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Prevalence and Severity of Anterior Deep Bite in a Sample of Orthodontic Patients

Authors:

Abstract

Background: The maxillary dental arch being larger than the mandibular arch allows the maxillary anterior teeth to overlap the mandibular anterior teeth. This overlapping of the maxillary teeth occurs in both the horizontal and vertical directions. The horizontal overlap is called overjet while vertical overlap is termed overbite. accordingly some degree of vertical overlapping or overbite is a normal feature of human dentition. However, some patients present with excessive overbite. deep bite was defined as a condition of excessive overbite, where the vertical measurement between the maxillary and mandibular incisal margins is excessive when the mandible is brought into habitual or centric occlusion. Objective: The aim of this study was to evaluate prevalence and severity of anterior deep bite among a sample of orthodontic patients. Results: Out of patients having deep bite, the majority (80.8%) had mild deepbite, 15% had moderate deep bite and 4.2% had severe deep bite. There was a difference in the severity of deep bite between males and females. Higher percentage of males had moderate to severe deep bite, Skeletal contributing factors were associated with 15% of patients with deep bite. There was no difference in the prevalence of specific skeletal pattern between males and females with deep over bite.. Conclusion: The prevalence of anterior deep bite among the sample of Egyptian orthodontic patients was 65.6%. There was no difference in the prevalence of deep bite between males and females.
Australian Journal of Basic and Applied Sciences, 8(15) September 2014, Pages: 237-244
AENSI Journals
Australian Journal of Basic and Applied Sciences
ISSN:1991-8178
Journal home page: www.ajbasweb.com
Corresponding Author: Mohamed Abuelazayem, Post graduate student. Cairo university, orthodontic Department, faculty
of oral and dental medicine, Cairo. Egypt.
Tel: +201004116272, E-mail: mabaaaza84@yahoo.com.
Prevalence and Severity of Anterior Deep Bite in a Sample of Orthodontic Patients
1Mohamed Abuelazayem, 2Sayed Hafez, 3Foad Sharaby
1Post graduate student, Orthodontic department, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt.
2Professor, Orthodontic department, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt.
3Lecturer , Orthodontic department, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt.
A RT I C LE I NF O
A B ST R AC T
Article history:
Received 25 June 2014
Received in revised form
8 July 2014
Accepted 25 August July 2014
Available online 29 September 2014
Keywords:
Prevalence, skeletal, dental, deepbite
Background: The maxillary dental arch being larger than the mandibular arch allows
the maxillary anterior teeth to overlap the mandibular anterior teeth. This overlapping
of the maxillary teeth occurs in both the horizontal and vertical directions. The
horizontal overlap is called overjet while vertical overlap is termed overbite.
accordingly some degree of vertical overlapping or overbite is a normal feature of
human dentition. However, some patients present with excessive overbite. deep bite
was defined as a condition of excessive overbite, where the vertical measurement
between the maxillary and mandibular incisal margins is excessive when the mandible
is brought into habitual or centric occlusion. Objective: The aim of this study was to
evaluate prevalence and severity of anterior deep bite among a sample of orthodontic
patients. Results: Out of patients having deep bite, the majority (80.8%) had mild
deepbite, 15% had moderate deep bite and 4.2% had severe deep bite. There was a
difference in the severity of deep bite between males and females. Higher percentage of
males had moderate to severe deep bite, Skeletal contributing factors were associated
with 15% of patients with deep bite. There was no difference in the prevalence of
specific skeletal pattern between males and females with deep over bite.. Conclusion:
The prevalence of anterior deep bite among the sample of Egyptian orthodontic patients
was 65.6%. There was no difference in the prevalence of deep bite between males and
females.
© 2014 AENSI Publisher All rights reserved.
To Cite This Article: Mohamed Abuelazayem, Sayed Hafez, Foad Sharaby, Prevalence and severity of anterior deep bite in a sample of
orthodontic patients. Aust. J. Basic & Appl. Sci., 8(15): 237-244, 2014
INTRODUCTION
Deep bite was defined as a condition of excessive overbite, where the vertical measurement between the
maxillary and mandibular incisal margins is excessive when the mandible is brought into habitual or centric
occlusion (Graber, 2011).
Deep bite can be classified into skeletal and dental deep bite. Skeletal deep bites are usually of genetic
origin. This kind of deep bite is caused by upward and forward rotation of the mandible and can be worsened by
downward and forward inclination of the maxilla. On the other hand, dental deep bite is characterized by
absence of any skeletal complicating features that are seen in skeletal deep bites. Dental deep bites occur due to
over-eruption of anterior teeth or infra-occlusion of molars.
It was reported that the prevalence of deep bite varied from 11% to 26.1 % in adult populations(Soh et al.,
2005), (Gabris et al.,2006), and from 36.6% to 76% in adult orthodontic patients (Celikoglu et
al.,2010),(Naeem et al.,2008), skeletal deep bite has been found to be associated with smaller total anterior
facial hight, smaller lower anterior facial hight, more horizontal mandibular, occlusal and palatal planes, smaller
gonial angle (Beckmann,1998),(Ceylan,2001),(Isaacson et al.,1971),(Lauc et al.,2003),(Sassouni,1964).
Although, many studies of the prevalence of deep bite in different populations have been reported, a review
of the literature indicates that only a few studies evaluated the prevalence of deep bite in a referred
population(orthodontic patients). Accordingly, the aim of the current study was to investigate the prevalence of
skeletal and dental anterior deep bite in Egyptian orthodontic patients.
MATERIALS AND METHODS
The sample of the current study comprised pretreatment records of 800 patients (256 male, 544 female)
collected from the records of outpatient clinic of Orthodontic Department, Faculty of Oral and Dental Medicine,
Cairo University.
238 Mohamed Abuelazayem et al, 2014
Australian Journal of Basic and Applied Sciences, 8(15) September 2014, Pages: 237-244
All the selected cases in the current study fulfilled the following criteria: (1)Age ranged from 15 to 25
years.(2)No history of previous orthodontic treatment, trauma or surgery that could affect the occlusion.(3)No
serious disease in the craniofacial region.(4)No previous trauma or surgery (affects occlusion) in the craniofacial
region.(5)Patient free from any systemic disease.
The records for each case enrolled into the sample included panoramic, lateral cephalometric radiographs
and a well trimmed study model. For every case in the sample study model were analyzed regarding molar
relationship according to Angle’s Classification, overjet and overbite.
Records were then screened to identify cases with deep bite from which 200 patients were randomly
selected for cephalometric analysis. Lateral cephalometric radiographs of the 200 cases were traced and
analyzed to identify underlying skeletal pattern.
1-Study model analysis:
Overjet:
Defined as the distance between the incisal edge of the upper central incisor and the labial surface of the
lower central incisor measured in millimeters. The overjet from 0 to less than 2mm was accepted as normal.
Overjet more than 2 mm was considered increased. Reversed overjet was considered when all upper incisors in
cross bite. (Fig.1)
Overbite:
Defined as the percentage of vertical overlap of lower incisors by the upper incisors. Overbite was
considered normal when 1/3 of the lower incisor was covered by the upper incisor. Vertical overlap ranging
from 1/3 to less than 2/3 was considered mild deep bite, while from 2/3 to less than full length of the lower
incisor was considered moderate deep bite, equal to or more than full length of lower incisor was considered
severe deep bite. Open bite was considered when vertical overlap was less than 0 mm. (fig.2)
All Measurements was carried out using digital caliper.(fig.3)
Molar relationship: (according to Angle’s classification) (Angle,1899).
Fig. 1: Diagram showing overjet.
Fig. 2: Diagram showing overbite.
2-Lateral cephalometric tracing and reliability assessment:
Lateral cephalometric radiographs were hand traced on 8” x 10” matte acetate papers of 0.003-mm
thickness with a sharpened 2H lead-drafting pencil. Intra-examiner reliability was assessed by retracing (10%)
of the cephalometric radiographs by the same researcher after two weeks; also inter-examiner reliability was
assessed by evaluation of the identified landmarks in (10%) of the cephalometric radiographs by another
orthodontist.
239 Mohamed Abuelazayem et al, 2014
Australian Journal of Basic and Applied Sciences, 8(15) September 2014, Pages: 237-244
Fig. 3: Digital caliper used for linear measurements during study model analysis.
The following angles were traced and measured on lateral cephalometric radiogradiograph:
1- SNA angle: determined by S-N and N-A lines. It determines the Relationship of the maxilla to the cranial
base (average 83°+3).
2- SNB angle: determined by S-N and N-B lines. It determines the Relationship of the mandible to the cranial
base (average 80°+3).
3- ANB angle: determined by N-A and N-B lines. It determines anteroposterior relationship of the maxilla to
the mandible (average 2°+2).
4- MP/PP (maxillary mandibular plane angle): determined by mandibular and palatal planes. It
determines vertical relationship of the maxillary basal bone to the mandibular basal bone (fig.4)(average 25°
+3).
5- ANS Xi Pm angle (lower facial hight angle): the angle formed by the intersection of ANS-Xi line and
Xi-Pm line. It determines the vertical relation of the mandible and the maxilla (average 42° +4).
6- MPA (Mandibular plane angle): angle between mandibular plane and Frankfort horizontal plane
(average 26° +4).
7- Ar Go Me (Gonial angle): determined by Ar-Go and Go-Me lines it represents the angle of the mandible
(average 127° +5).
8- Y axis angle: the angle formed by the intersection of S-Gn line and frankfort horizontal plane. It
determines the growth patteren whether vertical or horizontal (average 60°).
9- PP/FH angle: the angle between palatal plane and Frankfort horizontal plane.
Fig. 4: MP/PP angle traced on a lateral cephalometric radiograph.
240 Mohamed Abuelazayem et al, 2014
Australian Journal of Basic and Applied Sciences, 8(15) September 2014, Pages: 237-244
Statistical analysis:
Numerical data were presented as mean, standard deviation (SD) and standard error (SE) values.
Student's t-test was used to compare between Cephalometric measurements in males and females except for
ANB °, PP/FH ° and PFH/LAFH °, overbite and overjet data which showed non-normal (non-parametric)
distribution. accordingly, Mann-Whitney U test was used to compare between males and females. This test is
the non-parametric alternative to Student's t-test.
Qualitative data were presented as frequencies and percentages. Chi-square (x2) test was used to compare
between males and females.
The significance level was set at P 0.05. Statistical analysis was performed with IBM SPSS Statistics
Version 20 for Windows.
Method error:
Inter and intra-observer reliability (agreement) were measured using Cronbach’s alpha reliability
coefficient. Cronbach’s alpha reliability coefficient normally range between 0 and 1. The closer Cronbach’s
alpha coefficient to1.0, the higher the reliability
Results:
The study was conducted on 800 subjects; 256 males (32%) and 544 females (68%). The age range was from 15
25 years with a mean and standard deviation values of 19.7 ± 4.5 years.
Prevalence of deep bite
525 subjects (65.6%) had deep bite, 161 males (30.7%) and 364 females (69.3%). Of those 525 subjects; 424
subjects (80.8%) had mild deep bite, 79 subjects (15%) had moderate deep bite and 22 subjects (4.2%) had
severe deep bite. (Fig. 18)
Amount of over bite
The mean and standard deviation values of overbite were 4.4 ± 1.4 mm with a minimum of 2 mm and a
maximum of 10 mm.
Over jet (in patients with deep bite)
23 subjects (4.4%) had reverse overjet, 116 subjects (22.1%) had normal overjet, 386 subjects(73.5%) had
increased overjet.
Molar relation (in patients with deep bite)
319 cases (60.8%) had Class I molar relation, 190 cases (36.2%) had Class II molar relation, 6 cases (1.1%)
had Class III molar relation while 10 cases (1.9%) had missing molars.
Canine relation (in patients with deep bite)
250 cases (47.6%) had Class I canine relation, 261 cases (49.7%) had Class II canine relation, 6 cases (1.1%)
had Class III canine relation while 8 cases (1.5%) had missing canines.
Cephalometric analysis
Angle
SNA
SNB
ANB
MP/PP
ANS-Xi-Pm
MPA
Gonial A.
Y Axis A.
PP/FH
Comparison between males and females
There was no statistically significant difference between males and females in prevalence of deep bite,
grades of overjet, molar relation, canine, SNB°, MPA, ANS Xi Pm, MP/PP°, ANB°, PP/FH, Y axis angle,
SNA°.
However, there was a statistically significant difference between males and females in grades of deep bite.
Females showed higher prevalence of mild deep bite than males. Males showed higher prevalence of moderate
and severe deep bite than females. Males showed statistically significantly higher prevalence of normal and
increased Gonial angle than females. Females showed statistically significantly higher prevalence of decreased
Gonial angle than males.
Discussion:
Deep over bite can be classified according to etiology into skeletal deep bite and dental deep bite. Skeletal
deep bite is usually of genetic origin. This kind of deep bite is caused by upward and forward rotation of the
mandible and can be worsened by downward and forward rotation of the maxilla. The skeletal deep bite is
241 Mohamed Abuelazayem et al, 2014
Australian Journal of Basic and Applied Sciences, 8(15) September 2014, Pages: 237-244
characterized by the presence of horizontal growth pattern, reduced anterior facial hight, reduced inter-occlusal
clearance(freeway space), and the cephalometric examination reveals that most of the horizontal cephalometric
planes such as mandibular plane, Frankfort horizontal plane, SN plane are parallel to each other Bhalajhi
(2009).
Dental deep bite is characterized by the absence of any skeletal complicating features that are seen in
skeletal deep bite. Dental deep bite occur due to over eruption of anterior teeth or infra occlusion of molars.
The present study was done to investigate the prevalence of anterior deep bite among Egyptian orthodontic
patients and identify possible skeletal factors associated with it.
In current retrospective study, cases were selected from the patients’ records of the outpatient clinic,
Orthodontic Department, Cairo University according to selection criteria to represent the orthodontic
population.
All subjects in the current sample were confirmed not to have any previous surgery or orthodontic treatment
as this might affect occlusion.
As transient or temporary deep bite could be related to lack of full eruption of posterior teeth. Accordingly,
the age of subjects selected for this study ranged from 15-25 years. This was to assure full eruption of all
permanent dentition with consequent reliability of the assessment of anterior deep bite. This goes in accordance
with Naeem et al (2008) who conducted a similar study on patients with mean age of 17.5 years. On the other
hand Lauc (2003) evaluated the prevalence of malocclusion among a sample aged between 7-14 years.
Both genders were included into the sample to explore any sex differences in malocclusion trait as the
studies of El-Mangoury and Mostafa (1990); Onyeaso (2004) and Rwakatema and Christian (2006) reported
significant sex difference in the prevalence normal occlusion, Angle’s Class I and Angle’s Class III
malocclusion.
The number of female patients (544) 68% compared to (256) 32% male patients in this study clearly
indicates the concern of orthodontic treatment among females in our socioeconomic setup, this is consistent with
the findings of Naeem et al (2008) who conducted a similar study on a sample of 75 female to 25 male and
Erum and Fida (2008) who conducted a study on a sample of 98 female and 58 male orthodontic patient.
The results showed that the prevalence of anterior deep bite among the sample was 65.6%. Naeem et al
(2008) found that 76% of Pakistani patients showed varying values of deep bite. In current study there was no
significant difference in the prevalence of deep bite between males and females. On the other hand in sample
examined by Naeem et al (2008) there was difference in prevalence of deep bite between males and females,
84% and 80% of males and females had deep bite respectively. Helm (1968) found that deep bite was present in
(22.7%) of Danish boys and (14.5%) of girls.
Out of 525 subjects, 424 (80.8%) had mild deep bite, 79 subjects (15%) had moderate deep bite and 22
subjects (4.2%) had severe deep bite. In sample examined by Naeem et al (2008) 50 patient (65.5%) mild, 20
patient (26.5%) moderate, 6 patient (8%) severe deep bite. On the other hand. Erum and Fida (2008) found that
48.7%,17.9% and 3.8% of Pakistani patients, had mild, moderate and severe deep bite respectively. In current
study there was significant difference in severity of deep bite between males and females as higher percentage
of males had moderate and severe deep bite. On the other hand Naeem et al (2008) reported that higher
percentage of females had more severe deep bite as 9% and 5% of females and males respectively showed
severe deep bite.
In the present study, the anterior deep bite was more evident in patients with Angle’s Class I malocclusion
followed by Angle’s Class II and Angle’s Class III respectively, With no significant difference between males
and females in the associations between deep bite and Angle’s Classification. On the other hand in study done
by Erum and Fida (2008), it was reported that anterior deep bite was more current with Angle’s Class II (79%),
followed by Class I (14.5%) and Class III (6.3%) respectively.
Despite the fact that deep bite is most associated with Class II division 2 malocclusion. In this study the
anterior deep bite was more evident in patients with Angle’s Class I malocclusion, this could be related to
mesial drift of lower first molars in some of the cases that might have affected the final results. This was
confirmed by the more evident prevalence of deep bite in patients with Class II canine relation followed by
Class I and Class III respectively in the current study which was coincident with the skeletal relation.
In this study, 12 % of cases had decreased ANS Xi Pm angle indicating skeletal component of deep bite
while 53%, 35% had normal and increased values respectively. There was no statistically significant difference
between males and females in values of this angle. No other study was conducted to assess ANS Xi Pm angle in
cases having deep bite.
In the current study, 15 % of cases had decreased maxillary mandibular plane angle indicating skeletal
component of deep bite while 32% and 53% had normal and increased values respectively. Again there was no
statistically significant difference between males and females in values of that angle. No other study was
conducted to assess the maxillary mandibular plane angle in cases having deep bite.
Concerning Mandibular Plane angle, 10.5 % of cases had decreased value indicating skeletal component of
deep bite while 47%, 42.5% had normal and increased values respectively. Sassouni and Nanda (1964) found
242 Mohamed Abuelazayem et al, 2014
Australian Journal of Basic and Applied Sciences, 8(15) September 2014, Pages: 237-244
that deep over bite was associated with more horizontal mandibular plane than average. There was no
statistically significant difference between males and females in values of that angle.
As far 59 % of cases had increased value of ANB angle indicating that skeletal Class II pattern was more
prevalent in cases having deep bite, this was consistent with findings of Trouten et al (1983) who found a
definite tendency towards skeletal Class II mandibular retrusion in cases having deep bite. In current study 38%,
3% had normal and decreased values of ANB angle respectively. There was no statistically significant
difference between males and females in values of ANB angle.
Regarding PP/FH angle, 27.5% had increased values indicating downward rotation of maxilla anteriorly
which was considered as a contributing factor of skeletal deep bite. 56% and 16.5% had normal and decreased
values respectively. Sassouni and Nanda (1964) reported that deep over bite was associated with more
horizontal palatal plane than average. There was no statistically significant difference between males and
females in values of PP/FH angle.
Concerning gonial angle 36% of cases had decreased values of gonial angle, 53% and 11% had normal and
increased gonial angle respectively. Ceylan et al (2001) and Sassouni and Nanda (1964) found that subjects
with deep bite had a smaller gonial angle than average. In current study males showed significantly higher
prevalence of normal and increased gonial angle than females. Females showed significantly higher prevalence
of decreased gonial angle than males.
Finally, it was found that 16.5% of cases had horizontal growth pattern according to Y axis angle. 45.5%
had vertical growth patteren and 38% had average growth, which indicate definite association between the
growth patteren and incidence of deep bite.
Conclusions:
From the results of the current study the following can be concluded.
1- The prevalence of anterior deep bite among the sample of Egyptian orthodontic patients was 65.6%. Out of
patients having deep bite, the majority (80.8%) had mild deepbite, 15% had moderate deep bite and 4.2% had
severe deep bite. Skeletal contributing factors were associated with 15% of patients with deep bite.
2- There was no difference in the prevalence of deep bite between males and females. There was no difference
in the prevalence of specific skeletal pattern between males and females with deep over bite.
3- There was a difference in the severity of deep bite between males and females. Higher percentage of males
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... An overbite was considered normal when 1/3 of the lower incisor was covered by the upper incisor (grade 0). A vertical overlap ranging from 1/3 to less than 2/3 was considered a mild deep bite (grade 1), a vertical overlap from 2/3 to less than full length of the lower incisor was considered a moderate deep bite (grade 2), and a vertical overlap equal to or more than the full length of a lower incisor was considered a severe deep bite (grade 3) [18]. A negative overbite was considered an open bite. ...
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... Regarding the gender criteria in the study both the genders were included in the groups. It was found by Mohamed Abuelazayemet al. [16]. thatthere was no difference in the prevalence of deep bite between males and females and there was no difference in the prevalence of specific skeletal pattern between males and females with deep over bite. ...
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