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International Journal of Medical and Biomedical Studies

Available Online at www.ijmbs.info
PubMed (National Library of Medicine ID: 101738825)
Index Copernicus Value 2018: 75.71
Original Research Article Volume 3, Issue 12; December: 2019; Page No. 140-149

THE PROBLEM CALLED DEEP BITE AND ITS MANAGEMENT - A REVIEW.

Dr. Priti Shukla1, Dr. Shraddha Gupta2
1
Senior Resident, Department of Orthodontics and Dentofacial Orthopaedics, King George Medical University,
Lucknow, Uttar Pradesh, India.
2
Senior Resident, Department of Orthodontics and Dentofacial Orthopaedics, King George Medical University,
Lucknow, Uttar Pradesh, India.
Article Info: Received 30 November 2019; Accepted 21 December 2019
DOI: https://doi.org/10.32553/ijmbs.v3i12.811
Corresponding author: Dr. Priti Shukla
Conflict of interest: No conflict of interest.
Abstract
Deep bite is one of the most common and most deleterious malocclusion seen in children as well as adults that can occur
along with other associated malocclusions. An unfavorable sequelae of this malocclusion predisposes a patient to
periodontal involvement. Abnormal function, improper mastication, excessive stresses, trauma, functional problems,
bruxism, clenching and temporomandibular joint disturbance.

Introduction 1. Supraeruption of maxillary or mandibular or both

1,2 anterior segments.
Graber has defined deep bite as a condition of
2. Infraocclusion of the maxillary or the mandibular
excessive overbite, where the vertical measurement
posterior teeth or both.
between the maxillary and mandibular incisor
3. Lack of downward and forward growth of the
margins is excessive when the mandible is brought
mandible during the transitional period from the
into habitual or centric occlusion while Proffit3
deciduous to the permanent dentition.
defined overbite as vertical overlap of the incisor
4. Retardation of ramus growth, with continuous
teeth when the posterior teeth are in contact.
eruption of the anterior teeth.
CLASSIFICATION:
5. Insufficient length of masticatory muscles,
Deep bite can been classified as
causing inadequate eruption of posterior teeth.
a) Dentoalveolar / Skeletal by Rakosi b) True/ 6. Severe disharmony of the dental arches.
Pseudo by Hotz and Muhlemann 7. Lack of dentoalveolar growth during the eruption
b) Incomplete/ Complete by Graber. of bicuspid and permanent posterior teeth as a result
ETIOLOGY: of crowding of dental arches.
3) Condylar growth pattern
I. INHERENT FACTORS Patients with deep bite have an upward and forward
1) Tooth morphology4 growth of the condyle with reduced anterior face
Anterior teeth with long crowns will appear to have a height. Growth in this direction often results in more
greater overbite than with short crowns, even though horizontal displacement of the mandible and is most
the contact relationship of the incisors in both cases effective in improving the position of chin, often
may be the same. desirable in patients with class II division I
Therefore, any measurement of the degree of malocclusion.
overbite should be derived not only from the amount Whether or not a deep bite develops depends on the
of incisor overlap but also from the point on the relationship between maxillary and mandibular
palatal surface at which the opposing tooth strikes. incisors. If the mandibular incisors have proper
2) Skeletal pattern and malocclusion4 contacts with the lingual surfaces of the maxillary
incisors, chances are best that a deep bite will not
An excessive overbite may be a manifestation of a develop.5
malocclusion in several ways.

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II. ACQUIRED FACTORS4  Maxillary buccal crossbites are commonly

1) Muscular habits associated with interdental spacing.
Severe clenching or grinding habits or hypertonicity  Gingival recession with maxillary and / or
of the masticatory muscles may cause depression of mandibular incisors is seen.
the posterior teeth. Excessive tooth wear also may Dentoalveolar deep bite shows following features.
result in a loss of vertical height.  Majorly created by premature loss of permanent
2) Changes in tooth position teeth causing a lingual collapse of maxillary or
Premature loss of deciduous molar teeth may permit mandibular anterior teeth.
mesial drifting of the first permanent molars with  Similarly loss and / or mesial tipping of the
subsequent impactions or crowding of bicuspid teeth. posterior teeth may also cause a deepening of the
This anterior displacement of the posterior support of overbite.
the dentition may lead to the development of an  Occasionally a deep bite may be caused or
excessive overbite. accentuated by an aberration in the tooth
3) The loss of posterior supporting teeth morphology. This can be diagnosed by careful
In the adult dentition, extraction of molar or bicuspid analysis of size and shape of teeth.
teeth without replacement will permit adjacent teeth Skeletal deep bite shows.
to drift toward the space. Such migration often  Malrelationship of alveolar bones and / or
causes abnormal axial inclinations and a deepening of underlying mandibular or maxillary bones.
the bite or commonly called as collapsed bites. This  In the mandibular dentition it may manifest as a
frequently directs excessive trauma against maxillary deep curve of spee or reverse curve of spee in the
incisor teeth, and anterior displacement may result. maxillary dentition.
4) Lateral tongue thrust habit.
A lateral tongue thrust or postural position frequently 2. STUDY MODELS
can produce an acquired deep overbite. This type of
dysfunction produces an infraocclusion of posterior
 Study models show excessive overbite.
teeth, which in turn leads to a deep bite. In these  Lower arch shows exaggerated curve of spee.
cases the free way space is usually large, which is  Typically reverse curve or compensatory curve of
favorable for functional appliance treatment. maxillary occlusal plane in cases of class II division 2
DIAGNOSIS: malocclusion.
1. CLINICAL & PHOTOGRAPHIC EXAMINATION6  Palatal vault appears to be flat.
A) Extraoral examination (in natural head position):  Molars are in infraocclusion in true deep bite
 Patient has a short, square face. cases.
 The upper lip curves downward and the corners  Incisors are supraerupted in pseudo deep bite
of mouth are below the occlusal line. cases.
 In centric occlusion, distinct skin folds are seen  Maxillary arch is wider.
lateral to the oral commissure.
 Sometimes teeth are in buccal cross bite.
 Broad alar bases and large nostrils. 3. CEPHALOGRAMS
 The posterior part of face appears wide because Cephalometrically skeletal deep bite and
of prominent mandibular angles. dentoalveolar deep bite can be differentiated from
 The nasolabial angle is normal or obtuse. each other as the dentoalveolar deep bite shows only
 With the mandible in a rest position and the changes in dentition and the maxillary and
upper lip relaxed, the incisal edges of the maxillary mandibular bases are normal.
anterior teeth are positioned above the inferior Few parameters in the different cephalometric
margin of upper lip. analysis emphasize and differentiate the vertical
 There is distinct chin button, which is made dysplasia.
more apparent by a deep mentolabial fold. They are -
B) Intraoral examination 1) DOWNS7 ANALYSIS (1948)
 Absolute transverse maxillary excess. In skeletal deep bite cases, the mandibular plane
angle and y-axis value decreases where as interincisal
 The maxillary arch is broad with flat palatal vault. angle increases.
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2) STEINER7 ANALYSIS (1953) d) LIP LENGTH11

In skeletal deep bite cases, mandibular plane angle Often a patient has a large interlabial gap or a large
decreases and interincisal angle increases. incision stomion distance because of a short upper
3) RICKETTS7 ANALYSIS (1957) lip. The treatment option of choice in these patients
In skeletal deep bite cases facial axis increases and is to correct deep overbite by intrusion of upper
mandibular plane angle decreases. incisors. This option prevents extrusion of posterior
4) SCHWARTZ7 ANALYSIS. (1958). teeth and helps in improving upper incisor -upper lip
Base plane angle and gonial angle decreases in relationship.
skeletal deep bite cases. Base plane angle decreases e) LIP TONICITY11
due to the anticlockwise rotation of mandible and or In patients who exhibit hyperactive and tense upper
clockwise rotation of palatal plane anteriorly. In the and lower lips, flaring of upper and lower incisors
skeletal deep bite it is 230 at 9 yrs of age and 20.50 at results in relapse, owing to muscle pressure.
15 yrs of age. 2) SKELETAL CONSIDERATION11
A careful assessment of the ratio of upper to lower
Interincisal angle increases in deep bite cases.
face height of 45%: 55% is optimal. In patients with
5) SASSOUNI8, 9, 10 (1969) large lower facial height, an extrusion of molars to
Sassouni developed an analysis for differentiating correct deep overbite is not the treatment of choice
deep bite and / or open bite relationship. According because it further lengthens the face with
to him, the constitution of each skeletal type may be concomitant undesirable changes of the soft tissues.
due to a positional or dimensional imbalance. Similarly, patients with short vertical dimension often
When it is positional, the direction of the have a class II division 2 malocclusion along with a
displacement is described as anterior or posterior, deep overbite. In these patients, extrusion of
downward or forward, upward and lateral. When it is posterior teeth may be the treatment of choice to
dimensional, it is described as large or small. open the bite.
3) FUNCTIONAL CONSIDERATION11
TREATMENT CONSIDERATIONS: Extrusion of posterior teeth drops the mandible
1) SOFT TISSUE CONSIDERATION11 downward and backward, and the condyle assumes a
a) INTERLABIAL GAP new position in the temporomandibular joint
Any extrusive mechanics in the molar area to correct articulation. This can result in two adjustments so
deep overbite swings the mandible downward and that equilibrium between function, muscles and TMJ
backward, thereby increasing the interlabial gap. This anatomy can take place following the orthodontic
corrects the dental problem but results in an treatment. First, if the extrusion of the posterior
undesirable soft tissue changes. teeth remains stable, the condyle, TMJ and muscles
If the patient does not have any interlabial gap with have to remodel or readapt to their new morphologic
deep overbite, extrusion of posterior teeth may be a position of the mandible. Second, the adjustment
treatment of choice, provided that other treatment results in relapse because the muscles of mastication
planning considerations allow it. and altered occlusion may pound the extruded
posterior teeth back to their original position until a
b) INCISION - STOMION DISTANCE11 soft tissue and hard tissue equilibrium is attained
A 3 to 4 mm incision - stomion distance is esthetically again.
pleasing. Any attempt to correct deep overbite with 4) DENTAL CONSIDERATION11
extrusion of molars increases this distance with Intrusion of incisors is an ideal option to correct deep
concomitant increase in the interlabial gap. bite because it maintains the vertical dimension of
c) SMILE LINE11 the patient. If a patient needs intrusion of incisors to
During an esthetically pleasing smile, the upper lip correct deep overbite, up to 4.0 mm upper incisor
line should be at or near the gingivoenamel junction. intrusion can be accomplished without any significant
Often patients have a smile that shows an abundance root resorption. If a patient needs more than 4.0 mm,
of gingival tissue. The objective in these patients of upper incisor intrusion, it can be combined with
should be to prevent extrusion of posterior teeth at the intrusion of lower incisors.
any cost. Otherwise, the esthetic result is poor. Intrusion should also be the treatment of choice for
adult patients who have had significant bone loss

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around the incisors. Periodontal disease should be Herschleb in 1981 suggested use of 80-100 gram of
under control in adult patients before the start of force for four incisor intrusion. Nicolai14 in 1985
orthodontic treatment. advocated that intrusive force should be 60 gram/cm2
5) STABILITY11 of occlusoapical projection of root surface area.
Stability of attained results should be prime concern Kesling15,16 in 1985 suggested 14 gram of net force
in correction of deep bite. In children, often the for six upper anterior intrusion 35 gram for lower six
growth acts as a major catalyst in taking care of anteriors. Proffit3 in 1993 suggested 15 gram of force
extrusive side effects. In adults, adaptation of the needed for incisor intrusion. Siatkowski in 1997,
muscles, vertical dimension, and TMJ is difficult. The based on the work of Dermaut suggested 10-15 gram
treatment option in adults should be limited to teeth for upper central incisor where as 5-10 gram for
whenever possible. Intrusion of teeth can be upper lateral and 15-25 gram for upper canines.
accomplished without any change in skeletal and Karanth and Shetty17 in 2001 advocated 60 gram of
muscular components of the face. force for four upper incisors and 100 gram of force
6) OCCLUSAL PLANE11 for six anteriors; where as 40 gram of force for lower
This objective, if not considered along with lip and four incisors and 80 gram for six lower incisors.
vertical facial height considerations may result in Thus the force ranges on an average from 15 - 20 gm
unpleasant and unstable conditions in deep bite for each upper incisor and 10 - 15 gm for each lower
cases. incisor.
7) INTEROCCLUSAL SPACE11
But in adults the forces are to be applied carefully
The correction of a deep overbite by extruding
and somewhat towards a lower range.
posterior teeth to encroach on this space should be
avoided as it often results in relapse caused by the TREATMENT MODALITIES:
muscles of mastication and because of full occlusal A. CORRECTION OF DEEP BITE WITH REMOVABLE
contact of posterior teeth during speech and APPLIANCES
mastication. It is also believed that this may also
result in pathologic changes at the 1) Bite plane or bite plate
temporomandibular joint. Used in 1879 by Miller,4 it permits the elongation of
8) TREATMENT TIME AND AGE OF PATIENT11 posterior teeth which depends on the growth of
In adult patients showing excessive deep bite with alveolar bone. This new bone must be conditioned to
accompanying high smile line, decreased vertical withstand the stresses of mastication by withdrawal
facial height and alveolar problems, the length of of bite plate gradually.
treatment may be very long. In these instances, the 2) Sved Bite Plane
patient should be given a choice for an orthognathic
correction of problem. In these patients, the Sved4,18 modified the bite plate to attempt to obtain
treatment plan to correct the excessive overbite some depression of the maxillary anterior teeth as
should be done in conjunction with oral and well as the mandibular anterior teeth. He has covered
maxillofacial surgeons. acrylic on the entire palatal and incisal surfaces and
extended up one third of the labial surfaces of the
OPTIMAL INTRUSIVE FORCE FOR ANTERIOR anterior teeth
INTRUSION 3) Posterior tongue crib19
Burstone12 in 1977, suggested 50 gram of intrusive Lateral tongue thrust or lateral positioning of the
force for upper central incisors, 100 gram force for tongue during function causes deep bite due to
centrals and laterals and 200 gram for six upper infraocclusion of molars. This true deep bite is called
anteriors. He advocated use of 40 gram for four lower as functional deep bite as the tongue is positioned on
incisors and 60 gram for all six lower anterior the occlusal surfaces during function.
intrusion. Bench, Gugino and Hilgers13 in 1978, 4) An Essix intrusion appliance20
advocated the intrusive force of 15 to 20 gram per An Essix appliance does not require clasps; it is easily
lower incisor or 60 to 80 gram for all four lower constructed, and can be thermoformed from a single
incisors. Ricketts in 1980 advocated the use of 125 1mm sheet of Essix plastic.
gram to 160 gram of force for upper incisor intrusion
and 60 to 75 gram for lower incisors. Liu and

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B. CORRETION OF DEEP OVERBITE WITH distally to encourage eruption of lower molars. It is

MYOFUNCTIONAL APPLIANCES essential that this be done as early as possible in
Treatment in the mixed dentition period requires the treatment, usually when fitting twin blocks, to allow
elimination of environmental factors that are vertical development to proceed concurrently with
inhibiting eruption of the posterior teeth.21 sagittal correction because vertical development is
slower than sagittal correction which is normally
1) THE ACTIVATOR21
achieved within 6-9 months.
Deep overbite cases with infraocclusion of molars can CORRECTION OF DEEP OVERBITE BY HEADGEAR21
be treated by activators designed and trimmed to The cervical pull headgear is indicated in deep bite
permit extrusion of these teeth with either moderate cases. It exerts a vertically downward component of
or high construction bite depending on the freeway force with the potential for extrusion of the molars.
space. So with the cervical pull headgear the molars get
In deep overbite cases caused by supraocclusion of distalized and extruded by applying 200-300 gm of
the incisors, the interocclusal space is usually small so force per side. The force duration should be 14 to 16
the activator should not be constructed with a high hours per day or more.
construction bite.
C. CORRECTION OF DEEP BITE WITH FIXED
Trimming of activator in deep bite cases21,22
APPLIANCE THERAPY
Selective trimming of the activator can be done to
C.1) CORRECTION OF DEEP BITE WITH FIXED BITE
intrude or extrude the teeth.
PLANES
In deep bite cases, intrusion of the incisors is
achieved by loading the incisal edge of these teeth I) MODIFIED NANCE APPLIANCE24
with acrylic. Extrusion of molars is achieved by The size of anterior buttons can be varied to create
loading the palatal surface above the area of greatest an inclined plane that will bring condyle forward into
convexity in maxillary and below the area of greatest a harmonious relationship. Once a true centric
convexity in mandible. relation has been reached, the occlusion can easily be
adjusted as necessary.
2) THE BIONATOR21,22
II) BONDED BITE PLANES WITH COMPOSITE RESIN
Cases of a deep overbite can be successfully managed (INDIRECT TECHNIQUE)25
with the standard type of Bionator, after grinding Bonded bite planes allows:
away of the acrylic in a manner that permits step by  Mandibular brackets placement at the same
step uninhibited eruption of the buccal segment appointment as the bite planes.
teeth.  Unimpeded movement of posterior teeth caused
3) FUNCTIONAL REGULATOR21,22 by occlusal interferences.
For correction of deep overbite FR Ia and FR Ib  Mandibular brackets are almost never sheared
appliances are used. Increase of vertical extraoral away.
space is possible because the construction bite is III) BONDED ACRYLIC LINGUAL BITE PLANES (DIRECT
taken so that the bite is opened in the posterior TECHNIQUE)26
segments as the mandible is held forward. The
eruption or elongation of the posterior teeth takes This produces an intrusive effect or growth restrain
place in manner similar to that seen with anterior on the incisors while allowing the extrusion of the
biteplates, except that the buccal soft tissue into the posterior teeth. It is also called as lingual bite steps or
interocclusal space. bite turbos.
4) THE TWIN BLOCK FUNCTIONAL APPLIANCE23 IV) A FIXED LABIAL AND LINGUAL TECHNIQUE FOR
Deep overbite by twin block is reduced by vertical RAPID BITE OPENING27
over correction to an edge-to-edge incisor The bite plane which is a feature of lingual bracket,
relationship with an interincisal clearance of 2-3 mm eliminates the need for patient co-operation. Bite
in the protrusive bites. Occlusal cover of the posterior opening is hastened by the simultaneous bonding of
molars of 1 mm is equivalent to 3 mm to 4 mm the upper and lower arch, and the lingual brackets
vertical clearance in the first premolar region. can be removed soon after bite is opened.
Overbite reduction is achieved by trimming the V) TEMPORARY BITE RAISER
occlusal cover on the upper twin block occluso- Given by Guray28 is made of 0.036” stainless steel
wire. A double molar tube is welded on the buccal
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side of molar band along with a lingual button which bends. These bends placed 3 mm mesial to the molar
is welded. Acessory slot is used to prepare a bite tube, tend to cause more intrusion of the upper
raiser. One end of 0.036” Stainless steel wire is canines and progressively less intrusion of the lateral
inserted 3-4 mm into the tube from the mesial side and central incisors due to bowing of the arch wire in
and the other end of the wire is inserted from the canine area.
distal side. The section of wire between the two ends b) Gable bend
is adapted to the occlusal morphology of the tooth. A Gable bends placed distal to the canines, normally
bend in the lingual portion of the wire is ligated to a made in the third stage archwire to maintain bite
welded lingual button on the maxillary tooth. The opening attained in the earlier stages. It tends to
ligature wire can be cut to allow the occlusion to be cause relative extrusion of canines, while there is
checked without removing the entire auxiliary. The progressively more intrusion of the lateral and central
ends of the bite raiser hinge on the molar tube. incisors. This has a more intrusive effect on central
Recently however, Richard Ceen29 has introduced a and lateral incisors.
prefabricated version of temporary bite raiser. c) Hocevar’s modification
The bite raiser has several advantages over existing In the Hocevar’s modification a bend on either side of
techniques. the canines are given. With this modification, the
central incisors are subjected to intrusion while the
 It can be placed or removed easily and quickly
canine and lateral incisors are extruded (canine more
with minimum patient discomfort.
than lateral incisor) with respect to the central
 The patient’s bite relationship can be assessed
incisors.
by hinging the device out of occlusion.
 No laboratory procedures are required. d) Kameda’s modification16
 Increased patient acceptance. Using a simultaneous anchor and gable bends, the
 The stainless steel appliance is adjustable and canines and the premolars if engaged are extruded,
designed for use with either occlusally or gingivally while the lateral and centrals experience
placed headgear tubes. progressively more intrusive effect. Thus the bite
C.2) CORRECTION OF DEEP BITE WITH BEGG’S opening takes place by extrusion of posteriors and
TECHNIQUE15,16 intrusion of anteriors.
Deep overbites are eliminated and overcorrected in e) Dr. Jayade’s modification16
the first stage of Begg’s technique. A mild gingival curve is incorporated in the anterior
section, starting from mesial one cuspid circle to the
I) Arch wires15,16 corresponding point on the other side. This should lift
According to Kesling 0.016” arch wires are better for the archwire at the midpoint by about 3mm over the
opening the bite by elevating the mesial marginal brackets.
ridges of anchor molars which tends to relapse after He further augmented the intrusive action of the
active treatment. gingival curve by incorporating a vertical step-up
Mollenhauer suggests the use of 0.018” premium bend 4-5mm in height and placed 2 to 3mm mesial to
plus wire for upper anterior intrusion. This wire can the molar tube on both sides. Anchor (tip-back) bend
generate 75gm of force with an anchor bend of of the required degree is placed at the upper end of
approximately 50 degrees. However, the 0.18” arch the step. This results in uniform intrusion of all the six
wire producing such high magnitude of intrusive upper anterior teeth.
force can also severely tip the anchor molars distally III) Class II elastics
especially so, if there are no teeth present distal to
the anchor molars. The Class II intermaxillary elastics are applied at the
start of treatment. In the first stage of treatment
II) Bite opening bends15,16 these intermaxillary Class II elastics, by their force, tip
Many authors have proposed different sites for bite back the crowns of the six upper anteriors.
opening bends in the arch wires. A net intrusive force of 60gm can be obtained by a
combination of 75gm archwire generated intrusive
a) Anchor bend or conventional bite opening bends
force and appropriate modifications of Class II elastics
Earlier these bends were called as tip back bends. Dr.
as follow: -
Kesling has appropriately named them as anchor

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a) By using light elastic force for longer periods 6) Band or bracket second molars as early as
(from 2 to 5 days). Elastics if not changed for 5 days possible.
exert a very light Class II force, most of the time, since 7) Use Class II elastics selectively.
the elastic force diminishes rapidly in the oral 8) Do not hurry final leveling of the archwires, use
environment. Such low force values do not adversely flat rectangular archwires at first, and then bite
affect concomitant retraction, because forces as light opening curves as needed.
as 5gm are known to be capable of achieving tipping 9) Use gentle forces for space closure in extraction
movements in the Begg technique. cases.
b) Sims has suggested the use of 3/8” ultra light
C.5) CORRECTION OF DEEP BITE WITH SEGMENTED
elastics instead of routinely used 5/16” light elastics.
ARCH TECHINQUE12
He suggested continuing the same elastics for 4-5
days, till they break. There are six major principles governing deep
C.3) CORRECTION OF DEEP BITE WITH EDGEWISE overbite correction by intrusion with a segmented
TECHNIQUE30 arch technique.
1) Use of optimal magnitude of force and the
I) Intrusion of individual teeth
delivery of this force constantly with low-load
For intrusion of a tooth, the segment of arch wire is deflection rate springs.
made to lie gingivally to the bracket groove. When 2) Use of point contact in the anterior region.
forced into place it exerts an intrusive force on the 3) Position of the force – careful selection of the
tooth. point of force application with respect to the center
of resistance of all the teeth to be intruded.
II) Mass movements
4) Selective intrusion based on anterior tooth
Using remaining teeth in the arch as anchors, it is geometry.
possible to depress the incisors or bicuspids as a unit, 5) Control over the reactive units by formation of a
but it will require the entire arch to depress one posterior anchorage unit.
canine or one molar. The reaction to depress teeth 6) Inhibition of eruption of posterior teeth and
with the archwire is often dissipated by the occlusion, avoidance of undesirable eruptive mechanics.
which can prevent the eruption of anchor teeth. This The basic mechanism for intrusion consists of three
type of bend is commonly referred as a step bend. parts.
Thus, a step bend that will raise or lower a contact 1) A posterior anchorage unit,
point relation is a bend that changes the level of the 2) An anterior segment and
archwire. 3) An intrusive arch spring.
Supra erupted anterior teeth may also be depressed
A) THREE-PIECE INTRUSION ARCH31,32
by ligation to a straight arch wire that lies gingivally
to their brackets. A three-piece base arch is used to intrude the
anterior segment. A heavy stainless steel segment
C.4) CORRECTION OF DEEP BITE WITH PREADJUSTED
(0.018” x 0.025”) with distal extensions below the
EDGEWISE TECHNIQUE (STRAIGHT WIRE APPLIANCE)
center of resistance of anterior teeth is placed
Deep overbites can be effectively controlled with passively in the anterior brackets. The distal
preadjusted appliances when the following principles extensions end 2 to 3 mm distal to the center of
are observed. resistance of the anterior segment.
1) Avoid extractions in low angle cases whenever The intrusive force is applied with a 0.017” x 0.025”
possible. TMA tip-back springs. The overall force system
2) Use 0.022” slots with 0.019” x 0.25” working obtained is an intrusive force anterior and an
archwires and 0.018” slots with 0.017” x 0.25” extrusive force posterior associated with the tip back
working archwires. moment. The design of this appliance enables low-
3) Use anterior bite plates at the beginning of friction sliding to occur along the distal extension of
treatment in moderate to low angle cases. the anterior segment during space closure.
4) Use light initial forces to avoid deepening the
The application of light, distal force delivered by a
bite.
class I elastic to the anterior segment is used to alter
5) Avoid elastic retraction of cuspid brackets.
the direction of the intrusive force on the anterior

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segment. This appliance design allows the application The tip back produces light intrusive forces on the
of the intrusive force to get true intrusion of the incisors. In cases of growing patients the intrusive
incisors along their long axis. force should be light to hold the incisors at their
B) CORRECTION OF DEEP BITE WITH UTILITY positions. In adult patients with deep bite, heavier
ARCHES intrusive force is used for intrusion of the anteriors.
Late in the 1950’s Robert Ricketts13 gave the utility C.6) KALRA SIMULTANEOUS INTRUSION AND
arch mechanics for the intrusion of lower incisors RETRACTION
which has shown clinically that the four lower incisors The K-SIR (Kalra simultaneous Intrusion and
can be intruded very efficiently with forces of 15 to Retraction) archwire given by Varun Kalra34 is a
20 gram per lower incisor or 60 to 80 gram for all four modification of the segmented loop mechanics of
lower incisor teeth. The upper incisors have a root Burstone. It is a continuous 0.019” x 0.025” TMA
surface cross section that is almost twice as large as archwire with closed 7mm x 2mm U – loops at the
the lower incisors and, therefore the force required extraction sites.
for their intrusions is twice as much as the lower To obtain bodily movement and prevent tipping of
arch, approximately 160 gram or 40 gram per each the teeth into the extraction spaces, a 900 V- bend is
tooth. placed in the archwire at the level of each U – loop.
This V – bend, when centered between the first molar
The mandibular utility arch is best fabricated from
and canine during space closure, creates two equal
0.016 x 0.016 Blue Elgiloy wire to deliver a continuous
and opposite moments to counter the moments
force to the lower incisors. The design of the
caused by the activation forces of the closing loops.
mandibular utility arch is dictated by the requirement
A 600 V- bend located posterior to the center of the
that this light force be delivered in a continuous
interbracket distance produces an increased
manner of a long lever arm from the molar to the
clockwise moment on the first molar, which
incisors.
augments molar anchorage as well as the intrusion of
The maxillary utility arch takes approximately double
the anterior teeth.
the force to intrude the upper incisors, compared to
To prevent the buccal segments from rolling
the lower incisors, approximately 125 – 160 grams.
mesiolingually due to force produced by the loop
This is one of the reasons for using the 0.016 x 0.022”
activation, a 200 antirotation bend is placed in the
blue Elgiloy or Nitinol maxillary utility arch in the
archwire just distal to each U – loop.
initial phase of treatment. The second reason is that
the span between the upper molars and the incisors C.7) THE CONNECTICUT INTRUSION ARCH
is a greater distance and, therefore, decreases the
The Connecticut intrusion arch (CTA) given by
force delivered to the maxillary incisors.
Ravindra Nanda35 is fabricated from a nickel titanium
The use of the 0.016 x 0.022” utility arch in order to alloy to provide the advantages of shape memory,
create the added force needed to intrude the spring back and light continuous force distribution
maxillary incisors has an adverse tipping effect on the (Image 17). It incorporates the characteristics of the
maxillary molars. It therefore, becomes necessary to utility arch as well as those of the conventional
stabilize the molars. The use of Quad-Helix, lingual intrusion arch. The CTA is preformed with the
arch, or transpalatal arch will help in stabilizing the appropriate bends necessary for easy insertion and
maxillary molars. use.
C) MULLIGAN’S INTRUSION ARCH Two wire sizes are available: 0.016” x 0.022” and
0.017” x 0.025”. The maxillary and mandibular
Mulligan’s33 intrusion arch is used for incisor
versions have anterior dimensions of 34 mm and 25
intrusion and molar extrusion in deep bite cases. The
mm, respectively
archwire used is round 0.016” stainless steel. The
C.8) BITE OPENING AND SPACE CLOSING ARCHWIRE
bracket slot is 0.022 x 0.025”. All brackets are leveled
This arch wire is given by Leonard Bernstein.36 The
and uprighted with initial wires. Then the 0.016”
purpose of this archwire is to provide an upward and
round stainless steel wire is placed in the setup. Arch
backward force in an arc-shaped motion to the
wire is tightly cinched back distal to the molars. The
maxillary central and lateral incisors with retraction
tipback bends or ‘V’ bend given to the arch wire for
force at the same time. By keeping a distal closing
intrusive action on incisors and extrusive action on
force on these teeth, the upward and backward force
molars.
producing bite opening seems to be enhanced.
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0.018” x slot bracket with wires of 0.016, 0.018 and It is much more difficult to permanently increase
0.016 x 0.022 gauge are most commonly used. anterior face height by rotating the mandible at the
C.9) EQUIPLAN – QUAD HELIX COMBINATION condyles than it is to rotate it within the body-ramus
Dr. J. M. S. Pato37 developed the appliance in 1992 by region via a ramus osteotomy. The first approach
attaching a planas equiplan to a quad helix or a requires lengthening of elevator muscles because
transpalatal bar. The palatal expander is inserted into ramus osteotomy allows the muscles to shorten as
the lingual tubes of the first molar bands or welded the chin goes down but the gonial angles go up.
directly to the molar bands. The planas equiplan is Relapse of overbite correction following mandibular
attached to the anterior arms with acrylic or directly subapical advancement also is likely to occur, due to
to the anterior helices of the Quad helix. strong musculature in short face patients. One reason
It can be used successfully in patients of any age with for considering mandibular subapical advancement
dental deep bite, in growing patients with skeletal rather than a ramus osteotomy is the tendency for
deep bite. Its main advantage is that the fixed Quad these patients to have a prominent chin relative to
Helix expands the palate at the same time that the their dentition. If face height is only slightly short and
occlusal plane is unlocked to allow uninterrupted overbite is not a major problem the subapical
orthodontic movements. osteotomy may be an ideal solution, but if significant
C.10) A LINGUAL ARCH FOR INTRUDING AND vertical change is needed, a ramus osteotomy is
UPRIGNTING LOWER INCISORS38 needed.
A simple lingual arch with elastomeric chain attached The surgical treatment options56 in deep bite patients
to lingual buttons on the incisors overcomes the are
problems of both sectional and full arches by creating 1. Orthodontics and interpositional genioplasty
equal downward force vectors that pass behind the 2. Orthodontics and Inferior onlay mandibuloplasty
centers of resistance of all four incisors. 3. Orthodontics and mandibular advancement
Four elastic chains are attached to the anterior bridge 4. Orthodontics and total subapical mandibular
of the lingual arch with the mosquito forceps. If advancement
intrusion is primary goal and the teeth are already 5. Orthodontics and inferior repositioning of
fairly upright, the elastic chains should come off the maxilla and mandibular advancement
lingual arch on the labial side. 6. Orthodontics and combined maxillary and
C.11) CORRECTION OF DEEP BITE WITH MINI SCREW mandibular surgery
ANCHORAGE SYSTEM39
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