Management of deep bite (1)
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1) A 12-year-old patient presented with mucosal trauma from a deep overbite. 2) Traumatic deep overbites can be classified based on their skeletal and dental characteristics. 3) Treatment aims to relieve pain, correct vertical and anteroposterior discrepancies, and ensure stability.
Management of deep bite (1)
- 1. A patient aged 12 years present to the dental clinic with mucosal trauma resulting from a deep overbite. Discuss the management of such problems. Aghimien Osaronse Anthony
- 2. Introduction Definition Classification of traumatic deep overbite Management History Patient assessment Clinical record/investigation treatment
- 3. Treatment aims Treatment considerations Treatment options Prognosis Retention Follow up Conclusion
- 4. Malocclusion can occur as a form of vertical discrepancy as well as transverse and anterio-posterior relationship. overbite is the distance which the maxillary incisor margin closes vertically past the mandibular incisor margin when the teeth are brought into habitual or centric occlusion. The deviation from this can be an open bite or deep overbite.
- 5. Traumatic deep overbite is mostly associated with skeletal class II component associated with incisal class II division I or II. These manifest as trauma to the palatal mucosal, gingival, gingival stripping, food packing, enamel stripping, dentin hypersensitivity etc.
- 6. A condition of excessive overbite where the vertical measurement between the maxillary and mandibular incisors margins is excessive when mandible is brought into habitual or centric occlusion( Graber).
- 7. Several classification exist but Akerly has detailed classification that would aid the understanding of this patient condition. AKERLY 1. Has a skeletal class II pattern Angle’s class II division I Lower incisor push against the palatal mucosal causing mucosal trauma of the palate away from the palatal gingival margin.
- 8. AKERLY II SP I or II Angle’s class II div I/II Causes trauma to palatal gingival of maxillary incisor Causes impaction of food of foreign body in the gingival crevices
- 9. AKERLY III SP II Angle’s class II division I Stripping of the lower labial and upper palatal gingival surrounding the incisor teeth AKERLY IV SP I or II Angle’s class I or II division I Wear facets on the palatal surface of the upper incisor and labial surfaces of the lower incisors….usually due to loss of occlusal support or para-functional habit
- 10. History Patient assessment Clinical record/investigation treatment
- 11. Age ; patient is 12 years old. active growth period aid timing of intervention aid in selection of appliance to be use assessment of patient dentition; as patient should be in late mixed/early permanent dentition patient ability to tolerate removable appliances is better than early mixed dentition
- 12. Sex; this was not stated but; female mature earlier than males hence, intervention at this age for females would just be appropriate. Sporting activities; these predisposes the male patient to trauma if anterior teeth are severely proclined.
- 13. History of presenting complains; mucosal pain proclined anterior teeth teasing from peer group
- 14. History of etiology; inherent/genetic; family member with such condition. Patient growth pattern, direction would need proper assessment. abnormal muscular activity; leads to increase wear facets of posterior teeth especially among bruxist. lateral tongue thrust habit’ leads to infra-occlusion of posterior teeth. loss of posterior
- 15. History of complication mucosal ulceration Gingival recession trauma to anterior teeth; if teeth are proclined
- 16. Any history of trauma to anterior teeth from falls or contact sport; anterior teeth would protection by a mouth gag.
- 17. Extra-orally skeletal pattern II or I as the case may be incompetent lip; from proclined maxillary incisors in Angle’s class II div. I Competent lip ; in Angle’s class II div. ii cases facial profile; severely convex for severe Skeletal pattern II facial height; appear clinical reduced. high mentalis activity deep mento-labial fold everted lower lip
- 18. Proclined maxillary incisors with increased overjet with deep and traumatic overbite in class II div. I Retroclined maxillary central and distal tipping of the laterals with decreased overjet and deep and traumatic overbite. Presence or absence of other mal-occlusion like rotations, crowding.
- 19. Indentation of incisal edges of lower incisors on the palatal mucosal behind the palatal incisors Mucosal could be inflamed with some level of erythemal or ulceration depending on the level of trauma. Stripping of palatal gingival causing recession; as patient attempt to reposture the lower jaw forward in an attempt to avoid palatal mucosal trauma.
- 20. Patient is in late mixed/ early permanent dentition. This also depend whether patient is an early erupter(earll maturer) or late erupter(late maturer). This will assist in timing of treatment whether a 2-stage early and late treatment or a 1-stage treatment will suffice. Wear facets on the molars; bruxism Over-erupted incisors Under-erupted molars Exaggerated curve of Spee
- 22. Treatment planning Mid-treatment comparison Medico-legal
- 23. Treatment planning space analysis Measurement of arch width and arch length Fabrication of appliance if needed
- 24. To assess stage of development of the teeth To ascertain presence of the remaining permanent teeth To rule out impacted teeth, supranumerary, pathology like odontome.
- 25. If the traumatic overbite is of skeletal origin the following will be evident; Reduced facial height Reduced gonial angle Parallel Sassouni planes Increased ramus height Reduced mandibular plane angle Reduced Jarabak ratio Reduced Y-growth axis
- 26. If of dental origin; o Height of the lower incisor from the incisal edge to the lower border of the mandible will increase indicating incisal supra-eruption o Height of cuspal tip of the molars to the palatal plane and lower border of the mandibular plane is reduced for upper and lower teeth respectively
- 27. Treatment aims Treatment considerations Treatment options Prognosis Retention Follow up
- 28. 1. To alleviate pains from trauma to the palatal mucosal 2. To treat any complicated existing periodontal problems 3. To prevent trauma to maxillary anterior teeth in class II div, I cases 4. To correct vertical discrepancies 5. To correct anterio-posterior discrepancies 6. To ensure a stable result
- 29. 1. Patient growth pattern/direction 2. Patient growth spurt; male/female 3. Patient compliance 4. Duration of treatment 5. Cost of treatment
- 30. 1. Ensure a sound surrounding soft tissue health and periodontal support 2. Correction of vertical and antero-posterior discrepancies
- 31. 1. Warm saline mouth bath with mild analgesic(acetaminophine); to relief pain and ensure sound palatal mucosal. This is important as patient wound be needing a functional appliance that might contact the palatal mucosal and could make not to wear the appliance if it causes discomfort. 2. Scaling and removal of foreign body inpaction
- 32. CORRECTION OF VERTICAL AND ANTERIO-POSTERIOR DISCREPANCIES.
- 33. 1. Two-stage(early and late) treatment 2. One-stage(late) treatment
- 34. Early stage. Use of function appliance to 1. Reposture the lower jaw forward 2. Facilitate eruption of the molars At 12 years patient has some amount of expected and this will facilitate functional appliance. Time of wear; almost 24 hours for Twin block or about 10 hours(evening and night) for Andresen appliance. Duration; depends on the level of compliance, from 8-10 months
- 35. Reposturing the mandible forward help to reduce the mandible. Mandibular growth is redirected downward and backward and with the eruption of the molars the bite is opened up and also increasing the facial height. Andresen appliance will give a good result as it causes passive eruption of the molars while it also reposition the mandible forward.
- 36. Twin block although reposition the mandible forward but intrude the molars which could worsen the overbite and makes transition into the second phase of fixed appliance difficult, thereby prolonging treatment time
- 37. Late stage; Functional appliance is discontinue and replace with fixed appliance. The anterior are further intruded and other complicating mal-occlusion are corrected
- 38. Possible reasons 1. Delay eruption of permanent teeth 2. Patient not complaint with functional appliance 3. To avoid long time of treatment associated with the two-treatment option. 4. To reduce the financial cost of two-stage treatment
- 39. A single stage fixed upper and lower orthodontic treatment. Anterior teeth are intruded while the posterior teeth are extruded. This will reduce the overbite. Retraction of the maxillary anterior segment to help reduce the overjet.
- 40. Under-eruption of molars: by relative intrusion A removable appliance with an anterior bite will cause supra-eruption of the molars. This will reduce the bite Supra-eruption of incisors: a bypass arch or utility arch can be use to intrude incisors in the fixed orthodontic therapy.
- 41. A post-treatment cephalometric radiograph would be take for super-imposition on the pre-treatment radiograph. This will aid comparison and to ascertain the amount of movement achieved.
- 42. Retainer will be given to patient at the completion of treatment This ensure stability of the treatment and prevent relapse. Maxillary Hawley’s retainer would be worn actively about 24 hours about 3-4 months and thereafter only at night for another 2 months. Bonded palatal retainer can be given to patient to prevent relapse.
- 43. The ensure compliance especially when patient is on removable retainer, preventing relapse. To ascertain the level of stability of the treatment achieved by taking another lateral cephalometry radiograph
- 44. Identification of etiology of the traumatic deep overbite coupled with correct facial skeletal assessment is important. Growth status vis-a-vis pattern and direction should be assessed. A stable is said to be joy of an orthodontic and effoert should be made to achieve this.