University of Southern California Dissertations and Theses

Overbite correction with fully customized lingual appliances

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Overbite correction with fully customized lingual appliances

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OVERBITE CORRECTION WITH FULLY CUSTOMIZED LINGUAL APPLIANCES

By

Scott Morita

____________________________________________________

A Thesis Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(CRANIOFACIAL BIOLOGY)

May 2013

Copyright 2013 Scott Morita

ii

DEDICATION

To my family, friends, and the RaHouse whom have forever impacted my life.
Mahalo & Fight on!

iii

ACKNOWLEDGEMENTS

Drs. Dan Grauer and Glenn Sameshima
Thank you for everything.

iv

TABLE OF CONTENTS

DEDICATION ii
ACKNOWLEDGEMENTS iii
LIST OF TABLES v
LIST OF FIGURES vi
ABSTRACT vii
INTRODUCTION 1
MATERIALS AND METHODS 24
RESULTS 27

DISCUSSION 29

CONCLUSIONS 41
TABLES 42
FIGURES 48
REFERENCES 52

v

LIST OF TABLES

TABLE 1. Selected Cephalometric Variables 42
TABLE 2. Definition of Landmarks 43
TABLE 3. Descriptive Statistics of Growing and Non-Growing Groups 45
TABLE 4. Descriptive Statistics of Entire Sample 46
TABLE 5. Descriptive Statistics Comparing Groups 47

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LIST OF FIGURES

FIGURE 1A. Customized Lingual Orthodontic Appliance 48
FIGURE 2A-B. Pre and Post Treatment Correction of Overbite 49
FIGURE 3A-C. Cephalometric Superimposition 50
FIGURE 4A-B. Average Changes in Growing and Non-Growing Groups 51

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ABSTRACT

BACKGROUND: Overbite is the vertical relation of the upper to lower incisors.
Normal overbite is considered normal within 1-3 mm, and excessive over 4 mm.

OBJECTIVE: Goal of this study is to determine the mechanism of overbite
correction with customized appliances.

MATERIALS AND METHODS: Cephalometric radiographs for 39 consecutive
cases with >4 mm. of overbite were digitized and traced in Dolphin Imaging
Software. In order to assess changes, tracings were superimposed by the Bjork
structural method. All cases were from a single orthodontic office in Germany
and treated with Incognito lingual system. Sample was divided into growing and
non-growing subgroups according to chronological age. Descriptive statistics
and comparison between subgroups are presented.

RESULTS: Treatment and growth changes in growing patients included: 1)
molar extrusion 2) anterior incisor intrusion 3) anterior incisor flaring. Treatment
and aging changes in growing patients included: 1) minimal molar extrusion 2)
anterior incisor intrusion 3) greater anterior incisor flaring 4) mandibular
autorotation. The difference between groups was the increase in facial heights.

viii

CONCLUSIONS: Growing and non-growing differed (as expected) in the
increase of facial heights. Incisor inclination depended on the desired inclination
designed into the custom lingual appliance as opposed to increased inclination
(flared) incisors often reported in other studies. Overbite correction was a
combination of molar extrusion, incisor intrusion, incisor flaring, and mandibular
autorotation. Future research is needed to define the target overbite for specific
patients in order to allow for optimum function.

1

INTRODUCTION

Definition
The common definition of overbite is "the overlapping of the upper anterior teeth
over the lower anterior teeth in the vertical plane (Thompson, 1953)." The
amount of vertical overlap often varies extensively and is one of the most
common and early manifestations of a malocclusion. Since this definition, the
national health survey has defined overbite as the vertical relation of the upper
incisors to the lower incisors. In literature overbite has been used to define two
implications: 1) measurement of overlap or 2) when excessive, referred as a
specific malocclusion. A vertical overbite is present when the incisal edges of
the upper anterior teeth overlap those of the opposing lower ones. When that
relation is reversed, so there is no vertical overlap this is defined as “open-bite.”
In 1945 Neff created an anterior coefficient to relate to the degree of overbite.
Overbite was determined on a percentage basis by measuring the amount of
coverage of the lower central incisors by the upper incisors. End-to-end relation
was defined as 0% and complete coverage was defined as 100%. Normal
occlusion was defined as 20% overbite and was used as the ideal anterior
coefficient (Neff, 1949).

2

During 1966-70, the Division of Health Exam information Statistics conducted a
survey that collected information about the health of the U.S. population ages
12-17 years. The survey was the third of a series of Health Examination Survey
programs, which obtain statistical information about the health of selected
segments of the U.S. population. A sample of 7,514 youths were evaluated, the
dental examination selected components of the occlusion of the teeth, including
their alignment, were either noted or measured and recorded. Based on this
study it was defined that overbite is considered normal within 1-3 mm, and
excessive over 4 mm (Kelly and Harvey, 1977).
Other studies, which have investigated overbite correction, have used the
national health survey in determining their sample inclusion criteria. In Dake &
Sinclair’s study excessive overbite was defined as an overbite greater than 50%
and a mandibular plane angle measured to Frankfort horizontal of less than 25
degrees (Dake and Sinclair, 1989). Baccetti’s investigation were a specific focus
on growth changes of untreated subjects with deep-bite at the initial
observation, defining excessive overbite at 4.5 mm; a longitudinal study, with
the same subjects evaluated at 4 time points; and the use of a biologic indicator
of individual skeletal maturity at all developmental periods (Baccetti et al., 2011).
Franchi’s study investigated the outcomes of two-phase orthodontic treatment
of excessive overbite malocclusion, defining overbite as ≥4.5mm (Franchi et al.,
2011). Parker’s study specifically looked at treatments results of Class I, Class

3

II, Division 1, and Class II, Division 2 malocclusions with excessive overbite
defined as 70% anterior overbite measure on the pretreatment dental casts
(Parker et al., 1995). Jonsson conducted a study observing occlusal traits and
dental arch space changes over a 25-year span studying 245 subjects as they
aged from adolescence to adulthood. Included in this study overbite was
analyzed, and excessive overbite was defined as ≥5mm (Jonsson et al., 2009).
Feldmann divided overbite definition based on zones. The definition of moderate
to severe deep-bite was a Classification based of four zone of overbite depth
which were delineated from the mildest category near the maxillary central
incisal edge (1st quarter,1/4) to the deepest category at the cervical-gingival
junction (4th quarter, 4/4) (Feldmann et al., 1999).

Overbite associated with specific Class II Division 2 malocclusions has been
associated with the term “Cover-Bite” (Lapatki et al., 2004). Cover-bite refers to
a dental malocclusion with extremely deep vertical overbite of the upper and
lower incisors with simultaneous retroclination of the upper central incisors.
Cover-bite is regarded as a highly relapse-prone malocclusion. In this context
the significance of a high lip line as an etiologic factor for the retroclination of the
upper central incisors was recently proven within the framework of lip pressure
measurements (Lapatki et al., 2004).

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Excessive overbite is often referred to as a “deep-bite”. Deep-bite is not
considered usually as a specific malocclusion, and it is regarded often as an
attribute of other discrepancies in the sagittal plane, with special regard to Class
II Division 1 and Division 2 malocclusions. On the other hand, unfavorable
consequences of an untreated deep-bite include an increase in anterior
crowding, maxillary dental flaring, and associated periodontal sequelae (Franchi
et al., 2011).

Epidemiology (incidence)
An increased overbite (deep-bite) is highly prevalent; approximately 50% of
white adolescents in the United States present with an overbite greater than 4
mm, and over 10% of them present with an overbite greater than 6 mm (Franchi
et al., 2011). The prevalence and the severity of overbite are associated with
ethnicity. Vertical overbite is present 96 percent of the white youths versus 84
percent of the black youths. Severe overbites, those measuring ≥6 mm, are
much more common in white adolescents (11.7 percent) than in black
adolescents (1.4 percent) (Kelly and Harvey, 1977).
25-year follow-up study of an Icelandic population showed that, from
adolescence to mid-adulthood, about 50% of the deep-bite subjects showed
improvement in overbite.

Improvements were seen in 15 of 24 subjects with
excessive overjet and in 15 of 31 with excessive overbite. Self-correction to this

5

extent is more frequent than expected and might affect treatment decisions
regarding overjet and overbite in borderline patients (Jonsson et al., 2009).
Etiology
It is important to note the inclination of an incisor is subject to the influence of
the muscular environment on its crown after emergence into the mouth, and that
the labiolingual contour of the alveolar process is in turn subject to the influence
of its contained teeth and their orientation. It is possible, that the alveolar
process itself may be subject to the direct effect of its muscular environment at
least in the very early stages of development before teeth erupt. This indicates
that tooth germ is not the principal determinant for the site of emergence. The
presence of adjacent teeth and the funnel shape of the alveolar process are
possible factors in guiding the crown towards the area enveloped by the
attached gingiva. Thus the contour of this funnel will, itself, have been
somewhat influenced by the inclination of the deciduous teeth, affecting both
overjet and overbite (Leighton and Adams, 1986).
There are many causes of severe overbite; of these causes are dental or skeletal
developments. The following dental traits have been related in the literature to
excessive overbite: 1) Incisor supraeruption, 2) excessive overjet, 3) interarch
tooth size discrepancy with deficient lower dentition 4) retroclined incisors, 5)
increased posterior to anterior facial height ratio 6) overclosure with posterior
vertical dimension (Parker et al., 1995).

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In addition Parker defined these specific factors directly related to the
development of deep bite:
Incisor supraeruption
In studies by Thompson, Prakash, and Popovich, it was correlated that
supraeruption of incisors led to an increase overbite (Popovich, 1955; Prakash
and Margolis, 1952; Thompson, 1953).
Excessive overjet
Goldstein conducted an extensive study evaluating various types of occlusion
and amounts of overbite in normal and abnormal occlusion of a sample of 306
children between 17 months and 12 years of age. It was suggested that, a
disturbance in the overbite in normal occlusion might therefore well be a first
sign of a tendency toward definite malocclusion. A significant correlation was
excess vertical overbite is almost always associated with excessive horizontal
overjet (Goldstein and Stanton, 1936).
Mesial to distal width of anterior teeth
Steadman, Neff, and Fleming all investigated overbite and the association with
tooth ratio. What was found was discrepancies in mesial and distal width of
anterior teeth could tend to lead to moderate and excessive overbite. It was
more commonly associated with discrepancies in the lower arch and specifically
if there was a lower missing lateral the tooth size discrepancy would not only

7

tend to have greater overjet but greater overbite as well (Fleming, 1961; Neff,
1949; Steadman, 1974).
Incisor angulation
Popovich investigated how angulations of incisors correlated with overbite. It
was found that the interincisal angle is highly correlated to the changes in the
overbite in the Class II cases, but correlation decreases in Class I deep overbite
cases. In both deep overbite groups the inter-incisal angle plays an important
role in determining the degree of overbite (Popovich, 1955).
Schudy introduced the occlusomandibular plane angle, the angle formed by the
occlusal plane and mandibular plane as an aid in measuring overbite. The
occlusomandibular plane angle provides a measurement of relative posterior
alveolar height. Schudy discovered that the: ramus height, posterior alveolar
height and interincisal angle measurement are significantly related to the
severity of overbites (Schudy, 1963).
Ludwig’s study evaluated cephalometrically the relationship between facial
pattern and interincisal angulation to anterior overbite changes. 100 cases were
evaluated pre and post orthodontic treatment. Correlations were made between
the amount of interincisal angulation and the severity of the overbite (Ludwig,
1967).
Steadman reported that overbite was dependent upon the degree of angulation

8

of the incisor teeth. It was shown that as the overbite decreased as the
interincisal angle decreased below 180 degrees. Similarly overbite increased at
a more rapid rate as the interincisal angle increased above 180 degrees
(Steadman, 1974).
Molar cusp height
Bolton’s study evaluated 55 cases with “excellent” occlusions investigating
tooth size and anatomy and its relation to the analysis and treatment of
malocclusion. What was found in relation to overbite development was that
while no significant correlation between overbite and incisor length could be
found, there was a significant correlation between molar cusp height and
overbite (Bolton, 1958). Likewise, in other studies conducted by Fleming and
Popovich it was found that overbite is affected by the depths of the cusps of the
molars and premolars. Thus, a strong positive correlation was found between
cusp height and the degree of vertical overbite in normal occlusions (Fleming,
1961; Popovich, 1955).
Mandibular ramus height
Fleming investigated the development of vertical overbite during the eruption of
permanent dentition. He was trying to determine the relationship between ramus
height and overbite development. In this study it was reported that relating
ramus height to overbite development, was the primary factor in increasing the
vertical development of dental height is the growth in the length of the ramus. It

9

is indicated that poor development of growth of the ramus length inhibited the
eruption of posterior teeth, ultimately resulting in an excessive degree of
overbite (Fleming, 1961).
Sassouni Classified skeletal facial types and skeletal factors which lead to
characterizations of deep-bites. The vertical relationship of the maxilla and the
mandible may be realated to the creation of a skeletal related deep-bite. The
unfavorable association of a lack of vertical growth between the cranial base
and the maxillary posterior teeth and an excess of growth of the ramus and
posterior cranial base permits the mandible to rotate in a closing direction.
When the teeth are reduced in size and number, the dental arches oppose less
resistance to mandibular closure. When the posterior vertical chain of muscle is
strong and anteriorly positioned, a greater depressive action is transmitted to
the dentition. Sassouni described deep-bite tendency based on skeletal
Classifications (Sassouni, 1969).
Vertical facial type
Wylie obtained results from clinical material comprising of ninety cases, which
indicated a relationship between vertical overbite and total height of the face.
The study demonstrated that as the total facial height diminishes there is an
associated increase in the depth of the bite (Wylie, 1946).

10

Janson conducted a study evaluating variations in maxillary and mandibular
molar and incisor vertical dimension in 12 year old subject with excess, normal,
and short, lower anterior face heights. A sample of 188 males and 156 females
at the age of 12 were separated into the facial height groups and evaluated. He
reported that short lower anterior face height is a frequent characteristic of
patients who have deep overbite. On the other hand, excessive lower anterior
face height (LAFH) is a frequent characteristic of many patients presenting with
anterior open bite. However, not all long-faced patients have open bites and not
all open bite patients are long faced (Janson et al., 1994).

Overbite in untreated populations
The first long term study of growth and changes in overbite was done in 1988 by
Bergersen. He

attempted an extensive study on the changes in overbite from 8
to 20 years of age. He classified the sample into subjects with increased
overbite (>3 mm) and normal or decreased overbite (<3 mm). General trends
observed in this study for the increased overbite group were that 80% of the
overbites greater than 3 mm at 8 years still exceeded 3 mm by adulthood, and
overbite increased during the exchange of incisors and deciduous molars from 8
to 11 years of age, whereas it decreased during eruption of the second and third
molars between 13 and 20 years of age (Bergersen, 1988). It is important to note
that this study was defined excessive overbite as >3mm, while all other studies

11

have defined overbite >4mm. Also the study was semilongitudinal due to the
fact that subjects were not the same a development ages. Finally, the study
investigated more the changes of overbite, not specifically focusing on severe
overbite malocclusions.
The findings of Feldmann studied a sample size of 47 untreated Swedish
children with specific malocclusions (Class II Division 1 deep-bites) over 11.5
year span. Neither orthodontic treatment nor tooth extractions were performed
on the sample during this period of observation. A minimum overbite qualifying
as deep-bite was approximately 75% of the clinical crown height of the
maxillary central incisors. From adolescence to adulthood average overbite
changed form 4.5mm to 3.9mm, with a difference of -0.6mm. Although, their
longitudinal study was small, it was statistically significant with improvements of
overbite (Feldmann et al., 1999).
Hong conducted a study evaluating changes in malocclusion over a 25-year
period. 46 subjects, eight had had orthodontic intervention (five males and three
females) although not necessarily full fixed appliances. It was determined that
over the 25-year period was overjet and overbite both decreased. The
limitations of this specific study although longitudinal over a period of 25 years,
the heterogeneity of the sample varied greatly (Hong et al., 2001).

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Studies have evaluated the natural development of overbite in growing
individuals ranging from prepubertal to pubertal to postpubertal development.
Those who observed similar changes in overbite in previous studies attributed
the changes mainly to the exfoliation of the deciduous teeth and the tooth
eruption sequences during the mixed dentition phase.

It is important to note that
no subject examined at Baccetti’s study attained any self-correction of the
deep-bite at the end of the prepubertal growth period. This would indicate
overbite worsens significantly during the prepubertal period, but improves
significantly at the pubertal growth spurt. This is related to the amount of
vertical growth of the mandibular ramus and the eruption of the mandibular
molars. It is important to note that is was concluded by Baccetti that
improvements in overbite cannot be solely predicted on the basis of skeletal
vertical relationships (Baccetti et al., 2011).
Other studies have also investigated the evolution of overbite in adult
populations. Sinclair also investigated the development of untreated normal
occlusions. 65 untreated cases were studied and evaluated occlusal changes
over the mixed dentition (9 to 10 years), early permanent dentition (12 to 13
years), and early adulthood (19 to 20 years). Changes were similar for males and
females and it was found that from 9 to 13 years, during the period of transition
from the mixed to the permanent dentition, the overjet and overbite were seen to
increase significantly, whereas from 13 to 20 years, during the maturation of the

13

permanent dentition, these changes were reversed and decreases in overjet and
overbite were noticed (Sinclair and Little, 1983).
Carter studied the longitudinal dental arch changes in adults. This study
investigated changes in the dental arches that occur in untreated persons
between late adolescence and the fifth or sixth decade of life. Longitudinal
dental casts from 82 subjects were obtained as part of a recall study of subjects
from the University of Michigan Elementary and Secondary School Growth
Study. The untreated sample comprised 53 subjects (27 males and 26 females).
A midadult sample of 10 persons, who had an additional set of records taken on
average during their fourth decade of life also was analyzed, as was a sample of
13 subjects who received orthodontic treatment as adolescents and were about
30 years posttreatment. It was found that no change in overbite in females or
males occurred. Attrition could affect an assessment of overbite; it was found
that overbite appears to be stable in un-treated adults (Carter and McNamara,
1998).
A similar study but with slightly different results was done by Bishara who
conducted a longitudinal investigation the facial and dental changes in untreated
adulthood between the ages of 25 and 46 years. Equal sample size of
orthodontically untreated 15 women and 15 men were evaluated. The goal of
Bishara’s study was to evaluate the normal “maturational” process of dentition.
Contrary to Carter’s study, it was noted that there was a statistically significant

14

increase in overbite (1.0mm) in females but not males over adult development
(Bishara et al., 1994).
With similar results, Bondevik’s study examined occlusal changes in adult
dentition between the age of 23 and 34 years. The sample size consisted of 64
females and 80 males of Norwegian descent. At initial time point alginate
impressions and wax bites were taken and study cast were poured up. The
same procedure was performed at a second time point, approximately 10 years
later. Overbite decreased significantly in males at 0.16mm, but the variation in
changes was large, overbite was 2.88mm in females and 3.15mm in males. It
was concluded that overbite decreases slightly in adult dentition with more
significant reduction in males over females (Bondevik, 1998).
Mechanism of correction
The correction of overbite is one of the primary objectives in orthodontic
treatment. Excessive overbite has been considered one of the most common
malocclusions and in the past, one of the most difficult to treat successfully
(Callaway, 1940; Grieve, 1928; Mershon, 1937).

Overbite can be corrected by one or the following mechanisms: 1) Maxillary
incisor intrusion 2) Mandibular incisor intrusion 3) Incisor proclination 4) Maxillary
posterior extrusion 5) Mandibular posterior extrusion 6) Mandibular autorotation
(Parker et al., 1995). Overbite treatment has been accomplished by fixed

15

appliances, removable, and surgical approaches. It is important to note that not
all patients with deep overbite should be treated with the same mechanics.
Some patients require intrusion of the anterior teeth, while others require
primarily extrusion based on esthetic evaluation and upper incisors display at
rest and at smile.

Incisor intrusion
Burstone’s segmental wire technique is used to for overbite correction by
intrusion. Six principles must be considered in incisor or canine intrusion: (1) the
use of optimal magnitudes of force and the delivery of this force constantly with
low-load-deflection springs; (2) the use of a single point contact in the anterior
region; (3) the careful selection of the point of force application with respect to
the center of resistance of the teeth to be intruded; (4) selective intrusion based
on anterior tooth geometry; (5) control over the reactive units by formation of a
posterior anchorage unit; and (6) inhibition of eruption of the posterior teeth and
avoidance of undesirable eruptive mechanics (Burstone, 1977). The Burstone
group, showed overbite reduction by incisor intrusion without any substantial
extrusion of posterior teeth. As a consequence, no significant posterior rotation
of the mandible took place. It is concluded that in adult patients the segmented
arch technique (Burstone) can be considered as being superior to a
conventional continuous arch wire technique if arch leveling by incisor intrusion

16

is indicated (Burstone, 1977). Ng found that true incisor intrusion is achievable in
both arches, but the clinical significance of the magnitude of true intrusion as
the sole treatment option is questionable for patients with severe deep-bite. In
non-growing patients, the segmented arch technique can produce 1.5 mm of
incisor intrusion in the maxillary arch and 1.9 mm in the mandibular arch (Ng et
al., 2005).
Weiland evaluated overbite correction using two different orthodontic
techniques continuous arch wire and segmented arches. It was found that in
certain cases, intrusion of incisors is absolutely indicated. This holds true
particularly in patients showing elongation of incisor teeth, e.g., in Class II,
Division 2 cases or after periodontal bone. However, intrusion of teeth may
aggravate the periodontal breakdown in the presence of plaque and
inflammation. Experiments on dogs clearly showed that orthodontic movement
can shift supragingival plaque into a subgingival position, producing infrabony
pockets (Ericsson et al., 1977). On the other hand, it has been shown that
orthodontic treatment, including intrusion of teeth, does not result in decrease of
the marginal bone level, provided the gingival inflammation is kept to a minimum
(Melsen et al., 1989). Therefore, in periodontally involved patients, as in all
adults, gingival inflammation should be brought to a minimum before starting
orthodontic treatment and the periodontal condition supervised meticulously
during the orthodontic procedure (Weiland et al., 1996).

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According to Proffit bite depth changes can be made in the mixed dentition by
intrusion of anterior teeth, intrusion is difficult to retain-even in later phases of
full appliance therapy. For this reason, intrusion as a part of early treatment is
seldom indicated. It is often better to defer this treatment until the early
permanent dentition, using an intrusion arch during the first stage of
comprehensive fixed appliance therapy (Proffit et al., 2013).
In a more recent study of overbite correction with the used of incisor intrusion
Aydogdu investigated the effects of mandibular incisor intrusion obtained using
a conventional utility arch versus bone anchorage. The sample consisted of 26
non-growing deep-bite patients with a overbite of ≥5mm. Patients were split
into 2 groups, mini-implants and segmental wire, with the goal of intrusion of the
lower incisors. It was found that incisor intrusion that was achieved using an
implant-supported segmented archwire was no different than the movement
achieved with a conventional intrusion utility arch. Overbite was corrected with
both methods, the only difference between the two methods was in the molar
movement (Aydogdu and Ozsoy, 2011).

When treating overbite by intrusion of incisors it is always important to take into
account the esthetic effects of the vertical position of upper incisors produced
by treatment. Zachrisson study demonstrated that an average smile, reveals 75-
100% of the maxillary incisors, and a low smile, displays less than 75% of the

18

maxillary incisors (Zachrisson, 2007). Lapatki’s study states that coverbite with
gummy smile is a good indication for intrusion of upper incisors and
improvement of the lip –tooth relationship (Lapatki et al., 2004).
Incisor proclination
Otto’s study aim was to determine whether there was a relationship between
amount of incisor intrusion achieved in deep-bite cases and age of patient. It
was reported that the amount of intrusion did not correlate with the age of the
patient. Overbite reduction was due to more than intrusion alone, contributing
factors included increase in lower face height, along with a labial flaring of
incisors during treatment. The overbite correction was the combination of
flaring and incisor intrusion, which produced a “pseudo-intrusion.” This is the
vertical effect of the incisal edge due to the change in inclination of an incisor
(Otto et al., 1980).
Ball evaluated overbite correction comparing orthodontic techniques of
Andresen, Harvold, Begg, and an untreated group. It was found that all three
appliances successfully reduced the overbite. Reduction tended to be more
stable with functional appliances. In contrast to fixed appliances, functional
appliances rely on passive eruption of the buccal segments and where the
upper segments are restrained as well as anterior capping allowing only lower
molar eruption. Some functional appliances involve incisor proclination, which
contributes to overbite reduction. Overbite was reduced by a combination of

19

factors which varied according to the appliance used. Overbite was primarily
corrected with Begg by primary lower incisor intrusion, while Harvold and
Andresen by incisor proclination, and molar eruption (Ball and Hunt, 1991).
In Franchi’s study their goal was to evaluate the correction of deep-bite patients
treated with two-phase orthodontic treatment. A sample of 58 subjects with
deepbite (mean age 9.7 years, overbite ≥4.5 mm) was treated consecutively with
a two-phase protocol. Overbite was reduced by 1.9 mm in the treated group as
a result of overall treatment. It was concluded that upper and lower incisor
proclination, leads to a reduction of the interincisal angle, and significant
overbite improvement (Franchi et al., 2011).
Posterior extrusion
Some investigators have concluded that extrusion of posterior teeth and flaring
of incisors, rather than intrusion, are responsible for much of the overbite
correction. Barton’s study evaluated overbite changes in the Begg and
edgewise treatment with cephalograms. They reported that mandibular molars
extruded and that the mandibular incisors maintained their vertical position. This
correction was accompanied by both upper incisor extrusion and by a decrease
in the maxillary incisor-cranial base angle. It was also found that both the
mandibular plane and occlusal plane angle increased significantly when treated
with Begg technique (Barton, 1972).

20

Dake’s study investigated differences in overbite correction between Ricketts
and Tweed leveling techniques. A sample from two offices of 60 growing
patients was used. Mandibular incisors in the Ricketts group demonstrated
more flaring and anterior bodily movement during treatment, with a greater
amount of post-treatment uprighting and overbite relapse than the Tweed
group. Both the Ricketts and Tweed-type arch leveling techniques were
successful in overbite correction, with minimal increases in mandibular plane
angle and anterior facial height noted. The Ricketts group demonstrated slightly
more than 1 mm of true lower incisor intrusion; this change was relatively stable
after treatment. Both techniques produced similar amounts of mandibular molar
extrusion during treatment; these changes remained stable after treatment
(Dake and Sinclair, 1989).
A study by Weiland evaluated overbite correction of 50 non-growing adult
patients with both segmental and continuous arch wire orthodontic treatment.
He concluded that the continuous arch wire treatment corrected overbite with
extrusion in the molar region (Weiland et al., 1996).

Mandibular Rotation
Overbite correction can be treated by different mechanisms. Although bite depth
changes can be made in the mixed dentition by intrusion of anterior teeth,
intrusion is difficult to retain in later phases of full appliance therapy. For this

21

reason, intrusion as a part of early treatment is seldom indicated. It is often
better to defer this treatment until the early permanent dentition, using an
intrusion arch during the first stage of comprehensive fixed appliance therapy
(Proffit et al., 2013). Use of continuous arch wire (CAW) which leads to extrusion
of the posterior teeth and subsequent posterior rotation of the mandible has
been shown to correct overbites (Weiland et al., 1996).

Based on the available evidence it appears that growing patients tend to have
overbite correction mainly by growth coupled with posterior extrusion, while
non-growing patient’s overbite correction is based on anterior intrusion, incisor
proclination, and mandibular rotation.

Customized appliances
Non-customized appliances consist of standard brackets. Tip, torque, rotations,
and in-and-outs are incorporated to the base of the non-customized bracket. In
contrast, customized appliances are setup on the individual case according to
the position of teeth. Thus unique, bases, brackets, and wires are fabricated
based on the initial setup. Incognito is a fully customized lingual orthodontic
appliance where brackets and wires are computer designed and manufactured
to provide individualized treatment solutions. When comparing non-customized
lingual brackets to customized Incognito
®
brackets, Stamm et al. (2005)

22

observed significantly less restriction of the lingual space, fewer speech
impediments and less biting and chewing impairments with the Incognito
®
appliance, as well as fewer pressure sores and lesions on the tongue.
Accuracy of custom appliances
Shpack conducted an experiment examining the accuracy of non-customized
bracket placement in labial versus customized lingual systems and indirect
versus direct bonding techniques. Forty pretreatment dental casts of 20
subjects were selected. For each dental cast, four types of bracket placement
were compared: labial direct, labial indirect, lingual direct, and lingual indirect.
Direct bonding was performed with the casts held in a mannequin head. Labial
brackets were oriented with a Boone gauge, and lingual brackets were oriented
with the Lingual-Bracket-Jig System. It was determined that labial and lingual
systems have the same level of inaccuracy. For both systems, indirect bonding
significantly reduces absolute torque error and rotation deviation (Shpack et al.,
2007).
Pauls’ study specifically evaluated the accuracy of customized bracket system
Incognito®. The patient group in this retrospective study included 50 dental
arches (25 upper and 25 lower arches) of 25 patients – 15 females and 10 males
– between the ages of 15 and 56. Each jaw was bonded with the Incognito
®
bracket system. The therapeutic set-up casts and final treatment casts were

23

digitalized using a 3D scanner, and the scans were subsequently superimposed.
The deviations in rotation and translation of each tooth in the three spatial
dimensions were calculated. The front teeth showed deviations in rotations of
less than 4.6° and in translations under 0.5 mm. It was concluded that lingual
orthodontic treatment using individualized brackets correlate satisfactorily with
the therapeutic set-ups (Pauls, 2010) and that was in agreement with Grauer
and Proffit (2011).
A study by Grauer and Proffit evaluated accuracy in tooth positioning with fully
customized lingual orthodontic appliance. In this study sample size consisted of
94 consecutive patients from 1 practice, with a broad range of orthodontic
problems. It was determined that fully customized lingual orthodontic
appliances were accurate in achieving the goals planned at the initial setup, with
slight discrepancies <1mm and 5 degrees of rotation between the setup and
outcome. The only larger discrepancies were seen in second molars (Grauer and
Proffit, 2011).
Goal
The purpose of this study is to determine the mechanism of overbite correction
with customized appliances.

24

MATERIALS AND METHODS

Sample
Sample consisted of 39 consecutively treated cases with the Incognito lingual
system from a single orthodontic office in Germany. All cases were treated by a
single practitioner with over 10 years of experience in customized lingual
appliances. The sample was divided into growing and non-growing groups
according to chronological age. 18 years of age was used to separate non-
growing and growing groups. The inclusion criteria consisted for our sample
consisted of patient with an overbite > 4mm measured on cepholgrams. All
patients were then fully treated with incognito lingual brackets seen in Figure 1.
Lateral cephalometric radiographs taken before treatment (T1) and immediately
after treatment (T2). In addition, pre and post orthodontic intraoral photos were
also available as seen in Figure 2.

There were 13 males and 26 females, with and age rage from 11 to 57, in the
sample. 19 individuals were growing patients and 20 were non-growing patients.
The sample consisted of angles Classification Class I, Class II Division 1, and
Class II Division 2 patients. Malocclusions included both crowding and spacing
representing all different malocclusions. Treatment was planned for each case’s
individual treatment needs, thus, extractions, interproximal reduction, and

25

elastics were used if indicated. Based on each cases individual treatment needs,
brackets were computer generated based on setup (manual), which was
prepared at the beginning of treatment. All cases were indirectly bonded.

Method
Cephalometric radiographs were digitized and traced in Dolphin Imaging
Software (Dolphin Imaging Chatworth, CA). All tracings were performed by the
author and verified by Dan Grauer. In case of disagreement cephalograms were
retraced. The following variables were measured: (SNA, SNB, ANB, U1_SN,
IMPA, Interincisal angle, OJ, Total_FH, Upper_FH, Lower_FH, Post_FH,
PFH_AFH, MPA, SN_GOGN, OCC_SN, U1_PP, L1_MP, U6_PP, L6_MP OB_INI,
Days_Tx, OB_Diff) In order to verify changes, tracings were superimposed by
the Bjork structural method (Table 1). Descriptive statistics and comparison
between subgroups are presented.

Cephalometric Analysis
Lateral cephalograms were acquired in maxium intercuspation the lips in a
relaxed position. Each cephalogram was reoriented to natural head position,
based on SN plane 7 degrees upward anteriorly to Frankford plane.

47 landmarks were digitized using Dolphin Imaging Software 11.5 for both time

26

points in the sample of 39 consecutive cases (Table 2). In order to assess
changes, tracings were superimposed by the Bjork structural method. When
cephalometric structures overlapped tracing points were taken based on the
average of left and right side.
Cephalometric superimposition were based on cranial base, key ridge, body of
the symphysis, third molar crypt, and mandibular canal as seen in Figure 3.
Statistical analysis
Descriptive statistics, comparison of means and comparison between
subgroups are presented. In order to account for repeated measurements the
level of significance was set to 0.01. Descriptive statistics for growing, non-
growing, and combined sample are presented. Significance of changes with
growth and treatment were tested by one-sample t-test and comparisons were
tested by independent samples t-test.

27

RESULTS

Treatment and aging changes in growing patients included: 1) molar extrusion
(U6 = 1.3mm, L6 =2.2mm) 2) anterior incisor extrusion (U1 = -0.6mm) 3) anterior
incisor intrusion (L1= 0.8mmm) 4) anterior incisor flaring (U1 1.7 degrees, L1 =
2.2 degrees). Molar extruded with a net extrusion of 3.5mm. Anterior intrusion
with a net intrusion of 0.2mm. Posterior facial height grew 3.1mm and lower
anterior facial height grew 2.3mm. The difference in overjet, LFH, PFH, extrusion
U6, extrusion L6, and correction of overbite were statistically different from 0
(Table 3).

Treatment and aging changes in non-growing patients included: 1) minimal
molar extrusion (U6 = 0.3mm, L6 =0.8mm) 2) anterior incisor extrusion (U1 =
0.3mm) 3) anterior incisor intrusion (L1= 1.4mmm) 4) greater anterior incisor
flaring (U1 2.6 degrees, L1 = 6.4 degrees) 5) mandibular autorotation (clockwise
0.5 degrees). Upper molar extruded with a net extrusion of 1.0mm. Upper
anterior extruded with a net intrusion of 1.1mm. The difference in overjet, IMPA,
Intrusion L1, extrusion L6, and correction of overbite were statistically different
from 0 (Table 3).

28

Treatment and aging changes in combine groups consisting of entire sample of
non-growing and growing patients included: 1) molar extrusion (U6 = 0.84mm,
L6 =1.5mm) 2) upper anterior incisor extrusion (U1 = 0.45mm) 3) lower anterior
intrusion (L1 = 1.1mm) 4) anterior incisor flaring (U1 2.1 degrees, L1 = 4.3
degrees). Molar extruded with a net extrusion of 2.34mm. Anterior intrusion with
a net intrusion of 0.65mm. Posterior facial height grew 0.83mm and lower
anterior facial height grew 0.74mm. The difference in overjet, LFH, PFH,
intrusion L1, extrusion U6, extrusion L6, and correction of overbite were
statistically different from 0 (Table 4).

There was a statistically significant difference in molar eruption between growing
and non-growing groups. The rest of the variables did not show a statistical
significant difference assuming level of significance at 0.01. SNB, LFH, and
PFH, almost reached significance with the following p values respectively:
p=0.04, p=0.046, p=0.012 (Table 5).

29

DISCUSSION

Sample selection
Our study consisted of a consecutively treated sample of patients with an
OB>4mm from a single orthodontic office. No effort was made to select specific
patterns of malocclusion. Cases where orthodontic treatment required
orthognathic surgery were excluded; as well as cases where skeletal anchorage
was employed. Because of that, some cases required retraction and
uprightment of incisors, while other cases require proclination of incisors. This
produced differences in results relative to other studies where samples were
selected based on a specific malocclusion criteria.

Type of appliance
A difference from most other studies is that the sample in our study was treated
with a fully customized lingual technique. Treatment goals are incorporated into
a setup before treatment and appliances are fabricated based on the individual
setup. Research has shown that CAD/CAM customized lingual appliances are
able to deliver results on average accurate within 1mm and 6 degrees of the
desired final position of each tooth (excluding 2
nd
molars) (Grauer and Proffit,
2011; Grauer et al., 2012; Pauls, 2010; Vu et al., 2012; Wiechmann et al., 2003).
Other studies employed conventional orthodontics where goals are achieved by

30

an optimization of treatment decisions and interventions during a period of
approximately 2 years.

By the same token, the sample was highly heterogeneous with patient
conditions varied from angle’s Classifications, crowding/spacing,
extraction/non-extraction, and growing/non-growing. This diversity of patient
conditions reduces the power of our study. Further research on a larger sample
with homogeneous groups will be needed in the future.

Correction of overbite in growing patients
In our study we obtained a 3.1mm of overbite correction. It is observed that the
overbite correction is related to the pre-treatment overbite, the desired post-
treatment overbite and the treatment/growth effects.
Dake reported overbite of Ricketts technique of 3.9mm change, and Tweed of a
4.3 mm change (Dake and Sinclair, 1989). Although it would appear the data
would indicate that both Ricketts and Tweed mechanics would result in greater
overbite correction, it depends on initial overbite and type of sample.
Differences of the inclusion criteria of Dake’s study required a 50% overbite
while our study defied our overbite sample as any >4mm. Also Dake’s sample
consisted of only Class II patients, this is expected to display greater overbite,
potentially attributing to a greater recorded overbite correction.

31

Our value of 3.11mm of overbite correction fell in-between values of 2.5mm and
3.3mm correction, evaluating correction mechanics with intrusion arch or
biteplate treatment respectively (Lindauer et al., 2005). The pretreatment
overbite mean differed from our 4.1mm initial overbite to the intrusion arch
sample of 5mm and the bite plate of 5.5mm. This would suggest a greater value
of overbite correction in both samples. The intrusion arch and biteplate study
had a similar sample of various Class I and Class II cases such as our sample.
With this assumption our data suggests that our customized lingual system
corrected overbite similarly to that of bite plate treatment than that of intrusion
arches. It is important to consider the difference between the studies, which
could account for variations of averaged values. The difference consisted that
the treatment method for each patient, intrusion arch or bite plate, was
determined by the orthodontic resident and attending orthodontist to be the
best treatment for that particular patient (Lindauer et al., 2005), while our sample
consisted of cases by a single orthodontist and consecutive cases.
Parker conducted a study of correction of overbite with a growing patient
sample similar to our study (Parker et al., 1995). The sample consisted of
growing patients with malocclusions of Class I and Class II, extraction and non-
extraction cases. The difference is that Parker separated the sample based on
angles Classification. It can be assumed that our value should fall somewhere
in-between these values, but instead Class I of 4.17mm, Class II-I of 6.08mm,

32

and Class II-II 4.86mm were all over our calculated average of 3.11mm. This can
be attributed that Parker used a greater initial overbite inclusion criteria of 70%
coverage.

In untreated individuals reported by Baccetti et al. (2011), natural development
of overbite correction was evaluated with over a time period from prepubertal to
postpubertal. Initial overbite inclusion criteria slightly differed from our study in
that overbite was ≥4.5mm. No treatment to overbite resulted in a 1.3mm
correction compared to our 3.11mm overbite correction. This would indicate
although there is some overbite correction is based solely on growth, there is
not enough correction without the aid of orthodontic treatment.

Angular skeletal measurements in growing patients
In our study the average SNA change was different from the one reported by
Ricketts and Tweed (Dake and Sinclair, 1989). We measured a SNA change -
0.46 degrees compared to Ricketts and Tweed values of -2.7 and -2.3
respectively. This difference can be attributed to the fact that their sample
consisted of only Class II non-extraction patients. In a study evaluating
correction by cervical headgear with bite plate (HG/BP) and headgear only (HG)
values were very similar to ours at -0.7 and -0.9 respectively (Thurman et al.,
2011). Their study included Class II patients and ours included all angle

33

classifications. In the non-treated sample there is a + 1.6 degree change
(Baccetti et al., 2011) most likely as a result of growth and no Class II treatment
mechanics applied.

In our study SNB value change +0.31 was very similar to other studies. SNB
values measured consisted of: Ricketts +0.6, Tweed+0.2, HG/BP -0.01, and HG
+0.5 (Dake and Sinclair, 1989; Thurman et al., 2011). Yet, there was a difference
in the non-treated sample with an SNB change of +2.1 degrees. This difference
in the untreated population can be attributed to the lack of posterior rotation of
the mandible induced by the extrusion, secondary to orthodontic treatment.

Based upon the recorded values of change in SNA and SNB our recorded value
of ANB change of -0.73 was similar to that HG/BP -0.7, HG -0.9, and untreated -
0.5 (Baccetti et al., 2011; Thurman et al., 2011). Since there was a difference of
SNA value in Dake’s study it is expected to see a difference in ANB values in
Ricketts -3.3 and Tweed -2.5 (Dake and Sinclair, 1989).

Angular incisal measurements in growing patients
The calculated U1-SN change in our study of +1.66 degrees and IMPA change
of +2.25 degrees was within the range measured of other studies. The variation
of incisor inclination change can be attributed to the overbite correction

34

mechanism. For example Tweed U1-SN change was -2.4 degrees indicating a
preference of upright incisors and that overbite correction mechanics is not
based on anterior flaring (Dake and Sinclair, 1989). Another example is Ricketts
had a IMPA change of +5.3 degrees, intrusion arch +4.2 degrees and bite plate
+5.2 degrees indicating overbite correction mechanics of lower incisor flaring
(Dake and Sinclair, 1989; Lindauer et al., 2005). Meanwhile the no treatment
study had an U1-SN of -0.9 and IMPA +1.1 degrees, indicating natural
development of dentition does not include anterior flaring of incisors (Baccetti et
al., 2011). Orthodontic correction of overbite and Class II often involves some
degree of extrusion and posterior rotation of mandible as well as flaring of
incisor. These consequences have negative impact on stability of orthodontic
treatment results.

Linear skeletal measurements in growing patients
Our study indicated increase of both lower and posterior facial heights, of
+2.29mm and +3.13mm respectively, while minimal change in MPA of -0.04
degrees and SN-GOGN of -0.08 degrees. When compared to other studies
similarities were seen in PFH both Ricketts +3.8mm and Tweed +3.9, while
minimal change in LFH in Ricketts -0.6mm and Tweed +0.7 (Dake and Sinclair,
1989). This would indicate that Ricketts, Tweed, and our study, the posterior
growth was similar to anterior growth and that overbite was reduced by some

35

molar extrusion without changes in MPA. An example of different use of overbite
mechanisms can be seen in the Lindauer’s study. The intrusion arch sample
demonstrated minimal LFH growth of +0.9mm due to the incisor intrusion to
correct overbite. While the bite-plate sample had a greater change of LFH due
to posterior extrusion mechanics to correct overbite (Lindauer et al., 2005).
Based on the no treatment sample it is expected to have increases in both LFH
+7.9 and PFH +12 with slight changes of SN-GOGN -2.8 and MPA -3.8 (Baccetti
et al., 2011). It is important to take into account that this study evaluated growth
over a much greater period of time than our study ranging from pre-pubertal to
post pubertal, while our growing sample primarily consisted of pubertal to
postpubertal. This would account for the difference seen in both LFH and PFH.
Nevertheless when our study is compared to the non-growing sample, it is
apparent that uniform growth in LFH and PFH is expected.

Linear incisal/molar measurements in growing patients
Measured values of U1-PP of +0.65mm, L1-MP of -0.78mm, U6-PP of
+1.34mm, L6-MP +2.25mm, indicate treatment with customized lingual
appliance resulted in slight upper incisor extrusion, slight lower incisor intrusion,
and upper and lower molar extrusion. Even though one would expect some
upper incisor intrusion while correcting overbite we were able to maintain the
upper incisor vertical position while correcting the overbite. Intruding upper

36

central and lateral incisor often has negative esthetic consequences for the
patient, except when indicated. Class II with over eruption of upper incisor
intrusion of upper incisor produces an appearance of unaesthetic smile (Sarver,
2001; Sarver and Ackerman, 2003; Zachrisson, 2007). Based on our values it
indicates a very slight net anterior intrusion with greater molar extrusion. This is
similarly seen in Dake’s study where Ricketts treated patients had an anterior
net intrusion of 0.1mm and U6-PP of +2.5mm and L6-MP of +2.6mm. As
expected from minimal LFH change with greater PFH change, the tweed sample
had a minimal net anterior extrusion of +0.5mm with a greater posterior
extrusion value of U6-PP +2.5mm and L6-MP +3.7mm (Dake and Sinclair,
1989). As expected the use of an intrusion arch resulted in an U1-PP of -2.4mm
while biteplate treatment had only minimal change on the U1 with a value of U1-
PP change of -0.9mm (Lindauer et al., 2005). It is important to note for
Lindauer’s study variation in comparison of results can be attributed to the value
of incisor intrusion was based on the clinical lip-tooth change. The posterior
extrusion can be attributed to compensation of PFH growth. This can be seen in
the non-treated study, which both PFH changed greatly and as a result of molar
extrusion compensated for growth resulting in U6-PP of +5.5mm and L6-MP of
+5.8mm (Baccetti et al., 2011).

37

All studies showed molar extrusion, this is due to orthodontic treatment and
growth. The lower incisor showed intrusion and this is due to specific
mechanics of pure intrusion or a combination of intrusion and flaring. The
combination of intrusion and flaring occurs when an incisor is flared and its
incisal edge assumes a lower position relative to upper incisor reference.

Correction of overbite in non-growing patients
The average change of overbite correction in non-growing patients recorded in
our study was 2.69mm of correction. A similar study compared overbite
correction between continuous arch wire (CAW) and Burstone segmental wire
treatment. Slightly greater average overbite correction recorded in both CAW of
3.17mm and Burstone 3.56mm. While inclusion criteria similarly defined initial
overbite patients as ≥4mm, initial overbite average was slightly greater in this
study at 5.39mm while in our study overbite initial was 4.72mm. This difference
in initial overbite could attribute to the slightly greater overbite correction
recorded. Additional differences in their study consisted that only “low angle”
patients were used in the sample (Weiland et al., 1996).

Angular incisal measurements in non-growing patients
When compared our reported change in incisor proclination with the study of
continuous arch wire (CAW) and segmental Burstone technique our recorded

38

value of U1-SN +2.62 degrees differed to CAW -2.35 degrees and Burstone -0.1
degrees (Weiland et al., 1996). This difference can be attributed that there were
more notable cases in CAW than Burstone, which were treated with extractions
or had existing congenitally missing teeth, thus it is expected to see incisor
retraction in these extraction cases.

The recorded change in IMPA with customized brackets of +6.45 degrees was
slightly greater than CAW +5.71 degrees and Burstone +3.94 degrees (Weiland
et al., 1996). It is expected to see more incisor proclination to correct overbite
in continuous arch wires versus segmental mechanics. Also in non-growing
patients there is no active facial growth to compensate for molar extrusion and
posterior rotation of the mandible. As mentioned before the extractions and
congenital missing teeth in different samples will affect the amount of incisor
proclination, which is expressed in the change values of both the CAW and
Burstone sample.

Linear skeletal measurements in growing patients
Our recorded LFH change of +0.74mm fell in-between the CAW +2.35mm and
Burstone +0.38mm. The greater value of LFH change in CAW would indicate
more extrusive mechanics, while as expected the sectional wire of Burstone
mechanics is intended for intrusion, hence the minimal LFH change (Weiland et

39

al., 1996). This may suggest that customized mechanics with a continuous
archwire induces less extrusive forces that non-customized systems due to
better of intercuspation and final occlusion.

In our study we recorded the least amount of PFH change with customized
lingual appliances of +0.57mm, which was similar to Burstone +0.61mm change,
while different to CAW +1.35mm change. It is expected as non-growing
patients that there is minimal changes in the PFH, thus, any significant changes
could be attributed to posterior extrusion. Thus we can expect minimal posterior
extrusion in both the customized lingual appliances and Burstone.

Differences in MPA between our +0.55 degrees from CAW +1.94 and Burstone
+1.62 degrees is attributed to the other study’s sample consisted of only low
mandibular angle patients.

Linear incisal/molar measurements in non-growing patients
In non-growing patients it minimum facial height changes will occur. Overbite
correction mechanics must be accomplished by anterior flaring or incisor
intrusion. Our study demonstrated that with customized lingual appliance slight
U1-PP extrusion of +0.25mm and greater L1-MP intrusion of -1.4mm, with
minimal posterior extrusion of U6-PP of +0.33 and L6-MP of +0.77mm. When

40

compared to CAW similar changes are expressed in the anterior segment with
slight extrusion U1-PP +0.26 and more intrusion of the L1-MP -1.03mm. The
difference is that CAW has more posterior extrusion of U6-PP +1.63mm and L6-
MP of +1.3mm, thus manifesting in a greater LFH and PFH change and causing
mandibular posterior rotation. While Burstone’s segmental wire goal is to intrude
incisors with an intrusion change of U1-PP -1.5mm and L1-MP -1.7mm. It is
important to note that with upper incisor intrusion there are associated negative
esthetic effects on smile appearance (Sarver, 2001; Sarver and Ackerman,
2003). In addition, there is minimal posterior change, as Burstone sample
resulted in change of U6-PP -0.14 and L6-MP +0.56mm. Based on these values
we may assume Burstone has more anterior intrusion mechanism, resulting less
mandibular rotation and minimal increase of LFH, when compared to
customized lingual and CAW systems.

41

CONCLUSIONS

Growing and non-growing differed (as expected) in the increase of facial
heights. Growing patients had significant posterior and anterior facial height
growth resulting in more posterior extrusion to correct the overbite. Non-
growing patient had very minimal posterior facial height growth. This resulted in
greater incisor flaring and autorotation of the mandible in overbite correction.

Incisor inclination depended on the desired inclination designed into the custom
lingual appliance as opposed to increased inclination (flared) incisors often
reported in other studies. Overbite correction was a combination of molar
extrusion, incisor intrusion, incisor flaring, and mandibular autorotation. Future
research is needed to define the target overbite for specific patients in order to
prevent wear and allow for optimum function.

42

TABLE 1. Selected cephalometric variables given to depict the change of
overbite and the neighboring structures.

Variable Description
SNA
This angle indicates the horizontal position of the maxilla relative to the
cranial base
SNB
This angle expresses the horizontal position of the mandible relative to
the cranial base
ANB Angle measures the relative position of the maxilla to mandible.
U1-SN
This angular measurement determines the inclination of the central
incisor relative to the anterior cranial base
IMPA
The axial inclination between the mandibular incisor and the inferior
border of the mandible
OJ
The extent of vertical overlap of the maxillary central incisors over the
mandibular central incisors
LFH Linear measurement from Anterior Nasal Spine to Menton
PFH Linear measurement from Sella to Gonion
MPA
The anterior angle formed by the intersection of SN and GoGn is
measured for assessment of the steepness of the mandibular plane in
relation to the cranial base
SN-
GOGN
Angle measuring the inclination of the mandibular plane in relation to
the anterior base of the cranium.
OB-INI Initial overbite measurement
U1-PP Upper incisor to palatal plane
L1-MP Lower incisor to palatal plane
U6-PP Upper molar to palatal plane
L6-MP Lower molar to palatal plane
OB-
DIFF Change of overbite

43

TABLE 2. Definition of landmarks.

Landmark Definition
Point A
The inner most point on the contour of the premaxilla between anterior nasal
spine and the tooth
ANS (anterior nasal
spine) The tip of the anteiror nasal spine
Point B
The inner most pointon the contour of the mandible between the incisor tooth
and the bony chin
Ba (Basion)
The lowest point on the anterior margin of foramen magnum, at the base of the
clivus
Gn (gnathion) The center of the inferior point on the mandibular symphysis
Na (Nasion) The anterior point of the intersection between the nasal and frontal bones
PNS (posterior nasal
spine) The tip of the posterior spine of the palatine bone
Pog (pogonion) The most anterior point on the contour of the chin
Ar (Articular)
The point of intersection between the shadow of the zygomatic arch and the
posterior border of the neck of the condyle
Po (porion) The midpoint of the upper contour of the external auditory canal
SO (sphenoccipital
syncondrosis) The junctions between the occipital and basisphenoid bone
S (sella) The midpoint of the cavity sella turcica
Ptm
(pterygomaxillary
fissure) The point at the base of the fissure where the anterior and posterior walls meet
Or (orbitale) The lowest point on the inferior margin of the orbit
Me (menton) The most inferior point on the mandibular symphysis
Go (gonion) The midpoint of the contour connecting the ramus and body of the mandible
Floor of sella Most inferior point of the pituitary
Clinoidale Posterior point of the roof of orbit, where it meets anterior of sella turcica
Roof of orbit Most superior point of the roof of the orbit
Supraorbitale
Most anterior point of the intersection of the shadow of the roof of the orbit and
its lateral
Center of symphysis The center of the symphysis structure
Ramus point Most posterior point up the border of the ramus
Mid Ramus Most concave point on the inferior ramus
Sigmoid notch Most inferior border along the top of the ramus
Condylion Most posterior superior point of the condyle
U6 Occlusal Mesial buccal cusp tip of the maxillary molar
L6 occlusal Mesial buccal cusp tip of the mandibular molar
Distal U6 Distal surface of the upper first molar
Mesial U6 Mesial surface of the upper first molar
Distal L6 Distal surface of the lower first molar, perpendicular to the occlusal plane

44

Mesial L6 Mesial surface of the lower first molar, perpendicular to the occlusal plane
Third molar distal The most distal border of the developing third molar crown
Third molar mesial The most mesial border of the developing third molar crown
IA superior posterior The superior posterior point along the inferior alveolar canal
IA superior anterior The superior anterior point along the inferior alveolar canal
IA inferior posterior The inferior posterior point along the inferior alveolar canal
IA inferior anterior The inferior anterior point along the inferior alveolar canal
L1 labial gingival
border Labial cemento-enamel junction of the lower central incisor
L1 tip Tip of lower central incisor
L1 root Root apex of the lower central incisor
L1 lingual gingival
border Lingual cemento-enamel junction of the lower central incisor
Internal symphysis
superior
The most superior point along the internal aspect of the posterior symphasial
border
Internal symphysis
inferior
The most anterior point, on the inferior portion, along the internal aspect of the
posterior symphasial border
U1 labial ginigval
border Labial cemento-enamel junction of the upper central incisor
U1 tip Incisal tip of the upper central incisor
U1 root Root apex of the upper central incisor
U1 lingual ginigval
border Lingual cemento-enamel junction of the upper central incisor

45

TABLE 3. Descriptive statistics for overbite correction in growing and non-
growing individuals are depicted. Note “avg” is the average change and “SD” is
the standard deviation. Significant changes in growing group were: overjet,
lower facial height, posterior facial height, upper molar extrusion, lower molar
extrusion and overbite correction. Significant changes in non-growing group
were: lower incisor flaring, overjet, lower incisor intrusion, lower molar extrusion,
and overbite correction. We consider significance when p≤0.01 (highlighted in
bold).

Variable
Growing
avg
Growing
SD
Growing
p value
Non-Growing
avg
Non-Growing
SD
Non-Growing
p value
SNA -0.46 1.53 0.194 -0.72 1.14 0.013
SNB 0.31 1.27 0.29 -0.5 1.09 0.06
ANB -0.73 1.39 0.03 -0.21 0.77 0.25
U1-SN 1.66 8.49 0.393 2.62 6.88 0.114
IMPA 2.25 7.47 0.194 6.45 6.31 ≤0.01
OJ -2.11 1.2 0 -1.97 1.66 ≤0.01
LFH 2.29 2.91 0.002 0.74 1.54 0.051
PFH 3.13 3.59 0.001 0.57 2.25 0.282
MPA -0.04 2.46 0.943 0.55 1.69 0.177
SN-GOGN -0.08 1.87 0.85 0.54 1.97 0.251
U1-PP 0.65 1.64 0.095 0.25 1.26 0.394
L1-MP -0.78 1.76 0.061 -1.4 1.18 ≤0.01
U6-PP 1.34 1.5 0.001 0.33 0.6 0.03
L6-MP 2.25 1.99 ≤0.01 0.77 0.95 0.002
OB-DIFF -3.11 1.17 ≤0.01 -2.69 1.17 ≤0.01
*p≤0.01

46

TABLE 4. Combine descriptive statistics for the entire sample. Both growing
and non-growing cases are combined in this table. Note “avg” is the average
change and “SD” is the standard deviation. Significant changes in the entire
sample were: SNA angle, lower incisor flaring, overjet, lower facial height,
posterior facial height, lower incisor intrusion, upper molar extrusion, lower
molar extrusion and overbite correction. We consider significance when p≤0.01
(highlighted in bold).

Variable
Combine
avg
Combine
SD
Combine
p value
SNA -0.59 1.34 0.01
SNB -0.08 1.24 0.672
ANB -0.48 1.15 0.014
U1-SN 2.13 7.66 0.091
IMPA 4.29 7.16 0.001
OJ -2.05 1.43 ≤0.01
LFH 1.53 2.44 ≤0.01
PFH 1.89 3.25 0.001
MPA 0.25 2.11 0.473
SN-GOGN 0.22 1.92 0.478
U1-PP 0.45 1.46 0.06
L1-MP -1.08 1.52 ≤0.01
U6-PP 0.84 1.25 ≤0.01
L6-MP 1.53 1.72 ≤0.01
OB-DIFF -2.91 1.17 ≤0.01
*p≤0.01

47

TABLE 5. Descriptive statistics comparison between growing and non-growing
groups. Significant differences between the 2 groups were: upper molar
extrusion and lower molar extrusion. We consider significance when p≤0.01
(highlighted in bold).

Variable Comparison of differences
SNA 0.551
SNB 0.04
ANB 0.161
U1-SN 0.701
IMPA 0.066
OJ 0.762
LFH 0.046
PFH 0.012
MPA 0.394
SN-GOGN 0.322
U1-PP 0.41
L1-MP 0.206
U6-PP 0.01
L6-MP 0.006
OB-DIFF 0.28
*p≤0.01

48

FIGURE 1A. Incognito fully customized lingual orthodontic appliance, with a full
sized wire. Each bracket is customized to the lingual surface of each tooth. Wire
was customized and bent by robot bent wire. Note the wire is fully engaged in
the slot of all the braces.

49

FIGURE 2A-B. Severe overbite patient pre and post customized lingual
orthodontic appliance treatment. Figure 2A is initial overbite malocclusion.
Figure 2B is post orthodontic treatment, note the overbite correction in as well
as the leveling and alignment of dentition.

50

FIGURE 3A-C. Figure 3A superimposition of initial and post customized lingual
orthodontic treatment. Case was a non-growing female treated with non-
extraction treated with fully customized lingual braces. Figure 3A was
superimposed over cranial base, figure 3B was superimposed over key ridge,
and figure 3C was superimposed over incisive canal, 3
rd
molar crypt, and
internal symphysis. Note the upper and lower anterior flaring and lower incisor
intrusion, with slight posterior extrusion to correct the overbite in this case.

51

FIGURE 4A-B. Figure depicting average changes in growing and non-growing
groups. (Red) posterior facial growth. (Green) upper and lower molar extrusion
with net extrusion value. (Orange) upper and lower facial height. (Blue) upper
and lower anterior flaring. (Purple) mandibular rotation. (Pink) upper and lower
anterior incisor extrusion and intrusion with net intrusion value. (Black) overbite
correction. Note that in Figure 4A, growing cases tend to have more facial height
growth and posterior extrusion, while Figure 2B, non-growing cases tend to
have more anterior flaring, anterior intrusion, and mandibular rotation. Both
groups have similar overbite correction.

52

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Abstract (if available)

Abstract BACKGROUND: Overbite is the vertical relation of the upper to lower incisors. Normal overbite is considered normal within 1-3 mm, and excessive over 4 mm. ❧ OBJECTIVE: Goal of this study is to determine the mechanism of overbite correction with customized appliances. ❧ MATERIALS AND METHODS: Cephalometric radiographs for 39 consecutive cases with >4 mm. of overbite were digitized and traced in Dolphin Imaging Software. In order to assess changes, tracings were superimposed by the Bjork structural method. All cases were from a single orthodontic office in Germany and treated with Incognito lingual system. Sample was divided into growing and non-growing subgroups according to chronological age. Descriptive statistics and comparison between subgroups are presented. ❧ RESULTS: Treatment and growth changes in growing patients included: 1) molar extrusion 2) anterior incisor intrusion 3) anterior incisor flaring. Treatment and aging changes in growing patients included: 1) minimal molar extrusion 2) anterior incisor intrusion 3) greater anterior incisor flaring 4) mandibular autorotation. The difference between groups was the increase in facial heights. ❧ CONCLUSIONS: Growing and non-growing differed (as expected) in the increase of facial heights. Incisor inclination depended on the desired inclination designed into the custom lingual appliance as opposed to increased inclination (flared) incisors often reported in other studies. Overbite correction was a combination of molar extrusion, incisor intrusion, incisor flaring, and mandibular autorotation. Future research is needed to define the target overbite for specific patients in order to allow for optimum function.

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Creator Morita, Scott L. (author)

Core Title Overbite correction with fully customized lingual appliances

School School of Dentistry

Degree Master of Science

Degree Program Craniofacial Biology

Publication Date 04/09/2013

Defense Date 03/07/2013

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag braces,customized appliances,deepbite,lingual,OAI-PMH Harvest,orthodontics,overbite

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Sameshima, Glenn T. (committee chair), Grauer, Dan (committee member), Paine, Michael L. (committee member)

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