a guide on management

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.

45. Thanks for listening…