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Introduction
eep overbite refers to the increase of overlap
of maxillary incisors over mandibular incisors beyond the normally reported coverage of 30
40%.1 Although many practitioners refer to the
overbite in millimeters, the percentage computation is more revealing because of the variation in
the crown height of the mandibular incisors. Also,
the inclination of both maxillary and mandibular
incisors impacts the amount of overbite, which
would decrease when these teeth are proclined
and increase when the incisors are retroclined.
When the mandibular incisors impinge on the
maxillary palatal mucosa behind the maxillary
incisors, the deep bite is severe, regardless of the
amount of virtual coverage of the mandibular
incisors by their antimeres. In addition to the
functional problems they cause, very deep impinging overbites2 can jeopardize the maxillary palatal
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highly biased evidence27; however, guidelines for treatment are drawn on current
evidence until further research provides
more generalizable results.
(9) Randomized clinical trials (RCT) are needed
to understand the biological and mechanical
outcomes of intrusion, its optimal application with respect to function, periodontium
and esthetics, and whether intrusion mechanics produce a more stable overbite correction than other methods of leveling.
However, RCTs are difcult to conduct for
ethical, administrative, and nancial reasons.27
Treatment options
Mechanical considerations
Three main orthodontic mechanics constitute
the basis to correct a deep anterior overbite:
intrusion of the incisors, extrusion of posterior
teeth, and proclination of incisors. These
modalities are indicated separately or in combination depending on the diagnostic component
analysis. We discuss them briey with differentiation of their application in growing and
non-growing patients.
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Intrusion of incisors
In patients with deep bite and a normal or increased
lower facial height, the indication of intrusion of
maxillary and/or mandibular incisors encompasses
the following conditions: excessive distance between
the incisal edge (incision) and stomion, large
interlabial gap, and more occlusal level of central
incisors relative to lateral incisors. However, the
upper lip line during smile is a critical factor in
determining whether the maxillary incisors should
be intruded, rather than the molar teeth needing
extrusion. The lip line may actually intersect the
maxillary incisors, which paradoxically would need
to be extruded for better smile esthetics, while the
deep bite may otherwise dictate intrusion.
The intrusive force should be exerted through
the center of resistance of the incisors to avoid
their proclination.28 Different methods have
been developed to intrude incisors, basically
classied in continuous arches (Fig. 1) or
segmental techniques. Continuous arches
(usually including increased curves of Spee
and/or selective vertical steps) have been
described to result in molar extrusion29 and
incisor buccal tipping.30 Segmental techniques
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).
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(2)
(3)
(4)
(5)
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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.
Proclination of incisors
The proclination of maxillary and mandibular
incisors decreases the amount of overbite,41 and
unlike the previous two options, it occurs as a side
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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.
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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.
Esthetic considerations
Although the increase in lower face height concomitant with bite opening is usually an esthetic
advantage in the treatment of deep overbite,
particularly when associated with skeletal hypodivergence, other esthetic considerations are
warranted. The most critical concerns relate to the
upper lip line in relation to the maxillary incisors
and the depth of the mental sulcus in relation to
the mandibular incisors.
Often, and particularly in association with a
decreased lower face height and in males, the
intrusion of incisors would be contraindicated
because of a low lip line during smile. In these
instances, the upper lip tends to be longer than
average, but this detail must be corroborated with
further research. In a growing child, appliances
may be used to favor extrusion of posterior teeth
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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.
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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 malocclusion would not look orthognathic despite the
correction to neutroclusion. Only surgery might
be expected to minimize the original phenotype.
Treatment challenges
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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 stepdown 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.
compromised dental health (existing restorations/severe caries and root resorption), and
mechanical limitations (difcult space closure,
especially extraction spaces, and resistance to
intrusionmainly in adults).
Compliance is obviously a primary component
of success, particularly in children required to
wear a headgear, a functional appliance,
removable bite plates, or elastics. Growth direction and amount are also dening factors for
treatment success in children.
Discussion
Research issues and challenges
Confounding the study of deep overbite is the
usual coexistence of a sagittal component
(mainly Class II), which may qualify the malocclusion as tting the study of the sagittal problem
more than the vertical problem. In this perspective, it may be useful in research to assign
severity scores to the malocclusion components
in each dimension and to classify predominantly
vertical malocclusions when the relative vertical
severity score is greater than the grades in the
other dimensions (sagittal and transverse).
Ideally, randomized clinical trials should be
conducted, but we suggest that even deep bite
phenotypes may not be grouped together simply
on the overlap between anterior teeth and
should at least be differentiated on the basis of
presence or absence of maxillary and mandibular
vertical skeletal hypoplasia. In its simplest form,
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Conclusion
While the centerpiece of this analysis is the deep
overbite, the skeletal components around it vary
in a myriad of arrangements, ranging from the
severe hypodivergent pattern with diminished
lower face height to even the high-angle skeletal pattern. Esthetic and mechanical considerations obviously vary in a parallel way,
disclosing potential for improvement but also
with many challenges, the most potent of which
are the stability of results in the severe malocclusions, and favorable facial esthetics. Often the
achievement of the latter requires long-term
retention. Existing protocols for treatment follow more generic than individual guidelines,
progressing to surgical considerations with
increased severity of an underlying hypodivergence. Most of the available publications
remain at the lower tier of the evidence scale, and
research at the various levels is indicated.
References
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