Deep Bite Correction with Aligners: A Successful Case Study

Table of Contents

1. General Overview, Etiology and Diagnosis
2. Biomechanics of deep bite correction
3. Effectiveness of Clear aligners in resolving deep bite
4. Case Report
5. Treatment objectives, treatment plan and progress
6. Results and Conclusion

General Overview

A deep bite, also known as a deep overbite, occurs when there is excessive vertical overlap between the maxillary and mandibular anterior teeth. Normal overbite range from 2- 4 mm; however, in deep overbites, the maxillary anterior teeth cover more than one-third of the crown length of mandibular anteriors (1).  

Deep bites have damaging effects on the overall oral dental health, including the teeth, adjacent periodontal structures, and the TMJ, leading to issues regarding the aesthetics and function of oral structures.  (1).

They can lead to increased dental attrition, gingival recession, and speech difficulties (2).  As per the National Health and Nutritional Estimates survey III, 21.9% of the general population suffers from a deep bite. (3)

Treatment for deep bite typically involves orthodontic intervention to correct the vertical overlap and restore proper function.

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Etiology and Diagnosis

The etiology of a deep bite is multifactorial, which could be genetic, environmental, or a combination of both. A discrepancy in the growth patterns of the jaw bone in the sagittal and vertical dimensions can result in deep bites (1). Two types of deep bites exist: Skeletal and dental deep bites.

Skeletal deep bites are seen in patients with a horizontal growth pattern. The presenting features include:

• Irregular or improper jaw bone growth
• Counter-clockwise mandibular rotation
• Decreased height of mandibular ramus
• Decreased lower facial height

In contrast, dental deep bites show abnormality only with the dental component. There may be supra-occlusion of the anteriors, infra-occlusion of the posteriors, or a combination of both.

Dental deep bites in adults are usually treated with orthodontic treatment, whereas skeletal deep bites may require orthognathic surgery. The diagnosis of a deep bite is made following a clinical examination, along with a cephalometric analysis.

Biomechanics of Deep Bite Correction

Orthodontic deep bite correction aims to level the curve of Spee, which can be achieved by either intruding the upper or lower anterior teeth or extruding the posterior teeth, depending on the patient's incisal and gingival exposure (4).  

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For patients with a gummy smile, it is advisable to plan for the intrusion of upper incisors.

Conversely, for those with good exposure of the upper incisors, greater intrusion of the lower incisors and extrusion of the posterior teeth may be planned.

Deep Bite Correction with Aligners

Deep bite correction with clear aligners has become increasingly popular because of its aesthetic and comfortable nature. In addition, treatment time is shorter with aligners, and there is a lesser periodontal risk when compared to braces because aligners allow for better maintenance of oral hygiene (5).

In most cases, deep bites are corrected by the relative intrusion of anterior teeth, a combination of intrusion and labial tipping.

Resolution of constricted dental arches through labial tipping and expansion, and resolution of crowding may also contribute to the correction of deep bite to some extent (5).

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In the end, patient compliance is crucial to obtain predictable and successful outcomes.

Below are some treatment considerations which should be taken into account with clear aligner deep bite correction :

Bite Ramps:

By design, aligners tend towards posterior teeth intrusion and prevent posterior teeth extrusion due to the “bite block” effect (4). This issue can be solved by placing bite ramps on the palatal surfaces of upper anterior teeth.

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The placement of Bite ramps will serve two main functions. It causes dis-occlusion of the posterior teeth and also exerts intrusive forces on the anterior teeth.

When the patient bites anteriorly with the aligners on, the posterior teeth will dis-occlude, removing any posterior bite forces and allowing more freedom of movement for posterior teeth.

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Additionally, each time the patient bites and hits the bite ramps, extra intrusive forces will be applied. Watch our video on Eon Academy to learn more about the role of bite ramps in deep bite correction with aligners.

Attachments:

Another important consideration for deep bite correction with aligners is the use of attachments. Horizontal bevelled rectangular attachments (HRB) are most commonly placed on the premolar teeth (4). These attachments improve force application for anterior intrusion, while also preventing the aligner from disengaging posteriorly.  

Overcorrection:

Treatment planning for deep bite correction with aligners should always include overcorrection to reduce the number of midcourse corrections or refinements.

The ability of the teeth to track properly influences the treatment outcome and overall treatment duration.

Mid-course corrections and refinements lead to longer treatment time, increased chair time, and increased material demand for the orthodontist

In addition to the above, other auxiliary methods may also help to improve the predictability of deep bite cases and reduce refinements. These include reinforcement of anchorage using TADs, and possible incisor intrusion with TADs (6) (7).

Now, let's look at a deep bite case treated using the Eon Aligner system by Dr. Mohammad Al-Jayousi, an orthodontist with 11 years of experience with clear aligners treatments.

Case Report-

A 16-year-old female patient presented with a chief complaint of crowding. Intraoral examination revealed a severe deep bite of more than 5 mm, Class I molar relationship, and a bilateral Class II canine relationship. The upper and lower midlines were centered, and the patient exhibited a Class II skeletal relationship. Clinical examination revealed missing lower 5s on both sides. The end goal was to open spaces for the lower fives to place fixed prosthesis and finish with a Class I.

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Treatment Objectives

The treatment objectives for this patient were:

• Correction of deep bite while improving the overall overjet, overbite, and arch form
• Maintenance of Class I molar relationship
• Achieving ideal Class I canine relationship

Treatment Plan and Progress

Treatment began with the placement of attachments on both upper and lower laterals, canines, premolars, and the first molar. The patient was put on a one-week wear cycle.

The first phase of orthodontic treatment accomplished expansion of the upper arch, followed by expansion and proclination of the lower arch. Subsequently,  intrusion of lower anteriors and mesialization of lower 4s was done. Torque enhancers were placed on upper centrals from step 3, and precision cuts on upper canines for Class II elastics were used. A  total of 44 upper and 84 lower aligners were used during the treatment.

Results

The patient's deep bite was successfully corrected within 20 months, achieving proper overjet, overbite, and arch form. The Class I molar and canine relationships were maintained, and spaces were opened for the lower fives to place fixed prostheses. Furthermore, orthodontic deep bite correction with aligners resulted in improved facial balance, an aesthetic smile, and functional occlusion.

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Conclusion

The above case report demonstrates the efficacy of deep bite correction with aligners. Hence, it can be concluded that clear aligners are an effective and aesthetic orthodontic modality for treating deep bite malocclusions. They offer patients a more comfortable and visually appealing alternative to traditional braces.

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