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Contents lists available at ScienceDirect

Seminars in Orthodontics
journal homepage:

A three-dimensional perspective on Brodie Bite’s diagnosis, planning,

treatment alternatives, and complications
Carol Weinstein a, Miguel Hirschhaut b, Patricia Vergara c, Angelica de la Hoz Chois d,
Carlos Flores-Mir e,f,*
a
Private practice limited to Orthodontics in Santiago de Chile, Chile
b
Universidad Central de Venezuela, Caracas, Venezuela
c
Private practice limited to Orthodontics in Cartagena, Colombia
d
Private practice limited to Orthodontics in Barranquilla, Colombia
e
Graduate Orthodontic Program, Department of Dentistry, University of Alberta, Edmonton, Canada
f
Part-time Private Practice limited to Orthodontics, Edmonton, Alberta, Canada

A R T I C L E I N F O A B S T R A C T

Keywords: This narrative review describes the different diagnostic, prognostic, management aspects and complications of the
Brodie bite Brodie Bite. A current literature review was completed to identify relevant case reports, case series, and reviews
Three-dimensional approach about the Brodie Bite. Brodie Bite cases, fortunately, are not frequent. A checklist for this malocclusion is pre-
TADS
sented. Additionally, a description of the advantages of an early diagnosis will be discussed to avoid its progres-
Fixed and functional appliances
Disocclusion
sion to a more complex clinical scenario. The importance of solving the Brodie Bite before correcting any other
simultaneous malocclusion problem is stressed. Emphasis is given on a three-dimensional diagnosis and planning.
Different management mechanics are presented - ranging from TADS to fixed and functional appliances. Alterna-
tive disocclusion methods are also discussed. It is noted that some cases benefit from a combined surgical ortho-
dontic correction. Finally, periodontal issues and difficulties are addressed.

Introduction in a forward-centred position to evaluate arch coordination, resulting

in a normal transverse relationship once the sagittal discrepancy is
Scissor bite, a buccal crossbite, is an uncommon malocclusion corrected.
affecting between 1.0 % to 1.5 % of the population.1−3 Brodie first This malocclusion can occur in a skeletal presentation due to exces-
described it in 1952.4 He defined this malocclusion as a “Brodie sive maxillary width, mandibular constriction, or a combination of both.
bite” or “Brodie syndrome” when the mandibular teeth are partially In a dentoalveolar depiction, it is characterized by abnormal buccolin-
or wholly contained within the maxillary arch.5 Clinically, it is por- gual inclinations of posterior teeth.6,7 Proper measurements to arrive at
trayed by the buccal surfaces of the lower posterior teeth being in an adequate diagnosis are the orientation of the alveolar processes at
contact with the palatal surfaces of the upper posterior teeth, with the canine, premolar and molar levels. To attain that clinical evaluation,
no adequate cusps-fissures contacts.6 study models, photographs, stereophotogrammetry, and 2D/3D radio-
The Brodie Bite is caused, seen from the frontal plane, by a transverse graphic analysis allow us to differentiate between the skeletal and den-
occlusal discrepancy. A vertical component is also usually involved, toalveolar etiology of the Brodie Bite.8,9 The shape of the palatal vault
which is more pronounced the more severe the Brodie Bite. The sagittal and the mid-palatal raphe should be examined as part of the diagnosis.8
plane will mostly be an aggravating condition. The more sagittal (ante- The curves of Spee, Wilson, and occlusal canting must also be considered
roposterior) the skeletal relationship, the greater the tendency and since the vertical plane is compromised. When linked to skeletal imbal-
severity of the Brodie Bite. Suppose a sagittal correction is required ances, it can be accompanied by different degrees of facial asymmetry.
because of an increased overjet. In that case, studying digital or plaster Dentoalveolar compensations, which can occur both in the transverse
models in a corrected anteroposterior position will enable a more accu- and vertical planes, should be considered.8 The Brodie Bite can also be
rate assessment of the Brodie Bite. This is important because what may associated with other malocclusions such as mandibular rotation or lat-
appear to be a buccal crossbite may disappear when checking the casts eral shift, an occlusal plane and facial asymmetry inclination, deep

* Corresponding author at: Division of Orthodontics, Department of Dentistry, University of Alberta, College of Health Sciences. Faculty of Medicine and Dentistry. 5-
528 Edmonton Clinic Health Academy. Edmonton, AB, Canada, T6G 1C2
E-mail address: [email protected] (C. Flores-Mir).

https://doi.org/10.1053/j.sodo.2023.12.008

1073-8746/© 2023 Elsevier Inc. All rights reserved.

Please cite this article as: C. Weinstein et al., A three-dimensional perspective on Brodie Bite’s diagnosis, planning, treatment alternatives, and
complications, Seminars in Orthodontics (2023), https://doi.org/10.1053/j.sodo.2023.12.008
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C. Weinstein et al. Seminars in Orthodontics 00 (2023) 1−19

teeth involved in this malocclusion.3 Although it might initially be a

transverse discrepancy with the fault in the maxilla or the mandible or
in both jaws, it becomes a vertical problem because the unopposed teeth
in each arch over-erupt, creating a situation in which the elongated pos-
terior teeth need to be intruded several millimetres and repositioned
laterally.12

Severity and timing of diagnosis

The demands for correcting severe buccal crossbites warrant early

intervention as soon as the malocclusion is identified. Buccal crossbites
are a developmental malocclusion that worsens with time.3 A typical
scenario is a buccal ectopic eruption of the maxillary molar at about age
6 years. Initially, the Brodie Bite mainly develops as a single tooth prob-
lem; however, if it remains untreated and eruption occurs, the neigh-
Fig. 1. A. Unilateral Brodie Bite shows asymmetric malocclusion. B. Bilateral bouring teeth will be compromised. They will erupt similarly to the
Brodie Bite shows symmetric malocclusion. affected segment.2 Additional functional problems might increase the
severity. An untreated unilateral Brodie Bite malocclusion will progres-
anterior and posterior bite, and unilateral chewing contralateral to the sively shift towards a more stable position with bilateral tooth contacts.
scissor bite.10 Potential effects on the health of the temporomandibular joints have
Its etiology can be attributed to genetic factors and functional or been reported. Although the crossbite might not cause pathosis, compro-
muscular imbalances. Fig. 1 shows that the Brodie Bite can be unilateral, mised mastication could eventually lead to temporomandibular dysfunc-
characterized by a flat and asymmetric palatal vault and often a cant to tion.12 This abnormal pattern may produce a functional shift of the
the occlusal plane and lateral deviation or bilateral, where the palatal mandible, resulting in the rest of the buccal segment erupting in a buccal
vault is flat but symmetric, and the mandible may be functionally ret- crossbite during the late transitional stage of dental development (10-12
ruded.5 As the development of this malocclusion has yet to be fully years).5 Figs. 2 and 3 show two examples of single premolar scissor bites.
understood, its prevention and management are quite challenging.5 A One was identified during the eruption of permanent teeth, and the
late diagnosis of Brodie Bite can increase treatment difficulty and, there- other when the full permanent dentition erupted. These two scenarios
fore, affect the prognosis. represent the simplest version of this malocclusion.
As soon as a buccal crossbite is consolidated, its developmental effect The scissor bite does not self-correct and progressively worsens.
may cause important sequelae such as deep bite, overeruption of the Simultaneously, these malposed teeth gradually migrate in the trans-
maxillary segment, lingually inclined mandibular posterior segments, verse and vertical planes. Vertically, migrations will take place until
occlusal plane cant, asymmetry, limited lateral excursions, temporoman- upper and lower teeth reach contact. Maxillary teeth continue to erupt
dibular disorder, growth interference, and periodontal problems.3 Adap- in excess and occlude on the buccal surfaces of the mandibular posterior
tive remodeling of the temporomandibular joints can promote teeth (as noted earlier). Occlusion causes tipping of maxillary posterior
asymmetrical mandibular growth, with less condyle and ramus height teeth buccally and mandibular posterior teeth lingually due to muscular
on the scissor-bite side than on the opposite side. Efficient mastication is forces when chewing in this more comfortable position. If this condition
impossible when the mandibular arch is telescoped within the maxillary persists, mandibular posterior teeth can become completely tipped lin-
arch, and lateral excursive movements may be limited, potentially lead- gually, and the alveolar bone may be severely affected.13 Therefore,
ing to temporomandibular dysfunction.10 early detection of the Brodie Bite is very important since, most likely,
If the problem is of dentoalveolar origin, without a severe skeletal the anteroposterior extension of the problem is limited, as well as the
asymmetry, maxillary constriction plates, intermaxillary cross elastics, vertical alterations. Fig. 4 shows a 2-year period between the initial eval-
"dragon helix appliance", and functional appliances have been sug- uation and when parents were willing to treat the malocclusion. An
gested.4 Temporary skeletal anchorage devices (TADs) are a valuable increase in the vertical overlap of the upper right molar can be seen.
option for treating transverse discrepancies since they avoid undesirable Clinical observations have determined that extrusion is found in low per-
secondary effects of anchorage teeth.11 The bilateral form is likely easier centages of the cases that range between 5 and 20 % of the vertical
to treat than the unilateral as most transversal-acting appliances are height of posterior teeth when the scissor bite is identified early. As the
bilateral, making applying forces only unilaterally challenging.12 Never- patient ages, the vertical component increases as the extrusion can be
theless, normal bone development can be resumed in patients with presented in as much as a 100 to 120 % overlap compared to the ideal
growth potential when the transverse buccal crossbite is corrected.11 original vertical position.
It is important to note that the Brodie Bite often does not affect the
Brodie Bite development patient’s anterior aesthetics. For this reason, it can stay undiagnosed
until late in development,11 causing an untimely referral to the ortho-
During the eruption process of permanent teeth, sometimes one dontist. The chief complaint may appear later and can be related to diffi-
tooth emerges into the oral cavity with an inadequate transverse inclina- culty chewing.2,5,10,14−16 Some patients are aware of facial asymmetry
tion. Its etiology is attributed to heredity, lack of space or a muscular and canting of the occlusal plane but are not concerned by those prob-
imbalance. Such eruption direction can incorrectly guide teeth on the lems. They are mostly worried about impaired occlusion due to a poste-
other arch exacerbating the problem or a mandibular lateral shift to the rior scissor bite.11
opposite side as a proprioceptive reaction of the occlusion to avoid a
strong premature contact. Consequently, the upper palatal cusps glide Vertical component
gradually along the buccal lower cusps. This is explained by the fact that
these two surfaces have a very subtle curvature, and the movement does One of the difficulties of Brodie Bite diagnosis is that part of the mal-
not have a natural anatomical stop. Along with this displacement, extru- occlusion is hidden since, in important vertical migrations, the upper
sion of teeth occurs, generating an occlusal plane compromise. The arch extrusion generally hides the lower arch partially or completely.
neighbouring teeth may also enter the cycle, which is how premolars Therefore, the degree of compromise of the mandible cannot be evalu-
and second molars are progressively affected, increasing the number of ated sometimes. This explains why the upper arch is frequently blamed

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Fig. 2. Single premolar scissor bite identified during the eruption of permanent Fig. 3. Single premolar Brodie bite identified in full permanent dentition.
teeth.

as the main cause of the problem. Today we know that by clinical obser- buccal tipping in the maxillary arch and lingual tipping in the mandibu-
vation of the gingival margins. We can determine how much each arch lar arch, chances of extrusion are greater.Therefore, the severity of the
is affected and ultimately dictate the treatment mechanics for each case. Brodie Bite will increase.
Fig. 5 shows a scenario, in which each arch must be evaluated separately The Brodie Bite can also appear after rapid palatal expansion. Fre-
with enough mouth opening to visualize the upper and lower teeth quently narrow deficient maxilla has buccally tipped upper first perma-
completely. Three different vertical scenarios can occur. The first sce- nent molars and lingualized lower first and second molars, especially in
nario is the upper arch extrusion with relative normal levelling of the the absence of clinical crossbites, as a dental compensation to the trans-
lower arch. A second scenario will present a relatively levelled upper verse skeletal deficiency. When palatal expansion is done, an iatrogenic
arch with an extruded lower arch. Finally, both upper and lower arches Brodie Bite can easily develop because of the mentioned abnormal tor-
can be vertically over-erupted. que in the molars. In these cases, compression mechanics need to be
applied to the upper posterior teeth and uprighting of lingualized lower
Transverse component posterior teeth needs to be made.
Fig. 6 shows a bilateral Brodie Bite was developed after expansion,
The maxillary arch width will determine the extent and speed at more severe on the right than on the left side. Aligners were used to
which the vertical problem develops. If the dentoalveolar bone is in a decompensate the lower arch and correct buccal upper tipping.
more buccal position, occlusion has a lower chance of naturally restrain- Anterior ramps, lingual to the incisors, were used to disoclude the
ing the vertical migration of the segment involved in the Brodie Bite. molars. The buccal crossbite was corrected during the first stage of
The wider the maxilla to the mandible, the higher the chance of develop- treatment in nine months. Fig. 7 shows a failed skeletal expansion is
ing a buccal crossbite with an important overlap percentage. The degree shown. Only the right side expanded. A unilateral Brodie Bite devel-
of tooth buccal inclination is another aggravating factor. The greater the oped consequently.

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Fig. 5. Case with significant vertical migration of the dentoalveolar segments.

Maxillary overgrowth almost completely hides the lower teeth.

adolescence, a nighttime splint was used for retention purposes to avoid

extrusion, dental compensations, canting of the occlusal plane and man-
dibular shift. At the same time, the patient finished active growth, which
would add difficulties to the future orthognathic surgery procedure.
Congenitally missing teeth may facilitate the development of a Bro-
die Bite. A case with two missing lower incisors allowed migrations of
posterior teeth that shifted the lower arch mesially, and the lower left
Fig. 4. A. Initial evaluation. B. 2 years later, when parents were willing to treat posterior teeth tipped lingually. Transverse interarch relationships
the malocclusion. An increase in the vertical overlap of the upper right molar changed as sagittal interarch relationships were modified. Customized
can be seen. mechanics began with maxillary arch constriction and mandibular pos-
terior segments uprighting. It was continued with intermaxillary elastics
and stainless-steel rectangular wires, which were used to upright the
lower left molars and eliminate the unilateral scissor bite. Finally, extru-
Predisposing conditions sion of the lower molars reduced the overbite and increased the lower
facial height.10
The Brodie Bite may be related to a Class II skeletal malocclusion.16
When all the teeth are involved in a Brodie Bite, the condition usually
results from a retrognathic mandible and is often related to what has Macroesthetics vs. microesthetics
been defined as the Brodie’s Syndrome.11 A unilateral Brodie Bite can
inhibit mandibular advancement, contributing to an increasingly retro- A clinical evaluation involves an extraoral as well as an intraoral
gnathic mandible.12 The more retrusive a mandible is, the narrower, exam. The macroesthetics analysis during a facial exam occasionally
more anterior part of the lower arch will relate or coordinate with a provides some diagnostic information when evaluating facial symmetry
wider part of the upper arch favoring the development of a Brodie Bite. and muscular development. Occlusal plane canting and asymmetric
Fig. 8 shows a patient presented with a skeletal surgical Class II with smile are the most noticeable characteristics. However, sometimes, the
mandibular asymmetry characterized by a right scissor bite. Occasion- Brodie Bite stays unnoticed extraorally. The unilateral expression of a
ally, when the anteroposterior correction is made, once the models are Brodie Bite has a higher chance of facial esthetics involvement than the
brought into occlusion, a “False Brodie Bite” is evidenced. During bilateral form, where the face stays symmetric.

Fig. 6. A. Bilateral Brodie Bite was developed after expansion,

more severe on the right than on the left side. B. Aligners were
used to decompensate the lower arch and correct buccal upper
tipping. Anterior ramps, lingual to the incisors, were used to
disoclude the molars. C. The buccal crossbite was corrected
during the first stage of treatment in nine months.

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Fig. 7. A. Initial records. B. Failed skeletal expansion. Only the

right side expanded. A unilateral Brodie Bite developed conse-
quently.

Fig. 9 shows a patient was diagnosed early with a skeletal Class II Assessment and checklist
facial pattern with bilateral buccal crossbites. Clear aligner treatment
was chosen to correct the malocclusion. A symmetrical midline was With the purpose of doing a complete evaluation of the different
noted. After six months into treatment, the Brodie Bite was corrected. variations of Brodie Bites and affected segments, the use of a Brodie
The patient’s arch form and alignment were improved, even though the Bite Checklist is suggested in this article for extraoral, intraoral,
skeletal problem was left for a later surgical correction once growth was functional, and radiographic characteristics. The aspects of the clini-
finished. cal exam that can be affected in a unilateral Brodie Bite are listed in
The microesthetic evaluation generally provides more information Table 1 & Fig. 11. As noted, the facial exam in many patients does
on this syndrome. Some anatomical factors such as dental midline evalu- not suggest this malocclusion. This checklist covers the transverse
ation, leveling of the gingival margins, and buccal/lingual tipping will and vertical planes of space during the intraoral exam. Dental mid-
help diagnose this malocclusion and determine which arch is more com- line relationships and inclinations must be recorded in the trans-
promised and the treatment strategy to be used. Identifying functional verse plane. Occlusal-gingival tooth positions must be observed
mandibular shifts also provides important diagnostic information in the vertically. By looking at the gingival shape and contour, a
transverse plane since it influences facial asymmetry.5,11 A typical uni-
lateral Brodie Bite description will include canting of the occlusal plane
down on the affected side and a mandibular deviation to the opposite
side on closure resulting in a degree of dental midline shift.5 Fig. 10
shows a diagrammatic representation presents a normal scenario and
changes a unilateral Brodie Bite generates.

Fig. 8. A. patient presented with a right scissor bite B. Skeletal Class II with
mandibular asymmetry. C. A “False Brodie Bite” is evidenced when an antero- Fig. 9. A. Patient was diagnosed early with a skeletal Class II facial pattern with
posterior correction is made by bringing the models into occlusion. D. A night- bilateral buccal crossbites and symmetrical midlines. B. Clear aligner treatment
time splint was used during adolescence for retention purposes to avoid was chosen to correct the malocclusion. C. The Brodie Bite was corrected in six
extrusion, dental compensations, canting of the occlusal plane and mandibular months. Arch form and alignment improved. The skeletal correction was left for
shift, while the patient waits for a surgical correction. a later surgical procedure.

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Fig. 11. Diagram of extraoral and characteristics of a right Brodie Bite.

in the radiographic exam. In the panoramic radiographic film, since

Fig. 10. A. Diagram of a normal scenario with centered midlines, leveled occlu-
sal plane and arch coordination. B. Representation of a right unilateral Brodie it is taken with a bite-raising ramp in the front, the Brodie side will
Bite generates, aside from the buccal crossbite, canting of the occlusal plane and appear with less interocclusal space than the non-Brodie side due to
midline deviation to the normal side. the overeruption of teeth. At the same time, a normal occlusal vertical
relationship on the non-affected side explains the fact that the distance
of mandibular teeth will be closer to the mandibular border.
periodontal assessment of the situation in the frontal plane helps Figs. 12−15 show an interesting case is presented to showcase the
identify the most affected arch. The functional component is regis- use of this tool. The clinical analysis of this treatment followed the
tered by diagnosing the mandibular deviation and joint and mastica- guidelines presented in the checklist. The patient came in with a left uni-
tory issues. The condylar size and articular spaces must be observed lateral Brodie Bite. The extraoral picture presents a slightly noticeable
occlusal cant at the level of the upper canines, higher on the right side.
In the intraoral exam, the gingival margins were vertically affected on
Table 1 the Brodie Bite side. Both upper and lower teeth were extruded, and the
Brodie Bite Checklist noting extraoral, intraoral, functional, and radiographic gingival margins were, therefore, at a more occlusal level than the
characteristics to be considered. (Modified from J Clin Orthod MS 23193 neighbouring teeth. Extrusion is evidenced in the panoramic film show-
accepted for publication) ing a smaller interocclusal space on the Brodie Bite side. In the trans-
verse plane, upper teeth were inclined buccally and lower teeth
Extraoral

Normal Side Brodie Side

Chin Deviation
Asymmetric Smile: Higher Asymmetric Smile: Lower Commissure
Commissure

Intraoral

Normal Side Brodie Side

Lower Midline Deviation Upper Midline Deviation

Vertical Plane: Leveled Upper Extrusion (Greater display generates
canting of occlusal plane)
Lower Extrusion (Hidden lower teeth)
Leveled alveolar bone Extruded maxillary and mandibular alveolar
process
Leveled gingival contours More occlusal maxillary and mandibular gingi-
val contours
Less gingival display Greater gingival display
Transverse plane: Normal Upper buccal inclination
inclinations Lower lingual inclination
Functional Analysis
Normal Side Brodie Side
Normal position Anterior joint displacement
Upper midline deviation due to Premature contacts
accommodating position
Chewing difficulty

Radiographic Analysis

Normal Side Brodie Side

TMJ Images
Normal condylar size Larger condyle in case of hyperplasia
Reduced posterior joint space Even joint spaces of forward condylar position
Chewing difficulty
Panoramic Film
Wider interocclusal space Narrower interocclusal space (extrusion)
Fig. 12. Patient with a left unilateral Brodie Bite. The extraoral picture presents
Apices closer to mandibular Apices distant from mandibular border
a slightly noticeable occlusal cant at the level of the upper canines, higher on the
border
right side.

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Fig. 13. A. Initial lateral right and left intraoral images. B. Gingival contours Fig. 16. A. Occlusal views of treatment mechanics with TADS and occlusal
were traced to visualize their vertical migration on the Brodie bite side. Both ramps on the non-affected side. B. Diagram (courtesy of Dr. Viviane Tinoco) rep-
upper and lower teeth were extruded, and therefore the gingival margins are at resents a single central upper TAD used in the palate for transverse and vertical
a more occlusal level compared to the contralateral teeth. correction of the left upper molars. In the mandible, an interradicular TAD was
used with the same objective.

protrusion with buccal shelf TADs. Lower space was opened with coils
to restore a congenitally missing lower incisor. This was the third ortho-
dontic treatment for the patient, and a lower premolar had been previ-
ously removed. A decision was made to reopen the space with nitinol
coils as well. Figs. 16−20 show the finished case with a well-balanced
face, centered midlines, and a transverse and vertical correction of the
Brodie Bite. The patient was referred to the restorative dentist for lower
implant placement.

Transverse analysis available approaches

From the frontal view, information can be acquired from transverse

cuts from a cone-beam computed tomography reconstruction. The trans-
verse meausurements from Tamburino et al. can be helpful.17,18 In this
Fig. 14. A. Initial occlusal upper and lower intraoral images. B. Gingival con- appraisal, the maxillary transverse measurement at the level of the fur-
tours were traced in green to visualize the non-affected arch form. Blue arrows cation of the first permanent molar should be 5mm wider compared to
represent upper buccal and lower lingual inclinations in the transverse plane. the lower first permanent molar measurement at the Wala ridge. If a
skeletal transverse Brodie Bite discrepancy is present, it will most likely
reveal an augmented maxillary width greater than 5 mm. This exam
helps differentiate dentoalveolar compensations from the presence of a
skeletal component. Fig. 21 shows a case where the lower distance mea-
surement is 54 mm. The expected upper measurement should be
59 mm, but the patient measurement was 64 mm. A skeletal maxillary
transverse excess in width of 5 mm is present.
Andrews’s element III analysis is a clinical transverse skeletal usefull
measurement.19 The distance from palatal cusps of the upper first per-
manent molars is supposed to be equivalent to the distance between the
central fossae of the lower first permanent molars considering an opti-
mum axial inclination. In the lower arch, the lingual inclination needs to
be determined by measuring the distance between the central fossa of
the right and left lower first permanent molars. In a second step the

Fig. 15. A. Initial panoramic film taken routinely with upper and lower teeth
separated. B. Teeth and interocclusal space tracing shows teeth are extruded.
There is a smaller interocclusal space on the Brodie bite side.

lingually. The scissor bite was corrected with TADS and occlusal ramps
on the non-affected side. A single central upper TAD was used in the pal-
ate for transverse and vertical correction of the left upper molars. In the Fig. 17. Lower teeth were controlled from incisor protrusion with buccal shelf
mandible, an interradicular TAD was used with the same objective. The TADs to achieve the complete solution of the case. Implants were treatment
Brodie Bite correction was accomplished in 6 months. To achieve the planned for reconstruction of the congenitally missing lower incisor and previ-
complete solution of the case, lower teeth were controlled from incisor ously extracted premolar.

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Fig. 18. The finished case shows Brodie bite correction, cen-
tered midlines, leveled occlusal planes and spaces for future
restorative work.

measurement must be corrected if tooth inclinations are not ideal. This

is done by measuring the horizontal distance of a vertical imaginary line
at the Wala ridge to the FA point in the crown of the lower first perma-
nent molars. A lower first permanent molar with normal inclination will
be separated 2 mm lingual to this vertical reference. Depending on the
severity, the lower first permanent molars on the Brodie side are
expected to be lingually inclined with values greater than 2 mm. If a
molar is inclined -4 mm from FA point to the imaginary vertical line.
Then 2 mm should be added to the original measurement since this is
the amount of molar uprighting required. Upper first permanent molars
are usually inclined buccally in a Brodie Bite with an increased trans-
verse dimension. The correction is to narrow the upper arch, by inclining
the maxillary molars in a palatal direction. The amount of mm of move-
ment of the affected palatal cusp needs to be subtracted from the initial
Fig. 19. A. Before and B. after extraoral views with centred midlines and cant
correction of occlusal planes. distance between the right and left palatal cusps of the maxillary first
permanent molars. The final difference between the upper and lower
corrected measurements will provide the skeletal transverse diagnosis.
In Fig. 22, Andrew’s transverse appraisalof element III revealed a
maxillary excess of 4,5 mm. The lower first permanent molars on the left
side were lingually inclined, a torque correction of 2 mm to the buccal
was planned. In the maxillary molars, a correction of 2 mm towards the
palate was made for the upper arch measurement. In summary, the ini-
tial measurement in the maxilla from palatal cusp to palatal cusp was
46 mm. After the correction of the left molar, it became 44 mm. In the
mandibular arch, the fossa-to-fossa measurement was 37.5 mm. After
correcting the lower first left permanent molars, the measurement
should increase to 39.5 mm. Therefor, a difference of 44 -
39.5 = 4.5 mm. of maxillary transverse excess was determined.

Management alternatives

Three different diagnostic possibilities for upper positions and two

Fig. 20. A. Before and B. after lateral intraoral views with the Brodie bite solved
mandibular scenarios will determine treatment mechanics. The simplest
and cant correction of occlusal planes.
upper situation is the bodily extrusion of the Brodie side. A second sce-
nario includes extrusion and buccal inclination. A third situation
includes the affected segments’ upper extrusion and lingual crown incli-
nation. The lower arch will always present lingual inclination. The sim-
plest scenario is pure lingual inclination, while the more complex
scenario has both lingual inclination as well as extrusion of mandibular
teeth. These two situations will match the three different maxillary sce-
narios. Table 2 summarizes proposed management alternatives in the lit-
erature.

Biomechanical considerations

A non-surgical approach is feasible when the problem is caused

Fig. 21. Transverse analysis with cone beam CT. The lower distance measures mainly by buccolingual tipping of the dentition rather than an underly-
54 mm. The expected upper measurement should have been 59 mm, but the ing skeletal problem. The plan includes mandibular arch expansion
actual measurement was 64 mm. A skeletal maxillary transverse excess of 5 mm through molar uprighting and maxillary arch constriction through molar
was identified. (previously published in J Clin Orthod MS 23193 accepted for decompensation.12 In some cases, orthognathic surgery or functional
publication − reproduction authorized by J Clin Orthod editor). appliances can be used depending on the patient’s discrepancy and

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Fig. 22. Andrew’s transverse analysis of element III. On the Brodie side, a torque correction of 2 mm. to the buccal of the lower molars was considered. Therefore, the
initial fossa-to-fossa measurement increases from 37.5 mm to 39.5 mm. A torque correction of 2 mm towards the palate was made in the upper arch. So, the initial mea-
surement from the palatal cusp to the palatal cusp decreases from 46 mm. to 44 mm. Hence, a difference of 44 - 39.5 = 4.5 mm. of maxillary transverse excess was
determined. (previously published in J Clin Orthod MS 23193 accepted for publication − reproduction authorized by J Clin Orthod editor).

Table 2
Summary of proposed Brodie Bite management alternatives depicted in the literature.

Author Journal Article Type Dentition Disocclusion Technique Advantage Disadvantage /

Shortcomes

King et al. AJODO, April 2004 Case Report Permanent A full-coverage maxillary Midsymphyseal osteotomy Full correction Surgery was required
splint and mandibular distraction achived. with the extra cost
osteogenesis. and morbidity
involving surgery.
Yun et al. AJODO, December Case Report Permanent Was achieved through Fixed appliances with finger Non-surgical conserva- Method for single
2007 molar intrusion with the spring using indirect tive treatment with tooth or two teeth.
spring. anchorage from a minis- excellent occlusal The cost of the tad
crew. results. and fabrication of
screw.
Imada et al. Journal of Cranioman- Case Report Primary Upper fixed constriction None Conservative early None noted.
dibular Practice, orthodontic appliance approach. Allowing
April 2008 reduced his upper dental normalization of
arch width. A lingual growth.
arch appliance with a
finger spring was placed
to expand his lower den-
tal arch laterally.
Chugh et al. AJODO, May, 2010 Case Report Permanent A maxillary removable 0.40” expanded arch in round Non-surgical conserva- Required use of High-
plate. tubes in lower molar tive approach pull headgear and
bands. Combined with crosselastics.
crossbite elastics. Using a
high pull headgear as
anchorage.
Jung. AJODO, April 2011. Case Report Permanent Posterior biteblock. Upper molar intrusion against Non-surgical conserva- Facial profile convex
upper buccal and palatal tive option. after treatment.
tads. Lower molar upright-
ing against vestibular inter-
radicular tads.
Park et al. International Journal Case Report Permanent Series of aligners Aligner allows disoclussion. Conservative Single molar correc-
of Orthodontics, approach. tion.
Summer 2011.
Pinho JCO, September 2011. Case series Primary in 3 cases, Screw incorporated into Posterior Bite Block Conservative early None noted.
permanent in one posterior cemented bite approach. Allowing
case. block expansion appli- normalization of
ance, intraarch elastics growth.
to cemented button,
crossbite elastics.
Suda et al. AJODO, January Case Report Permanent dentition. None. Throught orthog- Posterior mandibular subapi- Improved facial Surgical Costs and
2012. nathic surgery bone seg- cal osteotomy to correct appearance. morbidity.
ments were moved. mandibular right premo-
lars and molars. That were
moved by using a lingual

(continued)

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Table 2 (Continued)

Author Journal Article Type Dentition Disocclusion Technique Advantage Disadvantage /

Shortcomes

arch appliance after the

subapical osteotomy. Le
Fort I osteotomy and sagit-
tal split ramus osteotomy
to correct the patien facial
asymmetry
Reddy et al. JCO, May, 2012. None Transpalatal bar with elasto- Cost effective and effi- Single tooth tech-
merics. cient, simple and nique.
less technique sensi-
tive than other
methods.
Kalia et al. JCO, September 2012 . Case Report Permanent Composite turbos on lower Use of palatal tads in the Conservative non-sur- Facial profile presents
first molars upper and in the lower gical approach. convexity due to
buccal interradicular tads mandibular defi-
with elastomerics. ciency.
Hua et al. AJODO, December, Case Report Permanent dentition. Posterior biteplane incor- Slow contraction maxillary Conservative non-sur- Facial profile not
2012. porated into constriction device plus fixed applian- gical approach. improved after
appliance. ces. treatment.
Shimazaki et al. Angle Orthodontist, Case Report Permanent Presurgical orthodontic Le Fort I osteotomy combined Facial esthetics Facial appearance is
Febraury 2014. occlusal resin build ups with mid-alveolar improvement and excellent. No short-
osteotomy occlusal correction comes noted.
Surgical costs and
morbidity
associated
Ishihara et al. AJODO, April, 2014. Case Report Permanent dentition None First, the mandibular poste- Non-surgical conserva-
rior teeth were labially tive option.
expanded with a lingual
arch appliance. Upper pre-
molar extractions. Use of
palatal tad to intrude and
bring palatally molars in
scissor bite.
Li et al. JCO, April 2014. Case Report Permanent Posterior bite plate Maxillary constriction spring Conservative non-sur- Facial profile presents
incorporated into posterior gical approach. convexity due to
bite plate. After nine mandibular defi-
months of constriction. ciency.
Lower .018" × .025" stain-
less steel archwire with
cross-elastics on left side
for uprighting the first
molar.
Sakamoto et al. Bull Tokyo Dent Col- Case Report Permanent Quadhelix in the upper Corticotomy followed by Satisfactory case reso- Extra costs and mor-
lege, April, 2016. arch to eliminate rapid mandibular lution. Correcting bidity associated
mechanical obstruction expansion arch forms and the with corticotomy.
to mandibular expan- scissor bite.
sion.
Kumar-Sharma et al. International journal Case series Permanent dentition. Anterior biteplane. Transpalatal arch Conservative non-sur- No facial profile
of orthodontics, gical approach for shown. Incomplete
December 2016 individual teeth records
Du et al. JCO, Febraury, 2018. Case Report Permanent Upper removable bite Miniscrew in lower arch with Conservative early Facial profile presents
plate. elastomerics. approach. convexity due to
mandibular
deficiency
Song et al. AJODO, September Case Report Permanent Andressen activator Fixed appliances with upper Non-surgical conserva- Despite the pro-
2018 premolar extractions. tive treatment with longued treatment
Andressen activator excellent occlusal of 3 years. Facial
results. post treatment
changes favorable.
Lee et al. AJODO, October 2018 Case Report Permanent Glass ionomer bite turbos Buccal shelf, elastomeric Non-surgical, conser- None noted, facial post
bonded on occlusal sur- chains anchored to buccal vative management treatment changes
faces of the maxillary left shelf tads extended to lin- favorable.
molars. Latter anterior gual buttons bonded on the
bite turbo lingually inclined mandib-
ular molars. Cross elastics
added as secondary
uprighting mechanics. Lat-
ter infracigomatic tads for
Class II correction and
upper anterior retraction.
Nakamura et al. Angle Orthodontist, Case Report Permanent Anterior bite block Fixed appliances. A lower lin- Non-surgical, conser- None noted besides
March, 2019. gual arch with anterior and vative approach. the cost associated
posterior palatal minis- with upper premo-
crews were used to lar extractions and
improve the bilateral placement of 6

(continued)

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Table 2 (Continued)

Author Journal Article Type Dentition Disocclusion Technique Advantage Disadvantage /

Shortcomes

scissors bite. Upper and miniscrews (2 pala-

lower anterior miniscrews tal), 4 anterior inter-
were used to address ante- radicular (two
rior deep bite. upper and 2 lower).
Facial post treat-
ment changes favor-
able.
Baik et al. AJODO, July, 2019 Case Report Permanent Bite plate Buccal and palatal tads, lower Non-surgical conserva- Post treatment profile
lingual arch with extension tive treatment still has mandibular
for lower molar uprighting. deficiency.
Left side upper and lower
premolar extractions
Simsuchin et al. Children, August, Case Report Primary Modified Frankell III. Modified Frankel III appli- Conservative early None noted.
2021. ance to induce mandible to approach. Allowing
move backwards and normalization of
relieve an occlusion dis- growth.
crepancy of the dental
arch. Functional dental
rehabilitation with resin
and myofunctional exer-
cises with a PFA which was
modified from an oral
screen appliance.
Araujo et al. AJODO CC, December, Case series Mixed dentition. Vacuum retainer and func- A combination of lip bumper, Conservative manage- Treatment length asso-
2021 tional appliances. FR-2 appliance, cross elas- ment of patients ciated to treatment
tics, fixed functional and starting early in starting in mixed
later full braces used. development dentition. Several
phases of treatment.
Yasir International Ortho- Case Report Permanent Glass ionomer bite turbos Tads, crossbite elastics, fixed Conservative non-sur- None. Excellent facial
dontist, September appliances gical approach. balance post treat-
2022 ment.
Venugopal et al. JCO, April, 2023 Case Report Permanent Premolar bite blocks Fixed appliances,buccal shelf Non-surgical conserva- Profile improved but
tads, transpalatal arch, tive management of surgery what have
intrusion arch a severe given more length
malocclusion to lower jaw.

skeletal maturity.10 Myofunctional therapy and oral screens were used Fig. 23 shows a simple power arm extension was added to the first
in a reported case.20 molar to pull the premolar in the scissor bite palatally. Just 1.5 months
Different orthodontic treatment methods are suggested for correcting was enough to correct the problem. Fig. 24 shows a minor raise in the
scissor bites. Among them: maxillary constriction plates, intermaxillary bite with occlusal bite turbos on the day of appliance placement. The
elastics, quad-helix, transpalatal arch, fixed bonded bi-helix appliances, Brodie Bite was corrected during the levelling and aligning process.
extractions, lip bumper, mandibular lingual holding arches, Frankel Arch constriction in the upper arch is also possible when treating
functional (FR-2) appliances, distraction osteogenesis procedures, Brodie Bite patients.14 Intra-arch medium to heavy rubber bands,
orthognathic surgery. These treatments can improve masticatory func- changed daily, can be used to collapse two single teeth buccally dis-
tion, esthetics, occlusion, and overall periodontal condition.12 placed in opposite quadrants in the upper arch, bringing them into align-
ment. This approach will likely work better for two upper second molars
Non-skeletally supported management alternatives than multiple teeth or a posterior buccal segment.21
Some published examples are briefly discussed here. A maxillary
Appliances that work with a functional component, such as lip bum- constriction spring was incorporated into a posterior bite plate. After
per and Frankel 2, are a choice when a tongue or muscular imbalance is nine months of constriction. The lower arch was worked up to
identified. Functional mandibular appliances help reduce the transverse .018" × .025" stainless steel archwire with cross-elastics on the left side
discrepancy when the mandible is positioned forward.3 The Frankel 2 for uprighting the first molar.22 An intra-arch elastomeric chain extend-
appliance has the advantage that it can be customized either for bilateral ing twice its length to correct a buccally displaced upper second molar
or unilateral treatments. Lip bumpers address the tongue versus the with the help of a transpalatal arch as anchorage has been published as
cheek functional equilibrium. In a growing patient, an orthopedic appli- a valid approach.23 Another reported alternative is a slow maxillary con-
ance can be used to advance the mandible, followed by fixed mechano- traction appliance followed by fixed appliance treatment. This strategy
therapy to finish the occlusion on the corrected skeletal bases.10 was used in a child with a maxillary asymmetric dentition 10 mm wider
Treatment selection becomes a personal decision by the orthodontist, than normal for his age.24 Another option is a constricting spring.10 The
and each procedure has pros and cons.3,13,15 Some management strate- use of a hyrax expander in an open position to produce palatal constric-
gies might be considered non-invasive alternatives to surgical treatment; tion by narrowing the maxilla bilaterally has a higher risk of creating a
their limitations include excessive extrusive force requirements on the contralateral posterior crossbite on the non-affected side. To avoid this
anchor teeth and a need for patient compliance. To avoid these dental undesired effect, the lab prepares an appliance with an expansion screw
side effects in scissor bite correction, temporary anchorage devices which is narrowed gradually as treatment progresses. Special care to
(TADs) have begun to be used in recent years.13 When the Brodie Bite is strengthen the non-Brodie side anchorage is important. The anterior sec-
identified early when the eruption occurs, simple fixed appliance tion can be included with the non-Brodie side, covering it with more
mechanics can be used for correction. acrylic than in the compromised side where the constriction is desired.14

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Fig. 23. A. Occlusal and lateral views of a second left premolar

erupting in buccal crossbite. B. A simple power arm extension
was added to the first molar to pull the premolar palatally. C.
In 1.5 months, the abnormal position was corrected.

Fig. 24. A. Occlusal and lateral views of a first right premolar

erupting in buccal crossbite B. Bite turbos were placed on the
day of appliance placement to raise the occlusion. C. The Bro-
die Bite was corrected during the levelling and aligning stage.

Different rubber band mechanics have been proposed for Brodie Bite Fig. 25 shows a diagram of the different biomechanical approaches
correction: including intermaxillary cross elastics, multibracket applian- for the upper arch. In the first scenario, when the extrusion is pure, with-
ces, transpalatal arches and lingual arches with intramaxillary elastics. out any inclinations, two TADs should be placed. One in a buccal posi-
These mechanics can generate extrusive forces on the second molars in tion and the other one in a palatal position.13 Upon activation, the
both arches, possibly inducing an undesirable reduction in the overbite, resultant intrusive force should pass through the center of resistance of
clockwise rotation of the mandible, and premature contacts. This situa- the tooth. Elastic chains must be engaged from both buccal and palatal
tion is especially undesirable in high-angle cases.15,16 To avoid increas- attachments to the TADS. To secure the elastic chains, a wire through
ing lower facial height, it is important to maintain the vertical height of the contact point connecting two adjacent molars in buccal crossbites
teeth by using devices with a relatively intrusive effect.2 Rubber bands, was placed with cured composite on the occlusal surfaces. In this way
especially cross intermaxillary elastics, can be used as a complementary two teeth can be intruded with two TAD.15 The second scenario requires
mechanism for skeletal anchorage.5 Unfortunately, intermaxillary elas- extrusion in addition to buccal tooth inclination. One TAD located in the
tics depend on excellent patient cooperation for a successful palate will probably be enough to add both a palatal and intrusive com-
treatment.15,16 ponent to achieve the correction. Finally, a third scenario is character-
ized by a molar in an extruded as well as a lingually inclined position. In
this case, mechanics for correction require two steps. First a TAD needs
Skeletally supported management alternatives to be placed buccally to upright the tooth and position it in the center of
the bone. During a second stage a TAD needs to be placed in the palate
Skeletal anchorage is an effective, non-compliant correction for Bro- to proceed with bodily intrusion with a vertical vector along the center
die Bite, which can be obtained with minimum undesirable side of resistance.
effects.15,16 Currently, it is considered the gold standard in related treat- Fig. 26 shows a diagram of the different biomechanical approaches
ment mechanics. Adequate selection of anatomical insertion sites, length for the lower arch. Mechanics in the lower arch have less variability
of screws and physical characteristics need to be considered to avoid since teeth involved in the Brodie Bite are always expected to be lin-
temporary anchorage device failure. As most Brodie Bites require a mix- gually inclined. The difference is whether they are leveled to the occlu-
ture of vertical and transverse corrections, successful intrusive move- sal plane or extruded. For pure lingual inclination correction, the head
ments of large segments must be considered. Applying adequate force of the TAD needs to be at the level of the occlusal plane so that the vector
when activating skeletal anchorage is a must.25 of movement produces verticalization of the tooth. Variations can be

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Fig. 25. There are three different biomechanical approaches

for the upper arch in a unilateral Brodie bite. The blue lines
represent the occlusal plane. A. Pure extrusion. B two TADs
should be placed, one in a buccal position and the other in a
palatal position. The resultant intrusive force should pass
through the center of resistance. Elastic chains must be
engaged from buccal and palatal attachments to the TADs. C.
Extrusion and buccal tooth inclination. D. One TAD in the pal-
ate adds a palatal and intrusive component to achieve the cor-
rection. E. Extrusion and lingual tooth inclination. F.
Mechanics for correction require two steps. A Buccal TAD is
used to upright the tooth and position it in the center of the
bone. G. A TAD is added in the second stage in the palate to
proceed with bodily intrusion with a vertical vector along the
center of resistance. (Modified from J Clin Orthod MS 23193
accepted for publication).

made in the length of the buccal-shelf screw. A longer TAD is suggested position is beneficial since it can provide adequate space to upright the
so that the head of the screw is closer to the wire level or to approximate entire buccal segment with one bone screw. Conversely, inter-radicular
FA point of the anatomical crown. Therefore, the intrusive vector is TADs quickly interfere with the nearby teeth’ movement, and frequent
smaller. If teeth are lingually inclined and extruded, then the head of the replacement is necessary.5 When indicated, the extra radicular mini-
TAD needs to be below the occlusal plane. For an activation vector to screw can be placed with the head close to the occlusal plane and in a
have both a verticalizing and intrusive component TADS can be placed buccal position relative to the center of rotation of the molar root. This
in an interradicular position. is advantageous for the inclination correction of the molar since a more
There are biomechanical differences between using an interradicular buccal and less intrusive force is generated compared with a TAD in an
compared to an extra radicular mandibular buccal shelf mini-screw in interradicular position.26 The clinician can screw the buccal shelf TAD
the lower arch for Brodie Bite correction. There are more benefits favor- deeper when a more intrusive force component is needed.
ing a mandibular buccal shelf bone screw compared with interradicular Figs. 27 and 28 shows a unilateral Brodie Bite on the left side. An
bone screw. The possibility of a prominent head that can retain elasto- upper anterior bite plate was used as a disocclusion strategy to raise the
meric chains, which can efficiently upright a mandibular segment is an bite. Mini-screws were placed for Brodie Bite correction. This was
advantage. If anatomy permits, an extra-alveolar TAD can be placed up accomplished in 6 months. Fig. 29 shows TADs that were initially placed
to 10 mm to the buccal aspect of the lingually tipped molars. This too close to the affected teeth; therefore, they had to be repositioned.

Fig. 26. Diagram of the different biomechanical approaches

for the lower arch. The blue lines represent the occlusal plane.
Lower teeth can be A. Lingually inclined. B. The TAD should be
placed at the level of the occlusal plane to generate a verticaliz-
ing vector to C. successfully level the molar. The other possibil-
ity is D. lingually inclined and extruded teeth. E. The TAD
should be placed below the level of the occlusal plane to gener-
ate a verticalizing and intrusive vector to F. successfully level
the molar. (Modified from J Clin Orthod MS 23193 accepted
for publication).

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Fig. 27. Pretreatment facial and intraoral photos. (previously

published in J Clin Orthod MS 23193 accepted for publication
− reproduction authorized by J Clin Orthod editor).

Figs. 30 and 31 show the rest of the treatment involved solving the den- with intra-arch elastics to cemented buttons and crossbite elastics.28
tal Class II with infrazygomatic TADs and detailing and finishing proce- Fixed appliances and a lower lingual arch with anterior and posterior
dures. The total treatment time was 35 months. palatal mini-screws were used to improve bilateral scissors bite. Upper
The extraction of a single tooth in a scissor bite with replacement by and lower anterior mini-screws were also used to address anterior deep
an adjacent tooth or by future implant placement is considered a viable bite.29 A strategy combining fixed appliances with upper premolar
treatment alternative.2 Fig. 32 presents this type of case with the Brodie extractions and an Andressen activator was also reported.30 Finally,
Bite involving only one tooth. The tooth was severely lingualized, with a fixed orthodontic appliances, TADS and crossbite elastics were used
significant degree of tooth mobility. It failed to upright with a TAD. A simultaneously.31
decision was made to extract it and replace it with a future implant.
Additional management strategies have been published in the litera- Disocclusion strategy
ture underlying these principles. Fixed appliances with a finger spring
using indirect anchorage from a mini-screw.27 A screw was incorporated Mechanics for Brodie Bite cases are generally planned to address the
into a posterior cemented bite block expansion appliance in conjunction scissor bite during the first 7-8 months of treatment and continue the
case with the other required corrections. Sometimes an extreme vertical
overlap on the affected side makes it impossible to place orthodontic

Fig. 29. A. TADs were placed too close to the teeth, which limited the amount of
Fig. 28. Left side Brodie bite. Longitudinal cone-beam cuts on the teeth’ long tooth movement. An upper bite plate was used to disoclude the bite. B. Both
axis to visualize compromised teeth’ position and bone support. (previously pub- TADs had to be moved for further movement: buccally in the lower arch and pal-
lished in J Clin Orthod MS 23193 accepted for publication − reproduction atally in the upper arch. (previously published in J Clin Orthod MS 23193
authorized by J Clin Orthod editor). accepted for publication − reproduction authorized by J Clin Orthod editor).

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Fig. 30. Posttreatment facial and intraoral photos. (previously

published in J Clin Orthod MS 23193 accepted for publication
− reproduction authorized by J Clin Orthod editor)

attachments on the facial surfaces of the mandibular teeth.13 Therefore, raised on the normal side. Creating enough clearance to upright lin-
Brodie Bite treatment generally requires disarticulating upper and lower gually inclined and sometimes extruded lower posterior teeth with elas-
teeth to correct the buccal crossbite free of interferences and occlusal tic traction to mini-screws correcting the scissor bite.2,13,32
trauma. The patient will have a Brodie and a non-Brodie side in a unilat- Unfortunately, undesired intrusion may occur during scissor bite correc-
eral buccal crossbite. The occlusion on the non-Brodie side can be per- tion, generating problems (to be discussed in the complications section).
fectly normal and not affected. The disocclusion strategy should be as The disocclusion can be done with several different treatment strategies,
minimal as required to avoid altering the correct occlusion of the non- as seen in Table 2.
involved side. Appliances to be used are an acrylic bite plate or a vacuum appliance
Temporary bite raising during fixed orthodontic treatment is com- stabilizing normal occlusal contacts in the upper and lower arches. Other
monly obtained through removable occlusal appliances. However, appliances to open the bite are acetate plates with bite blocks on the side
patient cooperation is required since full-time use of the bite plate is without scissor bite or modified Hawley bite plate appliances. The use of
required for approximately 7 to 9 months.12 Most frequently, the bite is anterior bite planes as a simple method to disarticulate arches has also
been proposed.33
Upper palatal and lower lingual bonded bite turbos can also be used
on compromised teeth, contributing to raising the bite and helping with
the intrusion while the transverse correction is taking place. Bonding
with resin, the occlusal surface of the opposite side to provide the

Fig. 31. The left side corrected Brodie Bite. Upper and lower longitudinal cone-
beam cuts on the long axis of the involved teeth are presented to visualize the
buccal and palatal bone after the correction. (previously published in J Clin Fig. 32. A. Brodie Bite involving only one tooth. B. The tooth was severely lin-
Orthod MS 23193 accepted for publication − reproduction authorized by J Clin gualized, with a significant degree of tooth mobility. It failed to upright with a
Orthod editor) TAD. A decision was made to extract it and replace it with a future implant.

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Fig. 33. A. Treatment mechanics used to solve the case pre-

sented in Fig. 5. B. Schematic representation of the treatment
mechanics. C. Bite turbos were bonded, both in the upper and
lower arch, on the affected side. D. Lower molars were acti-
vated as a segment to a buccal shelf screw. This bite-raising
strategy helped both intrusion and inclination correction free
of occlusal trauma.

necessary clearance has also been described.16 Ideally, the disarticulat- almost always treated with dental compensations. However, research
ing strategy covers most teeth instead of loading a few with masticatory has shown an inherent instability when intercanine width is expanded
forces. The goal is to prevent occlusal interferences when the mandibu- dentally. Similarly, intermolar width might be unstable if expanded
lar posterior teeth are being moved buccally and simultaneously avoid excessively during orthodontic treatment. During distraction osteogene-
unwanted extrusion of the maxillary posterior teeth. Glass ionomer bite sis, a transverse skeletal deficiency can be treated with mandibular wid-
turbos bonded on occlusal surfaces of the maxillary molars, and later ening when a true skeletal discrepancy is present.36
anterior bite turbos have been used as well for treating a Brodie Bite.34 A combination of orthognathic surgery and orthodontic treatment is
Figs. 33 and 34 show the treatment mechanics to solve the case pre- sometimes used to address the mandibular and facial asymmetries. This
sented in Fig. 5, where bite turbos were bonded on the affected side, approach uses a 3-piece Le Fort I surgery to address the unilateral poste-
both in the upper and lower arch. Vertical compromise on the Brodie rior scissors bite. Occasionally combined with a midline split for maxil-
side was so severe that upper extrusion completely covered the lower lary constriction and a bilateral sagittal ramus osteotomy or mandibular
teeth. This bite-raising strategy helped both intrusion and inclination symphyseal distraction.2,11,37 Upper segmental osteotomies can be
correction free of occlusal trauma. Upper teeth were moved lingually to designed, as well as subapical mandibular surgery to relocate the
a TAD in the palate, and lower molars were activated as a segment to a affected segments.14 A scissors bite involving many teeth and a large
buccal shelf screw. vertical overlap is very difficult to correct exclusively with orthodontic
Aligners have also been used for disocclusion in situations of one therapy, especially for non-growing patients. However, surgical options
molar correction.35 Aligners can be an effective alternative to correct are often rejected by patients.11
scissor bites, particularly if the patient refuses to use conventional fixed Different surgical approaches have been suggested in reported Brodie
appliances. Anterior bite ramps are incorporated during the virtual plan- Bite cases. An extensive maxillary surgical case was treated with a 3-
ning as a bite-raising alternative. The problem is that aligners do not lift piece Le Fort I osteotomy. The inter-molar maxillary width was reduced
the bite while not in the mouth. Fig. 35 shows another alternative is to bilaterally during surgery. While maintaining the intercanine distance.
bond permanent bite ramps and design the plastic on top of them. The posterior segments were also managed vertically, solving the over-
eruption problem with segmental intrusion.7 Corticotomies followed by
Surgical treatment options rapid mandibular expansion to obtain inter-arch coordination were pro-
posed.38 Posterior mandibular subapical osteotomy was utilized to cor-
It is important to consider surgery as a reasonable alternative to more rect mandibular right premolars and molars on a Brodie Bite pattern.
complex Brodie Bite cases. Sometimes the surgery addresses other skele- Teeth were moved by using a lingual arch appliance after the subapical
tal problems, but sometimes it is part of the Brodie Bite problem. Differ-
ent surgical treatment options for Brodie Bites depend mostly on the
patient’s age. Until recently, a mandibular transverse deficiency was

Fig. 35. A. Permanent bite ramps are bonded to upper incisors to ensure a bite-
Fig. 34. A. Schematic representation of the treatment mechanics. B. Upper teeth opening strategy while aligners are not in the mouth. B. The plastic is designed
were moved lingually by elastic activation to a TAD in the palate. to fit and the plastic on top of them.

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Fig. 36. A. Case (Courtesy of Dr. Macarena Alvarado) with a

skeletal Class II and a unilateral right Brodie Bite affected pre-
molars and molars. B. An acrylic removable appliance was
used for bite opening in the lower arch. For the scissor bite
correction, upper right TADS were used both in a buccal and
palatal position. Initially, the upper molars were only activated
to the palatal TAD for the buccal inclination correction. C. The
buccal screw was used when a purely intrusive vector to the
whole segment was activated. The lower arch was only treated
with fixed appliances. Brackets in the lingualized teeth were
bonded upside down to produce positive torque values.

the mandibular teeth should occlude properly. Therefore, this relation

itself functions as a retainer to prevent relapse.15 However, Brodie Bite’s
treatment stability may be compromised when treatment involves dental
expansion. For this reason, it is important to evaluate if the Brodie Bite
was originally mostly a skeletal and/or a dentoalveolar component.
Clinicians are frequently faced with the dilemma of either treating the
skeletal base or a dental compensation. It has been shown that the
Fig. 37. A. Canted occlusal plane before Brodie Bite correction. B. Levelled expansion of basal bone relative to alveolar bone is critical in establish-
occlusal plane after scissor bite treatment. ing long-term stability.13 Stability issues are mostly related to other
problems associated with the Brodie Bite.
Treatment mechanics can also be a threat to stability. One of the
osteotomy. Le Fort I osteotomy and sagittal split ramus osteotomy were complications associated with molar intrusion facilitated with tempo-
then used to correct the patient’s facial asymmetry.38 rary skeletal anchorage devices is that intruded posterior teeth may con-
Figs. 36−39 shows a case with a skeletal Class II with a unilateral sequently experience a relapse rate as high as 30 %. Therefore, if
right Brodie Bite which affected premolars and molars. For the scissor possible, overcorrection of molar intrusion is necessary to achieve a
bite correction, upper right TADS were used both in a buccal and palatal proper result.13
position. Initially, the upper molars were only activated to the palatal Another important aspect of stability is to evaluate function in the
TAD for the buccal inclination correction. The buccal screw was also treatment result. The fact that the patient’s malocclusion is corrected
activated for a purely intrusive vector applied to the whole segment. does not mean it is always accompanied by a functional masticatory
The upper wire was then segmented both for intrusion and correction of improvement. It is well known that orthodontic treatment morphologi-
the occlusal plane canting. An acrylic removable appliance was used for cally rearranges the occlusion. However, obvious improvement in func-
bite opening in the lower arch. The lower arch was only treated with tion does not occur instantly and sometimes requires specific further
fixed appliances. The lingualized teeth were bonded upside down to pro- treatment to avoid reverse masticatory cycles and dual bite.24 In some
duce positive torque values. The Brodie Bite was solved in nine months. instances, the asymmetric movement of the incisor paths and bilateral
The patient went thereafter through orthognathic surgery for the skele- condyles during lateral excursions disappeared after treatment provid-
tal Class II correction. Total treatment time was 3 years. ing instant functional improvement.15

Stability Periodontal considerations

Once the Brodie Bite is corrected, the lingual incline of the buccal When the Brodie Bite is diagnosed early, periodontal consequences
cusp of the maxillary teeth and the lingual incline of the lingual cusp of are minimal and most likely addressed through orthodontic movements

Fig. 38. A. Pre-surgical Intraoral photos. B. Post-surgical

intraoral photos.

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C. Weinstein et al. Seminars in Orthodontics 00 (2023) 1−19

extrusion initially. Later, begin with lower corrective mechanics in a sec-

ond stage when space is available.
Iatrogenic open bites can appear after the use of intermaxillary elas-
tics as an undesired effect of treatment mechanics. This might be a sig-
nificant problem in high-angle cases.15,16 Open bites could also appear
because of the mouth opening strategy or insufficient intrusion of the
Brodie segments. If there is insufficient intrusion of the Brodie segment,
it is sometimes better to further intrude molars on the affected side.5 If
the lateral open bite is on the contralateral side, a careful analysis of the
bite raising mechanics needs to be made. Bite opening in the anterior
region sometimes appears inevitably. Vertical control of the mandibular
molars cannot be done while simultaneously uprighting them. Mastica-
Fig. 39. Before and After images after orthognathic surgery for the skeletal Class tory muscle exercises are an important adjunctive treatment to correct
II correction. Total treatment time was 3 years. and maintain an open bite.12
The non-Brodie side, which generally has a good occlusion, is consid-
ered the anchorage zone to correct the affected teeth. Unfortunately, it
with the help of craniofacial growth and additional natural tooth erup- can get compromised because of the correction. The planned disocclu-
tion. At later ages, especially when craniofacial growth potential and sion strategy can generate undesirable intrusive movements and inclina-
natural eruption processes are minimal, periodontal bone and soft tissue tions. Then they need to be fixed as a newly created problem. Especially
defects may persist even after proper orthodontic movements. Hence, in with fixed strategies such as bite turbos, an undesired open bite or cant-
older patients with Brodie Bite malocclusion, interdisciplinary planning ing of the occlusal plane may appear, extending treatment time and diffi-
and management with a periodontist is paramount. culty. To avoid this complication, ideally, the appliance used for
It is important to note that, in general, periodontal conditions are not correction stabilizes the complete arch rather than just a group of teeth.
affected in terms of inflammatory pathology; however, the typical bony If few teeth are used to raise the entire dentition, such as with composite
architecture is altered as extrusions and dental compensations are turbos, it is better if those teeth are part of the Brodie Bite side as they
expressed. As stated in this proposed checklist, periodontal anatomy will are generally over erupted.16 When a unilateral buccal crossbite is pres-
become affected by the level of alveolar bone and gingival contours, ent, the biomechanics of appliance selection is a concern. The expansion
together with gum display. In the transverse plane, inclinations may also has its effect on both sides. It is not simple to expand just one side of the
affect the thickness of the buccal cortex and express gingival recession mandibular arch. To control this side effect, it is necessary to minimize
in the most extreme cases, especially in the mandible. it. By creating an acrylic indentation or addition of composite on the
opposing arch or using elastics.3
Surgical complications are traditional problems that may arise
Complications because of orthognathic surgery. These include non-union of bone seg-
ments, post-surgical infections, condylar resorption, facial sensitivity
Several associated complications with the Brodie Bite treatment have issues, devitalized teeth, and tooth loss. In the case of mandibular mid-
been reported. A late diagnosis of this malocclusion may lead to compli- line distraction to widen the lower arch, tooth loss is a possible
cations such as mandibular development disorders, Class II malocclu- complication.40
sion, TMD, asymmetric growth and lateral deviations with functional
shifts.8,39 Dentoalveolar compensations in the vertical plane may cause
periodontal lesions and ulcers in the oral mucosa due to dental extru- Conclusions
sions.8 Maxillary extruded teeth can impinge the mandibular
gingiva.5,10 Intrusion with heavy force can cause pulpal damage and The Brodie Bite is a malocclusion that presents different degrees of
root resorption. The magnitude of force should be limited to 250 g per severity. It can be skeletal, as well as dentoalveolar, and bilateral or uni-
molar to prevent root resorption.13 lateral. Usually, it should be treated before any other malocclusion com-
Anatomical considerations for TAD placement need to be addressed. ponent. Early diagnosis and management will reduce the complexity of
In the maxilla, caution must be exercised when placing mini-screws in orthodontic mechanics and improve the overall prognosis. Efficient
the posterior palate because the greater palatine nerve emerges from, treatment strategies need to be individualized depending on vertical and
the greater palatal foramen medial to the third molars.16 When the alve- transverse components. Ideally, the current standard of care is using
olar bone is severely tilted buccally in the mandible, buccal insertion of skeletal anchorage with a disocclusion strategy, stabilizing the teeth not
temporary skeletal anchorage devices may cause significant patient dis- involved in the Boride Bite. Complications are related to the timing of
comfort. In addition, TADs placed in the mandible are known to have diagnosis, compensations, TAD mechanics and the development of unde-
higher failure rates. To avoid potential complications with TADs, a mod- sired open bites. Generally, the Brodie Bite treatment is stable and
ified lingual holding arch for molar uprighting is a management alterna- presents a good long-term prognosis when addressed correctly
tive.13 Additionally, one unique unit of skeletal anchorage might not be
enough to correct a scissor bite involving a larger segment of teeth Declaration of Generative AI and AI-assisted technologies in the
(canine, premolars, and molars). In this case, the buccal shelf might be writing process
located too posterior. More than one TAD, additional interradicular
TADS, or even a mixed solution might be reasonable. While preparing this work, the author(s) did not use Generative AI or
The selection of the insertion site for mini-screws depends not only AI-assisted technologies.
on bone availability but the required movement direction should also be
considered. Initially, a 6 mm distance between the mandibular mini-
screw and the molar tube was described. Once the molar was uprighted, Declaration of competing interest
it decreased to 0 mm.38 The amount of extrusion in the upper arch can
be so significant that there might be no space to fit a buccal shelf screw The authors declare that they have no known competing financial
since it would interfere with it during occlusion. An alternative is the interests or personal relationships that could have appeared to influence
use of a lower interradicular screw. Another option is to solve the upper the work reported in this paper.

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ARTICLE IN PRESS [m5GeS;January 9, 2024;3:04]

C. Weinstein et al. Seminars in Orthodontics 00 (2023) 1−19

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