American Journal of ORTHODONTICS

volume 77. Number I January, 1980

ORIGINAL ARTICLES

Treatment of deep-bite eases

Gary Engel, B.A., MS., Gary Cornforth, D.D.S., MS.,
J. M. Damerell, D.D.S., MS., Joseph Gordon, D.D.S., Paula Levy, D.D.S.,
James McAlpine, D.D.S., M.S., Ronald Otto, D.D.S., M.S.,
Roland Walters, D.D.S., M.S., and Spiro Chaconas, D.D.S., M.S.
Encino, Loma Linda, and Los Angeles, Cal$

T here are basically four ways to treat a deep bite: (1) leveling of the arch
through eruption of premolars, associated with a clockwise rotation of the mandible,
which serves to increase lower facial height; (2) intrusion of lower and/or upper incisors;
(3) labial inclination of the incisors; and (4) molar extrusion.
There is considerable controversy over treatment of deep bite, especially when the
patient exhibits a deep-bite facial pattern. Schudy has stated that in nearly all cases
eruption of premolars and molars to rotate the mandible open is the treatment of choice.
Rickett? has long been an advocate of treatment of deep bites through intrusion of
incisors, particularly lower incisors.
Under the auspices of the Foundation for Orthodontic Research, many projects relative
to deep-bite cases have been completed as masters theses. The purpose of this article,
therefore, is to summarize several of these masters theses completed at UCLA and Loma
Linda University, as well as several others dealing with deep-bite patients, with the intent
of shedding some light on this controversial and important subject.
The studies under consideration are summarized individually.

Gary Engel, B.A., M.S.

0002-9416/80/010001+13$01.30/0 0 1980The C. V. Mosby Co

Table I. Mandibular rotation a\ indicated b> the taci,J a~15 durrn;: ;a, .itriltr!i
and postretention

+ = Close
~ = Open.

Table II. Probability of opening during treatment according to the mandibular arc

Type of mundibular arc Probabilig qfopening during treutment

Weak 14 of 22 (64%)
Normal 21 of 29 (83%)
Strong 26 of 49 (53%)

Table Ill. Probability of bite closure after opening of the bite during treatment

Probability of closure
Type of
mandibulur arc Some closure 50% or mow closure 100% or more

Weak 10 of I5 (66%) 6 of 15 (40%) 5 of 15 (33%)

Normal 17 of 26 (65%) 9 of 26 (35%) 6 of 26 (36%)
Strong 15 of 26 (56%) 14 of 26 (54%) 12 of 26 (46%)

Study 1: Cornforth (Loma Linda University)

Cornforth studied mandibular rotation in a sample of 108 treated patients with long-
term records from the practice of Dr. R. M. Ricketts. This was a totally random sample of
patients and included thirty-six extractions, seventy-two nonextractions; some were
treated with only cervical headgear, some with intermaxillary elastics, and some with a
combination of elastics and headgear; some began with deep bites, and some began with
open-bites. It is safe to assume that, in the open-bite situation, a clinical attempt was made
to close the bite or to induce mandibular rotation in a counterclockwise direction, whereas
in the deep-bite patterns bite opening through clockwise rotation was being attempted.
Of the 108 patients, 63 percent showed rotation open during treatment, while 37
percent showed rotation closed during treatment. Considering the behavior of the mandi-
ble during treatment as compared to the behavior after treatment, there are four possibili-
ties: (1) close during treatment, close after treatment. (2) open during treatment, close
after treatment. (3) open during treatment, open after treatment. (4) close during treat-
ment, open after treatment.
Table I illustrates these findings. Clearly, the most likely occurrence was an opening
during treatment with a subsequent closing (recovery) after treatment in cases treated on a
nonextraction basis with cervical headgear. Cornforth found a relationship between the
original morphology of the mandible and the propensity to both open during treatment and
Fig. 1. The mandibular arc measurement is a useful indicator to determine the likelihood of the mandi-
ble opening during treatment and closing after treatment. A stronger than average mandibular arc
indicated the least opening during treatment and the most closing after treatment.

Fig. 2. The lower facial height (ANS-XI-PO) is relative to deep-bite relapse. The greatest amount of
relapse in treated deep-bite cases was found in those patients with brachyfacial patterns with a short
lower facial height and low mandibular plane angle.

close after treatment. He found that the mandibular arc measurement (the small angle
between the corpus and condyle axes) was the most useful in this regard. Patients with a
stronger than average mandibular arc, unfortunately, showed the least opening during
treatment and the greatest closing after treatment (Tables II and III). In fact, the cases that
opened during treatment with strong mandibular arcs averaged more than 100 percent
return of the facial axis (Fig. I).
Thus, the indications from this experiment showed that rotation of the mandible during
deep-bite treatment in a true brachyfacial pattern, if measured by a strong mandibular XC,
is difficult during treatment and is more than likely to return 100 percent, to relapse. or to
have continuation of the growth pattern.
Fig. 3. The position of the upper central incisor appeared dependent upon the chin position, the lower
incisor position, and the anterior cranial base inclination. Thus, the position of the upper incisor should
be individualized by placing the long axis of the upper central incisor 5.8 degrees more vertical to the
facial axis.

Study 2: McAlpine4 (Loma Linda University)

McAlpine studied a sample of forty-nine cases from the practice of Dr. R. M. Rick-
etts, selected only for their deep-bite tendency with a beginning overbite measurement
greater than 4.0 mm. Relapse was studied as a function of individual patient factors.
Statistical computations were performed to determine if significant correlations could be
found between overbite relapse and (1) age, (2) interincisal angle, and (3) lower face
height. McAlpines primary findings show a direct relationship between interincisal angle
and deep-bite relapse. Those deep-bite cases finished to an interincisal angle between 125
and 135 degrees showed the greatest stability. Cases treated to extreme interincisal
angles-either procumbent (less than 125 degrees) or retracted (greater than 135 degrees)
showed the greatest amount of relapse.
Studying relapse as a function of factors before treatment, original lower facial height
was shown to have a bearing on deep-bite relapse (Fig. 2). Patterns of the brachyfacial
type, again with a short lower face height and low mandibular plane angle, showed the
greatest amount of relapse. The results of this study also indicated that there was no
disadvantage to early treatment since those cases treated early had no more vertical relapse
than those cases treated at the end of growth, which is a contradiction to previous studies.
Studying the individual cases, the greatest relapse was noticed in those deep-bite cases
in which the mandible was rotated open during treatment for the purpose of bite opening.
In these cases, the mandible tended to return and the deep bite tended to relapse. An
interesting point was that those cases with normal to dolichofacial patterns in which the
mandible returned after treatment did not show a relapse of the dental deep bite, again
suggesting that there is a risk of relapse in a deep-bite facial pattern when mandibular
rotation is used as the vehicle.
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Treatment of deep-bite cases 5

Fig. 4. In the average deep-bite cases treated by Ricketts with intrusion, the average intrusion was 3
mm. and the average posttreatment relapse was 1 mm.

Study 3: DamereW (Loma Linda University)

The purpose of this thesis was to determine the ideal inclination of the upper incisor,
individualized for the patient. There were 167 subjects in this sample, which were divided
into three distinct groups: (1) 99 Caucasians with ideal or normal occlusion, (2) 49
persons selected at random from the University of Michigan growth studies, and (3) 19
Japanese patients with Class III malocclusions. Selected measurements relative to the
upper central incisor were made on the tracings of these samples. The most reliable
reference plane relative to the upper central incisor was the Frankfort plane. The position
of the upper central incisor appeared dependent upon the chin position, the lower incisor
position, and the anterior cranial base inclination (the angle formed by the basion-nasion
plane and the Frankfort plane).
Therefore, the basic results showed that the inclination of the upper incisor should be
individualized by treating the upper incisor to the facial axis, with the long axis of the
upper central incisor 5.8 degrees more vertical to the facial axis (the angle formed by the
basion-nasion plane and the plane from foramen rotundum to gnathion) (Fig. 3). This
supports the concept of having a greater interincisal angle in dolichofacial patterns but a
lesser interincisal angle in deep-bite facial patterns.

Study 4: Gordon (UCLA)

Gordon studied a sample of twenty-five patients from the practice of Dr. R. M.
Ricketts, who were treated with lower incisor intrusion. The amount of intrusion is
difficult to measure in treated cases, because of the vertical height increase that occurs
with normal growth during the 2 to 3 years of patient treatment. It is often difficult to
assess the exact amount of intrusion. Therefore, the following method was used.
In order to eliminate bite opening by posterior extrusion, patients in whom opening of
the mandibular plane was limited to 2 degrees maximum during treatment were selected.
In addition, the tipping forward of the lower incisor during treatment was limited to 10
degrees or less, so that the effect on the intrusion or extrusion measurements would be
minimal.
Both internal and external bony reference points were used in two separate methods of
measurement. Several growth-prediction methods were used for estimation of the un-
treated normal lower incisor growth and calculation of an expected lower incisor position
Fig. 5. Two indicators of the difference between Class II, Division 2 patients and normal patients are the
mean ratio of corpus length change to cranial base change (2 for Class II, Division 2 and 1 for normal
cases), and the mean ratio of condyle length change to cranial base change (1.5 for Class II, Division 2,
and 0.5 for normal patients).

at the end-of-treatment and posttreatment periods. Then a comparison was made between
the expected lower incisor positions and the actual lower incisor positions. so that the
relative intrusion or extrusion could be determined.
The results were that, in the average deep-bite case that Ricketts treated with intrusion,
the average intrusion was 3 mm. and the average posttreatment relapse was 1 mm.
Therefore, approximately two-thirds of the intrusion held. with 2 mm. being a reasonable
amount of intrusion to expect (Fig. 4).
This result, showing about a two-thirds retention of lower incisor intrusion. agrees
with the work of Chamberlin.

Study 5: Otto9 (Loma Linda University)

Records of twenty-four adults and thirty-one children were selected from three bio-
progressive practices (those practices in which the orthodontic philosophy encompasses a
broad concept of total treatment which considers biologic progressions, including growth.
development, and function, and guides them in such a way as to achieve normal function
and a positive esthetic effect)). Cases were selected at random from those with a deep
overbite prior to treatment. Another criterion for selection was that the patient must have
been treated according to the bio-progressive technique, involving molar and incisor
banding with a utility type of arch wire to intrude lower teeth.
His findings showed again that it was reasonable to expect about 2 mm. of incisor
intrusion, with a maximum of 5.5 mm. Statistical t tests showed that there was no
significant difference in the total amount of intrusion (both arches) between the adults and
children at the p = 0.05 level. He did find, however, that the majority of the true
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Treatment of deep-bite cases 7
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Fig. 6. lnterincisal angle and overbite can be used as reliable indicators of increased mandibular
growth. The higher the measurements, the higher the probability of increased mandibular growth.

deep-bite facial patterns were treated with a combination of lower incisor intrusion and
incisor pro&nation.

Study 6: Levy UCLA

This study was undertaken to determine if there was more than the normal amount of
mandibular growth following correction of the deep overbite and unfavorable incisor
inclination of the Class II, Division 2 malocclusion.
The sample consisted of thirty-four cases of Division 2 malocclusion. Interincisal
angles were 140 degrees or greater. The sample included boys under 18 and girls under 14
years of age.
The results indicated that the mean ratio of corpus length change to cranial base
change was 2.0, while in the normal case it is 1.O. In addition, it was found that the mean
ratio of condyle length change to cranial base change was 1.5 in the Division 2 patient, as
compared to the normal value of 0.5 (Fig. 5). Statistical analysis of the data indicated that
two measurements could be used as reliable predictors of excessive mandibular growth.
These were found to be the interincisal angle and overbite. The greater these mea-
surements, the higher the probability is for increased mandibular growth (Fig. 6).
Finally, it was found that when the interincisal angle exceeds 145 degrees, in a Class
II, Division 2 malocclusion, there is a very high probability of excessive mandibular
growth.

Discussion
Summarizing these results does give some insight into the problem: (1) Deep-bite
cases with deep-bite facial patterns, as measured by mandibular arc, lower face height, or
mandibular plane angle, present the orthodontist with the special treatment problem of a
significant probability of relapse. (2) Despite those who take a stand on one extreme or the
other, these cases are probably treated with a combination of incisor intrusion, proclina-
Fig. 7. The ideal position of the occlusal plane is 3 mm. below the lip embrasure, allowing the correct
amount of the crown of the upper incisors to be shown.

Fig. 8. The standard Ricketts growth forecast without treatment.

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Treatment of deep-bite cases 9

verbite

Fig. 9. Mandibular rotation is figured as follows: (1) 1 degree of opening per 3 mm. of Class II correction;
(2) 1 degree of opening per 4 mm. of overbite correction; (3) facial pattern-l degree of rotation is
deducted from above for every 5 degrees of variation from the normal with regard to mandibular plane
angle in the brachyfacial direction.

Fig. 10. The occlusal plane maintains the same relative relationship between anterior nasal spine and
gnathion as before treatment.

tion, and mandibular rotation. Since growth tends to increase the vertical distance between
maxilla and mandible, it is probably useful to treat these cases during a period of mandibu-
lar growth. In addition, the needs of particular patients will vary, and esthetic consid-
erations in particular must be considered.
When the arch is leveled, the ideal relationship of the functional occlusal plane is
Fig. 11. The ideal position of the lower incisor is 1 mm. above the occlusal plane and 1 mm. ahead of
the A-PO plane with an inclination to the A-PO plane of 22 degrees.

Fig. 12. An additional 2 degrees proclination of the lower incisor can be assumed for each millimeter
forward of + 1.

about 3 mm. below the embrasure of the lips in the anterior region (Fig. 7). This allows
the proper amount of clinical crown of the upper incisor to be displayed. An occlusal plane
significantly below that factor will show excessive gingiva, while one placed too high will
show too little upper incisor and too much lower incisor.
Since none of the previous theories-either intrusion or rotation-seem to be without
their difficulties and compromises, the relationship of the final occlusal plane to the lip
embrasure should also be considered. Iz
The specific treatment plan, then, for a deep-bite patient is a multifactored one. The
technique used for diagnosis at both UCLA and Loma Linda is to have students prepare
a visual treatment objective for the case. This allows a particular case to be planned
specifically, considering the factors of (1) vertical contribution of growth, (2) desired
position of the occlusal plane and esthetics, (3) desired proclination of lower incisors, (4)
possibilities of lower incisor intrusion, and (5) possible contribution of mandibular
rotation.
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Fig. 13. The normal position for the upper incisor has 5 degrees less root torque than if the tooth were
absolutely parallel to the facial axis.

Fig. 14. The required lower incisor intrusion can be measured by superimposing the original tracing and
the VT0 on the corpus axis at PM.

Each of these factors should be considered for the sum total according to the following
method:
Step I. The standard Ricketts growth forecasti is prepared, showing expected posi-
tions of maxilla, mandible, and cranial base without treatment (Fig. 8).
Step 2. A reasonable amount of mandibular rotation is built into the forecast, consider-
ing the following factors:
A. Eruption of molars due to Class II correction. Baumrind and associatesl
have shown this correlation. As a rule of thumb, it is expected that 2 mm. of
molar correction can occur during the growth period. After that, however, we
expect a degree of opening for each 3 mm. of Class II correction.
B. Depth of the overbite. A total of at least 1 degree should be built in for
each 4 mm. of overbite that needs to be corrected. The previous rotation due to
Class II correction can be used as part of this goal.
Fig. 15. The required upper incisor intrusion can be measured by superimposing the original tracing
and the VT0 on the palatal plane at ANS.

C. The facial pattern. The above factors will suffice for the normal facial
pattern. For each 5 degrees that the patient varies from the normal with regard to
mandibular plane angle in the brachyfacial direction, 1 degree of rotation is
deducted from the above, showing that in severe brachyfacial patterns it would be
more difficult to open the bite (Fig. 9).
Once the mandibular rotation has been planned, about 50 percent of the alveolar height
will go to the upper arch and 50 percent to the lower arch. The occlusal plane will
maintain the same relative relationship between anterior nasal spine and gnathion as
before treatment (Fig. 10).
Step 3. The original relation of the lip embrasure to occlusal plane is then considered.
The occlusal plane can be varied, either up or down, 2 to 3 mm. in order to get closer to
the norm of 3 mm. to present idea1 esthetics.
Step 4. The lower incisor is positioned 1 mm. above the occlusal plane and relative to
the A-PO plane according to arch length consideration. If the incisor is to be treated to + 1.
a 22-degree inclination of the lower incisor is selected (Fig. I 1). For each millimeter
forward of + 1, another 2-degree proclination of the lower incisor can be assumed (Fig.
12). The upper incisor is placed to the lower incisor at a 2 mm. overbite and overjet. using
the facial axis as a guide. The norm for the upper incisor shows 5 degrees less root torque
than if it were perfectly parallel to the facial axis (Fig. 13).
This would give an ideal result according to the individual facial pattern, arch length
requirements, esthetics, and, most likely, growth during treatment.
Step 5. The original tracing and VT0 are superimposed on the corpus axis at PM to
measure the required lower incisor intrusion (Fig. 14) and on the palatal plane at ANS
(Fig. 15) to determine the required upper incisor intrusion. If more than 2 mm. (with 3
mm. being the maximum) of actual intrusion of the lower incisor is required, the plan
should probably be compromised, with less lower incisor intrusion used and probably a
greater proclination of the lower incisors or eruption of premolars to be expected. If more
than 2 mm. of upper intrusion is required. then a high-pull headgear to the incisors for
intrusion purposes may be necessary.

REFERENCES
I. Schudy, F. F.: The control of vertical overbite in clinical orthodontics, Angle Orthod. 38: 19-38, 1968.
2. Ricketts, R. M., Bench, R. W., Gugino, C. F., Hilgers, J. J., and Schulhof. R. J.: Bioprogressive therapy,
Denver, 1979, Rocky Mountain Orthodontics, Book I, p. 25.
3. Comforth, Gary: A computerized study of the behavior of the facial axis during treatment and post-
retention, Masters Thesis, Loma Linda University
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Treatment of deep-bite cu.se.s 13

4. McAlpine, J. E.: A comparison of overbite relapse to age, interincisal angle and lower face height in Class
II deepbite cases, Masters Thesis, Loma Linda University, July, 1976.
5. Nemeth, Robert B., and Isaacson, Robert J.: Vertical interior relapse, AM. J. ORTHOD. 65: 565-584, 1974.
6. Damerell, J. M.: Cephalometric objectives for the maxillary central incisor, Masters Thesis, Loma Linda
University, 1977.
7. Gordon, J. B.: Lower incisor intrusion in low mandibular plane angle, deep overbite cases, Masters Thesis,
UCLA, 1977.
8. Chamberlin, T.: A controlled cephalometric study of the stability of lower incisors when intruded by the
utility arch, Masters Thesis, St. Louis University, 1975.
9. Otto, Ron: Limits of adult incisor intrusion, Masters Thesis, Loma Linda University, 1979.
10. Bench, R. W., Gugino, C. F., and Hilgers, J. J.: Bio-progressive therapy. Part I. J. Clin. Orthod.
pp. 616-627, 1977.
11. Levy, Paula: Growth of the mandible after correction of the Class II, Division 2 malocclusion, Masters
Thesis, UCLA, 1979.
12. Janzen, E. K.: A balanced smile-A most important treatment objective, AM. J. ORTHOD. 72: 359, 1977.
13. Bench, R. W., and Gugino, C. F.: Orthodontic treatment design. Part 1. Manual construction of visual
treatment objective, revised edition, Encino, Calif., Rocky Mountain Data Systems.
14. Baumrind, S., Molthen, R., West, E., and Miller, D.: Mandibular plane changes during maxillary retrac-
tion, AM. J. ORTHOD. 74: 32, 1978.