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Asymmetric deep bite with a canted occlusal


plane: a case report
Article in Australian orthodontic journal May 2013
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Asymmetric deep bite with a canted occlusal


plane: a case report
Teresa Pinho
Health Sciences Research Center (CICS), Superior Institute of Health Sciences North, CESPU, Gandra, PRD, Portugal

Introduction: Asymmetry and deep bite malocclusions provide management difficulties for clinicians and the combination invites
special concern.
Aim: The purpose of the present paper is to describe a clinical case presenting with an asymmetric deep bite, a canted occlusal
plane, a Class II canine relationship on the right side and a Class III canine relationship on the left side, with deviations of
both dental midlines to the right. A lower right premolar impaction contributed to the asymmetry and a left first maxillary molar
extraction was required for endodontic reasons.
Methods: A straight-wire technique was used for eighteen months to achieve second molar mesialisation, as well as dental
levelling and alignment. To unravel the mandibular arch, resolve the deep bite and manage the canted the lower occlusal plane,
two bite turbos were attached to the palatal surface of the maxillary central incisors. In addition, a sectional Multiloop Edgewise
Arch-Wire (MEAW) was placed on the left side and maintained for nine months. Different lower MEAW activation (lateral left
lower extrusion) and tip-back control on the posterior teeth were essential mechanics to increase vertical dimension on the lower
left side and allow for Class III dental correction. Short Class II vertical elastics on the right side and Class III elastics on the left
side were applied.
Conclusion: The asymmetric mechanics allowed the case to be treated to a stable sagittal and vertical occlusal result.
(Aust Orthod J 2013; 29: 115-122)

Received for publication: July 2012


Accepted: February 2013
Teresa Pinho: teresa.pinho@iscsn.cespu.pt

Introduction
An asymmetric malocclusion may be corrected using
a variety of treatment mechanics directed at the
aetiological factor(s) which produce the asymmetric
characteristics of the malocclusion.1-8 The correction
of an anterior deep bite can be achieved by incisor
intrusion, incisor proclination or molar extrusion.9
However, orthodontic treatment and orthognathic
surgery may be required when the dental discrepancy
is unable to be corrected by orthodontic mechanics
alone, or when facial aesthetics might be unduly
compromised.7
To maximise the potential for smile improvement,
maxillary anterior teeth must be moved vertically to
enhance aesthetics.10 A previous report has speculated
Australian Society of Orthodontists Inc. 2013

that overbite correction, achieved by maxillary incisor


intrusion, will lead to a flattening of the smile arc
and consequently will reduce smile attractiveness. It
has been recommended that other overbite corrective
mechanics be employed to avoid this detrimental
outcome.11 However, other authors have described
changes in the smile arc which are likely due to
orthodontic tooth alignment and not necessarily
attributable to the overbite correction method used
during treatment.12
The present case describes the orthodontic treatment
of a young patient who had an asymmetric deep bite
accompanied by the deviation of both dental midlines
to the right, a canted occlusal plane, a Class II canine
relationship on the right side and a Class III canine
relationship on the left.
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Figure 1. Pretreatment extra- and intra-oral photographs.

Case report
A 13-year-old female patient presented with a chief
complaint of malaligned teeth associated with an
anterior asymmetric deep bite. Extra-oral photos
revealed a symmetrical face and a low smile line
(exposing less than 75% of the anterior maxillary
teeth) (Figure 1). Intra-orally, a Class II and Class
III dental relationship was evident on the right and
left side, respectively. The occlusal plane was canted
upward on the right side. Both dental midlines were
displaced to the right with the mandibular midline
displaced 3 mm more than the maxillary midline. Mild
crowding was present in the maxillary arch which had
suffered a recent upper left molar extraction. There
was moderate crowding in the mandibular arch which
contained an impacted right second premolar. Lingual
tipping of the upper anterior teeth and a deep bite
(overbite of about 7 mm on the left side) was evident.
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Australian Orthodontic Journal Volume 29 No. 1 May 2013

The maxillary and mandibular arches were narrowed


but without the generation of crossbites (Figure 1).
A panoramic radiograph indicated that there was
asymmetrical condylar morphology as the left side was
slightly more elongated. All third molars were present
(Figure 2). A lateral cephalometric analysis showed
a mandibular plane angle within normal range but
with a tendency towards hypodivergence, a skeletal

Figure 2. Pretreatment panoramic x-ray.

ASYMMETRIC DEEP BITE WITH A CANTED OCCLUSAL PLANE CASE REPORT

Class I with normal maxillary and mandibular sagittal


position, upright upper and lower incisors with a large
interincisal angle and accompanying deep overbite
(Figure 3 and Table I).
The treatment objectives were to:
1. Close the space created by the upper left first molar
extraction, by moving the second molar mesially
and allowing the third molar to erupt.
2. Align the anterior teeth through proclination of
the upper and lower incisors, but with minimal
intrusion of the left central and lateral incisors and
the avoidance of right side intrusion.
3. Re-establish the occlusal plane, thereby improving
intercuspation and decreasing the overbite, through
intrusion of the lower incisors and extrusion of
lower posterior teeth.
The facial objectives were to maintain the profile, avoid
retraction of the upper and lower lips and improve the
smile while managing the other objectives.

Treatment plan
An initial stage of treatment aimed at levelling and
alignment of the upper arch with a straight wire
appliance, the intrusion of the upper left incisors and
the movement of the upper second molar into the first
molar extraction space. Secondly, in order to relieve
the mandibular crowding, resolve the asymmetric
deep bite and manage the canted occlusal plane, two
bite turbos were to be attached to the palatal face of
the maxillary central incisors. A sectional Multiloop
Edgewise Arch-Wire (MEAW) was planned for the
left side.

Treatment
A fixed appliance with an 0.022 inch bracket slot was
placed on the maxillary and mandibular arches. Due
to the crowding, lingual tipping and the asymmetric
vertical position of the maxillary incisors, the dental
levelling and alignment were achieved with a sequence
of 0.014 inch and 0.018 inch nickel titanium arch
wires. These were followed by rectangular nickel
titanium arch wires (0.016 x 0.022 inch and 0.019 x
0.025 inch), leading to 0.019 x 0.025 inch and 0.020
x 0.025 inch stainless steel arch wires to control the
second molar in its mesial movement (Figure 4).

In order to unravel the mandibular teeth and resolve


the deep bite, two bite turbos were attached to the
palatal face of the maxillary central incisors. Crown
alignment and root levelling were achieved using the
same arch wire sequences employed in the upper arch.
A nitinol open coil spring was applied to open and
maintain space for the impacted second premolar
(Figures 5 and 6).
Eighteen months after the beginning of treatment,
a 0.017 x 0.025 inch sectional Multiloop Edgewise
Arch-Wire (MEAW) was inserted on the lower left
side, and intermaxillary Class II and Class III elastics
were placed on the right and left sides respectively to
attempt to control the occlusal plane and improve
the inter-arch relationship. With sequential extrusive
steps incorporated into the loops on the left side and
omega loops directed to the posterior teeth, the lower
occlusal plane was levelled by intrusion of the lower
incisors and extrusion of the posterior teeth (Figure
7). After obtaining stable posterior occlusal contact,
the bite turbos were removed.
Fixed appliance treatment took 27 months, after
which orthodontic records including photographs,
panoramic and cephalometric x-rays were obtained
(Figures 8, 9 and 10). A maxillary wrap-around
appliance and a mandibular bonded lingual retainer
were inserted to maintain treatment results.

Treatment results
The extra-oral photographs showed a symmetric and
balanced relationship of the facial soft tissues, an
improved profile and a pleasant smile. A significant
improvement in the occlusion was achieved,
highlighted by a molar and canine Class I relationship.
The upper midline was co-incident with the facial
midline, and overjet and overbite were normal. The
aims of increasing the vertical dimension as well as
relieving the deep overbite were achieved. The goal of
levelling and proclining the maxillary and mandibular
incisors was also achieved. The post-treatment
panoramic radiograph (Figure 9) confirmed that there
was good root positioning following the mesial bodily
movement of the maxillary second molar.
A cephalometric analysis (Figure 10) identified that
ANB decreased from 5 to 2.2 whilst maintaining the
underlying skeletal Class I relationship. SNA decreased
from 84.6 to 82.1 due to the root torque applied
to the upper incisors, but SNB remained the same.
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PINHO

Figure 3. Pretreatment lateral cephalometric radiograph and tracing.

Figure 4. Intra-oral photos at the end of the crown alignment and the root levelling with second molar mesialised in the first molar position.

Figure 5. Two bite turbos placed in palatal face of both central incisors; nitinol open coil spring, in third and fourth quadrant.

Figure 6. End of the crown alignment and the root levelling with space recuperation on the fourth quadrant for second premolar eruption; Class II elastics
on the right side and Class III on the left side.

Figure 7. Sectional Multiloop Edgewise Archwire technic on the lower left side; Short Class II vertical elastics on the right side and Class III on the
left side.

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Australian Orthodontic Journal Volume 29 No. 1 May 2013

ASYMMETRIC DEEP BITE WITH A CANTED OCCLUSAL PLANE CASE REPORT

Figure 8. Post-treatment extra- and intra-oral photos.

and a counterclockwise rotation of the mandible.


The interincisal angle, overjet and the overbite were
corrected to normal. An analysis of the cephalometric
superimpositions (Figure 11) showed considerable
horizontal mandibular growth with significant facial
development involving the nose and an anticlockwise
rotation of the occlusal plane.
Figure 9. Post-treatment panoramic x-ray.

Dentally, the upper incisor (UI/NA) increased from


10 to 30, and the lower incisor angulation (IMPA)
increased from 80.4 to 89 degrees. The Frankfortmandibular plane angle (FMA) decreased by two
degrees which slightly increased the hypodivergency,
in spite of the maintenance of SNB. This was likely
due to the increase in lower incisor angulation (IMPA)

One year after orthodontic treatment, the occlusion


and the aesthetic results remained stable (Figures 12
and 13).

Discussion
No discernable mandibular lateral deviation was
identified in the presented case, but there was
dentoalveolar distortion indicated by non-coincidence and displacement of the dental midlines and
an asymmetric deep bite. The asymmetry of the upper
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PINHO

Figure 10. Post-treatment lateral cephalometric radiograph and tracing.

Figure 11. Cephalometric superposition pre- (grey line) and post- (black line) treatment (Bjork method); general,
maxillary, mandibular and perfil superimpositions.

arch worsened with the extraction of the maxillary


left first molar, and combined with the imbalance and
impaction in the lower arch (Figures 1 and 2), the use
of managed fixed appliances was necessary.
It has been suggested that asymmetric malocclusions
may be treated by the asymmetric extraction of
premolars.3,13 In the present case, asymmetric
extractions were not planned because of the patients
profile, and due to the significant lingual tipping of the
anterior teeth. Additionally, retraction of the incisors
was contra-indicated as the maxillary and mandibular
arches were narrowed due to the dental tipping. The
arch length discrepancies were resolved by lateral
expansion and incisor proclination, facilitated by the
good gingival biotype. This contributed to overall
smile improvement.10
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Australian Orthodontic Journal Volume 29 No. 1 May 2013

The long-term success and stability of treatment in


asymmetric deep bite cases depends on reducing or
opening the bite to restore the occlusal plane.7,14,15
A Le Fort I osteotomy with asymmetric maxillary
impaction is often used to correct the cant of the
maxillary occlusal plane when the involvement of the
skeletal structures is significant.7 However, canting
caused by extruded teeth may be corrected with
conventional orthodontic appliances and skeletal
anchorage using miniscrew implants.14 This occurs
through the intrusion of extruded teeth, which
therefore avoids a more aggressive surgical approach.14
Furthermore, differential MEAW activation, short
elastics vectored differently on each side and temporary
occlusal composite bite blocks on the posterior teeth
(at the side with lower vertical dimension) may also be

ASYMMETRIC DEEP BITE WITH A CANTED OCCLUSAL PLANE CASE REPORT

Figure 12. Intra-oral photos one year after the orthodontic treatment.

Figure 13. Smile before and one year after orthodontic treatment.
Table I. Cephalometric analysis before and after treatment.

Cephalometric
analysis

Normal

Before treatment

After treatment

FMIA (degrees)

67 3

75.8

69.1

FMA (degrees)

25 3

23.8

21.9

IMPA (degrees)

88 3

80.4

89.0

SNA (degrees)

82 2

84.6

82.1

SNB (degrees)

80 2

79.6

79.9

ANB (degrees)

1 5

5.0

2.2

22

1.4

22 2

10.0

30.0

10.4

7.3

77.0

80.6

Ao Bo (mm)
UI/NA (degrees)
Occlusal plane (degrees)
Angle Z (degrees)

8 12
75 5

Overjet (mm)

2.5 2.5

5.4

3.7

Overbite (mm)

2.5 2.5

7.3

2.7

155.4

129.6

Interincisal angle (degrees)

126 10

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PINHO

used.15 It has also been suggested that the resolution of


a deep bite may be achieved by the use of an anterior
bite plate.12,16
In the presented case, the bite turbos attached to
the palatal face of the maxillary central incisors were
vital to manage the deep bite, accelerate treatment
and more predictably achieve tooth alignment. In
addition, the bite turbos allowed the restoration of
the lower occlusal plane through tip-back control
of the posterior teeth and lateral lower left premolar
extrusion into a Class I relationship. The sectional
MEAW activation, the omega bends directed at the
posterior teeth, the short left side Class III elastics
and short Class II elastics on right side, allowed for
differential orthodontic forces which facilitated the
occlusal plane levelling.15

Conclusion
This clinical case shows that, in a young patient,
orthodontic correction of an asymmetric deep
bite, the restoration of a canted occlusal plane to a
stable dental articulation with optimal aesthetic and
functional results, can be achieved.

Corresponding author
Dr Teresa Pinho
Centro de Investigao Cincias da Sade (CICS),
Instituto Superior de Cincias da Sade-Norte/CESPU
Rua Central de Gandra, 1317
4585-116 Gandra,PRD
Portugal
Email: teresa.pinho@iscsn.cespu.pt

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Australian Orthodontic Journal Volume 29 No. 1 May 2013

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