical Correction 261

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

retrognathism associated with Class II maloc- Depending on the diagnostic features, the
clusion would not look orthognathic despite the clinician may end up selecting a compromise
correction to neutroclusion. Only surgery might alternative plan to the ideal approach in the
be expected to minimize the original phenotype. following ways:

Treatment challenges
 Addressing limited objectives to resolve a
specic patient complaint, reduce treatment
Potential limitations in treatment outcome relate time, or avoid surgery (Fig. 6). In the latter
to treatment planning, whether a specic plan is consideration, full treatment would disclose a
actually achievable, or to treatment methods, in worse malocclusion that can only be resolved
essence technical and mechanical limitations. through orthognathic surgery.
262 Ghafari et al

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

 Giving more weight to esthetic considerations compromised dental health (existing restora-
and awareness, sometimes at the expense of tions/severe caries and root resorption), and
evidence available for occlusal stability. mechanical limitations (difcult space closure,
 Minimizing the side effects of treatment such especially extraction spaces, and resistance to
as root resorption, periodontal complications, intrusionmainly in adults).
or temporomandibular joint dysfunction. Compliance is obviously a primary component
of success, particularly in children required to
While most of these choices might be patient wear a headgear, a functional appliance,
driven, certain limitations are necessary for more removable bite plates, or elastics. Growth direc-
objective reasons: the nature of the occlusion tion and amount are also dening factors for
(missing teeth and mutilated dentition), treatment success in children.
Potential and Limitations of Vertical Correction 263

The long-lasting challenge of deep overbite treatment of deep bite may be the strategy to
correction is the stability of tooth movements, overcome vertical hypoplasia as the expression of
particularly posterior teeth extrusion in severe various etiologic and developmental factors, and
hypodivergent facies with hyperactive muscu- then retain it with the possible persistence of
lature. In a 10-year postretention study of deep these factors.
bite correction, Simon and Joondeph45 repor- The evidence on amount of intrusion of
ted that proclination of mandibular incisors incisors versus extrusion of molars is difcult to
and a clockwise rotation of the occlusal plane gauge because cephalometric records are scarce
during treatment were signicant relapse and are often forbidden just for the purpose of
factors. Binda et al.46 found the relapse of immediate post-intrusion evaluation. Long-term
overbite correction of Class II, division 2 to be post-treatment records often include additional
only at about 20% at 2-year postretention; this variables that mask the exclusive effect of the
percentage doubled at 15-year follow-up. The intrusion mechanics. A meta-analysis48 aimed at
authors further indicated that with large indi- quantifying the amount of true incisor intrusion
vidual variations, the tendency for maxillary determined on cephalometric superimpositions
incisor relapse was greater than that of the yielded only four studies that met the inclusion
molar correction. On the other hand, Burzin criteria. While true incisor intrusion is achievable
and Nanda47 reported that the intrusion of in both arches, the clinical signicance of the
maxillary incisors was stable at long-term; their magnitude of true intrusion as the sole treatment
results showing that an average incisor intrusion option was questionable for patients with severe
of 2.3 mm relapsed an insignicant average deep bite. In non-growing patients, the seg-
amount of 0.15 mm up to 2 years after treat- mented arch technique can produce 1.5 mm of
ment. The issue of stability remains contro- incisor intrusion in the maxillary arch and
versial. In addition to variations in orthodontic 1.9 mm in the mandibular arch.48
mechanics, variables such as amount of growth, Tooth extrusion reects a basic form of tissue
muscle strength, muscle adaptation, and the engineering,49 facilitating bone formation and
original malocclusion are factors contributing corresponding movement of the periodontal
to the long-term stability, which require further attachment apparatus. The biological changes
research. following intrusion are not as clearly dened,
which is again probably because intrusion is more
difcult to achieve, and as an orthopedic
Discussion movement, it aims at resorbing bone in a
direction (up or down) more restrained than
Research issues and challenges
in other movements (e.g., mesial and distal)
Confounding the study of deep overbite is the where bone resorption occurs. Both animal and
usual coexistence of a sagittal component clinical research22,50 has shown that intrusion of
(mainly Class II), which may qualify the maloc- incisors is possible with a controlled force system,
clusion as tting the study of the sagittal problem even in reduced periodontium, but is variable
more than the vertical problem. In this per- (03.5 mm in adults22). Much work is required to
spective, it may be useful in research to assign gauge the predictability of the movement under
severity scores to the malocclusion components various clinical conditions.
in each dimension and to classify predominantly Research has not fully explored the overbite
vertical malocclusions when the relative vertical malocclusion with attention to its variable com-
severity score is greater than the grades in the ponents. The basic tenet remains that when
other dimensions (sagittal and transverse). indicated, intrusion and/or proclination of
Ideally, randomized clinical trials should be maxillary anterior teeth and extrusion of the
conducted, but we suggest that even deep bite posterior teeth are applied and often maximized
phenotypes may not be grouped together simply to obtain a more optimal occlusion. Commen-
on the overlap between anterior teeth and surate facial esthetics and long-term stability,
should at least be differentiated on the basis of understandably connected with the original
presence or absence of maxillary and mandibular severity of the problem, also require targeted
vertical skeletal hypoplasia. In its simplest form, investigation. In this endeavor, the consideration
264 Ghafari et al

of deep bite as the biologic opposite of open bite lower face height to even the high-angle skel-
is a misguided conception, much like the thought etal pattern. Esthetic and mechanical consid-
that Class III is the opposite of Class II. The erations obviously vary in a parallel way,
extreme poles reect totally different phenotypes disclosing potential for improvement but also
with differing etiologies, with research indicating with many challenges, the most potent of which
that more genetic components may be at play in are the stability of results in the severe maloc-
the deep bite (mainly Class II, division 2)5 and clusions, and favorable facial esthetics. Often the
Class III mandibular prognathism,51 while more achievement of the latter requires long-term
environmental factors would participate in the retention. Existing protocols for treatment fol-
evolution of open bite and distoclusion. low more generic than individual guidelines,
progressing to surgical considerations with
Guidelines for stability increased severity of an underlying hypo-
divergence. Most of the available publications
Based on present evidence, a number of clinical
remain at the lower tier of the evidence scale, and
guidelines may be derived to foster stability:
research at the various levels is indicated.
(1) Treat a developing deep overbite early,
probably as soon as a worsening growth
pattern is recognized. The strategy is to
eliminate any known etiology and maintain References
the bite open. In a Class II, division 2 1. Moorrees CFA, Gron AM, Lebret LM, et al: Growth
studies of the dentition: a review. Am J Orthod 55:600-
malocclusion, the severe retroclination of
616, 1963
maxillary incisors would be addressed in a 2. Nasry HA, Barclay SC: Periodontal lesions associated with
timely manner consistent with the develop- deep traumatic overbite. Br Dent J 200:557-561, 2006
ment of the roots to avoid dilacerations. 3. Ghafari J, Street KW: Dental development in children
(2) Avoid extraction of premolars, particularly in with Class II, division 2 malocclusionFour types of the
malocclusion dened In: Davidovitch Z, Mah J eds.
very deep bites, given the potential for
Biological Mechanisms of Tooth Eruption, Resorption,
deepening of overbite, reopening of extrac- and Replacement by Implants. Boston, The Harvard
tion spaces, and detrimental effects on facial Society for the Advancement of Orthodontics 1998,
esthetics (upper lip retrusion and increased pp 8589-8596
nasolabial angle, particularly with thin upper 4. Janson GR, Metaxas A, Woodside DG: Variation in
maxillary and mandibular molar and incisor vertical
lip).27,52 Such side effects would favor non-
dimension in 12-year-old subjects with excess, normal,
extraction or if necessary extraction of more and short lower anterior face height. Am J Orthod
posterior teeth (such as second molar and Dentofacial Orthop 106:409-418, 1994
distalization of teeth or second premolar and 5. Hartseld JK Jr.: Genetics and orthodontics In: Graber
minor retraction of the teeth mesial to it). LW, Vanarsdall RL, Vig KWL eds. Orthodontics: Current
Principles and Techniques 5th ed. St Louis, Elsevier
(3) Long-term retention, particularly if maxillary
Mosby, 2011, pp 139-156
incisor inclination has been compromised: 6. Al-Farra ET, Vandenborne K, Swift A, et al: Magnetic
retroclined in the maxilla and proclined in resonance spectroscopy of the masseter muscle in
the mandible. The latter may lead to later different facial morphological patterns. Am J Orthod
crowding without prolonged retention.27 Dentofacial Orthop 120:427-434, 2001
7. Boom HP, Spronsen PH, Ginkel FC, et al: A comparison
(4) Enhance sustainability of the correction with the
of human jaw muscle cross-sectional area and volume in
mode of retention, such as the use of a bite plate long- and short-face subjects, using MRI. Arch Oral Biol
at least at night (particularly in growing patients) 53:273-281, 2008
to keep the molars elevated and the incisors at 8. Parker CD, Nanda RS, Currier GF: Skeletal and dental
the corrected height and inclination.27,53 changes associated with the treatment of deep bite
malocclusion. Am J Orthod Dentofacial Orthop
107:382-393, 1995
Conclusion 9. Sankey WL, Buschang PH, English J, et al: Early treat-
ment of vertical skeletal dysplasia: the hyperdivergent
While the centerpiece of this analysis is the deep
phenotype. Am J Orthod Dentofacial Orthop 118:317-
overbite, the skeletal components around it vary 327, 2000
in a myriad of arrangements, ranging from the 10. Otto R, Anholm J, Engel G: A comparative analysis of
severe hypodivergent pattern with diminished intrusion of incisor teeth achieved in adults and children
Potential and Limitations of Vertical Correction 265

according to facial type. Am J Orthod Dentofacial Orthop and adolescents: a systematic review. Am J Orthod
77:437-446, 1980 Dentofacial Orthop 142:159-169, 2012
11. Al-Buraiki H, Sadowsky C, Schneider B: The effectiveness 28. van Steenbergen E, Burstone CJ, Prahl-Andersen B, et al:
and long-term stability of overbite correction with incisor The relation between the point of force application and
intrusion mechanics. Am J Orthod Dentofacial Orthop aring of the anterior segment. Angle Orthod 75:730-
127:47-55, 2005 735, 2005
12. Franchi L, Baccetti T, Giuntini V, Masucci C, Vangelisti A, 29. Cangialosi T: Skeletal morphologic features of anterior
Defraia E: Outcomes of two-phase orthodontic treatment open bite. Am J Orthod 85:28-36, 1984
of deepbite malocclusions. Angle Orthod 81:945-952, 30. Chang Y, Moon S: Cephalometric evaluation of the
2011 anterior open bite treatment. Am J Orthod Dentofacial
13. Baccetti T, Franchi L, Giuntini V, Masucci C, Vangelisti A, Orthop 115:29-38, 1999
Defraia E: Early vs late orthodontic treatment of deep- 31. Cozza P, Mucedero M, Baccetti T, et al: Early orthodontic
bite: a prospective clinical trial in growing subjects. Am J treatment of skeletal open-bite malocclusion: a systematic
Orthod Dentofacial Orthop 142:75-82, 2012 review. Angle Orthod 75:707-713, 2005
14. Betzenberger D, Ruf S, Pancherz H: The compensatory 32. Kikuchi M, Higurashi N, Miyazaki S, et al: Facial pattern
mechanism in high-angle malocclusions: a comparison of categories of sleep breathing-disordered children using
subjects in the mixed and permanent dentition. Angle Ricketts analysis. Psychiatry Clin Neurosci 56:329-330,
Orthod 69:27-32, 1999 2002
15. Harrison JE, Shaw WC, Worthington HV, et al: Ortho- 33. Beane R: Nonsurgical management of the anterior open
dontic treatment for prominent lower front teeth in bite: a review of the options. Semin Orthod 5:275-283,
children. Cochrane Database Syst Rev: 18 [CD003452], 1999
2007 34. Burstone CJ, van Steenbergen E, Hanley KJ: Deep
16. Kim YH: Anterior openbite malocclusion: nature, diag- overbite correction In: Burstone CJ eds. Modern Edge-
nosis and treatment by means of multiloop edgewise wise Mechanics. Glendora, California, Ormco Corp,
archwire technique. Angle Orthod 57:290-321, 1987 1995, pp 33-48
17. Worms F, Meskin LH, Isaacson RJ: Open bite. Am J 35. Shroff B, Yoon WM, Lindauer SJ, et al: Simultaneous
Orthod 59:589-595, 1971 intrusion and retraction using a three-piece base arch.
18. Weiland FJ, Bantleon HP, Droschl H: Evaluation of Angle Orthod 67:455-461, 1997
continuous arch and segmented arch leveling techniques 36. Begg PR, Kesling PC: The differential force method of
in adult patientsa clinical study. Am J Orthod Dento- orthodontic treatment. Am J Orthod 71:1-39, 1977
facial Orthop 110:647-652, 1996 37. Ricketts RM, Bench RW, Hilgers JJ: Mandibular utility
19. Hans M, Kishiyama C: Cephalometric evaluation of two arch. The basic arch in the light progressive technique.
treatment strategies for deep overbite correction. Angle Proc Found Orthod Res 120-125, 1972
Orthod 64:265-276, 1994 38. Greig DG: Bioprogressive therapy: overbite reduction
20. Noroozi H, Moeinzad H: Extrusion-based leveling with with the lower utility arch. Br J Orthod 10:214-216, 1983
segmented arch mechanics. Int J Adult Orthodon 39. Ghafari J: Root resorption associated with orthognathic
Orthognath Surg 17:47-49, 2002 surgery: modied denitions of the resorptive process In:
21. Van Steenbergen E, Burstone CJ, Prahl-Andersen B, et al: Davidovitch Z eds. Biological Mechanisms of Tooth
The relation between the point of force application and Eruption, Resorption, and Replacement by Implants.
aring of the anterior segment. Angle Orthod 75:730- Boston, Harvard Society for the Advancement of Ortho-
735, 2005 dontics, 1995, pp 545-556
22. Melsen B, Agerbaek N, Markenstam G: Intrusion of 40. Dahl BL, Krogstad O, Karlsen K: An alternative treatment
incisors in adult patients with marginal bone loss. Am J in cases with advanced localized attrition. J Oral Rehabil
Orthod Dentofacial Orthop 96:232-241, 1989 2:209-214, 1975
23. Polat-zsoy , Arman-zrpc A, Vezirolu F, etina- 41. Ball JV, Hunt NP: The effect of Andresen, Harvold, and
hin A: Comparison of the intrusive effects of miniscrews Begg treatment on overbite and molar eruption. Eur J
and utility arches. Am J Orthod Dentofacial Orthop Orthod 13:53-58, 1991
139:526-532, 2011 42. Buschang PH, Sankey W, English JP: Early treatment of
24. McFadden WM, Engstrom C, Engstrom H, et al: A study hyperdivergent open-bite malocclusions. Semin Orthod
of the relationship between incisor intrusion and root 8:130-140, 2002
shortening. Am J Orthod Dentofacial Orthop 96:390-396, 43. Hering K, Ruf S, Pancherz H: Orthodontic treatment of
1989 openbite and deepbite high-angle malocclusions. Angle
25. Upadhyay M, Yadav S, Nagaraj K, Patil S: Treatment Orthod 69:470-477, 1999
effects of mini-implants for en-masse retraction of 44. Proft WR, Turvey TA, Phillips C: The hierarchy of
anterior teeth in bialveolar dental protrusion patients: stability and predictability in orthognathic surgery with
a randomized controlled trial. Am J Orthod Dentofacial rigid xation: an update and extension. Head Face Med
Orthop 134:18-29.e1, 2008 3:21, 2007
26. Ohnishi H, Yagi T, Yasuda Y, et al: A mini-implant for 45. Simon M, Joondeph D: Changes in overbite. A ten years
orthodontic anchorage in a deep overbite case. Angle post-retention study. Am J Orthod 64:349-367, 1973
Orthod 75:444-452, 2005 46. Binda SK, Kuijpers-Jagtman AM, Maertens JK, et al: A
27. Millett DT, Cunningham SJ, O'Brien KD, et al: Treatment long-term cephalometric evaluation of treated Class II
and stability of Class II division 2 malocclusion in children division 2 malocclusions. Eur J Orthod 16:301-308, 1994
266 Ghafari et al

47. Burzin J, Nanda R: The stability of deep overbite 50. Melsen B, Agerbaek N, Eriksen J, et al: New attachment
correction In: Nanda R, Burstone CJ eds. Retention through periodontal treatment and orthodontic intru-
and Stability in Orthodontics. Philadelphia, Pa, W.B. sion. Am J Orthod Dentofacial Orthop 94:104-116, 1988
Saunders Co, 1993, pp 61-79 51. Ghafari J, Haddad R, Saadeh M: Evidence-based treat-
48. Ng J, Major P, Heo G, et al: True incisor intrusion ment of Class III malocclusion In: Huang G, Richmond S,
attained during orthodontic treatment: a systematic Vig K eds. Evidence-based Orthodontics. Wiley-Blackwell;
review and meta-analysis. Am J Orthod Dentofacial 2011, pp 247-280
Orthop 128:212-219, 2005 52. Stellzig A, Basdra EK, Kube C, Komposch G: Extraction
49. Ghafari JG: Preprosthetic orthodontic tooth eruption In: therapy in patients with Class II/2 malocclusion. J Orofac
Baba NZ eds. Contemporary Restoration of Endodonti- Orthop 60:39-52, 1999
cally Treated Teeth: Evidenced Based Diagnosis and 53. Devreese H, De Pauw G, Van Maele G, et al: Stability of
Treatment Planning. Chicago, Quintessence Publishing upper incisor inclination changes in Class II division 2
Co, 2012, pp 115-126 patients. Eur J Orthod 29:314-320, 2007

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