Doha Mohammad Hussein Al-Dujeili

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BDS, Specialty Diploma Candidate,
Department of Developmental Sciences,
Division of Orthodontics, Faculty of Dentistry
 OUTLINE
I. INTRODUCTION ……………………………………………..…page.2
II. DEFINITION…………………………………………………..….page.2
III. CLASSIFICATION………………………………………………page.3
IV. ETIOLOGY……………………………………………………….page.5
V. FEATURES AND EFFECT OF DEEPBITE…………………..page.6
VI. DIAGNOSIS……………………………………………………...page.7
VII. MANAGEMENT OF DEEP OVERBITE……………………….page.8
VIII. PLANNING TREATMENT IN DIFEERENT AGE GROUPS..page.9
IX. RETENSION……………………………………………………..page.15
X. CONCLUSION………………………………………………..….page

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 I. Introduction
Deep bite is one of the frequently seen
malocclusions next to crowding. It can occur
along with other associated malocclusions. It
is said to be one of the most perpetuating
and damaging malocclusions. It may
jeopardize the periodontal support, occlusion
itself or TMJ. The excessive overbite is a
complex orthodontic problem that may
involve a group of teeth or whole dentition,
alveolar bone, of maxillary and mandibular
basal bones, and/or soft tissue of the face.
The management of this problem demands a
careful diagnostic analysis, treatment plan,
and selection of appropriate treatment therapy. Normally the lower incisal edges
contact the lingual surface of the upper incisors at or slightly above the cingulum
(i.e., normally there is 1 to 2 mm overbite). This vertical overlap is either described
in millimeters or as the percentage of mandibular incisor crown length overlapped
by maxillary central incisors. Since the crown length of the lower incisors
significantly varies in individual, a notation of the overbite in percentage is more
descriptive and desirable.
II. Definition
The deep over bite or deep bite can be
defined by the excess amount or percentage
of overlap of the lower incisors by the upper
incisors. Graber has defined ‘Deep bite’ as a
condition of excessive overbite, where the
vertical measurement between the maxillary
and mandibular incisal margins is excessive
when the mandible is brought into habitual or
centric occlusion’. It is customary to diagnose deep bite when the incisors' overlap
exceeds one third of the crown height of the lower incisors. The term "closed bite"
is excessive overbite resulting from loss of posterior teeth. It is rarely seen in young
children, must not be confused with deep bite. Excessive overbite is the most
prevalent in the mixed dentition and is a self-correcting transient malocclusion.

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III. Classification
A. According to its origin:
a) Dental deep bites (Simple).
b) Skeletal deep bite (Complex).
B. According to functional classification:
a) True deep bite.
b) Pseudo deep bite.
C. Depending on the extent of deep bite
a) incomplete over bite
b) complete over bite
D. According to dentition:
a) Primary dentition deep bite.
b) Mixed dentition deep bite.
c) Permanent dentition deep bite.
• Dental and skeletal deep bite
a) Simple (dental) deep bite
A simple deep bite is localized to the teeth and alveolar processes. In this
type of deep overbite, the problem lies mainly within the dentition. Dental
deep bites occur due to over-eruption of anterior or infraocclusion of molars.
The result may be labial version of the upper incisors and impingement of
the lowers into the palatal mucosa a majority of the problems in this category
are created by the loss of permanent teeth causing a lingual collapse of
maxillary or mandibular anterior teeth. The denial of a skeletal contribution
to the condition is critical to the diagnosis. This kind of deep bite is
characterized by the absence of any skeletal complicating features which are
seen in skeletal deep bites .In the mandibular dentition, it may manifest as a
deep curve of Spee or a reverse curve of Spee in the maxillary dentition.
These patients frequently show temporomandibular dysfunction and a
limited range of functional occlusal movements.
b) Complex (skeletal) deep bite is a deep bite associated with basic skeletal
features with which the alveolar process cannot cope. Malrelationship of
alveolar bones and/or underlying mandibular or maxillary bones or to an
overgrowth or undergrowth of one or more alveolar segments. The demised
anterior vertical height of the face is also an important criterion for diagnosis
of skeletal deep overbites. Complex deep bite is frequently associated with
class II div 2 and occasionally with Class III.

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 • True and pseudo-deep overbite
True deep overbite Pseudo-deep overbite
This is caused by infraocclusion of the is caused by over eruption of the
posterior segments i.e. molars anterior teeth that already has normal
eruption of the posterior segment
teeth
Seen in class II div II malocclusion Seen in class II div I malocclusions
It is often the result of a lateral tongue It is the result of over eruption of the
posture of tongue thrust. The incisors. Due to the presence of the
interposition of tongue prevents the increased overjet, the lower incisors to
eruption of the posterior teeth. It can over-erupt until they meet the palatal
also occur due to premature loss of mucosa.
posterior teeth
These patients have near flat curve of These patients hence exhibit an
spee. excessive curve of spee
There is a large interocclusal The interocclusal clearance is usually
clearance normal or small as the molars are fully
erupted.
Some Class II division II, Some Class II division I, malocclusions
malocclusion with adequate lip line with a "gummy" smile and a poor lip line
relationships are good examples relation can fall into this category
Treatment in the mixed dentition Incisors cannot be intruded effectively
period requires the elimination of using functional methods during mixed
environmental factors that are dentition
inhibiting eruption of the posterior
teeth. Ideal for functional appliance
therapy
Extrusive mechanics of molars All possible intrusive mechanics on the
possible incisor teeth with fixed appliances is
usually indicated. extrusion of molars is
possible only to a limited extent

• Incomplete and complete deep bite

a) 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
b) 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
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 when the teeth are in centric occlusion. This kind of deep bite often results
in trauma of the mucous palatal to the maxillary incisors.

IV. Etiology of deep bite

The etiology of deep overbite is a complex problem and may include one or more
of the following;
1) Hereditary and may follow a genetic pattern or familial condition
2) Skeletal:
a. An overgrowth or undergrowth of one or more alveolar segments.
b. An excess of growth of the ramus and posterior cranial base permits the
mandible to rotate upward. Thus Long ramus and short body with
decreased gonial angle is characterstic feature.
c. Convergent upper and lower jaw bases.
d. Horizontal growth pattern or forward rotation or anticlock wise rotation
of the of the lower jaw.
e. The four planes of the face (Frankfort, palatal, occlusal, and mandibular
plane ) as seen from lateral cephalogram are horizontal and nearly
parallel to each other.
3) Dental:
a. Loss and/or mesial tipping of posterior teeth. In other words diminished
posterior dental height.
b. Early loss of teeth and lingual collapse of the anterior teeth.
c. Over eruption of the incisor teeth, infraocclusion of the buccal segment
or a combination of both.
d. Overbite may be because or accentuated by an aberration in the tooth
morphology.
e. Periodontal disease. Bite may deepen if the posterior tooth drift mesially
during the pathological migration and worsen the existing condition.
f. When the teeth are reduced in size and number, the dental arches
oppose less resistance against mandibular closure.
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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 When the posterior vertical chain of muscles is strong and anteriorly
positioned, a greater depressive action is transmitted to the dentition
5) Habits:
a. lateral Tongue thrust swallow
b. Finger sucking,
c. Lip sucking

V. Features and Effect of deep over bite

A. Extra oral features:
1. Brachycephalic and europroscopic face. Facial esthetics is impaired
(muscular 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 gnathion.
4. Diminished anterior lower face height. Short nose-chin distance.
5. Normal distance from the chin to the incisal edge.
6. The lips are thin and with an excess of lip height relative to face height.
This gives a curled appearance of the lips.
7. Mento-labial sulcus: There is usually deep furrow, or sulcus, between the
prominent chin and the lower lip.
8. 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.

B. 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
event 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.

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 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.
9. Often the maxillary incisors are tipped lingually in Angle's Class II, division
2 pattern.

C. Other features:
1. The mandible cannot be opened to an appreciable degree in skeletal
cases.
2. Temporomandibular joint dysfunction due to over closure of the mandible
characterized by clicking sensation of the joint.
3. Periodontal conditions may be found as a result of such occlusion.

VI. Diagnosis
Excessive overbite is not to be viewed as an isolated entity: it must be seen as a
part of the total malocclusion. The routine diagnostic aids such as clinical
examination, study models and lateral cephalogram are used of the diagnostic
exercise. The factors contributing to excessive overbite vary with the type of
occlusion and skeletal pattern.
Their determination is the most important step in diagnosis and Treatment
planning. Excessive overbite is not being viewed as an isolated entity. It must be
seen as a part of the total malocclusion.
The primary diagnostic problem in both deep bite and open bite is to ascertain the
site of the dysplasias whether dental or skeletal. The skeletal bite can be
differentiated from dental deep bite by cephalometric analysis.
Postural position is also used in the differential diagnosis of deep bite cases.
The freeway space will be larger than normal in cases with inadequate vertical
development of the buccal segments and normal in cases of over-eruption of the
incisor teeth.

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VII. Management of deep overbite
The extent of the intermaxillary distance "freeway space" is an important factor in
treatment planning. When the freeway space is minimal or even absent the
problem is more severe. Treatment modalities in growing and non-growing
patients.
A. Growing patients
a. Intrude anteriors
b. Erupt posteriors
c. Combination of posterior eruption and anterior intrusion
B. Non growing patients (little or no growth expected)
a. Orthognathic surgery
b. Intrusion of anteriors (posterior extrusion invariably relapses)
Whatever the treatment modality the management of deep bite is by intrusion of
anteriors, extrusion of posteriors or combination of the both
• Factors to be considered before intrusion or extrusion
1. Interlabial gap
2. Growth pattern whether vertical or Horizontal
3. Presence of adequate freeway space or interocclusal clearance

• Intrusion of anteriors
Intrusive mechanics is considered in the following situations Deep bite with large
interlabial gap (In a relaxed mandibular position, an individual has normal of 2 to 4
mm), intrusion is the ideal choice. Extrusion of posteriors may deteriorate the
esthetics and further increase the interlabial gap.
In a clinical situation, if incisor-stomion distance is large, (the distance between the
incisal edge of the maxillary central incisor to the lower most border of the upper
lip is an average of 2 to 4 mm) which is often associated with a high smile line or
"gummy smile", the best method of treating a deep overbite may be by intrusion of
the upper incisors.
In a Class II division I malocclusion with large vertical facial height, extrusion of
posterior teeth may cause serious functional, esthetic, and stability problems.
Extrusion of molar furthers causes the downward and backward rotation of the

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 mandible worsening the condition. In those cases the intrusion of anteriors is the
treatment option.
Intrusion mechanics are considered if there is inadequate or normal freeway
space. Encroachment of this space by extrusion of posterior teeth is determinant
and bound to relapse. It results in fatigue of the muscles of mastication which get
stretched and predispose to relapse. It also strains the TMJ.
• Extrusion of molars
In deep bite with redundant upper and /or lower lips, or no interlabial gap, posterior
extrusive mechanics may be desirable (if other considerations permit). If a patient
with deep overbite exhibits normal incision-stomion distance, the choice of
correction of deep bite by an intrusion of maxillary incisors is often contraindicated
since it will give the patient an edentulous appearance. Extrusion of posteriors is
the treatment option
In patients having excessive overbite with Class II, division 2 type of skeletal
malocclusion, an extrusion of the posterior teeth met be the treatment of choice (
if other considerations permit). Extrusion mechanics are considered if there is
adequate interocclusal space.
Intrusion of incisors Extrusion of molars
Deep bite with large interlabial gap Deep bite with no interlabial gap
If gummy smile is present Normal incisor-stomion distance
In class II div I patients with large In class II div II patients with short
vertical facial height vertical facial height
Considered if Inadequate freeway Considered if adequate freeway space
space is there is there

VIII. Planning Treatment in different age groups

A. Treatment planning in primary dentition

Both deep bite and open bite malocclusion occur in the primary dentition. Open
bite is more common. Anterior deep bites in the primary dentition are fairly
common but are rarely treated. When an excessive overbite is seen in the
primary dentition, it is likely to have a skeletal basis with the presence of
developing Class II malocclusions. Activator type appliance may he used to

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direct differential alveolar growth, reduce the interocclusal distance, and
improve skeletal morphology. As with Class II malocclusions, treatment
decisions are typically postponed until the mixed dentition when the child attains
maturity to wear the appliance.
Indications for treatment in the primary dentition include: impingement on the
palatal mucosa, excessive grinding, clenching, and headaches if they are
believed to be secondary to the deep bite.
B. Treatment planning for mixed dentition
The overbite is greater just after eruption of the prominent incisors and
decreases with eruption of the posterior teeth. If the skeletal bases are class I
with normal incisor angulation, it is better to wait and watch till the eruption of
the posterior teeth which results in resolution of deep bite. In non-skeletal deep
bites a utility arch that incorporates molar and incisor teeth can be used during
the mixed dentition to intrude, tip, or reposition both molars and incisors.
Realistically, although bite depth changes can be made in the mixed dentition
by intrusion of anterior teeth, intrusion is difficult to retain-even in later phases
of full appliance therapy. For this reason, intrusion as a part of early treatment
is seldom required. It is often better to defer this treatment until the early
permanent dentition, using an intrusion arch during the first stage of
comprehensive fixed appliance therapy.
Early childhood is the best time to treat complex deep bite. Functional jaw
orthopedic appliances can then guide the eruption of the permanent dentition
upper molars, while eruption can be manipulated with and help control vertical
skeletal growth .Cervical headgear produces more eruption of the upper molars
and with functional appliance either the upper or lower molars erupt more. Deep
bites with anterior vertical maxillary excess showing gummy smiles can be
intercepted by high pull headgears. Class I skeletal deep bites with horizontal
growth pattern can also be intercepted with the myofunctional appliances.
C. Treatment planning for early permanent
Dentition comprehensive orthodontic treatment is usually required to treat the
cases of deep bite. Leveling of the teeth tends to elevate the posterior teeth and
depress the anterior teeth while improving incisal stops and reducing the depth
of bite several factors such as the growth pattern, the pattern of the rotation of

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the mandible type of dental malocclusion, deleterious habits, and relationship
of intraoral and extra oral musculature should be considered.
The treatment becomes more complicated if there is, in addition, an excessive
overjet, reverse overjet , crowding in either anterior region or excessive alveolar
bone loss.
In cases of simple dental deep bites and when there is a normal interocclusal
distance in the mandibular postural position, treatment by arch leveling
mechanics alone may be possible.
In class II div I growing patient’s intrusion or prevention of excessive eruption of
the lower incisors is achieved by leveling out an excessive curve of Spee with
the continuous arch wire mechanics from molar to incisors.
In the absence of growth, absolute intrusion is required and segmented arch
mechanics must be used to achieve this. Eruption of the first molars can be
aided by the use of a flat maxillary bite plane or a monobloc and the incisors
depressed with utility arch wire.
Mild cases of skeletal deep bites in adolescent are treated with full-banded or
bracketed appliances. In moderate cases a flat maxillary bite plane is used in
conjunction with full-banded therapy. Severe cases of complex deep bite may
require orthognathic surgery later. Even in the most severe problems, it is
preferable to attempt treatment in adolescence and force the decision toward
surgery by the inadequate response to conservative therapy.
Adolescent treatment of moderately severe cases usually more successful in
boys than girls since boys normally have more remaining growth to utilize the
treatment.
❖ Removable appliances

- Maxillary acrylic bite plate or anterior bite plane:

The most popular method for correcting a deep overbite is by or anterior bite
plane. The anterior bite plane is a modified Hawley’s appliance with a built-in
flat acrylic bite plate or inclined plane or platform lingual to the maxillary incisors.
The anterior bite plane consists of:
i. Adam’s clasps on the molars which help in retaining the appliance.

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 ii. A labial bow is also incorporated to counter any forward component of
force on the upper anteriors.
The bite plane may be extended labially not to cover more than 1/3rd to produce
the same effect i.e.., to prevent the protusion of upper anteriors.
With this appliance in the mouth during the mandibular closing movement, the
mandibular incisors come in contact with the acrylic platform, which causes a
disocclusion of the posterior teeth. The disocclusion leaves the molars free to
erupt. The disocclusion of the bite accelerates the passive eruption of the
posterior teeth, which stops when one or more opposing teeth come in contact.
It is advisable not to disocclude the posterior teeth more than 2 mm. If bite
opening in the anterior region is not sufficient, the acrylic platform can be
augmented in small increments several times during the treatment. Small
increments also apparently do not cause a sudden temporomandibular joint or
myofunctional change. If used with a correct treatment plan, the bite plate can
also help in minor labiolingual and mesiodistal movements of teeth with the help
of a labial bow or auxiliary springs the patient wears this appliance almost 24
hours a day. The use of bite plates, at the time of attaining the desired overbite,
should not be suddenly stopped, the bite plate itself should be used as a retainer
and its discontinuance should be gradual.
A bite plate increases lower facial height by permitting posterior dentoalveolar
eruption but tends to rotate the mandible in a down-and back direction, this
diminishing mandibular projection. This is an advantage in horizontal growth
pattern but a disadvantage in vertical growth pattern.
- Myofunctional appliance
Deep bite due to developing class II div I pattern can be intercepted with the
myofunctional appliances like activator and bionator. Deep bite cases
diagnosed to be due to infra-occlusion of molars can be treated by an activator
designed and trimmed to allow the extrusion of these teeth. The inter-occlusal
acrylic is trimmed gradually to encourage the eruption of the posterior teeth.
Bionator can also be used for a similar purpose.
- Headgears:
When an extremely deep overbite is present because of the over eruption of the
maxillary anterior teeth, a high pull headgear can be attached to the anterior

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segment of the arch wire in an attempt to intrude these teeth. The cervical
headgear with its downward vector of force increases lower facial height by
extruding the molars.
❖ Fixed orthodontic appliances:
Fixed orthodontic appliances can be used to intrude the incisors or extrude the
molars. They can also produce mild skeletal effects. Appliances used for deep
bite correction are generically termed intrusion arches and variations include
base arches, utility arches, Connecticut arch and reverse curve of Spee wires
etc…
• Intrusion of anterior teeth can be obtained with the following
methods :
Use of anchorage bends: Anchor bends are given in the arch wire mesial to the
molar tubes so that the anterior part of the arch wire lies gingival to the bracket
slot. Thus when these arch wires are pulled occlusally and engaged into the
brackets, a gingival directed intrusive force is exerted on the incisors which
reduces the deep bite. When intrusion of anterior teeth is the goal, light forces
should be used. Heavier forces are more likely to create a greater tendency for
posterior teeth to erupt as a result of the equal and opposite extrusive force at
the molar.
Recommended forces for intrusion of lower incisors are in the range of 12.5 g
per tooth and for maxillary incisors about 15 to 20 g per tooth. The reactionary
extrusive force on molars is prevented by natural interdigitating occlusion or in
extreme cases by giving a posterior bite plane of minimum thickness Use of
arch wires with reverse curve of Spee. Resilient arch wires that have been
curved in a direction opposite to that of the curve of Spee can be used to intrude
lower anteriors. When these arch wires are inserted into the molar tubes, the
anterior segment curves gingivally. This anterior segment is forced occusally
into the bracket slot resulting in an intrusive force on the incisors. A reverse
curve of Spee wire on the lower arch acts mainly by tipping molars distally and
incisors labially. As the incisors flare labially, angular changes contribute to
overbite correction If the wire is in place for a long enough period and vertical
facial growth occurs, premolars extrude and, to a lesser degree molars and
incisors get intruded Use of utility arches. Utility arches are arch wires that are
bent is such a way that they bypass the buccal segment and are engaged on

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 the incisors. These arches can be used to perform a number of tooth
movements including intrusion of incisors, protraction or even retraction of
incisors. They are activated by giving a V bend in the buccal segment of the
wire so as to produce an intrusive force on the anteriors. Three piece segmental
wires, this type of wire is used in cases of absolute deepbite where there is no
growth potential. Simultaneous retraction and intrusion can be achieved.
• Extrusion of posterior teeth
Extrusion of posterior teeth can be obtained with the following methods Use of
arch wires with reverse curve of Spee The extrusion of posterior teeth can be
successfully attained by fixed orthodontic appliances by using 0.16 in. round
wire with a reverse curve of Spee. The disadvantage of round wire is that it
causes undesirable changes in the axial inclination of the buccal teeth and
flaring of the incisors Use of intermaxillary elastics. Extrusion of molars might
be fortified by means of elastics, which attempt to over erupt the molars in both
the upper and lower jaws. Use of anchorage bend in the upper jaw as well as
in the lower jaw in combination with Class II elastics may cause over eruption
of the lower molars and may help to correct a dental deep bite. One of the draw
backs of the class II elastics is that it results in extrusion of the upper incisors,
in an attempt to over erupt lower molars.
IX. Retention
Corrected deep overbites in either Class I or Class II malocclusions usually
require retention in a vertical plane (moderate retention). If anterior teeth were
depressed to achieve overbite correction, a bite plate on a maxillary retainer is
desirable. It is worn continuously for perhaps the first 4 to 6 months. Often the
incisal edges of the anterior teeth are unworn and require spot grinding and
adjusting in some class II Div. I cases. If cases of skeletal deepbite correction is
achieved as a result of bite opening. In these cases the mandible is forced away
from the maxilla and the vertical dimensions should be held until growth (i.e.,
mandibular ramal height) can catch up. The changes of the mandibular plane
angle suggest proper retention.

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