|Year : 2012 | Volume
| Issue : 1 | Page : 47-50
Perio-gnathic correction of traumatic anterior deep bite with skeletal class II and retrogenia
KV Arun Kumar, D Deepa
Departments of Oral and Maxillofacial Surgery, and Periodontics, Subharti Dental College, Meerut, Uttar Pradesh, India
|Date of Web Publication||22-Mar-2012|
K V Arun Kumar
Departments of Oral and Maxillofacial Surgery, and Periodontics, Subharti Dental College, Meerut, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Correction of class II deep bite can be achieved by orthodontic treatment alone or by combination of orthodontics and orthognathic surgery. Orthognathic surgery is indicated when dental discrepancy cannot be corrected by the use of orthodontic mechanotherapy alone or when facial aesthetics are compromised. The purpose of this paper is to describe a technique of subapical osteotomy performed along with periodontal therapy, to correct the anterior traumatic deep bite, thus salvaging the mutilated teeth and achieving facial aesthetics.
Keywords: Class II deep bite, skeletal class II, subapical osteotomy, traumatic bite
|How to cite this article:|
Arun Kumar K V, Deepa D. Perio-gnathic correction of traumatic anterior deep bite with skeletal class II and retrogenia. J Interdiscip Dentistry 2012;2:47-50
|How to cite this URL:|
Arun Kumar K V, Deepa D. Perio-gnathic correction of traumatic anterior deep bite with skeletal class II and retrogenia. J Interdiscip Dentistry [serial online] 2012 [cited 2020 Feb 26];2:47-50. Available from: http://www.jidonline.com/text.asp?2012/2/1/47/94194
| Introduction|| |
Anterior traumatic bite is very injurious to the dental and periodontal health, and can cause attrition, crowding and mobility, inability to maintain oral hygiene, gingival recession and alveolar bone defects. Management involves an interdisciplinary approach, addressing the correction of deep bite as well as the maintenance of health of periodontal tissues. This is achieved by controlled intrusion of anteriors and/or extrusion of posterior teeth, orthodontic decompensation, and maxillary or mandibular anterior subapical surgeries. ,, Here, we report an interdisciplinary approach to the management of a case of skeletal class II division-1, deep bite and retrogenia associated with mobility of lower anterior teeth that affected the oral hygiene maintenance.
| Case Report|| |
A 35 year old female patient presented to the department of periodontics, Subharti dental college, Meerut, Uttar Pradesh with a chief complaint of pain and swelling in the anterior palatal gingiva and mobility of the lower front teeth. Extra-oral examination revealed severe skeletal class II with convex profile, incompetent lips, and retrognathia with deep mento-labial sulcus [Figure 1]a. Intraoral examination revealed Angle's class II molar relation, deep bite with indentations in the palatal gingiva, edema and bleeding on slightest provocation/probing [Figure 1]b. The lower anterior teeth showed grade I/II mobility with poor oral hygiene. Maxillary anterior prosthesis (metal prosthetic bridge with porcelain veneering) was prepared by a local dentist in an attempt to correct the proclination and gummy smile. Treatment was planned with a focus to salvage the mutilated teeth. After analyzing the study models, orthopantomogram and lateral cephalogram, the procedure was planned in two stages. First stage included lower anterior subapical osteotomy and intrusion along with genioplasty to correct the lip incompetency, and was followed by periodontal therapy in the second stage.
|Figure 1: a: Pre-operative photograph showing convex profile , incompetent lips, and retrognathia with deep mento-labial sulcus|
Figure 1: b: Pre-operative intra-oral photograph
Click here to view
Under general anaesthesia, an intraoral translabial lip incision was made. The incision is made from canine to canine, about 5 mm from the labial sulcus on the lip mucosa. The incision is deepened through mucosa, submucosa, mentalis muscle and then subperiosteally to expose the bone till the mental foramen and the lower border of mandible bilaterally; and, the surgical site was exposed. Osteotomy cuts were made vertically avoiding the roots of canine and first premolar region bilaterally, and the horizontal cuts were made parallel to each other, about 5 mm apical to the anterior teeth [Figure 2]a and b. Apical reduction of 6 mm was done and the anterior segment was moved down and fixed using two 2 mm Miniplates (Orthomax Stainless Steel minplates, Orthomax surgical Pvt. Ltd., Baroda, Gujarat, India). The lateral oblique osteotomy cuts were made below the mental foramen from the horizontal cuts providing a trapezoidal shape for genioplasty, and advanced to the full cortical thickness and fixed with wires [Figure 2]c and d. Wound was closed in two layers using resorbable sutures. There was a significant reduction of palatal and lower labial gingival swelling. Post-operative healing was uneventful.
|Figure 2: a: Osteotomy design|
Figure 2: b: Intra-operative photograph showing osteotomy cuts
Figure 2: c: Intra-operative photograph showing sub-apical osteotomy and inferior positioning
Figure 2: d: Advancement genioplasty
Click here to view
Periodontal phase I therapy was performed; the tooth mobility was reduced to physiologic mobility by the end of 6 weeks. A permanent lingual retainer with composite splinting was done to prevent supraeruption and relapse. The lower anterior teeth were non-responsive for vitality test in first two weeks; however, regained complete vitality by the end of four months. A stable dento-alveolar unit was established at the end of 12 months. Patient was able to maintain the oral hygiene [Figure 3]a and b. Patient is still under follow-up for further correction of faulty prosthetic rehabilitation.
|Figure 3: a: Post-operative profile photograph|
Figure 3: b: Post-operative intra-oral photograph showing the reduction in occlusal step after anterior subapical osteotomy
Click here to view
| Discussion|| |
Deep traumatic overbite is mostly associated with a class II incisor relationship (either division I or II), with an associated skeletal class II and sometimes in skeletal class III occlusion with reverse overjet.  Deep bite corrections achieved during periods of active growth have been found to be more stable. In most of the cases it requires a prolonged retention, which usually is a removable appliance with a potential biteplane incorporated on to it.  In the present case, class II deep-bite deformity existed with a decreased lower anterior facial height. This was further worsened with crown preparation and a long anterior prosthesis with palatal tipping. Usually, treatment protocol of skeletal class II and anterior deep bite cases depends on the age and stage of skeletal growth. Functional growth modulators have shown promising results at the early or late stages of puberty. The outcome could be predictable and remain stable for longer durations.
In adults, the treatment would be a presurgical, surgical and post surgical orthodontics. The techniques may include anterior subapical osteotomies, upper jaw osteotomies alone or in combination with subapical surgery, and mandibular ramus and body osteotomies.  The mandibular body-ramus osteotomy most popularly performed is the sagittal split ramus surgery. With this technique, the lower jaw can be moved anterior or posteriorly, laterally to correct dental midline discrepancies and minor occlusal cant corrections. 
In the present case, the required presurgical orthodontics was not possible because of anterior prosthesis on root canal treated teeth with no overjet. Hence, treatment was focused to relieve the lower anterior teeth from traumatic occlusion, and periodontal therapy was planned to further enhance the longevity of teeth. Correction of lip competency and chin deficiency was achieved by a trapezoidal shaped chin osteotomy with a remaining chin height of 1.2 cm, and advanced to its full cortical thickness. With this, a reasonable improvement in lip competency and pleasing lower third facial height was achieved. Patient is under the follow-up for correction of faulty prosthesis.
| Conclusion|| |
Each technique of deep bite correction has its advantages and disadvantages, and must be carefully selected considering the specific etiology of the individual's malocclusion and the desired treatment outcome. In our case, the primary goal of salvaging lower anterior teeth was achieved and the lower third facial deficiency was restored with definite improvement. Thus, an interdisciplinary approach, involving surgical intervention, periodontal treatment and prosthodontic rehabilitation, which is still ongoing, will enabled to accomplish the desired results.
| References|| |
|1.||Wong RW. Combined orthodontic-dentofacial orthopaedic treatment of a class II division 2 patient with severe deep bite. J orthod 2002;29:181-8. |
|2.||Wolford LM, Stevao EL, Alexander CM, Goncalves JR. Orthodontics for orthognathic surgery. Peterson's principles of Oral and Maxillofacial Surgery; 2 nd Ed.: BC Decker Inc: Hamilton, London 2004. p. 1128. |
|3.||Nasry HA, Barclay SC. Periodontal lesions associated with deep traumatic overbite. Br Dent J 2006;200:557-61. |
|4.||Ustun K, Sari Z, Orucoglu H, Duran I, Hakki SS. Severe gingival recession caused by traumatic occlusion and mucogingival stress- A case report. Eur J Dent 2008;2:127-33. |
|5.||Blair FM, Thomason JM, Smith DG. The traumatic anterior overbite. Dent Update 1997;24:144-52. |
|6.||Bell WH, Proffit WR, White RP. Surgical correction of dentofacial deformities, Philadelphia: WB Saunders Co; 1980. |
|7.||Sreedhar CV, Baratam S. Deep overbite-A review. Ann Essences Dent 2009;1:8-25. |
[Figure 1], [Figure 2], [Figure 3]