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| CASE REPORT |
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| Year : 2020 | Volume
: 4
| Issue : 3 | Page : 129-133 |
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Deep bite correction with an anterior bite plate in a growing patient
Dwita Pratiwi, Miesje K Purwanegara
Department of Orthodontics, Faculty of Dentistry, University of Indonesia Dental Hospital, Universitas Indonesia, Jakarta, Indonesia
| Date of Submission | 26-Jun-2020 |
| Date of Decision | 29-Jul-2020 |
| Date of Acceptance | 03-Sep-2020 |
| Date of Web Publication | 17-Oct-2020 |
Correspondence Address:
Dwita Pratiwi
Department of Orthodontics, Faculty of Dentistry, Universitas Indonesia Rumah Sakit Khusus Gigi dan Mulut, Universitas Indonesia, Jakarta
Indonesia
 Source of Support: None, Conflict of Interest: None  | 1 |
DOI: 10.4103/SDJ.SDJ_24_20
Background: Deep bites represent one of the most difficult cases in orthodontic treatment. In growing patients, strategies for deep bite correction include extrusion of posterior teeth and intrusion of incisors, which can be achieved using anterior bite plates. This case report presents the treatment of a deep bite in a growing patient using an anterior bite plate. Case Report: A 13-year-old female presented with a convex profile, short lower facial height, a Class II skeletal relationship, a deep bite (6 mm overbite), a 6 mm overjet, and severe crowding on both arches. The patient was treated with a removable anterior bite plate in conjunction with a fixed appliance. A normal overbite (2 mm) was achieved, severe crowding was corrected on both arches, the lower facial height was increased, the interincisal angle remained favorable, the mandibular incisors were well positioned in the basal bone, and the smile esthetics improved. Conclusion: The use of an anterior bite plate in combination with fixed appliances is effective in treating deep bites in a growing patient.
Keywords: Anterior bite plates, deep bite, growing patient
How to cite this article:
Pratiwi D, Purwanegara MK. Deep bite correction with an anterior bite plate in a growing patient. Sci Dent J 2020;4:129-33 |
| Background | |  |
A deep bite is a malocclusion in which the maxillary incisors overlap the mandibular incisors beyond the normal coverage of 30%–40%, or 2–4 mm, and is one of the most challenging cases in orthodontic treatment.[1],[2],[3] According to population-based studies conducted in Korea, Malaysia, India, China, and Middle East country, the prevalence of deep bite cases has been estimated at 23.83% of the Asian population.[4] A deep bite could be caused by skeletal or dentoalveolar factors or a combination thereof. Deep bites caused by dentoalveolar factors are usually related to undereruption of posterior teeth or overeruption of anterior teeth.[2],[5] The clinical characteristics of deep bite patients include short anterior lower facial heights, flat mandibular plane angles, reduced gonion angles, extreme overjets, supraocclusion of incisors, infraocclusion of molars, and deep curves of Spee.[2],[6] Short lower facial height is a skeletal problem that requires complex treatment.
Approaches to treating deep bite cases include intrusion of the incisors, eruption/extrusion of the molars, proclination of the lower incisors, and in severe skeletal cases, a combination of orthodontics and surgery.[2],[7],[8] Many factors should be considered in determining the optimal mechanics, including the patient's growth potential, profile, and smile esthetics and the stability of the result. In growing patients, anterior bite plates are known to be effective in treating deep bites by allowing eruption of the molars.[9],[10],[11] This case report presents the treatment of a growing patient with a deep bite using an anterior bite plate in conjunction with a fixed appliance.
| Case Report | | |
A 13-year-old female patient referred to the Department of Orthodontics of Faculty of Dentistry, Universitas Indonesia, with a chief complaint of irregular upper and lower teeth. The patient had no systemic disease related to malocclusion. She had an unfinished root canal treatment in tooth 16 with a temporary filling and also had a one-sided chewing habit.
Extraoral examination showed a convex profile, a slightly asymmetric face, and short lower facial height [Figure 1]a. Intraoral examination revealed deep bite malocclusion (6 mm overbite), severe crowding on the upper and lower arches, scissor bite between teeth 15 and 45, a severe overjet (6 mm), and an extreme curve of Spee. The patient's oral hygiene was fair. She had a Class II canine relationship on the right side and no midline shifting [Figure 1]b. A panoramic radiograph revealed adequate levels of alveolar bone. All permanent teeth were present, except for the third molars. The roots of the teeth were not parallel [Figure 2]a. Cephalometric analysis confirmed Class II skeletal malocclusion with a retrognathic mandible (ANB = 5°, Wits appraisal = +8 mm). The incisor inclination was normal in both the upper and the lower jaws. Facial growth was favorable [Figure 2]b and [Table 1]. There were no signs of a temporomandibular joint disorder.
The treatment objectives in this case were to establish a Class I canine relationship, relieve crowding on both arches, achieve an ideal overbite and overjet, and level the curve of Spee. The patient was treated using a removable anterior bite plane and a straight wire appliance with an MBT prescription. Space to relieve the crowding on the upper arch was gained by lateral expansion and extraction of tooth 16, which was extracted because the prognosis of the root canal therapy was poor. On the lower arch, space was gained by lateral expansion and protraction of the lower incisors. At the beginning of the treatment, the patient was instructed to use a removable anterior bite plane so that the alignment process could take place simultaneously. The wire sequence for aligning process was 0.014, 0.016, 0.016 × 0.022, and 0.017 × 0.025-inch nickel–titanium wires.
After 15 months of treatment, the teeth on both arches were aligned, and a 3 mm overbite was achieved. The treatment was continued with distalization of tooth 13 to achieve a Class I canine relationship and mesialization of 17 to close the edentulous space of 16 and achieve a cusp-to-fossa occlusion with 46. Retraction of maxillary incisors was performed to achieve a normal, 2 mm overjet. Intrusion of incisors was performed on both arches to achieve a 2-mm overbite with a 0.017 × 0.025-inch stainless steel wire. At the finishing stage, buccal root torque was performed on 13 to correct the bite in the transverse direction. Debonding was performed after 26 months of treatment. The deep bite was corrected (2 mm overbite), a normal overjet was achieved, the maxillary and mandibular teeth were well aligned, and the smile was improved [Figure 3]a and [Figure 3]b. Impressions were made for Hawley retainers on both arches, with a modification in the anterior region of the upper arch.
| Discussion | | |
This patient referred to our institution with a chief complaint of irregular teeth and an unattractive smile. Upon clinical examination, the patient was diagnosed with Class II skeletal malocclusion (ANB = 5°) with a severe deep bite, severe crowding on both arches, an excessive overjet, and an extreme curve of Spee. According to El-Dawlatly et al., an extreme or steep mandibular curve of Spee is the most significant contributor to deep bite malocclusion, which was also seen in our patient.[12] A steep curve of Spee is caused by overeruption of the mandibular incisors as an adaptation to achieve occlusal contact with the maxillary incisors.[3],[12],[13] An untreated deep bite can cause trauma to the palatal mucosa, temporomandibular joint disorders, abnormal mandibular function, and attrition of lower incisors and, in severe cases, may even lead to the loss of lower incisors.[1],[6] Therefore, orthodontic treatment is required.
In growing patients, the use of anterior bite plates has been shown to be effective for deep bite correction. Anterior bite plates may be removable or fixed. The patient's compliance determines the success of the treatment with a removable appliance because the bite plate must be worn continually. In noncooperative patients, fixed bite plates can be used.[2],[11]
An acrylic extension of the anterior bite plate holds the lower incisors and opens up the bite in the posterior segment. This posterior disocclusion allows further eruption of the posterior teeth so that the anterior deep bite is reduced.[2],[3] This mechanic also produces relative incisor intrusion because vertical growth at the condyle helps compensate for any increase in the vertical dimension caused by molar extrusion. This combination of tooth movements has flattened the curve of Spee [Figure 4]a and [Figure 4]b. For these reasons, anterior bite plates are effective in treating deep bites in growing patients.[3] Moreover, it is known that for every 1 mm extrusion of the posterior teeth, the overbite is reduced by 1.5 mm anteriorly.[6] As a result, the lower facial height increases,[11] which was beneficial for the patient [Figure 5].
Removable anterior bite plates were used in conjunction with fixed appliances. They facilitate earlier placement of the lower brackets without impinging on the occlusion. This allows the mandibular arch alignment and leveling to be done from the start of treatment. In this case, the patient presented with severe crowding, particularly on the mandibular arch. The initial archwire was fully engaged to align the teeth, and in the process, proclination of the incisors was achieved. This proclination simultaneously reduced the anterior deep bite, the interincisal angle, and the overjet.[14] However, lower incisor proclination can be unstable, as the teeth tend to return to their pretreatment position. To overcome this problem, the upper incisor root should be placed behind the plane of the lower incisal edge,[3] as performed in this patient. Moreover, the combination of disocclusion and full engagement of the initial archwire allowed the mandibular arch to expand so that the scissor bite could be corrected [Figure 3]b.
In this case, the crowding on the upper arch was more severe on the right than on the left side. The upper right canine was slightly ectopic, and the right and left central incisors overlapped. Full engagement of a nitinol archwire on the upper arch allowed the crowded teeth to be aligned and leveled by moving them to the area of the upper right first molar, which had previously been extracted. At the end of this process, we achieved better interdigitation of the posterior teeth, but the canine relationship was still Class II ¼ unit, and there was a gap between the upper right canine and the first premolar. Therefore, we decided to distalize the upper right canine. The upper right second molar was moved mesially to replace the upper right first molar. Meanwhile, space was created on the left side between the upper left canine and the lateral incisor through wire expansion. This space was then used to retract the anterior teeth. However, because the space on the right side was wider than on the left side, we decided to perform interproximal reduction on the upper left canine and the lateral incisor to maintain the midline, which coincided with the facial midline already from the beginning of the treatment.
In treating malocclusion case, there are various components of smile need to be assessed in order to improve the smile esthetics, that is, the dental arrangement, the incisal and gingival show, the buccal corridor width, the dental and facial midline, and the relationship of the upper incisor edges with the lower lip which should be close to but not touching the lower lip.[7] This patient had anterior crowding on the upper arch, and her upper incisor edges were not parallel to the curvature of her lower lips and touched the lower lip. As a result, the patient's smile became less attractive. To achieve better esthetic smile, the anterior crowding was corrected by aligning the upper teeth. This process also results in more parallel position of the incisors to the lower lips. Absolute intrusion of the upper incisors was performed with second-order bends which contributed in reducing the overbite and improving the relationship between upper incisors edges with the lower lip. Costopoulos and Nanda reported that patients who undergo intrusion present with an average of 0.4 mm resorption more than those who did not.[15] To reduce the risk of root resorption and avoid excessive intrusion in upper incisors, a 0.5 mm intrusion was also performed on the lower incisors with the 0.017 × 0.025-inch stainless steel wire. This approach can also improve the stability of deep bite correction.[6],[12],[16] After debonding, we could observe that the patient had a more esthetic smile with a symmetrical dental arrangement and minimal buccal corridor, and her upper incisors were parallel to and did not come into contact with the lower lip. A posttreatment panoramic radiograph and superimposition of pre- and posttreatment radiographs showed no signs of root resorption in the lower incisors [Figure 4]a and [Figure 5].
Many factors affect the stability of deep bite correction, including a change in interincisal angle, leveling techniques, vertical position of the maxillary incisors, position of the mandibular incisors in the basal bone, and patient compliance in the retention phase.[10],[17] Maxillary and mandibular incisors that are too upright before treatment tend to return to their original relationship at the postretention stage.[18] For this reason, a favorable interincisal angle is recommended, which can be achieved by proclination of the maxillary or mandibular incisors or both. The interincisal angle should be corrected so that the tips of the mandibular incisors occlude onto the cingula of the maxillary incisors to produce an occlusal stop and prevent the incisors from erupting past each other.[7],[19] In this case, proclination of the maxillary and mandibular incisors was achieved through the leveling and aligning process. As a result, the mandibular incisors, which initially had a deep palatal bite, were corrected, and occlusion onto the cingula of the maxillary incisors was achieved [Figure 5]. Thus, an occlusal stop was formed, and the interincisal angle was reduced but remained favorable [Table 1].
Lapatki et al. reported an increased tendency of the corrected maxillary incisor inclination to relapse when the lower lip is high after treatment.[20] To achieve maximum stability, the lower lip should provide no more than 3 mm coverage to the upper incisors. In our case, we managed to reduce overlapping by intrusion of the maxillary incisors and achieve normal coverage [Figure 5].
Another factor that should be considered for achieving deep bite correction stability is the position of the mandibular incisors. The mandibular incisors should be positioned upright in relation to the basal bone. Excessive labial tipping of the mandibular incisors should be avoided to minimize the risk of root resorption and bone dehiscence. Posttreatment cephalometric analysis showed that our patient's mandibular incisors were well positioned in the basal bone, and the inclination was favorable [Figure 4]b and [Figure 5].[21]
As in any other orthodontic case, long-term retention in deep bite correction is essential. Danz et al. found that with successful treatment followed by the placement of a fixed retainer and a temporary removable upper plate, the degree of relapse is relatively small and clinically insignificant.[22] However, fixed retainers can increase the accumulation of calculus, which in turn can increase the marginal recession of the gingiva.[23],[24] Therefore, the use of a fixed retainer for our patient, who had fair oral hygiene, was not deemed beneficial. Moreover, in growing patients, it is recommended that a bite plate be used as a retainer to prevent deep bite relapse by keeping the molars and incisors at the corrected height and inclination.[2],[19] Accordingly, our patient was instructed to use a modified Hawley retainer with an acrylic extension at the anterior segment as a bite plate on the upper arch and a regular Hawley retainer on the lower arch.
| Conclusion | | |
The use of anterior bite plates in conjunction with fixed appliances yields good results in the treatment of deep bites in growing patients. An anterior bite plate allows the posterior segment to erupt freely and flattens the curve of Spee, while the fixed appliances align the teeth by proclination of the incisors. As a result, the overbite is reduced.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1]
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