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 Acta Scientific Dental Sciences
Volume 1 Issue 7 December 2017
Research Article

Open Bite and Deep Bite Malocclusions: A Comparative Analysis of the Vertical Problems

Mostafa Mohamed El-Dawlatly1, Mona M Salah Fayed2 and Yehya A Mostafa2

1
Lecturer, Department of Orthodontics and Dentofacial Orthopedics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt
2
Professor, Department of Orthodontics and Dentofacial Orthopedics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt

*Corresponding Author: Mostafa Mohamed El-Dawlatly, Lecturer, Department of Orthodontics and Dentofacial Orthopedics, Faculty of
Oral and Dental Medicine, Cairo University, Cairo, Egypt.

Received: June 30, 2017; Published: November 16, 2017

Abstract
Introduction: Open and Deep bite malocclusions should not be approached as disease entities; instead, they should be viewed as a
clinical manifestation of underlying discrepancies. The aim of this study was to investigate the various skeletal and dental compo-
nents contributing to vertical malocclusion, the significance of contribution of each, and if there are significant differences between
their contributions in deep and open bite malocclusions.

Methods: Dental and skeletal measurements were made on lateral cephalometric radiographs and study models of 203 patients
with deep or open bite. These measurements were statistically analysed.

Results: The discrepancy in the curve of Spee was the greatest shared dental component (76.4%), significantly higher than any other
component (P = 0.00000). The gonial angle angle was the greatest shared skeletal component (45.8%), highly significant compared
with the maxillary base angulation (P = 0.01988). When open and deep bite malocclusions were compared, the mandibular plane
angle and the angulation of upper incisors (P = 0.00000) were highly sharing in open bite, while the eruption of the upper incisors
and posterior teeth (P = 0.00000) were highly sharing in deep bite.

Conclusions: The discrepancy in the curve of Spee and the gonial angle were the greatest contributing components. This analysis
of deep and open bite components could help clinicians design individualized mechanotherapy’s based on offending cause, rather
than being biased toward predetermined mechanics.

Keywords: Deep Bite Malocclusions; Orthodontic Treatment; Cephalometric.

Introduction occlusions. Ceylan and Eroz [6] conducted their study on 4 groups
Vertical malocclusion problems comprise discrepancies in the of patients (20 patients in each group) with variable bite depths.
development of overbite whether an increase or a reduction. An ex- They found that the gonial angle was the largest in the open- bite
cessive overbite is referred to as deep overbite that is considered group and smallest in the deep bite group. Beane., et al. [7] com-
among the most common malocclusions in orthodontic practice. pared, using cephalometric analysis, black subjects; 51 with open
Severe deep bites (overbite ≥ 5 mm)are found in nearly 20% of chil- bite and 52 without open bite, to identify skeletal and dental differ-
dren and 13% of adults [1] representing about 95.2% of vertical ences between the two groups. They found that, the vertical skel-
occlusal problems. Several dental and skeletal components were etal growth pattern and the greater degree of dental proclination
deemed to share in a developing deep bite, the most contributing differentiated black patients with an anterior open bite from those
components were proven to be the deep curve of spee and the de- without open bite.
creased gonial angle [2]. The above-mentioned studies had either a small sample size or
On the other hand, open bite malocclusion is one of the highly undefined inclusion criteria of the selected subjects and no study
challenging orthodontic problems. The prevalence of anterior open had undergone a direct comparison between open bite and deep
bite ranges from 1.5% to 11% and varies between ethnic groups bite malocclusions regarding the underlying components. Hence
and according to age and dentition [3]. Profit., et al. recorded a there is an actual void in orthodontic literature concerning this
prevalence of approximately 3.5% in patients from 8 to 17 years of topic.
age [4]. An investigation on the components of open bite malocclu-
Accordingly, the current study aimed at elucidating the various
sion had shown that the flattened curve of Spee, mandibular plane
skeletal and dental components responsible for the development
angle, and the proclination of upper incisors were the highest con-
of the vertical problems, either open or deep bite, and the signifi-
tributing components in its development [5].
cance of the contribution of each component to the malocclusion.
From an expert orthodontist’s point of view the challenging Moreover, we aimed to draw certain measuring guidelines that
nature of any vertical discrepancy should not be restricted to the could differentiate between the two malocclusions.
treatment mechanics. Instead, the clinician should be aware of the
multifactorial nature of this type of malocclusion, including the Materials and Methods
components and factors that contribute to the decision-making The sample comprised pre-treatment lateral cephalograms and
process. study models of 203 patients (124 with deep bite and 79 with open
A limited number of studies had addressed indirectly the com- bite malocclusions), selected from approximately 5500 patient re-
parison between the components of open bite and deep bite mal-

Citation: Mostafa Mohamed El-Dawlatly. “Open Bite and Deep Bite Malocclusions: A Comparative Analysis of the Vertical Problems”. Acta Scientific Dental
Sciences 1.7 (2017): 06-13.
Open Bite and Deep Bite Malocclusions: A Comparative Analysis of the Vertical Problems

07

cords from the database of our department. The subjects were aged Inclusion criteria for open bite cases:
from 16 to 22 years, and their selection was based on the following: • Negative overbite
• Complete eruption of the premolars.
Inclusion criteria for deep bite cases:
• No history of orthodontic treatment.
• Deep overbite of more than 5 mm. • No severe craniofacial disorders.
• Complete eruption of the premolars. • No missing teeth.
• No history of previous orthodontic treatment.
The following measurements were utilized in the study:
• No severe craniofacial disorders.
a. Cephalometric dental measurements
• No missing teeth.

Figure 1 and 2: Dental Cephalometric Measurements

Figure 3 and 4: Dental Cephalometric Measurements
(1-Mx-AABH, 2-Md-AABH, 3-Mx-PABH 4-Md-PABH).
(1- U1/SN, 2- L1/MP), and Skeletal Cephalometric Mea-
surements (3-FH/Mnp, 4-Mxp-SN, 5-Gonial Angle (Ar-Go-
Me), 6-Ramus/FH).

Citation: Mostafa Mohamed El-Dawlatly. “Open Bite and Deep Bite Malocclusions: A Comparative Analysis of the Vertical Problems”. Acta Scientific Dental
Sciences 1.7 (2017): 06-13.
Open Bite and Deep Bite Malocclusions: A Comparative Analysis of the Vertical Problems

08

1. Maxillary anterior alveolar and basal The distance between the mid-point of the alveolar meatus of the maxillary central
height (Mx-AABH,mm)(21 ± 3 mm). incisor and the intersection point between the palatal plane and the long axis of the
maxillary central incisor.

2. Maxillary posterior alveolar and The perpendicular distance between the mid-pointof the alveolar meatus of themax-
basal height (Mx-PABH,mm) (26 ± 3 illary first molar and the palatal plane.
mm).
3. The inclination of the upper incisors The angle formed between the extension of the long axis of the upper incisor and
(U1/SN)(104 ± 6º). theSN plane.
4. Mandibular anterior alveolar and The distance between the mid-point of the alveolar meatus of the mandibular
basal height (Md-AABH, mm) (35 ± centralincisor and the intersection point between the mandibular plane and thelong
3 mm). axis ofthe mandibular central incisor.

5. Mandibular posterior alveolar and The perpendicular distance between the mid-point of the alveolar meatus of the
basal height (Md-PABH, mm.) (35±3 mandibular first molar and the mandibular plane
mm).
6. The inclination of the lower incisors The angle formed between the extension of the long axis of the lower incisor and the
(L1/MP) (95 ± 5º) mandibular plane.

Table 1: Dental Cephalometric Measurements.

b. Cephalometric dental measurements

1. Mandibular plane angle (MndP-FH) (27±5º) The angle formed between the mandibular plane and
the Frankfort horizontal plane.
2. Gonial angle (A r-Go-Me) (123±7º) The angle formed at the gonial area between the pos-
terior border of the ramus and a corpus line
3. Maxillary plane angle (SN-MaxP) (10±3º) The angle formed between the maxillary plane and
the SN plane.

Table 2: Skeletal Cephalometric Measurements.

c. Measurements on the dental cast

1. The length of the clinical crown of the upper The line formed between the midpoint of the cervical margin of the
central incisors (U1 clinical crown length) tooth and the midpoint of the incisal edge.
2. The length of the clinical crown of the lower The line formed between the midpoint of the cervical margin of the
central incisors (L1 clinical crown length) tooth and the midpoint of the incisal edge.
3. The curve of Spee. The line formed between the deepest point on the lower buccal
segment and a horizontal line formed between the most over-
erupted lower incisor and the most over-erupted molar tooth.

Table 3: Dental Cast Measurements.

Cephalometric and cast measurements of 20 cases were repeat- Inferential Statistics:

ed by both the same observer and by a second observer to measure 1) Hypothesis test (paired t-test) was used to compare
the intra- and inter- observer reliability. the significance of the contribution of each component to the
Statistical Analysis vertical malocclusions.

Descriptive Statistics: The mean and standard deviation of each 2) Hypothesis test (paired t-test) was used to compare
of the dental and skeletal components of the vertical malocclu- the occurrence of the dental and skeletal components in open and
sions, together with the percentage of contribution of each of the deep bite malocclusions
dental and skeletal components in the vertical malocclusions was
The concordance correlation coefficient was used to calcu-
calculated.
late the intra-observer and inter-observer reliabilities.

Citation: Mostafa Mohamed El-Dawlatly. “Open Bite and Deep Bite Malocclusions: A Comparative Analysis of the Vertical Problems”. Acta Scientific Dental
Sciences 1.7 (2017): 06-13.
Open Bite and Deep Bite Malocclusions: A Comparative Analysis of the Vertical Problems

09

Results
Statistical analysis of the measurements taken showed the fol-
lowing results:
i. The frequency and the percentage of contribution of
the different dental and skeletal components in vertical maloc-
clusions:

Number of Frequecy of
Percent
subjects Occurance
Curve of spee (d1) 203 155 76.4% Figure 7: The Percentages of Occurrence of Skeletal
Components in Vertical Malocclusion.
Gonial angle (s1) 203 93 45.8%
U1 eruption (d2) 203 87 42.9%
U1 inclination 203 83 40.9% a- Dental Components (Figure 6): The discrepancy in the curve
(d3) of Spee showed the highest contribution in the vertical maloc-
Mandibular plane 203 81 39.9% clusions (76.4%) followed by the eruption of the upper incisors
angle (s2)
(42.9%), inclination of the upper incisors (40.9%), the eruption
L1 eruption (d4) 203 71 35.0%
of the lower incisors (35%), and the eruption of the lower poste-
Maxillary plane 203 70 34.5%
rior segment (31%). This was followed by the upper incisors clini-
(s3)
cal crown length discrepancy (27.6%), the eruption of the upper
L6 eruption (d5) 203 63 31.0%
posterior segment (25.6%). The least contributing factors in the
U1 length (d6) 203 56 27.6%
vertical malocclusions were the inclination of the lower incisors
U6 eruption (d7) 203 52 25.6%
(23.6%) and the discrepancy in the length of the lower incisors
L1 inclination 203 48 23.6%
(16.7%).
(d8)
L1 length (d9) 203 34 16.7% b- Skeletal Components (Figure 7): The discrepancy in the goni-
al angle was found to be the most skeletal component contributing
Table 4: The Frequency and Percentage of Occurance of the Dif-
to the vertical malocclusions (45.8%) followed by the mandibular
ferent Dental and Skeletal Components in Vertical Malocclusion.
plane angle changes (39.9 %), and the least sharing skeletal com-
ponent was the maxillary plane rotation (34.5%).

ii. The significance of the contribution of each of the mea-

sured components to vertical malocclusion:

Regarding the contribution of the dental components (Table 5)

to the vertical problems; the discrepancy in the depth of the curve
of Spee (P = 0.00000) was significantly the highest of all the other
components. This was followed by the eruption (P = 0.01359) and
the inclination (P = 0.03860) of the upper incisors which were sig-
Figure 5: The Percentages of Occurrence of All Compo- nificantly contributing to the malocclusion than the lower sharing
nents in Vertical Malocclusion. components. The contributions of the eruption discrepancies of
the lower incisors, the eruptive problems of the lower posterior
segment and the discrepancies in the length of the upper incisors
to vertical malocclusions were not significant from each other.
While the contributions of the previous 3 components were sig-
nificantly higher from the least sharing components which were
the eruption of the upper posterior segment, the length and incli-
nation of the lower incisors.

Considering the skeletal components (Table 6), the contribu-

tion of the gonial angle was significantly higher (P = 0.01988) than
the sharing of the angulation of the maxillary plane to the vertical
Figure 6: The Percentages of Occurrence of Dental Com-
malocclusions. The angulation of the mandibular plane was not
ponents in Vertical Malocclusion.
statistically different (P = 0.22880) from the highest sharing skel-
etal component, the gonial angle.

Citation: Mostafa Mohamed El-Dawlatly. “Open Bite and Deep Bite Malocclusions: A Comparative Analysis of the Vertical Problems”. Acta Scientific Dental
Sciences 1.7 (2017): 06-13.
Open Bite and Deep Bite Malocclusions: A Comparative Analysis of the Vertical Problems

10

Variable P1 P2 z Probability
d1-d2 and smaller proportions 76.4% 42.9% 6.88 0.00000**
d2-d3,4 42.9% 40.9% 0.62 0.53226
d2-d5 42.9% 31.0% 2.47 0.01359*
d2-d6 42.9% 27.6% 3.22 0.00128**
d2-d7,8,9 42.9% 25.6% 3.66 0.00025**
d3-d4 40.9% 35.0% 1.23 0.21967
d3-d5 40.9% 31.0% 2.07 0.03860*
d3-d6,7 40.9% 27.6% 2.82 0.00474**
d3-d8,9 40.9% 23.6% 3.72 0.00020**
d4-d5,6 35.0% 31.0% 0.84 0.39848
d4-d7,8 35.0% 25.6% 2.05 0.04017*
d4-d9 35.0% 16.7% 4.19 0.00003**
d5-d6,7,8 31.0% 27.6% 0.76 0.44534
d5-d9 31.0% 16.7% 3.38 0.00074**
d6-d7,8 27.6% 25.6% 0.45 0.65324
d6-d9 27.6% 16.7% 2.63 0.00857**
d7-d8 25.6% 23.6% 0.46 0.64498
d7-d9 25.6% 16.7% 2.19 0.02879*
d8-d9 23.6% 16.7% 1.73 0.08351
Table 5: The Significance of Contribution of the Dental Components to Vertical Malocclusion,
Utilizing Hypothesis T-Test.
* Statistically significant * (P ≤ 0.05), ** (P ≤ 0.01)

Variable P1 P2 z Probability
S1-S2 45.8% 39.9% 1.20 0.22880
S1-S3 45.8% 34.5% 2.33 0.01988*
S2-S3 39.9% 34.5% 1.13 0.25868

Table 6: The Significance of Contribution of the Skeletal Components to Vertical

Malocclusion, Utilizing Hypothesis T-Test.
* Statistically significant * (P ≤ 0.05), ** (P ≤ 0.01).

iii. Comparative statistical analysis between the components contribution in deep bite and open bite malocclusions

Open - bite n = 79 Deep - bite n = 124 z Probability

Frequency Percent Frequency Percent
U1 eruption 5 6.3% 82 66.1% 8.39 0.00000
L1 eruption 25 31.6% 46 37.1% 0.79 0.42717
U6 eruption 1 1.3% 51 41.1% 6.34 0.00000
L6 eruption 1 1.3% 62 50.0% 7.32 0.00000
U1 inclination 53 67.1% 30 24.2% 6.06 0.00000
L1 inclination 21 26.6% 27 21.8% 0.79 0.43183
Curve of spee 58 73.4% 97 78.2% 0.79 0.43183
U1 length 16 20.3% 40 32.3% 1.87 0.06206
L1 length 19 24.1% 15 12.1% 2.22 0.02616
Mandibular plane angle 57 72.2% 24 19.4% 7.49 0.00000
Gonial angle 47 59.5% 46 37.1% 3.12 0.00179
Maxillary plane 30 38.0% 40 32.3% 0.84 0.40345

Table 7: Comparison of the Occurance of Different Components in Open- Bite and Deep Bite Malocclusions, Utiliz-
ing Hypothesis T-Test.

Citation: Mostafa Mohamed El-Dawlatly. “Open Bite and Deep Bite Malocclusions: A Comparative Analysis of the Vertical Problems”. Acta Scientific Dental
Sciences 1.7 (2017): 06-13.
Open Bite and Deep Bite Malocclusions: A Comparative Analysis of the Vertical Problems

11

of patients (20 patients in each group) with variable bite depths.

Among their significant findings was that the gonial angle was the
largest in the open-bite group and smallest in the deep bite group.
Direct comparisons between the contribution of the dental and
skeletal components in open and deep bite malocclusions, or eval-
uating their actual contribution in the development of the vertical
malocclusions as a whole, has never been tested.

The discrepancy in the depth of the curve of Spee was the high-
est sharing dental component. This elucidated the importance of
levelling and normalizing the curve of Spee in the various treat-
Figure 8: Comparison of the Occurrence of Different Com-
ment modalities. Also, the inclination and eruptive discrepancies
ponents in Open-Bite and Deep Bite Malocclusions.
of the upper incisors were shown to have a significant contribu-
tion in both open and deep overbite malocclusions. Thus, habits
Regarding open bite malocclusion the components which were and eruptive problems affecting the eruption and orientation of
highly sharing in its development were the skeletal mandibular the upper incisors early in life should be considered as main etio-
variables; the mandibular plane angle (P = 0.00000) and the go- logic factors in the development of the vertical aberrations.
nial angle (P = 0.00179) which were highly sharing in open bite as
compared to deep bite malocclusion. The dental components that Regarding the skeletal components, the mandibular param-
highly shared in open bite than deep bite was the angulation of the eters were shown to have a higher role in the etiology of the ver-
upper incisors (P = 0.00000), and the clinical crown length of the tical malocclusions. As the gonial angle was the highest sharing
lower incisors (P = 0.02616). While the discrepancy in the eruption skeletal component reflecting the importance of the growth and
of the upper incisors (P = 0.00000), the upper posterior segment (P orientation of the mandibular ramus, together with the angulation
= 0.00000), and the lower posterior segment (P = 0.00000) were of the body of the mandible, in the development of vertical maloc-
highly significantly sharing in the development of deep bite maloc- clusions.
clusion and lower in open bite. When the contributions of the components to open and deep
The contribution of some components had no significant differ- bite malocclusions were compared, the skeletal components had
ence between open and deep bite malocclusions which were the a more evident influence in the etiology of open bite. On the other
eruption and inclination of the lower incisors, the curve of Spee, the hand, the dental discrepancies were more sharing in the devel-
clinical crown length of the upper incisors and the angulation of the opment of deep bite. The mandibular skeletal parameters were
maxillary plane. shown to play a more important role in the development of open
bite malocclusion compared to deep overbite. Accordingly, the or-
iv. Inter-observer and intra-observer reliability:
thopaedic control of the mandibular growth and rotation can have
High intra-observer (0.9998) and inter-observer (0.9978) reli- a more profound impact in the treatment of open bite malocclu-
ability were found indicating reliable measurements. sion.

Discussion The dental component that had a role in the development of

open bite malocclusion compared to deep bite was the inclination
Vertical discrepancies comprise those problems that affect the
of the upper incisors; as the proclination of the upper incisors
anterior overbite. Multiple skeletal and dental components were
had a potent contribution in opening the anterior overbite. Thus,
deemed to contribute in the development of both deep bite and
a thorough analysis of the inclination of incisors should be done
open bite malocclusions. Only few studies had addressed this is-
prior to embarking on treating an open bite case. Normalizing the
sue where one study [6] conducted a comparison between 4 groups

Citation: Mostafa Mohamed El-Dawlatly. “Open Bite and Deep Bite Malocclusions: A Comparative Analysis of the Vertical Problems”. Acta Scientific Dental
Sciences 1.7 (2017): 06-13.
Open Bite and Deep Bite Malocclusions: A Comparative Analysis of the Vertical Problems

12

inclination of excessively flared upper incisors could close the bite Thereby, based on the current findings, we can draw some
without undue intrusion of posterior segments or extrusion of an- guidelines elucidating the sharing components in vertical maloc-
terior segments. clusion as a whole and also clarifying some components that could
differentiate between open and deep bite malocclusions (Figure
The eruption discrepancies of the upper incisors shared in es-
9). Our decision-making process in planning the treatments for
tablishing deep bite malocclusion compared to its contribution in
deep and open bite malocclusions should be directed to address
open bite. Their over-eruption contribution in deep bite justifies
the underlying cause; as every individual case should receive cus-
the intrusive mechanics of the upper incisors. However, certain fac-
tomized mechanics to resolve the offending component rather
tors control the amount of intrusion to prevent adverse effects to
than restricting our treatments to limited predetermined tech-
the facial aesthetics. The display of the maxillary incisors at rest and
niques.
the amount of their show on smile influence the treatment decision;
excessive incisor display favours intrusion of the maxillary anterior
teeth8. The smile arc influences the treatment of choice for deep
bite patients. In case of a flat or nearly flat smile arc, intrusion of the
maxillary incisors is contraindicated [8,9]. Also, it was proven in a
systematic review that the maximum amounts of intrusion for non-
growing subjects were merely 1.5 mm for the maxillary incisors and
1.9 mm for the mandibular incisors [10]. While the poor contribu-
tion of the under-eruption of the incisors in open bite emphasizes
on the concept that extruding the incisors increases the tendency
for relapse.
Figure 9: Diagram Showing Some Guidelines in Differenti-
Whilst, the over-eruption of the posterior segments was ac-
ating the Vertical Malocclusions.
cused in its sharing in open bite malocclusion [11], the findings of
Conclusion
the current study have shown surprisingly that this concept was
based on inaccurate assumptions. The very low contribution of the Conclusions
over eruption of the upper and lower first molars proves the dimin-
1) The discrepancy in the depth of the curve of Spee was the
ished need for the massive intrusion of posterior teeth in open bite
highest sharing dental component in the development of ver-
treatment protocols [12,13]. This also makes the claim that open
tical malocclusions.
bite treatment with molar intrusion is more stable unjustified [14].
2) The mandibular parameters were shown to have a higher role
Since both the under-eruption of the lower incisors together with
than the maxillary ones in the etiology of the vertical maloc-
the over-eruption of the lower molars are nearly not contributing
clusions.
to open bite malocclusion, while the reverse curve of Spee [15] is
highly contributing. Therefore, the over-eruption of the premolars 3) The skeletal components had a more marked influence in the
etiology of open, while the dental discrepancies were more
should be over emphasized as one of the main dento-alveolar eti-
sharing in the development of deep bite.
ologic factors in the development of open bite malocclusion. This
would highlight the importance of extracting or intruding the pre- 4) The proclination of the upper incisors had a potent contribu-
molars rather than the first molars in open bite extraction mechan- tion in open bite while the over-eruption of the upper incisors
ics. was highly sharing in the development of deep bite.

Citation: Mostafa Mohamed El-Dawlatly. “Open Bite and Deep Bite Malocclusions: A Comparative Analysis of the Vertical Problems”. Acta Scientific Dental
Sciences 1.7 (2017): 06-13.
Open Bite and Deep Bite Malocclusions: A Comparative Analysis of the Vertical Problems

13

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Citation: Mostafa Mohamed El-Dawlatly. “Open Bite and Deep Bite Malocclusions: A Comparative Analysis of the Vertical Problems”. Acta Scientific Dental
Sciences 1.7 (2017): 06-13.

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