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Management of Deep Bite _ Dr. Nabil Al-Zubair

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Management of Deep Bite _ Dr. Nabil Al-Zubair

  1. 1. MANAGEMENT of deep bite • Dr. Nabil Al-Zubair
  2. 2. MANAGEMENT of deep bite Dr. Nabil Al-Zubair
  3. 3. Overbite Definition: overbite defined as “the overlapping of the upper anterior teeth over the lowers in the vertical plane”. “the amount and percentage of overlap of the lower incisors by the upper incisors” . ideal overbite ranges from 5-25% overlap. 5-25% normal (yellow), 25-40% increased (orange) >40% excessive (red) Ranges of overbite.
  4. 4. The maxillary dental arch being LARGER than the mandibular arch allows the maxillary anteriors to overlap the mandibular anteriors. Thus some degree of vertical overlapping (overbite) is a normal feature of human dentition.
  5. 5. However, some patients present with excessive overbite. Such a condition where there is an excessive vertical overlapping of the mandibular anteriors by the maxillary anteriors is called deep bite. front upper incisor and canine teeth project over the lower. • Also called vertical overlap.
  6. 6. Deep bite is one of the most common malocclusion seen in children as well as adults that can occur along with other associated malocclusions. ‫مؤذ‬ ِ It is said to be one of the most deleterious malocclusion when considered from the viewpoint of the future health of the masticatory apparatus and the dental units.
  7. 7. Prevalence The prevalence of severe deep bite varies between racial groups twice as common in Caucasian Americans compared to African Americans and Hispanics 3-4 mm 5-7 mm > 7 mm
  8. 8. Tow types of deep verbite: • an incisor relationship • an incisor relationship in which in which the lower the lower incisors contact the incisors fail to occlude palatal surface of upper incisors with either the upper or the palatal tissue when the incisors or the mucosa teeth are in centric occlusion of the palate when the (results in trauma of the teeth are occluded mucosa palatal to maxillary Incomplete incisors. overbite Complete overbite
  9. 9. Incomplete overbite Normal overbite Complete overbite
  10. 10. Do deep overbites require correction?
  11. 11. If not treated, deep bites can result in:  TRAUMA to the palatal mucosa - behind the upper incisors or - to the labial gingiva of the lower incisors This can result in  Painful soft tissue and periodontal defects  overbites greater than 40% as excessive, compromising the periodontal tissues and acting as a co-contributing factor in the aetiology of TMD.
  12. 12.  Excessive ATTRITION of anterior teeth, especially lower incisors, is often associated with a deep anterior overbite and bruxism
  13. 13. Aetiology and Diagnosis Aetiology of Deep bites: Environmental Genetic Play a role in the development of deep bites.
  14. 14. CLASSIFICATION & Aetiology: A) Developmental deep bite B) Acquired Deep Bite 1) Skeletal deep bite 1) Lateral Tongue Thrust - horizontal growth pattern 2) Early loss of Deciduous Teeth 2) Dento alveolar deep bite 3) Wearing of Occlusal Surface - supra erupted incisors - infra eruption of molars
  15. 15. Skeletal deep bite Usually of Caused by: genetic origin - Upward & - Downward & forward rotation of forward inclination the mandible of the maxilla
  16. 16. Caused by: Skeletal deep bite - Upward & forward rotation of the mandible - Downward & forward inclination of the maxilla - Combination
  17. 17. - Characterized by the presence of the following features: Patients exhibit a horizontal growth The anterior facial height is reduced pattern. parallel horizontal A reduced inter- planes (mandibular occlusal clearance plane, F.H. plane, S.N. (freeway space). plane
  18. 18. Skeletal Deep Bites: Also described as brachyfacial or hypodivergent facial pattern skeletal deep bites exhibit characteristics including - Reduced lower anterior face height, - Reduced mandibular plane angle and - Reduced gonial angle.
  19. 19. Skeletal Deep Bites: Also described as brachyfacial or hypodivergent facial pattern skeletal deep bites exhibit characteristics including - Reduced lower anterior face height, - Reduced mandibular plane angle and - Reduced gonial angle.
  20. 20. Cephalometrically :
  21. 21. Cephalometrically : Acute cranial base angle
  22. 22. Skeletal Deep Bites: Cephalometrically : Acute cranial base angle reduced Jarabak ratio (proportion of posterior face height to anterior face height) reduced Y-axis increased ramal length forward growth rotation of the mandible Deep bites are often associated with Class II malocclusions
  23. 23. Dental deep bite Characterized by the absence of any skeletal complicating features which are seen in skeletal deep bites. - - Occurs due to: a. Over-eruption of anteriors or b. Infra-occlusion of molars. • Tooth loss can contribute to an occlusal imbalance resulting in lingual collapse of the anterior teeth and a deepening of the anterior bite Deep bites are commonly associated with an excessive Curve of Spee
  24. 24. Deep bites due to over-eruption of anteriors: Usually seen in Class II Excessive curve malocclusion of Spee Molars are fully erupted overjet the lower incisors allows over-erupt until they meet the palatal mucosa Normal inter-occlusal clearance
  25. 25. - Deep bites due to infra-occlusion of molars: Characterized by: - Occur due to: 1) Infra-occlusion of molars 2) Lateral tongue posture or lateral Large inter- The presence tongue thrust (prevent the molars occlusal of partially clearance erupted molars from erupting to their normal occlusal level) 3) Premature loss of posterior teeth Reduced crown length
  26. 26. Soft Tissue Deep Bites: Deep bites are often associated with Class II malocclusions Hypodivergent (short) facial patterns tend to have: - - stronger mandibular elevator musculature and - high mentalis activity - a deep mento-labial fold and - everted lower lip.
  27. 27. Diagnosis It is important to assess the patient facially, skeletally and dentally to ensure correct diagnosis of the vertical dimension
  28. 28. - The routine diagnostic aids: Identification of the aetiology of the deep bite will allow formulation of appropriate treatment mechanics.
  29. 29. Successful treatment requires: Careful analysis of the several possible contributing factors and this warrants a detailed clinical and cephalometric examination.
  30. 30. Tow modalities to correct deep bite: - Intrusion of the - Extrusion of the anterior teeth or posterior teeth
  31. 31. DIAGNOSTIC CONSIDERATIONS IN MANAGEMENT OF DEEP BITE 1)Soft tissue considerations 2)Dental considerations : 3)Skeletal considerations :
  32. 32. 1)Soft tissue considerations a)Interlabialgap : 2 to 3 mm is normal. If interlabial gap is EXCESSIVE, molar EXTRUSION should be AVOIDED. b)Smile line : In case of GUMMY SMILE , INTRUSION of maxillary incisors should be done. c)Lip length : In cases of SHORT UPPER LIP, INTRUSION should be carried out.
  33. 33. 2)Dental considerations : Incisor INTRUSION is ideal to treat deep bite in cases of SUPRAERUPTION and GUMMY SMILE. It maintains the vertical dimension. Upto 4 mm of incisor intrusion can be achieved.
  34. 34. 3)Skeletal considerations : In case of decreased lower anterior face height , EXTRUSION of molars is acceptable but it should be attempted only in growing children. If the same is attempted in adults, the stability of the result will be questionable. In patients with increased face height, INTRUSION of anteriors should be considered.
  35. 35. Factors to be considered in treatment of deep bite - Decision whether to intrude the anteriors or extrude the molars depend on certain factors include: (a)lip relationship (b) vertical facial relationship (c) inter-occlusal space
  36. 36. Lip relationship INTRUSION of the anteriors. - Patients with a shorter upper lip or a gummy smile should be treated by EXTRUDE the molars. - Patients exhibiting normal upper lip with only 2 – 3 mm of maxillary incisal edge exposed, it is deal to
  37. 37. Vertical facial relationship EXTRUSION of one or more posterior teeth - usually results in downward & backward rotation of the mandible (increase anterior facial height). -This can be a benefit in treating skeletal deep bites with excessive horizontal growth & upward rotation of the mandible
  38. 38. - The average inter-occlusal space is 2-4 mm in the Inter-occlusal space premolar region. - Increase inter-occlusal space is an indication that molars are not fully erupted (treated by EXTRUSION of posterior teeth). - The presence of normal inter-occlusal space is an indication for INTRUSION of incisors rather than extrusion of molars. - Reduction of normal inter-occlusal space by extrusion of molars can result in fatigue of the muscles of mastication which get stretched & predispose to relapse.
  39. 39. Treatment modalities
  40. 40. Orthodontic treatment mechanics to correct a deep bite must be specific for: - the TYPE of deep bite and - ETIOLOGICAL FACTORS identified in the diagnosis for each individual patient - The amount of GROWTH remaining also affects treatment decisions and modalities. Deep bite corrections achieved during periods of active growth have been found to be more stable than those in adult patients
  41. 41. Treatment modalities include: 1. Intrusion of upper and or lower incisors 2. Extrusion of upper and or lower posterior teeth 3. A combination of anterior intrusion and posterior extrusion 4. Proclination of incisors 5. Adult surgery
  42. 42. 1. Intrusion of upper and or lower incisors •1) Relative intrusion: It is achieved by preventing eruption of •2) Absolute intrusion: the incisors while growth provides There is pure intrusion of the incisors vertical space into which the posterior without extrusion of the posterior teeth erupt. teeth. J-Hook headgear Anterior bite plate Bypass and segmental mechanics Twin-Blocks Particularly with the assistance Implants of mandibular growth
  43. 43. Methods of relative intrusion include - Anterior Bite Plates contacting the anterior dentition while allowing posterior eruption - Twin-Blocks, where differential molar eruption can occur by trimming the posterior blocks. - Ant Bite Turbos
  44. 44. Anterior bite plate : This disoccludes the posterior teeth and hence causes their extrusion It can be used in growing patients. Stability of bite opening by extrusion will be questionable in adults especially those who have brachycephalic and horizontal growth pattern
  45. 45. Ant Bite Turbos
  46. 46. Twin-Blocks, where differential molar eruption can occur by trimming the posterior blocks.
  47. 47. RELATIVE INTRUSION: A)Reverse curve of Spee : It mainly causes extrusion of the posterior teeth. However there may be undesirable changes in the axial inclinations of the buccal teeth and flaring of the incisors.
  48. 48. B)Anchor bend: These bends are incorporated in the archwire, just mesial to the first molars and are used in conjunction with Cl II elastics.
  49. 49. Absolute intrusion : - involves moving the dentition deeper into bone and - can be used in both adolescent treatment and adult orthodontic treatment where there is no growth Methods of relative intrusion include ) J-Hook headgear ) Bypass and segmental mechanics ) Temporary skeletal anchorage (Micro Implants)
  50. 50. J-Hook headgear: J-Hook headgear can also be used for J-Hook Headgear intrusion of the anterior segment and it produces absolute intrusion
  51. 51. Bypass and segmental mechanics The bypass arch is a continuous arch wire that bypasses the premolars (and often canines) to maintain light forces by lengthening the span between molars and incisors
  52. 52. Micro Implants : Temporary skeletal anchorage Today, en masse intrusion of all anterior teeth is possible using temporary skeletal anchorage without relying on traditional, compliance dependent extra-oral appliances, or less predictable segmental intrusion mechanics. Implants can be used for true intrusion of anteriors or a combination of intrusion and retraction depending upon the site of implant placement and direction of force delivery.
  53. 53. 2. Extrusion of upper and or lower posterior teeth Active extrusion of the posterior teeth results in: an increase in lower anterior face height generally associated with a downward and backward rotation of the mandible. achieve posterior extrusion.
  54. 54. Cervical Headgear
  55. 55. 3. A combination of anterior intrusion and posterior extrusion Commonly used this can be achieved by : - placing anterior brackets more incisally and posterior brackets more gingivally or by- - using reverse-curve archwires..
  56. 56. 4. Proclination of ilower ncisors
  57. 57. 5. Adult surgery In severe adult skeletal deep bite cases, ORTHOGNATHIC SURGERY is an option to increase the efficiency of orthodontic mechanics, improve facial aesthetics and enhance long- term stability
  58. 58. Surgical options include: mandibular advancement, maxillary surgery and sub-apical osteotomy. mandibular advancement Anterior segmental osteotomies
  59. 59. Mechanics for overbite reduction
  60. 60. The successful treatment of deep bite correction depends on - an elaborate clinical examination, - thorough cephalometric analysis, - judicious treatment planning among the various available options and by - using appropriate mechanotherapy followed by - a proper retention protocol.
  61. 61. Mechanics for overbite reduction The following mechanisms are available for overbite reduction - removable acrylic anterior bite planes - fixed anterior bite planes metal e.g. bite turbo composite bite buttons - high-pull headgear to incisors - archwire curves of Spee - archwires with step-down T loops - sectional archwires - class 2 elastics - segmental surgery
  62. 62. Deep bites can be treated using: Removable appliances Myofunctional appliances Fixed appliances
  63. 63. REMOVABLE APPLIANCES - The anterior bite plane is a modified Hawley’s appliance with a flat ledge of acrylic behind the upper incisors. - The anterior bite plane consist of 1) Adam’s clasps on the molars (help in retaining the appliance) 2) A labial bow (counter any forward movement of incisors) 3) Base plate with anterior bite plane (1.5 – 2 mm) - As the posterior teeth erupt the height of the bite plane is gradually increased.
  64. 64. The anterior bite plane
  65. 65. The anterior bite plane
  66. 66. Before treatment with fixed anterior bite plane:
  67. 67. During treatment with fixed anterior bite plane:
  68. 68. After treatment with fixed anterior bite plane:
  69. 69. Myofunctional appliances - Activator: can be used to treat deep bites diagnosed to be due to infraocclusion of molars & trimmed to allow the extrusion of these teeth. - Bionator can be used for a similar purpose.
  70. 70. Fixed appliances 1) Use of anchorage bends: given in the arch wire mesial to the molar tubes (the anterior part of the arch wire lies gingival to bracket slot) 2) Use of archwires with reverse curve of Spee.
  71. 71. 3) Use of utility arches: Utility arches are arch wires that are bent in such a way that they bypass the buccal segment & are engaged on the incisors (activated by giving a V bend in the buccal segment of the wire.
  72. 72. The stability of deep bite correction has been a challenge to the orthodontist. In most of the cases it REQUIRES: a prolonged RETENTION protocol usually constitutes use of a removable appliance with a potential biteplane incorporated on to it.
  73. 73. Any Questions?

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