ORIGINAL ARTICLE

Deep overbite malocclusion: Analysis of the underlying components

Mostafa M. El-Dawlatly,a Mona M. Salah Fayed,b and Yehya A. Mostafac Cairo, Egypt

Introduction: A deepbite malocclusion should not be approached as a disease entity; instead, it should be viewed as a clinical manifestation of underlying discrepancies. The aim of this study was to investigate the various skeletal and dental components of deep bite malocclusion, the signicance of the contribution of each, and whether there are certain correlations between them. Methods: Dental and skeletal measurements were made on lateral cephalometric radiographs and study models of 124 patients with deepbite. These measurements were statistically analyzed. Results: An exaggerated curve of Spee was the greatest shared dental component (78%), signicantly higher than any other component (P 5 0.0335). A decreased gonial angle was the greatest shared skeletal component (37.1%), highly signicant compared with the other components (P 5 0.0019). A strong positive correlation was found between the ramus/Frankfort horizontal angle and the gonial angle; weaker correlations were found between various components. Conclusions: An exaggerated curve of Spee and a decreased gonial angle were the greatest contributing components. This analysis of deepbite components could help clinicians design individualized mechanotherapies based on the underlying cause, rather than being biased toward predetermined mechanics when treating patients with a deepbite malocclusion. (Am J Orthod Dentofacial Orthop 2012;142:473-80)

deep overbite is a common malocclusion encountered in an orthodontic practice.1 Severe deepbites (overbite $5 mm) are found in nearly 20% of children and 13% of adults, representing about 95.2% of vertical occlusal problems.2 A deepbite malocclusion overlies a multitude of hidden skeletal or dental discrepancies. Accordingly, a deepbite should not be approached as a disease entity; instead, it is a clinical manifestation of an underlying skeletal or dental discrepancy. Previous studies addressing deep overbite focused on detecting the changes in the dentoalveolar morphology accompanying the changes in overbite.3,4 Other studies aimed to evaluate the effect of age on the change in overbite5 and relate the increase in bite depth to other malocclusions.6
From the Department of Orthodontics and Dentofacial Orthopedics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt. a Associate lecturer. b Associate professor. c Professor. The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article. Reprint requests to: Yehya A. Mostafa, Department of Orthodontics and Dentofacial Orthopedics, Faculty of Oral and Dental Medicine, Cairo University, 52 Arab League St, Mohandesseen, Giza, Egypt; e-mail, mangoury@usa.net. Submitted, March 2012; revised and accepted, April 2012. 0889-5406/$36.00 Copyright 2012 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2012.04.020

Ceylan and Eroz3 studied some components of deep overbite in 4 groups of patients (20 patients in each group) with variable bite depths. Among their signicant ndings was that the gonial angle was the largest in the open-bite group and smallest in the deepbite group. Baydas et al4 studied the effect of the depth of the curve of Spee on bite depth in a sample of 137 subjects. They were divided into 3 groups; normal, at, and deep curves of Spee, and the groups were compared. The results showed statistically signicant correlations between the depth of the curve of Spee and overjet and overbite. Although certain components were deemed to share in a developing deepbite malocclusion, thus classifying deepbite into dental and skeletal deepbite according to the causative factor, yet the various components of a deepbite malocclusion and the signicance of their contributions to the problem have not been well investigated.3 Regarding dental deepbite, a deep curve of Spee4,7 and an increased buccal root torque of the maxillary incisors8 were proven to be correlated with deepbite malocclusions. The overerupted maxillary and mandibular anterior alveolar basal heights3 and the undereruption of the maxillary and mandibular posterior segments9 were also shown to have positive correlations with deepbite malocclusions. Extraction of the mandibular incisors leads to a collapse of that arch with consequent deepening of the bite.9
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A skeletal deepbite could result from a discrepancy in the vertical position of the maxilla, the mandible, or their cant.10 Few studies have dealt with the components of skeletal deepbite; it was shown that the vertical component of mandibular growth has a more remarkable effect than the rotational component,11,12 and that the mandibular skeletal changes were twice as important as the mandibular dental changes and about 2.5 times as important as the maxillary changes in inducing overbite changes.12 In this study, we aimed to explore the different components of deepbite malocclusion and determine their actual contributions in its development.
MATERIAL AND METHODS

Table I. Cephalometric measurements

Measurement Dental Maxillary anterior alveolar and basal height (Mx-AABH, mm) Denition Distance between the midpoint of the alveolar meatus of the maxillary central incisor and the intersection point between the palatal plane and the long axis of the maxillary central incisor Perpendicular distance between the midpoint of the alveolar meatus of the maxillary rst molar and the palatal plane Angle formed between the extension of the long axis of the maxillary incisor and the sella-nasion plane Distance between the midpoint of the alveolar meatus of the mandibular central incisor and the intersection point between the mandibular plane and the long axis of the mandibular central incisor Perpendicular distance between the midpoint of the alveolar meatus of the mandibular rst molar and the mandibular plane Angle formed between the extension of the long axis of the mandibular incisor and mandibular plane Angle formed between the mandibular plane and the Frankfort horizontal plane Angle formed at the gonial area between the posterior border of the ramus and a corpus line Angle formed between the maxillary plane and the sella-nasion plane A new skeletal measurement made between a tangent to the posterior border of the mandibular ramus and the Frankfort horizontal plane

Maxillary posterior alveolar and basal height (Mx-PABH, mm) Inclination of the upper incisors (U1/SN,  )

The sample comprised pretreatment lateral cephalograms and study models of 124 patients with deepbite, selected from approximately 2000 patient records at the outpatient clinic of the Department of Orthodontics of Cairo University in Egypt. The subjects were aged from 14 to 22 years, and their selection was based on following criteria: (1) deep overbite more than 5 mm, (2) complete eruption of the second molars, (3) no history of orthodontic treatment, (4) no severe craniofacial disorders, and (5) no missing teeth. Cephalometric dental and skeletal measurements (Table I; Figs 1 and 2) were used in this study.13 A new skeletal measurement, ramus/Frankfort horizontal, was made between a tangent to the posterior border of the mandibular ramus and the Frankfort horizontal plane. Measuring this angle in the deepbite sample aimed to test whether the direction of growth and the angulation of the mandibular ramus have signicant roles in developing deepbite malocclusions. Cephalometric and dental cast measurements of 10 patients were repeated by the same observer (M.D.) after 4 weeks and by a second observer (M.F.) to measure the intraobserver and interobserver reliabilities (Table II).
Statistical analysis

Mandibular anterior alveolar and basal height (Md-AABH, mm)

Mandibular posterior alveolar and basal height (Md-PABH, mm.)

Inclination of the mandibular incisors (L1/MP,  ) Skeletal Mandibular plane angle (MndP-FH,  ) Gonial angle (Ar-Go-Me,  )

Maxillary plane angle (SN-MxP,  ) Ramus/FH ( )

Descriptive statistics were calculated, including the mean and standard deviation of each dental and skeletal component of deepbite malocclusion, with the percentage of contribution of each component. Inferential statistics included the hypothesis test (paired t test) used to compare the signicance of the contribution of each component to a deepbite malocclusion. The Pearson correlation coefcient was used to correlate the various deepbite components. The concordance correlation coefcient was used to calculate the intraobserver and interobserver reliabilities.

RESULTS

The statistical analysis of the measurements showed the following results. The means, standard deviations, and percentages of contribution of the dental and skeletal components of deep overbite are given in Table III. Among the dental components (Fig 3), an exaggerated curve of Spee showed the highest contribution to

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Fig 1. Dental cephalometric measurements (1, MxAABH; 2, Md-AABH; 3, Mx-PABH; 4, Md-PABH).

a deepbite malocclusion (78%), followed by the overeruption of the maxillary incisors (66.1%), the undereruption of the mandibular buccal segment (50%), the undereruption of the maxillary posterior segment (41.1%), the overeruption of the mandibular incisors (37.1%), the increased clinical crown length of the maxillary incisors (32.3%), the retroclination of the maxillary incisors (24.2%), and the retroclination of the mandibular incisors (21.8%), and the least contributing factor was the increased clinical crown length of the mandibular incisors (12.1%). Among the skeletal components (Fig 4), a decreased gonial angle was found to contribute the most to a deepbite malocclusion (37.1%), followed by the maxillary plane's clockwise rotation (32.2%) and the mandibular plane angle (19.3%). The mean of the new measurement, ramus/Frankfort ( ) horizontal, was 82.06 6 5.54 in deepbite patients, representing the mean of the angulation of the mandibular ramus with respect to the Frankfort horizontal. Regarding the contribution of the dental components (Table IV) to a deepbite malocclusion, the curve of Spee was signicantly the highest of all other components (P 5 0.0335). The overeruption of the maxillary incisors was the second highest shared dental component in deepbite malocclusions and signicantly higher than all other shared components (P 5 0.0101). The undereruption of the mandibular posterior segment was signicantly

Fig 2. Dental cephalometric measurements (1, U1/SN; 2, L1/MP) and skeletal cephalometric measurements (3, FH/Mnp; 4, Mxp-SN; 5, gonial angle [Ar-Go-Me]; 6, ramus/Frankfort horizontal). Table II. Dental cast measurements
Measurement Length of the clinical crown of the maxillary central incisors Length of the clinical crown of the mandibular central incisors Curve of Spee Denition Line formed between the midpoint of the cervical margin of the tooth and the midpoint of the incisal edge Line formed between the midpoint of the cervical margin of the tooth and the midpoint of the incisal edge Line formed between the deepest point on the mandibular buccal segment and a horizontal line formed between the most overerupted mandibular incisor and the most overerupted molar

higher than other smaller components (P 5 0.0404). The undereruption of the maxillary posterior segment, the overeruption of the mandibular incisors, and the increased clinical crown length of the maxillary incisors were the fourth level dental components that share in deepbite malocclusion and were signicantly higher than the other smaller components (P 5 0.0275). The fth level of shared dental components included lingually inclined maxillary and mandibular incisors, which were signicantly greater in their contributions to deepbite

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Table III. Values of dental and skeletal components in deepbite malocclusion

Component U1 inclination ( ) L1 inclination ( ) Mandular plane ( ) U1 overeruption (mm) L1 overeruption (mm) U6 undereruption (mm) L6 undereruption (mm) U1 length (mm) L1 length (mm) Curve of Spee (mm) Maxillary plane ( ) Gonial angle ( ) Ramus/FH ( ) n 124 124 124 124 124 124 124 124 124 124 124 124 124 Minimum 78.00 61.00 14.00 19.00 25.00 14.00 21.00 7.00 5.00 0.10 3.00 109.00 64.00 Maximum 133.00 119.00 40.00 39.00 45.00 33.00 43.00 12.50 12.00 6.70 24.00 146.00 94.00 Mean 105.94 95.38 27.20 26.13 36.07 23.32 32.21 10.34 8.62 2.63 10.56 124.91 82.06 SD 10.58 8.76 5.23 3.91 3.90 2.93 4.19 1.21 1.16 1.12 3.78 6.60 5.54 Coefcient of variation 10.0% 9.2% 19.2% 14.9% 10.8% 12.5% 13.0% 11.7% 13.5% 42.5% 35.8% 5.3% 6.8%

90%
80% 70% 60% 50% 40% 30% 20% 10% 0% L1 length L1 U1 U1 length inclination inclination L1 overeruption U6 undereruption L6 undereruption U1 overeruption curve of spee 12.1% 21.8% 24.2% 32.3% 37.1% 41.1% 50.0% 78.2%

66.1%

Fig 3. Percentages of occurrence of dental components in deepbite malocclusion.

90% 80% 70% 60% 50% 40% 30% 19.35% 20% 10% 0% Mandibular plane Maxillary plane Gonial angle 37.10% 32.26%

Fig 4. Percentages of occurrence of skeletal components in deepbite malocclusion.

malocclusion (P 5 0.0135) than the least contributing component, which was the increased clinical crown length of the mandibular incisors. Of the skeletal components (Table V), a decreased gonial angle was the highest contributing factor with a signicant difference from the counterclockwise rotation of the mandibular plane angle (P 5 0.0019). The

clockwise rotation of the maxillary plane was the second skeletal shared component with a signicant difference (P 5 0.0202) from the counterclockwise rotation of the mandibular plane angle. In the correlation between skeletal components, the angle formed between the posterior border of the ramus and the Frankfort horizontal plane proved to have a strong

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Table IV. Signicance of contributions of the dental

components to deepbite malocclusion with the hypothesis t test

Variable Curve of spee-U1 overeruption and smaller U1 overeruption-L6 undereruption and smaller L6 undereruption-U6 undereruption L6 undereruption-U6 undereruption and smaller U6 undereruption-L1 overeruption U6 undereruption-U1 length U6 undereruption-U1 inclination and smaller L1 overeruption-U1 length L1 overeruption-U1 inclination and smaller U1 length-U1 inclination U1 length-L1 inclination U1 length-L1 length U1 inclination-L1 inclination U1 inclination-L1 length L1 inclination-L1 length First Second variable variable z Probability 78.2% 66.1% 2.13 0.0335* 66.1% 50.0% 50.0% 41.1% 41.1% 41.1% 37.1% 37.1% 32.3% 32.3% 32.3% 24.2% 24.2% 21.8% 50.0% 2.57 41.1% 1.40 37.1% 2.05 37.1% 0.65 32.3% 1.45 24.2% 2.84 32.3% 0.80 24.2% 2.20 24.2% 21.8% 12.1% 21.8% 12.1% 12.1% 1.41 1.86 3.82 0.43 2.47 1.98 0.0101* 0.1608 0.0404* 0.5153 0.1473 0.0045y 0.4234 0.0275* 0.1583 0.0630 0.0001y 0.6679 0.0135* 0.0480*

overeruption (P 5 0.2337), and the curve of Spee and undereruption of the mandibular posterior segment (P 5 0.2455). There were correlations between skeletal and dental components. There was also a weak positive correlation between the gonial angle and the mandibular incisor overeruption (P 5 0.1057), and the gonial angle and the undereruption of the mandibular posterior segment (P 5 0.0808). Also, the correlation between the gonial angle and the curve of Spee was shown to be weakly positive (P 5 0.1455). High intraobserver (0.9997) and interobserver (0.9981) reliability values were found.
DISCUSSION

Statistically signicant: *P #0.05; yP #0.01.

Table V. Signicance of contributions of the skeletal

components to deepbite malocclusion with the hypothesis t test

First Second Variable variable variable z Probability 0.4234 Gonial angle-maxillary 37.1% 32.3% 0.80 plane Gonial angle-mandular 37.1% 19.4% 3.10 0.0019* plane Maxillary plane-mandular 32.3% 19.4% 2.32 0.0202 plane Statistically signicant: *P #0.01.

positive correlation with the gonial angle (P 5 0.000) (Fig 5). Meanwhile, the ramus/Frankfort horizontal did not show a correlation with the mandibular plane angle (Fig 6). In the correlation between dental components, there was an intermediate positive correlation between the overeruption of the maxillary incisors and the mandibular incisors (P 5 0.000) (Fig 7). There was also an intermediate positive correlation between the undereruption of the maxillary and mandibular posterior segments (P 5 0.000) (Fig 8). On the other hand, there was a weak positive correlation between the curve of Spee and mandibular incisor

A deepbite malocclusion overlies many hidden skeletal and dental components. The awareness of such components by the orthodontist is the clue for the best control of the mechanotherapy to resolve the underlying discrepancy. Studies targeting the analysis of deepbite malocclusion components were done on small samples; Ceylan and Eroz3 studied some deepbite components in 4 groups with variable bite depths, with each group consisting of 20 subjects. The study of Baydas et al,4 although including 137 subjects, overruled the analysis of the skeletal components and investigated only some dental components. In our study, the sample comprised 124 patients, aiming at elucidating the various components of deepbite malocclusion, whether dental or skeletal, in addition to analyzing and comparing their specic contributions to the malocclusion, together with expounding whether there are any correlations between the studied components. According to these results, the analysis of the skeletal components showed that the gonial angle was the highest shared skeletal factor in deepbite malocclusion; this claried the greater contributions of mandibular growth and rotation to the development of skeletal deepbite compared with maxillary factors. Another interesting nding was that the gonial angle highly represents the mandibular plane rotation, more than the mandibular plane angle. This was evident by correlating a new angle, ramus/Frankfort horizontal with both the gonial and mandibular plane angles, and a positive correlation was found only with the gonial angle. The previous correlation not only proved that the mandibular plane angle did not represent the actual vertical position and angulation of the mandibular base, but also emphasized the importance of ramal length and angulation in developing deepbite malocclusions. The mean and standard deviation of the

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110 100 y = -0.641x + 162.1 R = 0.582

Ramus/FH

90 80 70 60 100 110 120 130 140 150

Gonial angle

Fig 5. Correlation between ramus/Frankfort horizontal and gonial angle with the Pearson correlation coefcient.
100

90 Ramus/FH

80

70

y = -0.097x + 84.70 R = 0.008

60 0 10 20 30 40 50

Mandibular plane

Fig 6. Correlation between ramus/Frankfort horizontal and mandibular plane angle with the Pearson correlation coefcient.

ramus/Frankfort horizontal in deepbite patients were shown in the results; further measurements of the same angle are needed in the future on a sample with normal occlusion. The exaggerated curve of Spee has been shown repeatedly to have a main role in developing dental deepbites.7 In our study, the exaggerated curve of Spee had the highest contributing component among all the dental and skeletal ones. This nding reects the importance of the mandibular dentoalveolar factor in deepbite malocclusions, emphasizing the need for extruding the mandibular buccal segment and intruding the mandibular incisors in most deepbite mechanotherapies. It has been proven that every 1 mm of posterior extrusion opens the bite anteriorly by 1.5 mm.14 This nding shows that small amounts of molar extrusion can result in signicant anterior bite opening. The overeruption of the maxillary incisors was the second highest contributing dental component. Deepbite treatment by intrusion of the maxillary incisors

has been advocated as the ideal modality in many previous studies.15 However, certain factors control the amount of intrusion to prevent adverse effects to the facial esthetics. The display of the maxillary incisors at rest and the amount of their show on smile inuence the treatment decision; excessive incisor display favors intrusion of the maxillary anterior teeth.16 Conversely, normal or decreased incisor display favors extrusion of posterior teeth or intrusion of mandibular anterior teeth. The smile arc inuences the treatment of choice for deepbite patients. In case of a at or nearly at smile arc, intrusion of the maxillary incisors is contraindicated.16,17 Also, it was proven in a recent systematic review that the maximum amounts of intrusion for nongrowing subjects were merely 1.5 mm for the maxillary incisors and 1.9 mm for the mandibular incisors.18 Changing the inclination of the maxillary incisors has been shown previously to have a direct effect on the amount of overbite; there is a negative correlation between the inclination of the maxillary incisors and the

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50 45 L1 overeruption 40 35 30 25 20 15 20 25 30 U1 overeruption 35 40 45 y = 0.5783x + 20.962 R2 = 0.3347

Fig 7. Correlation between L1 overeruption and U1 overeruption with the Pearson correlation coefcient.

50 L6 undereruption 40 30 20 10 0 10 15 20 25 30 35 y = 0.9226x + 10.692 R2 = 0.4141

U6 undereruption

Fig 8. Correlation between L6 undereruption and U6 undereruption with the Pearson correlation coefcient.

amount of overbite, and it was proven that a decrease of 6 in their inclination results in a 0.3-mm increase in overbite.8 Surprisingly, the lingual inclinations of the maxillary and mandibular incisors were among the least shared components in deepbite malocclusions found in this study. This nding draws the clinician's attention to the diminished importance of undue aring of the incisors in deepbite treatment. The positive correlation between the overeruption of the maxillary and mandibular incisors in this study shows the need for a thorough consideration of intruding the mandibular incisors in most patients in whom maxillary incisor intrusion is to be attempted, and vice versa. This would be benecial for the clinician, who can distribute the required intrusion between the maxillary and mandibular incisors, thus preventing higher ranges of intrusive mechanics that could cause a risk of root resorption and jeopardize the stability.

This analysis investigating the dental and skeletal components contributing to the development of deep overbite, their signicance, and correlations draws certain guidelines for the orthodontist that could help in more efcient treatment of these malocclusions. The clinician can focus on the main underlying component, design an individualized treatment plan, and tailor a mechanotherapy protocol suitable for each patient.
CONCLUSIONS

1. 2.

A deepbite malocclusion is multi-factorial, with definite dental and skeletal components. The gonial angle was the highest contributing skeletal factor to a deepbite, conrming the importance of the growth and angulation of the ramus in a developing deepbite.

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3.

4. 5.

6.

A deep curve of Spee was the highest contributing dental factor, conrming the importance of intruding the mandibular incisors in deepbite mechanotherapy. Overeruption of the maxillary incisors was the second highly contributing dental component. The lingual inclinations of the maxillary and mandibular incisors were among the least shared components in deepbite malocclusions. A thorough analysis of all deepbite components reduces the clinician's bias toward predetermined mechanics in treating these patients and allows for more individualized treatment planning and mechanotherapy.

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6. Al-Khateeb EA, Al-Khateeb SA. Anteroposterior and vertical components of Class II division 1 and division 2 malocclusion. Angle Orthod 2009;79:859-66. 7. Marshall SD, Caspersen M, Hardinger RR, Franciscus RG, Steven A, Aquilino SA, et al. Development of the curve of Spee. Am J Orthod Dentofacial Orthop 2008;134:344-52. 8. Sangcharearn Y, Christopher HO. Effect of incisors angulation on overjet and overbite in Class II camouage treatment. Angle Orthod 2007;77:1011-8. 9. Faerovig E, Zachrisson BU. Effects of mandibular incisor extraction on anterior occlusion in adults with Class III malocclusion and reduced overbite. Am J Orthod Dentofacial Orthop 1999;115: 113-24. 10. Nanda SK. Growth patterns in subjects with long and short faces. Am J Orthod Dentofacial Orthop 1990;98:247-58. 11. Naumann S, Behrents R, Buschang H. Vertical components of overbite change: a mathematical model. Am J Orthod Dentofacial Orthop 2000;117:486-95. 12. Bjork A. Prediction of mandibular growth rotation. Am J Orthod 1969;55:585-99. 13. Jacobson A. Radiographic cephalometry from basic to 3D imaging. 2nd ed. Hanover Park: Quintessence; 2006. 14. Noroozi H. A simple method of determining the bite-opening effect of posterior extrusion. J Clin Orthod 1999;33:712-4. 15. Burstone CR. Deep overbite correction by intrusion. Am J Orthod 1977;72:1-22. 16. Zachrisson BU. Esthetic factors involved in anterior tooth display and the smile vertical dimension. J Clin Orthod 1998;32:432-45. 17. Nanda R, Kuhlberg A. Management of deep overbite malocclusion. In: Nanda R, editor. Biomechanics and esthetic strategies in clinical orthodontics. St. Louis: Elsevier Saunders; 2005. p. 131-55. 18. Ng J, Major PW, Heo G, Flores-Mir C. True incisor intrusion attained during orthodontic treatment: a systematic review and meta-analysis. Am J Orthod Dentofacial Orthop 2005;128:212-9.

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