Biomechanics of Deep Overbite Correction

Charles J. Burstone

Correction of deep overbite can be accomplished in different ways depend-

ing on the treatment goals chosen for individual patients. The 2 primary
methods of correction are intrusion of anterior teeth or extrusion of poste-
rior teeth. Successful intrusion of the incisors depends on careful control of
the force system used. Low force magnitude, force constancy, a properly
selected single point of force application, and control of force direction are
all important factors to consider. The design of the intrusion arch may be
continuous, or a 3-piece intrusion arch may be selected depending on the
needs of the patient. Alternatively, extrusion of posterior teeth may be
indicated in patients who are still actively growing and who have short
vertical facial dimensions. (Semin Orthod 2001;7:26-33.) Copyright© 2001 by
W.B. Saunders Company

A c o m m o n finding in m a n y malocclusions is fectly permissible to extrude posterior teeth be-

the p r e s e n c e of d e e p overbite. Because cause the mandible would not be hinged o p e n
d e e p overbite is a s y m p t o m , it is n o t too sur- during treatment. By contrast, Figure 1B shows a
prising that t h e r e are n u m e r o u s etiologic fac- patient in w h o m minimal growth is expected
tors that can lead to d e e p overbite a n d m a n y during treatment. To control the vertical dimen-
d i f f e r e n t t r e a t m e n t goals for its c o r r e c t i o n . sion, it is necessary in this type of patient to
Patients that show l o n g faces or a Class II p o i n t intrude the incisors.
A to p o i n t B r e l a t i o n s h i p r e q u i r e c o n t r o l of T h e decision to intrude or extrude is based
the vertical d i m e n s i o n with no r o t a t i o n of the on at least 3 factors: skeletal convexity, vertical
m a n d i b l e d o w n w a r d a n d backward d u r i n g the dimension, and the interocclusal (freeway) space.
c o r r e c t i o n of the overbite. In these patients,
T h e estimated a m o u n t of growth during treat-
intrusion m e c h a n i c s of the incisors is re-
m e n t helps to d e t e r m i n e the a m o u n t that pos-
quired. O n the o t h e r h a n d , t h e r e are patients
terior teeth can be extruded. In some malocclu-
with smaller vertical d i m e n s i o n s or individuals
sions it may be m o r e convenient and efficient to
showing sufficient vertical growth p o t e n t i a l for
intrude anterior teeth initially, such as in a Class
w h o m the t r e a t m e n t of choice is the e x t r u s i o n
o f p o s t e r i o r teeth. II, Division 2 patient, even t h o u g h the final plan
Two patients with a 2-year growth prediction may not necessarily require intrusion.
are shown in Figure 1. In Figure 1A, typical Patients with fiat m a n d i b u l a r planes a n d
maxillary-mandibular differential growth not small vertical d i m e n s i o n s p r e s e n t an entirely
only improves the Class II relationship, but also d i f f e r e n t p r o b l e m t h a n do long-faced individ-
increases the vertical dimension f r o m anterior uals. It is desirable in m a n y o f these patients to
nasal spine to m e n t o n . In this patient it is per- increase the vertical d i m e n s i o n . However, this
may n o t be practical f r o m a p o i n t of view of
stability unless future growth will occur. Even
From the Department of Orthodontics, Sehool of Dental Medi-
in these patients, it may be necessary to in-
cine, University of Connecticut Health Center, Fa,vvnington, CT. t r u d e incisors. A b i o m e c h a n i c a l alternative to
Ad&~ss correspondence to CharlesJ. Burstone, DDS, MS, De- i n t r u s i o n of a n t e r i o r t e e t h in patients with
partment of Orthodontics, School of Dental Medicine, University of short vertical d i m e n s i o n s is to e x t r u d e poste-
Connecticut Health Center; Farmington, CT 06030.
Copyright © 2001 by W..B. Saunders Company
rior teeth initially a n d m a i n t a i n fixed arches in
1073-8746/01/0701-0004535.00/0 place d u r i n g t r e a t m e n t to allow time for adap-
doi:l O.1053/sodo. 2001.21059 tation to occur.

26 Seminars in Orthodontics, Vol 7, No 1 (March), 2001: cop 26-33

 Biomechanics of Deep Overbite Correction 27

ization would occur. Early studies of treated pa-

tients saw little intrusion of incisors because the
mechanics used tended to extrude posterior
teeth. It has been shown that the use of light
constant forces enables the intrusion of teeth
with minimal disruption of posterior a n c h o r
units. It has also been shown that as the forces
for intrusion are increased, more root resorp-
tion but not necessarily a greater rate of intru-
sive m o v e m e n t may result. 1 Figure 2 shows a
patient in whom intrusion was accomplished in
both the u p p e r and lower arches using light
constant forces. The u p p e r incisors c o m m o n l y
must be intruded more than lower incisors to
maintain the original cant of the plane of occlu-
sion. This requires controlled mechanics be-
cause in the Class II patient, the application of
Class H elastics or cervical headgear and other
similar mechanisms can steepen the plane of
occlusion and negate any intrusion effects.
There are 2 basic designs to an intrusion arch:
(1) a continuous arch, and (2) a 3-piece intru-
I ~.S I
I
t sion mechanism. 2-6 Both of these appliances are
"/ ¢"1
iS
described in this section. The application of
JI ' I
each is determined by the needs of the pa-
! .-T~
1." ti
tient.7, 8
The continuous intrusion arch is shown in
Figure 3. A relatively rigid anchorage unit con-
, 2

i,
nects the teeth of the posterior segment. The
cuspid is bypassed by placing a small step in the
region of the cuspid or eliminating the cuspid
bracket entirely. Anterior teeth are connected
Growth Estimate together with an incisor segment. A 0.017 ×
14 y r s . 0 mos. ---
0.025-inch or 0.016 × 0.022-inch titanium mo-
16 y r s . 0 mos. -- lybdenum alloy (TMA) intrusion arch from an
auxiliary tube places the intrusive force on the
Figure 1. Growth influences the decision to intrude incisors. As the wire is b r o u g h t down to the
incisors. Two-year growth prediction shows the over- central incisors or the lateral incisors, only single
bite corrected by growth. Posterior teeth can be forces are directed in an intrusive direction.
erupted (A). Little growth in 2-year prediction. Inci- The key to successful intrusion is control of
sor intrusion is needed (B).
the force system. Specifically, force magnitude,
constancy, the use of only a single-point applica-
The biomechanics of 2 different types of deep tion, control of the direction of force, and the
overbite correction are discussed separately in selection of a p r o p e r point for the force appli-
this article. First, incisor intrusion, and second, cation are carefully planned and delivered.
extrusion mechanics for posterior teeth. Force magnitude can be determined either
using tables or directly by a force gauge (Fig 4).
Sometimes the clinician will neglect to measure
Incisor Intrusion the forces and only place a V b e n d posteriorly.
For many years it was believed that it was impos- This can be dangerous because arches vary in
sible to intrude teeth and that if intrusion was length and there is not a constant angulation for
attempted, undesirable sequellae such as devital- a desirable activation. If too m u c h force is ap-
28 Charles J. Bu,:,tone

plied, undesirable side effects, including steep-

ening of the occlusal plane or distal tipping of a
molar, can occur, The magnitude of force de-
pends on the n u m b e r of teeth and their size. For
example, during intrusion of u p p e r incisors,
about 60 g of force for 4 incisors are used. Figure
5 shows a patient with a continuous intrusion
arch before and after intrusion. The use of low
forces and a stable anchorage unit will not upset
posterior anchorage and should maintain the
original plane of occlusion.
The force-deflection rate of the intrusion
arch is very low, usually u n d e r 10 g / m m , be-
cause the distance is large between the auxiliary
tube of the molar and the incisor brackets2 This
not only produces a large deflection, minimizing
the need for any reactivation, but also ensures
greater constancy of force. It also enhances the
accuracy of the appliance because any small er-
ror in activation produces a minimal change in
the delivered force.
A particularly important consideration in in-
trusion is to assure that the intrusion arch does
not fit into the brackets of the incisors. Instead,
a separate segment is placed. There are a nun>
bet of reasons why it is not desirable to put
either a rectangular or a r o u n d intrusion arch
wire directly into an edgewise bracket anteriorly.
The intrusive arch can change shape, p r o d u c i n g
mesial displacement of the roots of incisors. I i
Most importantly, any torque, labial or lingual, l'~ I l
I # I ~.#
can alter the intrusive force (Fig 6). If purposely
or accidentally placed lingual root torque is l I I
present, it could completely eliminate any intru-
sive force. At the other extreme, labial root
torque may increase the intrusive force with a I

concomitant increase of extrusive force and tip

back m o m e n t on the molar. Once an edgewise
intrusion arch wire is placed into the anterior
brackets, a precise mechanism is not present.
The clinician should carefully look at the an-
J~
atomic a r r a n g e m e n t of the teeth to determine s ~
which teeth require intrusion. The Class II, Di-
vision 2 patient may only need intrusion of 2
central incisors. Many Class II, Division 1 pa- I
#!
tients require intrusion of 4 incisors. These an-
\ II

Figure 2. Maxillary and mandibular intrusion using a

continuous intrusion arch. Cranial base superimposi- " lli~
tion (A). Separate maxillary and mandibular superim-
positions (B).
 Biomechanics of Deep Overbite Correction 29

Figure 3. Passive and active continuous intrusion arches. Separate posterior and anterior segments are placed.
The canine is bypassed. Buccal view passive (A) and active (B). Frontal view passive (C) and active (D).

a t o m i c discrepancies s h o u l d be eliminated by
segmental intrusion r a t h e r than by indiscrimi-
nate leveling. If the patient initially has leveling
wires placed in a full-arch wire, it t h e n almost
b e c o m e s impossible to p r o d u c e effective intru-
sion o f the incisors.
O n e o f the key aspects o f c o n t r o l l i n g the

~i~ !ii¸¸!iliii~i~/~!~ii~i:~i;~i~

t
Figure 4. The force system. Measuring the force with
a force gauge (A). The reactive force on the posterior
anchorage unit produces potential extrusion and Figure 5. Upper incisor intrusion. Before (A) and
steepening of the occlusal plane (B). after (B).
30 Charles J. Burstone

Figure 8. Frontal view of a 3-piece intrusion arch with

hooks attached distal to the lateral incisors. Separate
right and left springs apply intrusive force distal to the
lateral incisors.
B
the l o n g axis o f the tooth. T h e i n c i s o r will
readily i n t r u d e a n d n e i t h e r r e t r a c t n o r flare.
i!i!~ '~iiiii~ W i t h a typical axial i n c l i n a t i o n , the force is labial
to the c e n t e r of resistance so that the t o o t h will
i n t r u d e b u t also have a m o m e n t t h a t w o u l d re-
tract the r o o t p r o v i d e d the intrusive arch is tied
back. For Class II, Division 2 patients, some lin-
gual r o o t m o v e m e n t m a y be desirable. However,
i n p a t i e n t s with a l r e a d y flared incisors, p l a c i n g
a n intrusive force labial to the c e n t e r o f resis-
t a n c e is m o r e p r o b l e m a t i c . T h e r o o t is p r o b a b l y
Figure 6. Placing an arch wire in the incisor brackets
alters the magnitude of the intrusive force. Lingual
root torque produces extrusion (A). Labial root
torque produces intrusion (B).

force system d u r i n g i n t r u s i o n is to d i r e c t the

force s o m e w h a t parallel to the l o n g axis o f the
tooth. I n F i g u r e 7, 3 d i f f e r e n t axial i n c l i n a t i o n s
of incisors are shown. W i t h a vertical incisor, a
c o n t i n u o u s i n t r u s i o n arch c a n direct the force
close to the c e n t e r o f resistance a n d parallel to

Figure 7. An intrusive force labial to tile incisors

produces different effects as axial inclinations vary. Figure 9. Three-piece intrusion arch with chain elas-
The intrusion force unfavorably moves the incisor tic (A) or spring (B) redirects the force parallel to the
root lingually in a flared incisor. long axis of the incisor.
 Biomechanics of Deep Overbite Correction 31

Figure 10. Cantilever with eyelet. The direction of

the force is parallel to the ligature tie.

Figure 12. Force can be positioned either anterior or

too far lingual to begin with, a n d f u r t h e r m o r e , posterior to the center of resistance of the incisor
the force is n o t d i r e c t e d a l o n g the l o n g axis o f segment to produce intrusion-protrusion, pure intru-
the tooth. Consequently, there is a large labial sion, or intrusion-retraction.
c o m p o n e n t to the force. T h e t o o t h will n o t
readily i n t r u d e a n d can flare further. It is in this o f the force so that it is parallel to the l o n g axes
type o f patient that the 3-piece intrusion arch is o f the incisors. T h e intrusive force can be sup-
used. p l e m e n t e d by a distal force f r o m a chain elastic
T h e 3-piece intrusion arch is similar to the or a coil spring. T h e resultant force can t h e n
c o n t i n u o u s arch in that it requires a stable an- b e c o m e parallel to the l o n g axes o f the incisors
c h o r a g e unit for the posterior teeth a n d a sepa- (Fig 9).
rate a n t e r i o r segment. Instead o f a c o n t i n u o u s Two o t h e r m e t h o d s for redirecting the force
wire, separate tip back springs are applied o n the involve using separate cantilever intrusive springs.
right a n d left sides (Fig 8). T h e b e n t h o o k shown T h e first is shown in Figure 10. T h e o r i e n t a t i o n
in Figure 8 delivers an intrusive force distal to o f the tie is parallel to the direction o f force. By
the brackets o f the lateral incisors. W h e n the s h o r t e n i n g the arm, the force can be directed
force is directed at 90 ° to the occlusal plane, its m o r e distally. T h e s e c o n d very simple m e t h o d
p o i n t o f a t t a c h m e n t can t h e n be p l a c e d t h r o u g h for redirecting the force is shown in Figure 12. A
the c e n t e r o f resistance o f the incisors so that n o posterior e x t e n s i o n to the a n t e r i o r s e g m e n t is
flaring o f the teeth occurs. a n g l e d so that the force is n o w directed a l o n g
In addition to altering the p o i n t o f force ap- the l o n g axes o f the teeth. This assumes n o
plication, with flared incisors it may be necessary friction a l o n g the a r c h wire so that the resulting
to redirect the force. T h e r e are a n u m b e r o f force only acts at 90 ° to the posterior section o f
possible m e t h o d s for c h a n g i n g the line o f action the a n t e r i o r segment.

Figure 11. Angling the poste-

rior extension redirects the
force parallel to the incisor
long axis (A). Intrusive force
on posterior extension of the
anterior segment is 90 ° to the
~!~i!~ ii!~
~ii............./iI!
occlusal plane (B).
32 Charles.]. Bu~stone

Figure 13. Extrusive mechanics. Upper bite plate on precision lingual arch (A). Bite plate attached to
the lower arch allows separated posterior teeth to be extruded with vertical elastics or allowed to
erupt (B).

By using either a continuous intrusion arch or greater accuracy than that achieved when an
a 3-piece mechanism, the orthodontist can alter arch wire is placed into the brackets of the inci-
not only the magnitude of the force, but also the sors with a continuous arch or 2 × 4 mecha-
position of the force with respect to the center of nism. 11q4
resistance (Fig 12). 1° Furthermore, for optimal Key to anchorage control is the maintenance
results, it is necessary to orient the force so it of low-magnitude forces and the use of a rigid
approaches parallelism to the long axes of the posterior segment. This includes a lingual or
incisors. The use of a single tbrce leads to a transpalatal arch to maintain posterior widths.
Backup with occipital headgear may be consid-
ered. A posteriorly and intrusively directed force
from the headgear acting anterior to the center
of resistance of the molar segment produces a
m o m e n t that minimizes any steepening of the
occlusal plane. O f course, headgear should not
be used to cover up mistakes in intrusion me-
chanics where force magnitudes are too great.

Extrusion of Posterior Segments

The extrusion of posterior teeth for the correc-
tion of deep overbite may be less d e m a n d i n g
than intrusive mechanics but must still be ac-
complished carefully to avoid canting of the oc-
clusal plane. Many continuous arches extrude
teeth. More efficiently, a 3-piece tip back mech-
anism with increased forces to a large anterior
segment can be used to tip back and extrude the
posterior teeth. 15 To minimize any steepening of
the u p p e r plane of occlusion with larger forces,
cervical headgear with a long and high outer
bow can p r o d u c e a m o m e n t to bring the u p p e r
plane of occlusion vertically without a change of
cant.
Figure 14. Vertical elastic applied to posterior teeth An u p p e r bite plate attached to a precision
separated by a bite plate. Individual tooth extrusion lingual arch is a useful adjunct for posterior
(A). Segmental tooth extrusion (B). eruption with or without other mechanics (Fig
 Biomechanics of Deep Overbite Correction 33

13A). Unlike removable bite plates, the fixed 3. Burstone CJ. Mechanics of the segmented arch tech-
appliance is not under the control of the pa- nique. Angle Orthod 1966;36:99-120.
4. Burstone CJ, van Steenberg E, Hanley KJ. Modern Edge-
tient, which enhances its efficiency. A lower bite
wise Mechanics and the Segmented Arch. Ormco Press,
plate from cuspid to cuspid can also be used to 1995, pp 32-48.
separate the posterior teeth, allowing for vertical 5. Burstone CJ. Biomechanics of the orthodontic appli-
extrusive mechanics to be expressed more easily ance, in Graber TM (ed): Current Orthodontic Con-
(Fig 13B). With posterior teeth separated by cepts and Techniques. Philadelphia, PA, Saunders, 1969,
either an upper or lower bite plate, vertical elas- pp 160-178.
tics can be u s e d either to an entire segment or to 6. Lindauer SJ, lsaacson RJ. One-couple orthodontic appli-
ance systems. Semin Orthod 1995;1:12-24.
individual teeth, b e c a u s e often n o t all teeth have
7. Burstone CJ. Biomechanical rationale of orthodontic
to be e r u p t e d equally (Fig 14). T h e p o s i t i o n o f
therapy, in Melsen B (ed): Controversies in Orthodon-
the force as well as the n u m b e r o f teeth in the tics. Berlin, Germany, Quintessence, 1991, pp 131-146.
buccal s e g m e n t can be c o n t r o l l e d . 8. Burstone CJ. Deep overbite correction by intrusion.
A m J Orthod 1977;72:1-22.
9. Burstone CJ, Baldwin JJ, Lawless DT. The application of
Conclusion
continuous forces to orthodontics. Angle Orthod 1961;
The correction of deep overbite requires careful 31:1-14.
differential diagnosis and the determination of 10. Shroff B, Lindauer SJ, Burstone CJ, et al. Segmented
approach to simultaneous intrusion and space closure:
which teeth must be intruded or extruded for
Biomechanics of the three-piece base arch appliance.
proper correction. Therefore, the mechanics for
A m J Orthod Dentofac Orthop 1995;107:136-143.
treatment can differ radically from one patient 11. Koenig HA, Burstone cJ. Force systems from an ideal
t o a n o t h e r . T h e k e y t o s u c c e s s f u l c o r r e c t i o n is arch: Large deflection considerations. Angle Orthod
not only the proper treatment plan, but precise 1989;59:11-16.
mechanics to achieve the predetermined treat- 12. Ronay F, Kleinert MW, Melsen B, Burstone CJ. Force
ment plan goals. system developed by V bends in an elastic orthodontic
wire. A m J Orthod Dentofac Orthop 1989;96:295-301.
13. Burstone CJ, Koenig HA. Creative wire bending: The
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1. Dellinger EL. A histologic and cephalometric investiga- fac Orthop 1988;93:59-67.
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key. Am J Orthod 1967;53:325-355. arch. Am J Orthod 1974;65:270-289.
2. Burstone CJ. Rationale of the segmented arch. Am J 15. Romeo DA, Burstone CJ. Tip-back mechanics. Am J
Orthod 1962;48:805-822. Orthod 1977;72:414-421.