Journal of the World Federation of Orthodontists 6 (2017) 57e61

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Journal of the World Federation of Orthodontists

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Review Article

Does correction of deep bite malocclusion in growing Class II

patients using anterior bite plates induce changes in mandibular
growth or position? A systematic review
Mostafa M. El-Dawlatly a, *, Mohamed O. El-Koussy b, Mona M. Salah Fayed a,
Amr M. Abou-El-Ezz a, Yehya A. Mostafa a
a
Department of Orthodontics and Dentofacial Orthopedics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt
b
International Orthodontic Program. Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To elucidate the available evidence regarding the actual effect on mandibular growth and
Received 16 May 2016 position after early bite opening in growing patients with Class II deep bite malocclusion. This procedure
Received in revised form is claimed to be clinically effective in gaining changes in both anteroposterior and vertical skeletal
7 December 2016
mandibular position.
Accepted 15 April 2017
Available online 7 May 2017
Methods: The data were extracted from MEDLINE, EMBASE, OVID, LILACS, and The Cochrane Library,
which were searched until March 2016 in addition to hand searching of some orthodontic journals. There
was a language restriction in which only the articles written in English and French were included. The
Keywords:
Deep bite
eligibility criteria included randomized and quazi-randomized clinical trials, and growing subjects with
Class II both Class II and deep bite malocclusions.
Systematic review Results: The Search resulted in 1219 citations from which only one article was eligible to be included in
the qualitative analysis. The included study was a quazi-randomized controlled trial. By applying the
Cochrane tool for risk of bias assessment tool, it was shown to have a high risk of bias. The same study
was given a score of 19 on the Downs and Black scale.
Conclusions: Low-quality evidence was revealed in the studies addressing the effect of bite opening in
growing subjects with Class II deep bite malocclusion. Accordingly, the impact of early bite opening on
the mandibular skeletal component is still questionable and requires further and more well-designed
studies.
Ó 2017 World Federation of Orthodontists.

1. Introduction
Deep over bite malocclusion is commonly encountered in or-
thodontic practice, with a prevalence of 20% in growing patients
and 13% in adults [1]. It has been proven that deep bite overlies a
multitude of skeletal and dental components, with variable degrees
of contribution in the development of the malocclusion [2].
In spite of the high prevalence of increased over bite among
growing children, the existence of deep bite solely as a malocclu-
sion does not dictate early treatment. The exception is the existence
of an over bite that is complete to the palate, causing gingival
* Corresponding author: Department of Orthodontics and Dentofacial Orthope-
dics, Faculty of Oral and Dental Medicine, Cairo University, 8/1 5th section, Maadi,
Cairo, Egypt.
E-mail address: demalto@hotmail.com (M.M. El-Dawlatly).
trauma at the palatal surface of the upper incisors [3,4]. Deep bite is
usually accompanied by discrepancies in the sagittal plane, as all
Class II division 2 malocclusions and most Class II division 1 mal-
occlusions present with deep anterior over bites [5]. In this situa-
tion, especially in cases with Class II division 2 malocclusions, the
treatment of the vertical problem is generally aimed at correcting
the sagittal discrepancy through opening the bite and consequently
unlocking the restrained mandible [6,7]. Based on this concept, and
instead of using functional appliances or headgear, some ortho-
dontic clinicians merely open the bite, using anterior bite plates,
aiming to attain more forward mandibular position in mild Class II
deep bite cases [8,9].
To answer the question of whether deep bite correction at an
early stage in growing patients with Class II deep bite malocclusion
can result in actual mandibular growth or positional alteration
when compared with an untreated control group, a systematic re-
view of the available orthodontic literature was required.

2212-4438/$ e see front matter Ó 2017 World Federation of Orthodontists.

http://dx.doi.org/10.1016/j.ejwf.2017.04.004
58 M.M. El-Dawlatly et al. / Journal of the World Federation of Orthodontists 6 (2017) 57e61

2. Methods Table 2
Number, age, gender, and malocclusion of participants, and design, setting, type of
intervention, and imaging modality of the study by Forsberg and Hellsing 1984 [9]
The protocol of the systematic review was registered on the
National Institute of Health Research Database, University of York Setting Sweden
(www.crd.york.ac.uk/prospero, Protocol: CRD42015024702). Number of participants Total 40
Study group 20
The “PICOS” of the current review was set so that the population Control group 20
(P) comprised growing patients with Class II deep bite. The inter- Sex distribution Total Boys 24
vention (I) was restricted to deep bite treatment using anterior bite Girls 16
plates or anterior segment intrusion mechanics without applying Study group Boys 12
Girls 8
advancing forces to the mandible or restrictive forces to the maxilla.
Control group Boys 12
The control (C) included an untreated group matched to the Girls 8
treatment sample. The primary outcomes (O) to be assessed were Malocclusion Study group Class II division 1 18
the positional and dimensional skeletal mandibular changes. As for Class II division 2 2
the study (S) designs, only randomized and quasi-randomized trials Control group Class II division 1 18
Class II division 2 2
were included (Table 1). A follow-up period of not less than Mean age, y Whole sample Total 11.3  1.45
9 months was set to allow for some skeletal modifications. Boys 11.5  1.35
Five electronic databases were searched until March 2016: Girls 11.1  1.65
MEDLINE, EMBASE, OVID, LILACS, and The Cochrane Library. The Study group Total 11.3  1.4
Boys 11.5  1.3
following orthodontic journals were hand searched: American
Girls 11.1  1.7
Journal of Orthodontics and Dentofacial Orthopedics, Angle Ortho- Control group Total 11.3  1.5
dontist, European Journal of Orthodontics, Journal of Orthodontics, Boys 11.5  1.4
and Orthodontics and Craniofacial Research. There was no date re- Girls 11.1  1.6
striction, but there was a language restriction: only articles written Design Randomized controlled trial
Treatment Intervention Anterior bite
in English or French were included. The key words used in the plate on an
MEDLINE database search were (Deep overbite or excessive bite) upper lingual
and (closed bite) and orthodontics; (Incisal or incisor) and intrusion arch
and orthodontics; and (Molar or posterior) and extrusion and Type of appliance Fixed on
cemented
orthodontics.
molar bands
The eligibility criteria of the current research were designed to Duration 1.1 y
address the study design, growth stage of the participants, the in- Imaging modality Lateral cephalogram
terventions, and the outcome measures. Concerning the partici-
pants, growing patients (ages 10e15) [10] having Class II
malocclusion with deep over bite were the target population. The
further assessment of the risk of bias of the selected studies.
exclusion criteria comprised animal studies, adult subjects, and
Additional analysis might be required to be done aimed at
studies with treatment plans including correction of sagittal relation.
assessing the methodological soundness of the selected studies.
The primary outcome measure was the assessment of the skel-
Accordingly, the Downs and Black assessment tool was chosen for
etal mandibular dimensional or positional changes after treatment.
this purpose. This could be of benefit in case of quazi-randomized
The secondary measures were the correction of deep bite, correc-
controlled trials.
tion of buccal segment relation, changes in the inclination of in-
cisors, and root resorption during incisor intrusion.
The exclusion process of articles not eligible for inclusion in the
review was completed by two reviewers; assessment of risk of bias 3. Results
and extraction of data were performed independently by the same
two investigators. If any divergence in the assessment of the The current search protocol resulted in 1219 citations, and after
resulted articles was present, it was resolved by discussion and removal of the duplicates, 1048 articles remained. That was fol-
consultation with a third author. lowed by removal of totally irrelevant articles as assessed by the
The data extraction sheet of the included study (Tables 2 and 3) title. After this step, only 366 articles remained to be assessed for
was developed by the same two reviewers independently and in eligibility; their abstracts were read and the exclusion criteria were
case of disagreements, it was solved by consulting the third applied. The main reasons for exclusion were as follows: studies
author. The Cochrane risk of bias tool was the chosen method for including adult patients, studies including correction of the sagittal
discrepancy as part of the treatment plan, and studies in which
either headgear or functional appliances were used in conjunction
with the bite-opening appliance. Also, case reports and in vitro
Table 1 studies were salient reasons for the exclusion of some of the non-
PICOS eligible studies. Full-text reading of the 26 articles that resulted
Growing patients with Class II deep bite Population (P) from the previous step was done, and finally only 1 article was
Restricted to deep bite treatment using anterior Intervention (I) eligible for qualitative analysis (Fig. 1).
bite plates or incisor intrusion mechanics A data extraction sheet was tailored for the study by Forsberg
without applying advancing forces to the
and Hellsing [9] to aid in the process of qualitative analysis. Two
mandible or restrictive forces to the maxilla
Included an untreated group matched to the The control (C) separate tables were created. Table 2 comprised number, age,
treatment sample gender, and malocclusion of participants. The study design, setting,
The positional and dimensional skeletal The primary and imaging modality also were included in the same table. The
mandibular changes outcomes (O) intervention done during treatment and the time of intervention
Only randomized and quasi-randomized trials Study (S) designs
were included
also were taken into consideration. Table 3 concluded the skeletal
and dental outcomes of the study.
 M.M. El-Dawlatly et al. / Journal of the World Federation of Orthodontists 6 (2017) 57e61 59

Table 3
Skeletal and dental outcomes of the study by Forsberg and Hellsing 1984 [9]

Anteroposterior skeletal change Difference

Measurement Study group Control group Study vs. control t value

Mean SD Mean SD
SNB 76.5 2.8 76.4 2.2 0.3 1.39

Vertical skeletal change Difference Dental changes Difference

Measurement Study group Control Study vs. control t value Measurement Study group Control Study vs. control t value
group group

Mean SD Mean SD Mean SD Mean SD

Mx/MP angle 24.2 5.7 26.3 4.8 1.5 4.89*** U1/Mxp 112.5 5.7 115.4 5.2 0.7 0.99
SN/MP angle 32 5.3 32.5 5.5 0.9 3.23** L1/MnP 95.2 7.2 97 7.5 0.6 1.69

L1, lower central incisor; MP, mandibular plane; Mxp, maxillary plane; SD, standard deviation; SNB, sella nasion point B; U1, upper central incisor
Asterisks means t-value more than 1.

The Cochrane risk of bias tool resulted in a high risk of bias for 4. Discussion
the elected study (Table 4). The Downs and Black assessment tool
was applied to the elected study to check its methodological “Mandibular unlocking” is considered one of the clinical practices
soundness and resulted in a score of 19 (Table 5). done by some orthodontists to treat mandibular retrognathism in

Records identified Records identified

through database through hand searching
searching
n= 9
n= 1210

Records after duplicate removal

Records excluded (n= 340)
n= 1048
Studies on non-growing patients (n=88)

Case reports (n=66)

Records after removal of In-vitro studies (n=48)

irrelevant titles= 366
Studies combining correction of sagittal
discrepancies with deep bite correction

(n= 55)

Due to language restriction (n=33)

Records screened = 366
Animal studies, review articles, surgical
intervention, and other reasons (n=50)

Full text articles excluded (n= 25)

Full text articles assessed for Studies on non-growing patients (n=8)

eligibility (n= 26)
Case reports (n=3)

Studies combining correction of sagittal

discrepancies with deep bite correction

(n= 7)
Studies included in qualitative In-vitro studies (n=1)
analysis (n= 1)
Studies comprising patients with normal
overbite in the included sample, and
studies with irrelevant outcomes (n=6)

Fig. 1. Prisma diagram for article retrieval.

60 M.M. El-Dawlatly et al. / Journal of the World Federation of Orthodontists 6 (2017) 57e61

Table 4
Cochrane Collaboration’s tool for assessing risk of bias for the study by Forsberg and Hellsing 1984 [9]

Support for judgment Authors’ judgment Bias

Method of randomization or random sequence generation was not included High risk Random sequence generation (selection bias)
No concealment was reported while assigning subjects either to treatment or High risk Allocation concealment (selection bias)
control groups
No blinding of participants or researchers from knowledge of which High risk Blinding of participants and researchers
intervention they were performing
No reporting of the assessment blinding technique High risk Blinding of outcome assessment (detection bias)
No reporting of dropouts Unclear risk Incomplete outcome data (attrition bias)
All tested measurements were reported Low risk Selective reporting (reporting bias)

growing patients with Class II deep bite. This is usually accomplished
through opening of the bite anteriorly using anterior bite plates or
other appliances that work on intruding the anterior segment [4,7,8].
This unlocking procedure takes place at an early age, which is the
exact time of growth modification [10,11]. Accordingly, it takes up
the period during which functional appliance therapy could be
accomplished [12e14]. This long-established clinical procedure,
however, claimed to be clinically effective in gaining a more
advanced mandibular position, yet this philosophy needs to be
supported by solid evidence. Accordingly, a systematic review of
orthodontic literature was mandatory to answer this question.
Only controlled trials were included our review, as a control
group is essential to assess the mandibular growth changes in
preadolescent subjects, where skeletal changes of a growing
treatment group could not be claimed to be significant unless they
were compared with a matched control group in the same
population.
The criteria for selecting the prototype of the participants of the
included articles were set keeping in mind some perspectives. The
age range was from 10 to 15 years, as it was proven that subjects
with deep bite malocclusion attain their pubertal growth spurt in
late adolescence [10]. The growth stage would have been better
determined using a valid skeletal index [12], but unfortunately
most of the articles did not measure or mention the skeletal
maturation stage of the included sample, and accordingly a chro-
nological age range was taken as a reference.
Only articles including subjects having skeletal Class II and
anterior dental deep over bite were included. In this specific situ-
ation, the skeletal sagittal problem could be a direct result of the
anterior lock of the bite [15,16]. Accordingly, any study comprising
intrusion of the incisors in heterogeneous Class II samples
encompassing both deep and normal over bites was excluded due
to the inclusion of nonedeep bite subjects [17].
Regarding the intervention done, only the studies that were
merely correcting the vertical malocclusion without the use of an
appliance that corrects the sagittal discrepancy were included.
Consequently, studies that used headgear in conjunction with the
bite-opening device were all excluded [18]. Identically, all the
studies in which an advancing force, in the form of a functional
appliance or even Class II elastics [6], was applied to the mandible
were omitted from the current review. The reason is that we aimed
at testing the direct effect of the anterior unlocking of the bite on
the dimensions and position of the mandible, without the appli-
cation of any advancing forces.
After applying the inclusion and exclusion criteria, only one
study was found to be eligible for qualitative analysis [9]. The work
of Forsberg and Hellsing [9], however, fulfilled the inclusion crite-
rion of being a controlled study, yet no random sequence genera-
tion protocol or allocation concealment design was done. Therefore,
when the Cochrane tool for risk of bias assessment [19] was applied,
it proved a high risk of bias of the elected study (Table 4). The high
risk was a direct result of not performing either random sequence
generation or allocation concealment. There was no blinding of
participants or researchers from awareness of which intervention
they were executing and there was no reporting of a definite
assessment blinding technique. Moreover, there was no reporting
of dropouts. The Cochrane handbook categorized this type of trial as
a quasi-randomized controlled trial.
There is an actual debate concerning the inclusion of quasi-
randomized or nonrandomized controlled trials in the qualitative
analysis of systematic reviews; one Cochrane review group stated
that quasi-randomized controlled trials should be excluded. On the
other hand, others suggested that they should be included only if
there are only a few or no randomized controlled trials, or only for
adverse effects [20]. The cutoff point was reported by Liberati et al.
[21]. They stated that the inclusion of nonrandomized studies,
quasi-experimental studies, and interrupted time series is recom-
mended in some systematic reviews that evaluate the effects of
health care interventions.
Consequently, we decided to include this study in our qualitative
analysis protocol because no randomized controlled trials were
found to answer our current clinical question. The aim of the in-
clusion of this study was not to raise the level of evidence. Instead,
we attempted to solely test the methodological quality of the single
elected article that met our criteria and answered our question. This
could be a guide for further better-quality trials.
The Cochrane handbook highlights two tools for use in non-
randomized and quazi-randomized studies: the Downs and Black
and Newcastle Ottawa scales [21]. To assess the methodological
soundness of the elected study, the Downs and Black tool was fol-
lowed, having the advantage of testing external validity, construct
validity, and statistical conclusion validity [22].

Table 5
Downs and Black checklist score for the study by Forsberg and Hellsing 1984 [9]

Question 1 2 3 4 5 6 7 8 9
Score Yes (1) Yes (1) Yes (1) Yes (1) Partially (1) Yes (1) Yes (1) Yes (1) No (0)
Question 10 11 12 13 14 15 16 17 18
Score Yes (1) No (0) Unable (0) Yes (1) Yes (1) No (0) Yes (1) Yes (1) Yes (1)
Question 19 20 21 22 23 24 25 26 27
Score Yes (1) Yes (1) Yes (1) Yes (1) Yes (1) Unable (0) No (0) Unable (0) No (0)
Total score
19
 M.M. El-Dawlatly et al. / Journal of the World Federation of Orthodontists 6 (2017) 57e61
On the Downs and Black scale, the elected study was given a
score of 19, which was considered to be fair [23]. This score was an
accumulation of excellent reporting, poor external validity, and
very good internal validity (Table 5), although the negative side of
the methodology was a direct result of poor external validity and
absence of sample size calculation protocol before the start of
treatment [9]. However, being awarded a fair score in the meth-
odology, the quality of evidence that could be extracted from this
article was yet low. This is attributed to being a quasi-randomized
clinical trial.
Our current low-quality evidence dictates two main findings
regarding mandibular skeletal changes after the anterior bite
planeeonly therapy: there was a lack of mandibular sagittal growth
or positional change and a significant backward rotation of the
mandible in the treated group when compared with the controls.
Both of these results are not beneficial regarding the treatment of
growing subjects with Class II; however, this information should be
interpreted with caution, as it is based on a low-quality controlled
trial. Accordingly, the effects of early bite opening on mandibular
growth in growing patients with Class II deep bite malocclusion are
still questionable.
5. Conclusions
 There is poor low-quality evidence regarding the effect of early
deep bite correction on the anteroposterior and vertical growth
of the mandible.
 The available evidence could not eliminate the need for the use
of headgear or functional appliances in conjunction with the
bite-opening appliance in the treatment of growing patients
with Class II deep bite.
 There is an absence of well-designed randomized controlled
clinical trials that could answer our current clinical question.
 The orthodontic literature is in a great need of high-quality
evidence in the form of a well-designed randomized clinical
trial to answer the current question.
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