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Vertical Discrepancies –
Deep Bite
Presented by,
Dr. Shreyank G
Post Graduate Student
Department of Orthodontics
CONTENTS
Introduction
Development of a vertical problem
Etiology of vertical problems
Diagnosis of vertical problems
Deep bite
- Classification
- Etiology
- Diagnosis
- Management
- Conclusion
References
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INTRODUCTION
The vertical dimension of face is often altered, either
intentionally or non intentionally, during orthodontic
treatment
These changes have a great impact on the way the
mandible rotates and changes are seen in the facial
esthetics.
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DEVELOPMENT OF VERTICAL PROBLEM
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The major sites of bony additions contributing to the
facial growth are :
- Facial sutures
- Maxillary and mandibular alveolar processes
- Mandibular condyle
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GROWTH
After the cessation of the anterior cranial base growth at
an early age , the anterior half of the cranio-maxillary
complex is displaced in antero-superior direction by
the growth at the spheno-occipital suture until the
suture closes after puberty.
The spatial position of the maxillary dentition is
influenced by the eruption pattern of the teeth and the
growth of the maxilla and the anterior cranial base
whereas the spatial position of the mandibular dentition
is determined by the growth of the mandible and it’s
relationship to the temporal bone .
Condylar head , being the primary growth centre of the
mandible grows in upward and backward directions with
the resultant downward and forward displacements of
the mandible and carries the mandibular dentition away
from the vertebral column and cranial base.
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Therefore , the growth at the spheno-occipital
synchondrosis displaces the maxillary complex antero
superiorly, while the growth at the mandibular condyle
displaces the mandible downward and
forward,ie,anteroinferiorly.
These two diverging growth vectors create a space for
vertical facial growth, alveolar growth and tooth
eruption.
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The mandible demonstrates a great degree of variation
in the direction of its growth in the normal population as
shown in studies on facial growth by Bjork and Skieller
using metallic implants.
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- It is important for the clinician to consider, understand
and recognize the importance of mandibular growth
rotation as it relates to anterior facial height (AFH) and
overbite relationship.
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In addition to condylar growth direction, differences in
the AFH and PFH development play an important role in
development of vertical discrepancies.
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DIAGNOSIS OF VERTICAL DISCREPANCIES
1. Facial evaluation
Facial assessment begins with a three dimensional
assessment of the frontal and profile views in the
vertical, sagittal and transverse planes. The goal of
this assessment is to establish an accurate
description of the esthetic, skeletal and occlusal
abnormalities as well as functional disorders.
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LONG FACE PATIENTS SHORT-FACE PATIENTS
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LONG FACE PATIENTS SHORT FACE PATIENTS
17
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102
2. Functional assessment
An assessment of function is a very important part of the
clinical examination for planning treatment of vertical
discrepancies. Associated disorders involving airway,
speech and tongue function should be carefully
evaluated.
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3. Morphologic characteristics
BJORK ANALYSIS
• The cranial flexure angle(N-
S-Ar),articulare angle and
gonial angle(Ar-Go-Me) are
used to determine the
growth pattern of an
individual.
• The mean value of sum of
these angles is 396°+/-
4°,higher values are
suggestive of vertical growth
pattern, whereas low values
indicate horizontal growth
pattern
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• The gonial angle having a mean value
of 130°+/-7° is a good indicator of
vertical or horizontal growth pattern.
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• Mandibular plane angle(Go-Me-true horizontal)
have a mean value of 27°+/-5° is one of the most
commonly used parameters.
• It is increased in patients with a vertical growth
pattern while horizontally growing patients exhibit
low angle
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Jarabak’s proportions
4. Short ramus height or decreased 4. Reduced maxillary molar height - the strongest
posterior face height. measure of vertical maxillary deficiency
5. Increased maxillary and mandibular 5. Reduced incisor height maybe associated with
dentoalveolar height. deficient incisor
display.
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Bjork described morphologic method of predicting growth rotation
from a
single cephalogram and found seven structural signs for predicting
forward or backward growth rotation.
1. Inclination of the condylar head : Curved forward - forward
rotator
Straight or slopes up or back –
backward rotator
2. Curvature of the mandibular canal : curved – forward rotator
straight – backward rotator
3. Shape of mandibular lower border : Curved downwards –
forward rotator
notched – backward rotator
4. Inclination of the symphysis : Slopes backward - forward
rotator
Slopes forward – backward
rotator
Prediction of mandibular growth rotation evaluated from a
longitudinal
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implant 102 26
sample – Bjork, Skieller and Hansen, AJO, Nov 1984, pg. 359-370.
5. Inter-incisal angle : Vertical /obtuse - forward rotator
Acute – backward rotator
6. Inter- premolar/molar angle : Vertical /obtuse - forward
rotator
Acute – backward rotator
7. Anterior lower facial height : Short - forward rotator
Long – backward rotator
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DEEP BITE
Definition :
Graber has defined deep bite as a condition of excessive
overbite, where the vertical measurement between the
maxillary and mandibular incisor margins is excessive when
the mandible is brought into habitual or centric occlusion.
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2. Skeletal
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• 4. Muscular
The posterior vertical chain of muscles (masseter,
internal pterygoid, temporal) is strong and attached
anteriorly on the mandible and stretches in nearly a
straight line vertically. The molars are directly under the
impact of the masticatory forces of this chain.
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•Classification
1. According to its origin;
a) Dental deep bites
b) Skeletal deep bite
2. According to functional classification;
a) True deep bite.
b) Pseudo deep bite.
3. Depending on the extent of deep bite
a)incomplete over bite
b)complete over bite
4. According to dentition;
a) Primary dentition deep bite.
b) Mixed dentition deep bite.
c) Permanent dentition deep bite
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DENTOALVEOLAR DEEP
BITE
SKELETAL DEEP-BITE Due to infra-occlusion of molars(true)
1. Molars partially erupted
1. Horizontal growth
2. Large inter-occlusal space
pattern
3. Lateral tongue posture or
2. Convergence of
thrust
skeletal jaw bases
4. Distances between
3. Short LAFH
maxillary and mandibular
4. Long post. facial height.
basal planes and occlusal
5. The horizontal
plane are short.
cephalometric
planes (SN, PP, OP and Due to supra eruption of
MP) are approximately incisors(pseudo)
parallel or convergent 1. Incisal margins of incisors
to each other. extend beyond the functional
occlusal plane.
2. Molars are fully erupted.
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3. Excessive curve of spee.
3.Incomplete and complete deep bite
Incomplete over bite is an incisor relationship in which
the lower incisors fail to occlude with either the upper
incisors or the mucous of the palate when the teeth are
occluded
Complete over bite on the other hand is a relationship
in which the lower incisors contact the palatal surface of
the upper incisors or the palatal tissue when the teeth
are in centric occlusion . This kind of deep bite often
results in trauma of the mucous palatal to the maxillary
incisors
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V. Features and Effect of deep over bite
Extraoral features
1. Brachycephalic and europroscopic face. Strong contractions of
the masseter muscle can be seen in the face by clenching the
teeth
2. Straight to Mild convex profile
3. Short anterior face height as measured from nasion to menton
4. Diminished anterior lower face height. Short nose-chin
distance
5. The lips are thin and with an excess of lip height relative to
face height. This gives a curled appearance of the lips .
6. Mento labial sulcus :There is usually deep furrow, or sulcus,
between the prominent chin and the lower lip
7. Mandibular deficiency characterized by long mandibular ramus
and short body, Square gonial angle, flat mandibular plane,
prominent zygoma and prominent chin. Many of these features
are common to class II div II
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• Intra oral features
1. The maxillary dental arch is broad, with often a maxillary buccal
cross-bite
2. May involve a group of teeth or whole dentition.
3. In skeletal deep bites the patient may exhibit gummy smile if there is
clockwise rotation of maxilla . When the problem is in the anterior
maxillary region, the patients often show excessive gingival tissue
during smiling or even while speaking even when the upper lip is of
adequate length
4. The palatal vault is flat. The presence of deep bite may cause palatal
grooving by the indentations caused by lower anteriors.
5. The dentition exhibits a tendency to small teeth prone to abrasion and
a high increased percentage of congenitally missing teeth.
6. Although teeth tend to spaced, a crowding of lower incisors may be
present as a result of the deep bite.
7. A deep curve of Spee in lower arch or a reverse curve of spee in the
maxillary dentition
8. Occlusal functions become impaired.
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9. Often the maxillary incisors are tipped lingually in Angle's Class II, 39
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• Other features
1. The mandible cannot be opened to an appreciable
degree in skeletal cases.
2. Temporomandibular joint dysfunction due to
overclosure of the mandible characterized by clicking
sensation of the joint.
3. Periodontal conditions may be found as a result of
such occlusion.
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TREATMENT OF DEEP BITE
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Flat or near flat
curve of Spee
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Various options in the treatment of
deepbite
• Deep anterior overbite can be
opened using
extruding the posteriors
by intruding the anteriors
by correcting the inclinations of
the retroclined anteriors
By uprighting or distalizing the
molars(which rotates the
mandible downward by
increasing the ‘wedge effect’)
By a combination of any of
these
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• Intrusion is defined by Nicolai as “A transitional form of the
tooth movement directed apically and parallel to the long
axis.”
• Burstone defined intrusion as, “Apical movement of the
geometric center of root (centroid) in respect to the occlusal
plane or a plane based on long axis of the tooth.”
• Intrusion of incisors is commonly indicated in pseudo deep
bite cases or the cases with increased anterior face height.
• It is also indicated in cases where there is an excessive
gingival display during speaking or smiling.
• Pure incisor intrusion is not possible with removable
appliances.
• Fixed appliance therapy is probably the best to intrude the
teeth for correction of deep bite in children as well as
adults.
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True/absolute intrusion : Achieved
by moving the root apices of the
anteriors closer to the bony base.
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1.Primary dentition period
- In early stages of development of
occlusion,deep bite exists as a self
correcting anomaly.
-The initial eruption of the permanent
molars,growth of the jaw bases and
transition of incisors help in deep bite
correction.
- They may be associated with the
presence of developing class II
malocclusion
- As with class II malocclusions, treatment
decisions are typically postponed until the
mixed dentition period.
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Treatment in mixed and
Early permanent dentition
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a. Orthopedic appliance
1. Cervical headgears
• Very effective in extruding and
distalising the upper molars
• It exerts a vertically downward
component of force with the potential
for extrusion of the molars.
• So with the cervical pull headgear the
molars get distalized and extruded
and the mandible rotates downward
and backward and deep overbite gets
corrected.
• For extrusion and distalization of
molars 200-300 gm of force per side
is applied. The force duration should
be 14 to 16 hours per day or more
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- Another application of headgear is to apply the
intrusive force on the upper incisors directly by
using the J hook to the archwire as was described
by Terrel Root.
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Asher headgear
• Recommended by Dr.Cetlin and
Roth ,the Asher lasher facebow
is the facebow of choice for
intrusion and retraction.
• With a high pull cap,it retracts
and intrudes
• The bow is hooked to the
archwire mesial to the cuspid
against a keyhole loop or a hook
attached to the wire
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Correction of deep overbite and gummy smile by
using a mini-implant with a segmented wire in a
growing Class II Division 2 patient
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Kim, Kim, and Lee
American Journal of Orthodontics and Dentofacial Orthopedics Volume 130,
Number 5
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Correction of deep bite with
fixed appliance therapy
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•Reverse curve wires
• The archwires with reverse curve of
spee(RCS) made of superelastic alloys
such as NiTi are used to actively open
the bite.
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• Acrylic extensions are bonded to the lingual
surfaces of the maxillary incisors, producing an
intrusive effect or growth restrain on the
incisors while allowing the extrusion of the
posterior teeth. It is also called as lingual bite
steps or bite turbos.
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INCLUSION OF SECOND MOLARS
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UTILITY ARCH
This auxiliary archwire was developed according to the
biomechanical principles developed by Burstone and
refined by Ricketts for bioprogressive therapy
Material used :
Although stainless steel can be used, blue elgiloy of
0.016″ x 0.016″ or 0.016″X 0.022″ dimension in an
0.022″ slot is the material of choice
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Typically when activated ,Ricketts
utility arch produces 40-80 gm of
force,which is sufficient to intrude
four incisors
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Burstone’s Three piece intrusion arch
Simultaneous
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intrusion and retraction using a102three piece base arch .Bhavana Shroff, 66
Charles J Burstone, Won M Yoon. Angle orthod 1997;7(6);455-462
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Burstone ‘s continuous intrusion
arch
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Kalra V. Simultaneous Intrusion and Retraction of the Anterior Teeth. JCO 1998 ;35:535 –
540 6/30/2019 102 71
- A 90° V-bend is placed in the
archwire at the level of each U-
loop to create equal moments
that counteract tipping
moments produced by
activation forces.
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Translation Arch
• Translation Arch was given by Martina & Paduano in
1997
• Translation Arch has anterior segment inserted into
incisor brackets and two buccal segments inserted into
gingival first molar tubes.
• Vertical loops between segments extend as far as
possible. Palatal root torque given in the anterior
segment of the arch .
• An arc—should be bent into each buccal segment to
produce an intrusive force of 40g on the incisors..
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MULLIGAN’S 2X4
appliance
•The archwire used is round 0.016”
stainless steel archwires with tip back
ends.
•The tipback bends or ‘V’ bend given to
the arch wire for intrusive action on
incisors and extrusive action on molars.
•Since the canines and premolars are
not bracketed when this mechanism is
used,it is another way of applying a
bypass arch for incisor intrusion
•Though the anterior segment of the
wire is engaged in the incisor bracket, it
doesnot create a labiolingual moment
since a round wire is used.
•A helix is provided at the tip back bend
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for ligating to the molar tube,to resist
MODIFICATION OF LINGUAL ARCH
FOR DEEP BITE
• This technique was introduced by WINSTON
SENIOR.
• An .036" lower lingual arch is soldered to first molar
bands.
• Distal extensions form occlusal rests on the second
molars to prevent distal tipping of the first molars
as the incisors are intruded.
• Four elastic chains are attached to the anterior
bridge of the lingual arch.
• After cementation of the arch, the elastics are
stretched to four lingual buttons on the lower
incisors
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. A lingual arch for intruding and uprighting lower incisors. J
W Senior. 102 77
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Placement Site:
For enmasse intrusion of the maxillary anterior teeth the
most suitable site for the placement of implant selected
is the alveolar bone between lateral incisor and canine
bilaterally at the level of attached gingiva.
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2) Mid-implant For Intrusion Of Maxillary
Incisors
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SURGICAL TREATMENT
LEFORT I OSTEOTOMY
ANTERIOR SUB-APICAL
OSTEOTOMY
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Maxillary Intrusion Splint
•Maxillary Intrusion Splint (M.I.S.) system which
incorporates a near vertical pull headgear, is used in the
management of severe 'gummy' Class II division 1
malocclusion
•M.I.S. is a full coverage, acrylic palatal plate with both
anterior and posterior capping carried round and onto labial
surfaces of the incisor teeth and extra-oral traction tubes
incorporated in the base plate mesially to the cusp tip of
the first premolar.
•M.I.S reduces the visibility of the maxillary incisors by the
intrusion of maxillary teeth, restraining maxillary growth, and
encouraging an element of subsequent forward mandibular
rotation.
•Indicated in “gummy smile” patients.
The treatment of severe 'gummy' Class II division 1 malocclusion using the
maxillary
6/30/2019 intrusion splint. Eur J Orthod. 1992
102 Jun;14(3):216-23 84
Acrylic capping for the incisors and
canines should cover the incisal third of
the crown.
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•Vertical pull to the bow at about 60 degrees to
the occlusal plane is given.
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Orthodontic treatment of gummy smile by maxillary
total intrusion with a midpalatal absolute anchorage
system
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Early vs late orthodontic treatment of deepbite: a
prospective clinical trial in growing subjects.
• The aim of this prospective clinical trial was to compare the
outcomes of prepubertal vs pubertal treatment of deepbite
patients with a protocol including biteplane and fixed appliances.
• METHODS:
• A sample of 58 subjects with deepbite completed the study. A
total of 34 subjects received treatment with removable biteplane
appliances in the mixed dentition at a prepubertal stage of
skeletal maturation (early treatment group), and 24 subjects
were treated at a pubertal stage of skeletal maturation in the
permanent dentition (late treatment group).
• All subjects of both groups were reevaluated after an average
period of 15 months after the completion of fixed appliance
therapy. Treatment outcomes were assessed statistically after a
phase with removable biteplane appliances and at the
posttreatment observation.
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