DEEP OVER BITE

ContentsIntroductionDefinitionClassificationDiagnosisClinical featuresTreatment IN PEATreatment in beggsTreatment in functional appliance

IntroductionDeep overbite presents an orthodontist with challenge in any of its many forms.Diagnosis ,treatment planning and appropriate mechanics form an backbone of successful orthodontic treatment.

Etiological ConsiderationAccording to etiological stand point over bite can be differentiate into developmental deep bite and acquired deep bite.

Developmental ( Genetic) Deep BiteSkeletal over deep over bite with a horizontal growth pattern is a common malocclusion.Dentoalveolar deep bite caused by supra occlusion of the incisors, these cases the interocclusal clearance is usually small meaning the over bite is functionally a pseudodeep bite.

Acquired Deep BiteA lateral tongue thrust or postural position frequently can produce acquired deep bite this type of function produce a infra-occlusion of the posterior teeth which intern leads to a deep over bite, the freeway space is large which is favorable for dentofacial orthopedics functional appliance treatment. E.g. class II div. II.

Premature loss of deciduous molars or early loss of permanent posterior teeth can cause an acquired secondary deep over bite, particularly if the contiguous teeth are tipping into the extraction sites.The wearing away of the occlusal surface or teeth abrasion can produce an acquired secondary deep over bite in some patients.

Deep over bite can be localized in either

Dentoalveolar skeletal.

Dentoalveolar deepover biteSkeletal deep over bite

Dentoalveolar deep over biteDeep overbite caused by infraocclusion molars has the following symptoms. Molars are partially erupted.Interocclusal space is large.A lateral tongue thrust and posture are present.The distance between the maxillary and mandibular basal plane and occlusal plane are short.

Deep over bite caused by over eruption of the incisors has the following symptoms:Incisal margins of the incisors extend beyond the functional occlusal plane.Molars are fully erupted. Curve of spee is excessive(compensating curve).Interocclusal space is small.

Skeletal Deep Over BiteIs characterized by a horizontal type of growth pattern.Anterior facial height is short, particularly the lower facial third, where as posterior facial height is long. The horizontal cephalometric planes (sella-nasion, palatal, occlusal and mandibular planes) are parallel or convergent. Interocclusal clearance is usually small

The inclination of the maxillary base is significant in the evaluation of the treatment plane for this type of problem.An extreme horizontal growth pattern can be at least partially compensated by an up and forward inclination of the maxillary base (anti-inclination).The combination of the horizontal growth pattern with a downward and forward inclination (retroinclination) of the maxillary base results in a more severe skeletal deep bite.

Vertical Malocclusion Deep Bite Excessive over bite deciduous dentition.Over bite is the considered to be excessive when the incisors overlap by more than half.Genuine deep bite in a deciduous dentition where the lower anterior teeth are covered completely as result of an increased in the height of the upper anterior alveolar process.An excessive overbite may be encountered during any developmental period of dentition.

Deep bite with class III malocclusion Deep bite conjunction with mandibular prognathism and inverted over bite.This vertical deviation can be related with any anteroposterior or transverse malocclusion.

Length of the clinical crownDeep bite in a patient with long crowns of the incisors but without any increase in height of the anterior alveolar process.

Closed bite caused by loss of posterior teethGingivally supported closed bite resulting from premature extraction of teeth in the mixed dentition. Pathologically the closed bite is caused by an increased forward and upward rotation of the mandible, resulting form lack of posterior dental support.

Functional Classification According to Hotz and Muhlemann (1952) one should different between two types:True deep over bite. Pseudodeep overbite.

True deep over bite Infraocclusion of molars.Large freeway space.The prognosis for successful therapy with functional method is favorable. Pseudo deep over biteMolars are fully erupted.Over eruption of the incisors.The prognosis for successfully therapy with functional method is unfavorable.

If the freeway space is small, extrusion of the molars adversely effect the rest position and may create TMJ problems or cause a relapse of the deep overbite.

Occlusal position.Pseudo deep bite with small freeway space.True deep overbite with large freeway space.

DentoalveolarCephalometrically features are :Deep over bite in a case of vertical growth type, combined with anti-inclination of the maxilla.Lingual tipping of the lower incisors and infra-position of first molar. As downward and backward rotation of the mandible is to be expected, the prognosis for therapeutic bite opening is favourable.

Skeletal Deep BiteCephalometrically features are :Deep over bite is caused by the marked horizontal growth direction of the mandible, which is not compensated by the anti-inclination of the maxilla. Dento-alveolarly, the skeletal displasia is increased by the lingo-version of the upper anterior teeth.

Deep overbite cephalometric featuresDentoalveolar skeletal

Vertical plane normal incisor positionIn a correct vertical relationship the incisal edges contact the occlusal plane.The occlusal plane and the tuberosity plane perpendicularto it.The occlusal plane is defined by the tangent which runs through the tips of the mesiobuccal cusps of the first molars and the buccal cusp of the premalars

The depth of the cure of spee is defined as the distance from the vertx of the curvature to the side of a plastic template placed over the lower arch.The templates touches anteriorly the incisal edges and posteriorly the distsl-most molar cusps.

Supraversion of the incisors with overeruption in relation to the occlusal plane

Tomographic of theright left temporomandibular joints in full inter cuspation.differences between the right and left sides regarding the shape of the condyles, the roof of the fossa, and the with of the joint space.Right ---the condyle and the roof of the fossa are flattened severly; the condyle is dislocated anteriorlyin the glenoid cavity

Adolescent with classII,division I malocclusions and lip dysfunction (lip biting or sucking) are most frequently affected by TMJdisorders. For this reason,orofacial dysfunctions must also be assessed as a part of the functional analysis as they may lead to unbalanced loading of the joints and thus trigger off tempromandibular joint disturbances in adolescents.

Factors effecting the overbiteGrowth of body of maxilla.Vertical growth of the maxilla pushes the mandible downwards and backward thus increasing in anterior facial height and its is due to vertical growth of the maxilla. Ramus heightThe length of the ramus increased it cause the mandible to move away from the maxilla and therefore increase the interocclusal space, if growth of ramus length was restricted its slow down the eruption of the posterior teeth but it did not stop eruption of the anterior teeth leading to an deep overbite.

Madibular condyle Proportionate or disproportionate growth to the rest of the mandible can occur which will effect the over bite. Molar height Degree of eruption of posterior teeth. Incisor height Degree of eruption of incisors.

The degree of overbite was related to the mesiodistal dimension between the upper and lower incisor teeth.

Morphological featuresThe mandible in skeletal deep over bite shows certain distinct feature. Ramus is broad anteroposteriorly with a big coronoid process indicating a strong temporalis muscle. Flaring of gonial process laterally seen indicating a strong massceter action with the absence of the anti-gonial notch. The ramus and corpus length or almost equal.Mandibular symphysis is broad but short vertically.

True intusion is achived by moving the root apices closer to the lower border.Relative intrusion of the incisors is achived by keeping them where they are ,while the mandible grows and the posteriors teeth erupt Apparent intusion is achived by extrusion of posteriors teethTHREE POSSIBLE WAYS FOR INTRUSION

ABSOLUTE INTRUSIONRELATIVE INTRUSIONEXTRUSIONTHREE POSSIBLE WAYS FOR INTRUSION

Principles of intrusionControlling force magnitudeLowest magnitude of force capable of intruding must be used.Heavier forces may not increase the rate of intrusion, butIncrease in the rate of root resorptionthe side effects felt by the anchorage unit.

Anterior single point contacts Not inserted in brackets-torque may be introduced If lingual root torque is present intrusive forces reduced. Undesirable curves may be introduced in wire.

Point of force applicationIf the force is passed through center of resistance of any tooth it will intrude the tooth without producing any labial or lingual rotation of the tooth.Procumbent incisors must be handled carefullyBecause the intrusive force is farther from the center of resistance ,a much greater moment occurs and much more lingual root movement occur

There are two ways to handle it:To apply the vertical force lingual to the center of resistance either with a continuous intrusion arch or three piece intrusion arch.To retract the anterior teeth first and produce more upright axial inclinations and then proceed with intrusion

Selective intrusionIn classII division 2 cases ,the central incisors should be intruded using intras-egmental intrusion, so first central should be intruded more than the lateralsIndiscriminately placing an alignment segment into the four incisor will level them by erupting the laterals to the level of the centrals rather than intruding the centrals ,also movements are produced which cause the roots to converge mesially.

Control of reactive unitsBasic side effects could be anticipated from intrusion mechanics.Alters the plane of occlusion of the buccal segment , it is caused by the moment produced by the intrusion arch on the buccal segments. in maxilla, the plane of occlusion steepens in the mandible it flattens.

To minimize this side effect,several steps must be taken:In the anchorage unit , incorporate as many teeth as possible Keep the force of the intrusion arch as low as possibleTranspalatal arch in he maxilla or a lingual arch in the mandibleDo as much retraction initially as possible to decrease the length of the moment arm.

Avoiding extrusive mechanicsExtensive mechanics ,such as class II and class III elastics and cervical headgear with high outer bows to the maxillary arch.Placement of reverse cure of spee in the loxer arch wire to prevent extrusion of premolars,because patients who need genuine intrusion

Treatment of skeletal deep over biteThe treatment of skeletal deep over bite required consideration of the sagittal dimensions most skeletal deep over bite or combined with class ii sagittal intercuspation. During the growth period, the unfavorable inclination of the jaw bases should be corrected. This can be achieved by the use of extra-oral forces or partly by an functional therapy.

Growth inhibition of the upper jaw and growth promotion in the lower jaw combines with dentoalveolar changes should result in the improvement of deep over bite. Treatment can be performed by using headgear in combined with an activator. Distalization and elongation of the upper first permanent molar is the first step. The eruption of the teeth in the posterior segment can be guided properly trimmed activator.

Dentoalveolar compensation for a deep bite is needed especially in skeletal deep over bite treated after the growth period completed. This compensation can be achieved by the extrusion and distalization of the maxillary molars. Aided by second molar extraction intrusion and labial tippping of the lower incisors with leveling of the curve of spee further benefits the dentoalveolar compensation.

Dentoalveolar Deep Over Bite True Deep Over Bite In true deep bite the choice of treatment is extrusion of posterior teeth. If a lateral tongue thrust is present, a lateral tongue crib is added to the palatal plate.

Treatment of acquired deep biteTreatment being carried out during eruption levelling of the curve of spee can be carried out by the use of an activator.Anterior bite plane can be used.

Beggs TechniqeAnchor bend given in the arch causes intrusive force component.Class II elastics has vertical and horizontals component of forces.

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Intrusion Mechanic In Pre Adjusted Edgewise ApplianceIntrusion arch wireWith continous arch wire that bypass the premolar and canine teeth.With segmented base arch wire (so that there is not connection along the arch between anterior and posterior segment).

Indications for IntrusionLarge interlabial gap.Large incisor stomion-distance.Short upper lip.High gingival smile line.Large lower facial height.

Bypass ArchesIntrusion Utility Arch: The components of utility arch:Molar segment.Posterior vertical segment. Vestibular segment.Anterior vertical segment. Incisal segment.

Selection Of Wire For Fabrication Of Utility ArchIn a 018 slot 0.016 X 0.022 TMA or 0.016 X 0.016In a 022 slot 0.019 X 0.019 TMA

Activation of The Intrusion Utility ArchActivated so that it delivers 60-100 gms of force.30-400 of activation bend placed at posterior vertical segment and vestibular segment. Pull and chinch the arch wire to prevent flaring of incisors. V bend facing occlusally in the vestibular segment, this bend should be closed as much as possible to the distal vertical segment.

FORCED PRODUCED BY UTILITY ARCH ACTIVATION

INTRUSION OF THE LOWER INCISOR PRODUCED BY THE INTRSION BY THE UTILITY ARCHMILD INTRUSION AND RETRACTIONGREATTER INTRUSION AND RETRACTION

Intrusion with Alpha and Beta MovementsAnterior intrusion can be performed by application of differential movement. When retracting an anterior segment a net instrusive force can be produced on the anterior segment using a small anterior alpha movement than posterior beta movement.

Intrusion of Six Anterior TeethA alpha and beta bend are placed mesial and distal leg of the retraction loop. These produces moment in the anterior and posterior segments.If the beta moment is greater than alpha moment, an anchorage enhanced by the mesial root moment of the posterior segment and there is net intrusive force on the anterior teeth.

Apparent intrusion in PEAExaggerated reverse curve of speeSprings about intrusion of anterior along with extrusion of the posterior teeth. Reverse curve NiTi wire may also be used for the same.

Anterior bite planeIn growing patients anterior bite plane inhibits the vertical development of the lower incisors and allows differential eruption of the posterior teeth to take place. The posterior teeth will be occlusion and the over bite will reduced with in about 2 months.

Inclusion of second molarsExtrusion of second molars brings about a great of bite opening in the incisor region. Second molars are extruded by keeping molar tube more gingivally. One mm of extrusion of both upper and lower molars will be lead to back ward rotation of the mandible.

Three Peace Intrusion Arch Components Posterior anchorage unit.Anterior segment with posterior extension.Intrusion cantiliver.

Anterior segment should be made up of 0.021 x 0.025 s.s. wire, so that it should prevent side effect created by bending of the wire during force application. Intrusion cantiliver should be made up of 0.017 x 0.025 TMA. This wire is bend gingivally mesial to the molar tube and helix is formed.The mesial end of the cantiliver is bend into a hook.

Activation of Three Piece Intrusion Arch With this we can intrude flared incisors and tract, these teeth simultaneously.The center of resistance of the four incisors is usually estimated to be half way between the crest of alveolar and apex lateral incisors. An intrusive force through the center of resistance will cause pure intrusion of these incisors along the line of the action of the force.

If intrusion along the long axis of the incisors indicated the point of intrusive force can be moved interiorly and small distal force will help to direct the intrusive force along the long axis of the incisor.If the intrusive force is placed distal to the centre of resistance and an appropriate small distal force is applied intrusion and simultaneous retraction of the anterior teeth occur. This is because of the clockwise movement created around the centre of resistance of the anterior segment.

THREE PIECE INTRUSION ARCHPASSIVE POSITION ACTIVE POSITION

Tip back springsIndicated:Deep over bitedeep curve of spee Growing patients with forward growth rotation. the anchor molars are reinforced with TPAIn the upper and lingual holding arch in the lower arch.

The intrusion spring are made from 0.017x0.025TMA wire with out helix or0.017x0.025 SS wire with a helix so that the force can be made optimal for intrusionThe wire is bent gingivally mesial to the molar tube and then helix is formed .the mesial end of the spring is bent into a hook and is engaged on to the main archwire distal to the lateral incisorThe mesial end of the spring lies passively at the height of the mucobuccal fold and the spring is activated by pullying the hook down and engaging it on to the wire.

Correction of deep bite with activator In a dentoalveolar deep overbite:When the deep overbite is due to infraocclussion of the poaterior teeth, the interocclusal clearance is large and hence the construction bite is made high or moderate accroding to thee size of the freeway space.When the deep overbite is due to supraocclusion of the incisors, the interocclusal distance is small, high construction bite should not be used.

Correction of deep bite with activatorIn a skeletal deep overbite:The construction bite should be such that it is 5-6mm,more than the freeway space .Deep overbite due to infra occlusion of the molars,Can be treated with an activator which has been selective trimmed in such a manner so as to allow the supra eruption of the posterior teeth.Alternatively eruption of the upper molars can be inhibited while the mandibular molars are allowed to erupt.

Extusion of the molars is brought about by allowing the lingual surface of the maxillary teeth to touch above the area of the greatest contour and the mandibular teeth touch below the greatest convexityIntrusion of the lower incisors:Activator only minimal intrusion is possible.The intrusion which occur is relative, because the poterior teeth are allowed to erupt.Labial bow is placed on the incisal third of the tooth so that it will not interfere with the intrusion of the incisor.

Correction of deep bite with BionatorThe bionator is not rigid appliance some parts of the appliance are used as anchorage unitBalter called the anchorage areas as loading or prevention of growth areas; and the trimmed areas were called as unloading or grwth promotionareas.As treatment progress self curing acrylic is added or trimmed off accordingly, so that overbite due to infra-occlusion of the molars and premolars can be corrected effectively.

Labial bow with buccinator loop

Correction of deep bite with FrankelAbnormal perioral muscle function has an ability to exert a deforming action that prevents optimal growth and development.Frankel appliance has buccal sheilds and lip pads that the prevent the deforming muscle action in the dentoalveolar region both during deglutation and at rest. Frankel is indicated in the mixed dentition with short lower anterior facial height ,deep overbite and abnormal activity,leading to bite opening and facial esthetics.

ConclusionAll these various modalities described for the correction of the deep overbite have been time proven to be successful provided the right method of treatment is selected as per the demands if a particular case

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INTRODUCTION

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