ISSN 2179-9660 RFAIPE, v. 7, n. 2, p. 31-42, Jul./Dec.

2017

BITE TREATMENT PROTOCOL

PROFOUND
Deep bite treatment protocol

Kelli MORO1
Bruna Lorena dos SANTOS2

SUMMARY
Overbite is a type of malocclusion that has a multifactorial etiology and requires
of a specific and elaborated differential diagnosis, which can be defined when the
the vertical overlap of the upper incisors over the lower incisors exceeds a
third of the crown of the lower incisors in centric occlusion. This malocclusion is
frequently found in patients in orthodontics. Its treatment is
extremely complex. The etiological factors can be skeletal and/or dental.
It does not show a prevalence between the female and male genders. Its treatment
it can be done by the intrusion of the anterior teeth, the extrusion of the posterior teeth, or
the combination of both techniques. In this article, we will see the various ways of
treatment and what is the most satisfactory approach for each case.
Overbite treatment protocol. Bite treatment
deep. orthodontic planning.

ABSTRACT
Overbite is a type of malocclusion that has a multifactorial etiology and requires a
differential diagnosis elaborate and specific and can be set when the overbite of the
the upper incisors of the lower incisors exceeds a third of the crown of the lower incisors in
Centric occlusion. This malocclusion is often found in patients in orthodontics.
treatment is extremely complex. The etiological factors may be skeletal and/or dental. It
does not present a prevalence among females and males. The treatment is done by the
intrusion of the anterior teeth, extrusion of posterior teeth or a combination of both.
In this article, we look at the various forms of treatment and what the most suitable approach is.
for each case
Deep overbite treatment protocol. Treatment of deep bite. Orthodontic
planning.

1Postgraduate student at FAIPE, [email protected].

2Master in Orthodontics. FAIPE, [email protected].

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INTRODUCTION

According to Mota (2008), 'the etiology of this malocclusion has been studied and is related to

with changes in the growth of bone bases, functional modifications of

stomatognathic system and dentoalveolar changes.
According to Rosolem (2013), the overbite is the overlap of the crown of the incisors.

superior to the lower incisors. Despite the value of the overbite in

patients with normal occlusion can be variable, it is considered normal when
it presents values of 2 to 3 mm or one-third of the clinical crown. Above these values it remains

determined the existence of an accentuated, exaggerated or deep overbite.

To correct the deep overbite, it is necessary to perform a
appropriate diagnosis and create a treatment plan that is individualized, executing
thus, effective treatment mechanisms, combination of the treatment plan and the
mechanics aimed at treating deep overbite aim to achieve a
better aesthetic result and thus minimize recurrences during the post-
containment (BRITO, 2009).
According to Brito (2009), the treatment of overbite can use appliances.
orthodontic and orthopedic, being possible, if necessary, the use of more than one
types of mechanics applied at the same time, due to the complexity that is the bite
profound.
When it comes to deep overbite, there are several treatment options.
we can cite according to Rosolem (2013), 'extrusion of posterior teeth, intrusion of
anterior teeth, inclination of the anterior teeth. To achieve the
treatments with efficiency, there are many mechanics available.
The objectives of this article are to diagnose and plan the treatment of the bite.
deep, identify the treatment protocol, the main causes and demonstrate the
need to diagnose and treat overbite early. The treatment can
to be through, the intrusion mechanism of the anterior teeth, extrusion of the teeth
later citing the most used mechanisms, thus returning a function
balanced to the stomatognathic system (NANDA, 2007).
The cause of deep overbite may be related to dental loss.
posterior, mandibular retrusion, wear of posterior teeth, length of
upper and lower incisors, cusp height and vertical growth of the mandible,
as well as the height of the mandibular branch and facial pattern (SILVA, 2014).

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Thus, the excessive overbite should be treated so that there is no compromise.

aesthetic and functional (SILVA et al., 2014).

LITERATURE REVIEW

According to the literature (DIAMOND, 1944), untreated deep bite,

define a traumatic relationship between incisors, and an imbalance in the relationship between them

maxilla and mandible binomials, which can trigger periodontopathies, interferences in

opening and closing of the mouth, changes in the temporomandibular joint and of
stomatognathic system as a whole.
Neff (1949) described that a normal crossover can be considered when 20% of the
The lower incisors are overlapped by the upper ones.
Baume (1950) classifies overbite as mild, medium, and exaggerated. The first
it is verified when the lower incisors occlude with the incisal third of the incisors
superiors. The average occurs when the lower incisors occlude with the middle third of the
superior. And the exaggerated, when the lower incisors occlude with the cingulum of
superiors or the palatine gingiva.
The overbite is a characteristic of contemporary man. Ancient peoples
they had a top-to-top bite in adulthood and had very teeth
worn out due to eating habits (2000 years ago) (BEGG, 1954).
Strang (1950) concluded that deep overbite is associated with modifications.
of dental positions such as the excessive extrusion of the upper incisors or
lower or both, the intrusion of posterior teeth in one or both arches; the
combination of molar and premolar intrusion and incisor extrusion; the
axial lingual inclination of the lower molars and premolars; and complete lingual occlusion
two lower molars and premolars. Such associations have also been observed by
Silva (1990).
Silva (1990) also reveals that the overbite presents itself in varying degrees during
the stages of dental development, and that during the mixed dentition phase the
exaggerated overbite can be considered part of normal development of
occlusion.
Silva and Capelli Junior (1990) also mentioned the height of the cusps of the teeth, the height of
mandibular branch, or the degree of eruption of the posterior teeth and the interincisal angle as
factors that influence the degree of overbite.

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According to Silva (1990), there is no statistically significant difference.

regarding the incidence of overbite in the male and female genders. However, the
overbite can be found in Angle Classes I and II, being found in the
its most typical form in Class II second division.
The etiology of this malocclusion may be associated with growth alterations in
jaw and/or maxilla, modifications in the function of lips and tongue and, mainly, the
dentoalveolar changes, or even a combination of the two. The conditions
dentoalveolar are characterized by the supreruption of incisors, infreruption of
molars or a combination of these. And the skeletal characteristics consist of greater
condylar and temporal fossa growth, vertical direction of the growth vector
condyle that influences the direction of rotation of the jaw, AFAI, FMA, PP, and GoMe
are diminished, according to Moyers (1991).
In general terms, the complex nature of this malocclusion can already be observed in
avaliação das suas diferentes terminologias: sobremordida exagerada, sobremordida
deep, increased overbite, closed overbite, deep bite
increased vertical overlap, increased vertical projection, among others. All
these nomenclatures express the clinical condition in which the upper incisors
they cover the lower incisors at levels higher than the normal standards
(MOYERS, 1991).
An exaggerated overbite is a type of vertical malocclusion that has an etiology
multifactorial and requires a comprehensive and specific differential diagnosis. Many
sometimes, this malocclusion is the least understood and the most difficult to treat with
success and stability. How it is characterized as a very frequent malocclusion in
orthodontic clinic, the correction of overbite is one of the objectives
primordial aspects of orthodontic treatment (PARKER et al., 1995).
According to Marini Filho (1996), the etiology of deep overbite malocclusion is the
set of genetic, epigenetic, and local environmental factors that interact, and this
interaction, more frequently expressed the mandibular rotation during the period of
growth.
Marini Filho (1996) also cites other contributing etiological factors for the formation
of the characteristic framework of deep overbite, such as the height of the ramus
mandibular, the increased interincisal angle, the mandibular retraction, the
length of the upper and lower incisors and the imbalance of the musculature
facial. It also defines deep overbite as excessive vertical overlap.

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between the upper and lower incisors, which can be of skeletal origin or
dentoalveolar
According to Geron and Atalia (2005), in facial diagnosis we must take the smile into account.
gingival, some authors consider that, in the ideal smile, the upper lip should
position in a way to expose the entire crown of the upper central incisors up to 1 mm of
gum, up to 2 mm is considered acceptable. Above these values are considered
unaesthetic. These values are extremely important because in some cases where the
Gum exposure goes beyond these measures; some therapeutic measures are not included.
indicated.
Other factors such as pronounced Spee curve, change in the inter-incisal angle,
body size and mandibular branch are associated with this type of malocclusion
(NUNEZ, 2009).
Therapeutic strategies should be related to the etiology of the overbite.
presented, thus addressing the primary cause of the problem. The therapeutic options
available would then be: intrusion of anterior teeth, extrusion of posterior teeth,
the leveling of the Spee curve, associated with the rotation of the mandible in the sense

schedule or the combination of approaches (BRITO, 2009).

The deep overbite should be carefully evaluated and diagnosed. The clinician
you should always pay attention to the following aspects: magnitude (discrepancy between the

measured and the ideal), evolution (patient's age), skeletal etiology (long face,
short), and dental etiology (supra-eruption of the incisors). Three are the most common methods
common for correcting the overbite: extrusion of the posterior teeth inclination
of the anterior teeth and intrusion of the upper and lower incisors (ALMEIDA, 2010).
The cause of deep overbite may be related to both tooth loss.
posterior, mandibular retrusion, wear of posterior teeth, length of
upper and lower incisors, cusp height and vertical growth of the mandible,
such as the height of the mandibular branch and facial pattern (SILVA, 2014).

Extrusion of posterior teeth

The possibility of posterior tooth extrusion is old, Hemley (1938) described the
treatment of some patients where a plate with an anterior stop was used to
to enable the extrusion of posterior teeth.
After gathering observations from various researchers and clinicians, Silva and Capelli Junior

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(1990) concluded that the most commonly used device in the correction of
exaggerated overbite is the bite plate. Its main effects are intrusion.
two lower incisors; extrusion of the posterior teeth; growth of the alveolar bone
in the posterior region in the vertical direction; increase of the lower third of the face.

There are several mechanical resources to stimulate the extrusion of posterior teeth.
Didactically, these could be divided into active and passive resources. The
the first would be those that would generate forces directly on the back teeth, such as
the cervical extraoral appliance, the use of intermaxillary elastics and the use of mechanics
extrusive in fixed appliances. The latter, called passive, would be the plate with
the spacer and the functional appliances that promote posterior disocclusion (BENNETT;
MCLAUGHILIN, 1990).
Moyers (1991) stated that the extrusion of the first molars can be assisted by
use of a maxillary bite plan or a monoblock, which also promotes a
intrusion of the lower incisors.
The extrusion of posterior teeth has a direct impact on the amount of overlap.
vertical in the anterior region. For each 1mm of posterior extrusion, the vertical overlap
anterior reduced by 2mm (PROFFIT, 1995).
For the treatment of deep overbite in the deciduous and mixed dentition, Janson
et al. (1998) suggest the Eruption Guide device, which consists of a combination of
functional devices with dental positioning brackets. The thickness of the plastic material
keeps the posterior teeth disoccluded, allowing for their greater development
vertical, while allowing the application of intrusive forces on the teeth
previously, when the patient occludes forcefully on the appliance.
According to Nanda and Kuhlberg (2007), the most common in orthodontic practice is the use of

extrusive mechanics with fixed appliances. In situations of overbite

exaggerated, the alignment and leveling procedure using continuous wires
promotes, in most cases, the extrusion of posterior teeth. Similarly
form, the use of arches to manipulate the curve of Spee (with a pronounced curve in the upper)
the reverse in the lower part), regardless of the type of alloy, promotes dental extrusion
posterior, mainly of premolars, accompanied by the vestibularization of
incisors.
According to (JANSON; PITHON, 2008), the use of a stop in the anterior region that
allow the occlusion of only the lower incisors and provide space between the teeth
posteriors leveling the curve of Spee and treating the deep overbite. This option

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treatment is indicated mainly for patients who present a pattern of

horizontal or balanced growth, where there is an increase in the anteroinferior facial height
will not compromise the facial aesthetics.

In summary, the extrusion of posterior teeth is well indicated in patients with

growth, when one wishes to increase the anteroinferior facial height, as well as the
facial convexity, rotate the mandibular plane posteriorly and correct any eventual
changes in lip posture (BRITO, 2009).

Intrusions of anterior teeth

The orthodontic correction of deep bite through the intrusion of lower incisors and/or
superior is indicated for cases that present extrusion of incisors, in
patients with increased vertical dimension, excessive exposure of the incisors in
rest, gingival smile, or an increase in the interlabial gap, greater than 4 mm
(BURSTONE, 1977).
Different techniques for previous intrusion using auxiliary arches have been described.
1950. In all cases, the segmented arches incorporated inclined curves.
distal from the crown of the molars, thus exerting an intrusive force on the incisor. From
In general, these authors suggest that the main advantage of the intrusion arch is
which allows predicting the direction and magnitude of the forces on the teeth and their effects
in the domains of action and reaction (BURSTONE, 1977).

For the realization of anterior teeth intrusion, there are basically two types of
mechanics: the continuous intrusion arch and the 3-piece arch. In the first, the segment
of the arch that will promote the intrusion surrounds the entire dental arch and, in the anterior region,

it can be attached to the teeth by fitting directly into the slots of the brackets or
being tied to another previous segment. In the second system, called an arc
From 3 pieces, two segments of intrusion straps are made (one for each)
side) and fitted into another segment in the anterior region (BURSTONE, 2001).
The orthodontic procedure with segmented arches offers a beneficial alternative.
for the intrusion of anterior teeth, compared to the technique of the straight arch, which can
to produce a greater inclination of the incisors, as well as the instability of the results
(BURSTONE, 2001).
According to Burstone (2001), the key to success in intrusion is system control.
of forces used. Specifically, light and constant forces should be used, and

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the point of application and the direction of the force must be carefully assessed.
a force magnitude of 10 to 15g per incisor should be used, and to calculate the total
to strength, one must add the teeth that one wishes to intrude and apply the load
correspondent. Due to the importance of the magnitude of force for obtaining good
clinical results, it is suggested to use precision dynamometers to calculate the load
adequate.
The intrusion of incisors was considered, for many years, a complex movement.
it is difficult to be carried out. Furthermore, it has already been associated, several times, with reabsorptions

root and gum recessions. This occurs due to the intrusion movement generating
a pressure on the root apex, as well as when they are accompanied by
vestibularization, as the teeth move to an area of less support
bone (CHIQUETO et al., 2005).
In fact, regardless of the risks, when the intrusion movement is
carried out in a controlled and precise manner, little or no damage will be caused to your
dental structure or its periodontal supporting structure. In a systematic review
published by, it was concluded that the intrusion movement is viable and easier.
to be reached in the lower arc. According to the meta-analysis conducted, commonly, the
The selection technique for the intrusion of incisors is segmented and about 1.5mm of
upper incisors intrusion and 1.9mm of lower incisors are achieved (KUHLBERG,
2007).
The intrusion of upper incisors as a unique resource for bite correction
deep has been little used, as exposing upper teeth, as well as exposing a
small strip of gum tissue, it is aesthetic and rejuvenates patients. On the other hand,
In some selected clinical situations, the intrusion of upper incisors is acceptable.
indicated (BRITO, 2009).
Varlik, Alkapan and Turkoz (2014) investigated the long-term stability of the correction.
of overbite with intrusion of lower incisors with utility arches in patients
adults. The null hypothesis was that the correction of the overbite with the intrusion of the incisors

Inferior in adults is stable. For this, they analyzed pretreatment teleradiographs,

post treatment and 5 years post containment of 31 patients (average age of 26 years)
with class II, division 1 of angle and overbite, treated through extraction of
upper first molars and intrusion of lower incisors. They concluded that this type
of correction is considered effective and, above all, stable.

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Vestibularization of the anterior teeth

Vestibularization is an option that can be effective for correcting deep bite.

moderate elevation, with dental origin and with retroclination of anterior teeth, such as
in the case of Class II division 2. In this case, the labio-version of the incisors reduces the
overbite, moving the contact to incisal. When the vertical overlap is reduced
through the vestibularization, the position of the incisors and the interincisal angle must be
maintained within the limits that allow the balance of the perioral musculature and the tongue, of

so that there is stability (BALL et al., 1991; NANDA et al., 2007; NANDA 1981).

Combinations of mechanics

In some situations, the clinical and skeletal characteristics of the patients indicate
the correction of deep bite through the association of posterior dental extrusion
to the previous intrusion and/or correction of axial inclination. In these cases, the control

Biomechanics is not critical, and the use of simpler force systems is viable.
(BRITO, 2009).

Table 1 - Alternatives for the correction of deep overbite.

Bite plates Arches with curve Arches with Intrusion arches
reverse doubles in
step
Molar extrusion Great effects Moderate effects Effects Variable effects
moderates

Negligible Effects Inclination Average effects Average effects Variable effects

incisors for
vestibular
Intrusion of negligible effects Average effects Average effects Great effects
incisors
previous
Indications Lower facial height Moderate exposure Step between the Gummy smile.
short. the minimum of occlusal plane Exposure
Correction of upper incisors. previous and the excessive of
deep overbite Class I occlusion. posterior incisors.
inferior. (inferior). Upper lip
Excessive curve of Exhibition short.
inferior species moderate to Very incisive
minimum of two extruded.
incisors Correction
superiors. simultaneous molar
Occlusion of class II
class I
Characteristics Comfort and Protrusion of the Extrusion Minimum exposure
consent incisors to the plane posterior and two incisors
Stability mandibular previous intrusion superiors.
questionable in Questionable
adult patients. stability in
Increase in facial height adult patients.
anterior. Increase in height
inferior facial.

Source: Almeida (2010)

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DISCUSSION
The consulted literature on deep overbite is consistent with Marini Filho.
(1996), Moyers (1991) and Diamond (1944), when stating that the etiology of this malocclusion
it is the set of genetic, epigenetic, and local environmental factors that interact,
causing a counterclockwise rotation of the jaw.
For Diamond (1944) and Silva et al. (1990). The problem of overbite generates
serious consequences for the stomatognathic system as a whole.
Regarding the classification of deep overbites, Baume (1950) classified
dentally the overbite in slight, moderate, and exaggerated based on the point of
occlusion between the incisal of the lower incisors and the lingual surface of the upper incisors.
Marini Filho (1996) classified deep bites into dento-alveolar and
skeletal, based on the origin of malocclusion by an adaptation at the moment of
eruption of teeth, or due to skeletal changes respectively, where the
adaptations of tooth eruption can worsen a skeletal overbite.
A dental crossbite is normal when 20% of the lower incisor is overlapped by the upper one.
superior in Neff's view (1949). But each author cites a value that he defines as value.
normal, being: 1/3 of the crown of the incisors (RICHMOND, 1992,); 2/3 of the crown of
incisors (GRAINGER, 1967); 20% of the crown of the incisors (NEFF, 1949); 25-40% of the
crown of the incisors (NANDA, 1981); and 4mm or 50% of the crown of the incisors (OKESON,
1993).
According to Silva (1990), there is no statistically significant difference.
regarding the incidence of overbite in the male and female genders.
However, the overbite can be found in Angle Classes I and II, being
found in its most typical form in Class II second division.
Several factors are related to the development of excessive overbite.
Among them, we can highlight the supra occlusion of the anterior teeth, the infra occlusion.
of the back teeth and the combination of these two alternatives (SILVA; CAPELLI)
JÚNIOR, 1990; STRANG, 1950), the anterior rotation of the mandible (MARINI FILHO,
1996), the shortening of the mandibular branch (MOYERS, 1991;) and, more rarely, the
excessive lingual inclination of the lower molars (SILVA; CAPELLI JÚNIOR, 1990). A
Correction of excessive overbite includes at least one of the following mechanisms:
intrusion of incisors, extrusion of molars, inclination of incisors to labia,
labialization of lower incisors, and combinations of mechanics (BURSTONE,
1977; MOYERS, 1991; NANDA et al.; 2007, 1991; PROFITT, 1991; SILVA; CAPELLI

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JÚNIOR, 1990;). The device most commonly used to correct overbite

exaggerated in the mixed dentition phase is the bite plate (SILVA; CAPELLI JUNIOR,
1990). Treatment can also be done with mechanical orthopedic devices or
functional, cervical traction (MOYERS, 1991), eruption guidance device (JANSON,
1998) and through techniques that use the segmented intrusion arc (SILVA;
JÚNIOR HAIR, 1990; BURSTONE, 1977.
The containment should be done using a passive bite plate. The prognosis
it is never excellent, being dependent on free functional space and the standard
growth individual (GIL; MAIA, 1999; MOYERS, 1991; SILVA; CAPELLI JÚNIOR,
1990;).

FINAL CONSIDERATIONS
The prognosis of post-treatment for overbite is never satisfactory, due to
recurrence problem, which usually occurs 1 to 5 years after the active phase of
treatment. The intrusion of the upper and/or lower incisors is the form of correction
which provides greater stability post-treatment. Patients with facial pattern
vertical show a lower recurrence rate and greater stability of post-results
treatment. The recurrence of deep overbite is directly proportional to
amount of correction made.
Literature is unanimous in stating that the success of correcting deep overbite,
it can be compromised by post-treatment recurrence, regardless of the methods
the techniques used.

REFERENCES

ALMEIDA, M. R. Clinical Orthodontics and Biomechanics.

BAUME, L. J. Physiological tooth migration and its significance for the development of
occlusion.J Dental Res., v. 29, p. 440-7, 1950.
BRITO, H. H. A.; LEITE, H. R.; MACHADO, A. W. Exaggerated overbite: diagnosis and
treatment strategies. R Dental Press Orthodontics Facial Orthopedics, v. 14, n. 3, p. 128-57, 2009.
BURSTONE, C. J. Lip posture and its significance in treatment planning. Am J Orthod., v. 53,
n. 4, p. 262-84, Apr. 1967.
GERON, S.; ATALIA, W. Influence of sex on the perception of oral and smile esthetics with
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Sep. 2005.
JANSON, G. R. P. Correction of overbite with an eruption guidance appliance: presentation of
two clinical cases. Rev Dental Press Ortodon Ortop Facial, v. 3, n. 1, Jan./Feb. 1998.

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MARINI FILHO, R. L. Considerations on deep bite: development, treatment and

prevention. Rev Soc Paran Ortodon., no. 2, Mar./Jun. 1996.
MOTA, B. S. N. Treatment of deep bite. 2008. Monograph (Specialization)
of Orthodontics) - Brasília, DF, p.13-30, 2008.
MOYERS, R. E. Orthodontics. 4th ed. Rio de Janeiro: Guanabara Koogan, 1991. ch. 15. p. 292-
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NANDA, R. Biomechanics in clinical Orthodontics. 9th ed. Philadelphia: W. B. Saunders,
1997.
NANDA, R.; KUHLBERG, A. Treatment of deep bite malocclusion: strategies
biomechanics and aesthetics in the orthodontic clinic. São Paulo: Santos, 2007.
NEFF, C. W. Tailored occlusions with the anterior coefficient. Am J Orthodont., v. 35, n. 4, p.
309-13, Apr. 1949.
PROFFIT, W. R. Contemporary orthodontics. 2nd ed. Rio de Janeiro: Guanabara Koogan,
1995. cap. 13, p. 342-84.
SILVA, A. C. P.; CAPELLI JÚNIOR, J. O. The problem of excessive overbite. Braz J
Dentistry, v. 47, n. 4, p. 38-42, July/August 1990.
STRANG, R. Treatise on Orthodontics. 3rd ed. Buenos Aires: Bibliographic Argentina, 1957.

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