Deep bite in adults and children

A beautiful smooth dentition is not only the key to an attractive smile, but also one of the conditions for the normal functioning of the digestive, respiratory and even cardiovascular systems. Unfortunately, people often do not attach particular importance to the violation of the dentition, since it usually does not cause pain, and even outwardly it can be invisible. But in reality, the problem exists. For example, a deep bite associated with improper closing of the teeth can adversely affect the function of chewing, speech, lead to increased abrasion of the enamel coating, etc. With some degrees of such a violation, treatment should be mandatory.

Why is a deep bite dangerous?

Speaking of deep bite, dentists mean a vertical occlusion defect, which is accompanied by increased overlapping of the lower incisors by the upper ones by more than 1/3 of the height. With a deep bite, the appearance of the face suffers, the chewing process is difficult, speech disorders appear. Regular damage to the soft tissues of the gums and palate, increased abrasion of tooth enamel, and violation of the jaw functions are possible.

Correction with a deep bite is a long, difficult process that requires a fairly large investment of both finance and time. The duration of treatment varies, but the sooner the patient seeks help, the sooner he will be able to fix the problem. In addition, the duration of the treatment period depends on the degree of pathology, on the presence of additional deformations and diseases. In any case, the doctor will be able to correctly plan the treatment process, and over time, functional and aesthetic disorders will be eliminated.

If you do not proceed with the correction of a deep bite, then periodontal disease and the entire jaw system may develop in the future, premature tooth loss occurs.

Epidemiology

According to statistics, about 80% of the world's population have problems with bite. And about every third case of them requires specialized orthodontic treatment.

The frequency of such pathologies increases annually. Doctors explain this with the features of modern food. More and more people prefer to eat soft foods, but for the health of the chewing apparatus you need dense, hard foods - in particular, raw plant foods. As a result, the chewing mechanism does not receive the necessary load for it, the jaw does not develop correctly.

Dentists attribute a deep bite to the most common bite defects that patients seek medical attention. According to statistical information, the indicator of the population frequency of this disorder is estimated at 6-51%. Among all defects of occlusion, a deep bite occurs in 20% of cases. [1],  [2], [3]

Doctors call the pathology “traumatic bite”, “deep incisal or frontal overlap”, “deep incisal occlusion or disocclusion”.

Causes of the deep bite

Why is there a deep bite? Practicing dentists have identified a number of possible causes:

• hereditary predisposition;
• pathological overload of the jaw-muscle mechanism associated with various diseases and conditions;
• early loss of temporary teeth;
• improper tooth growth of "wisdom";
• general health problems;
• developmental anomalies, the presence of "extra" teeth.

All processes in the body are predetermined by the human genotype, so genetics largely determines the structure of the maxillofacial system. Often the same problem with the bite is passed on to subsequent generations, and here the fault is of a hereditary predisposition. [4]

As for overloads or improper loads on the maxillo-muscular system, several causal mechanisms are acting here. Firstly, most people prefer soft to rough foods. Secondly, few of us have thought about the principle by which teeth are divided into different functional categories: we are talking about incisors, fangs, premolars and molars.

• Cutters are designed to bite off. At the moment of “biting,” the necessary load enters along the dental axis.
• The purpose of fangs and premolars is tearing and gnawing food, crushing pieces into smaller fractions. At this time, there is a vertical load with a small horizontal force vector.
• Molars are tools for grinding food, which occurs when the lower jaw glides to the sides. During grinding, there are horizontal loads with a direction transverse to the longitudinal dental axis.

If a person has bad habits that violate the mechanism of "work" of the teeth, then sooner or later it leads to the development of certain dentofacial defects.

Another indirect reason for the formation of a deep bite is impaired nasal breathing, with predominant breathing through the mouth. How does the appearance of pathology occur? The fact is that in such a situation, adequate pressure is broken between the nasal and oral cavities. In addition, with a systematically open oral cavity, the tongue assumes a somewhat unnatural position, exerting excessive pressure on the lower jaw (while the upper "rests"). [5]

Incorrect operation and position of the tongue can not only cause dentition, but also reduce the effectiveness of the treatment of deep bite. Here are the factors that influence the occurrence of a violation:

• prolonged breastfeeding;
• prolonged use of nipples, dummies, drinkers;
• the use of food with large volumes of liquid, the habit of drinking at the same time as food;
• shortened frenum of the tongue.

A sucking of the fingers is also considered a negative childhood habit: during this process, the upper dentition is pushed forward, and the lower jaw moves back. This leads to the appearance of a problem.

A common mistake in many adults is a lack of attention to the baby’s temporary teeth. Some parents think that if the teeth change anyway, then you should not pay attention to them. However, displacement often occurs precisely in this period, due to early decay or extraction of milk teeth.

Systemic diseases are another factor that adversely affects the entire body, including the dentition. Metabolic processes are disturbed, a deficiency of vitamins and minerals develops, which over time negatively affects the state of bones and muscles.

Risk factors

The appearance of a deep bite usually occurs under the influence of various general and local factors.

The most common factors are considered:

• genetics, adverse heredity;
• dental diseases;
• diseases of the mother during pregnancy (infectious and inflammatory pathologies, metabolic disorders, polyhydramnios, hypoxia, etc.);
• malnutrition and malnutrition;
• systemic disorders in the body, chronic diseases of the thyroid gland, upper respiratory system, digestive organs;
• bad habits;
• birth defects of the maxillofacial system;
• deformation of bones and spinal column.

Pathogenesis

The main mechanism for the formation of a deep bite in humans is based on a violation of the normal physiology of the maxillofacial system. When the front dentition is deprived of the opportunity to experience the necessary chewing loads, then it loses its correct position, rushing towards the least resistance. Such a displacement is a slow process, but it occurs until the lower incisors come into focus, for example, in the soft tissues of the hard palate. In a similar situation, traumatic occlusion can develop, in which there is constant trauma to the sky.

Among the causes of load imbalance in the anterior region of the dentition, the following can be noted:

• too long a period of breastfeeding;
• prolonged use of pacifiers and bottle teats;
• lack of solid food in the diet;
• labial or linguistic parafunction, etc.

Deep bite refers to vertical bite pathologies. It can form due to genetic, intrauterine, postpartum reasons, among which are systemic diseases, dental and maxillofacial disorders, and bad habits.

Symptoms of the deep bite

A person may discover the first signs of a violation and the formation of a deep bite on his own, or the dentist will diagnose them during a routine appointment. The following are considered characteristic symptoms:

• the lower segment of the face is somewhat shortened, which looks disproportionate;
• the upper lip can be pushed forward, and the lower lip is beveled or slightly tucked under the upper one;
• thinning of the lips occurs;
• if the dentitions overlap significantly, the marginal gingival line may be damaged;
• a person experiences discomfort when biting off and / or chewing food;
• the process of chewing can be accompanied by unaesthetic sounds (champing, etc.);
• many patients have increased abrasion of enamel and periodontal disease;
• speech is disturbed, it is difficult for a person to pronounce individual letters.

Deep bite in adults attracts attention with various aesthetic and functional disorders. External signs are facial and oral. Facial symptomatology consists in shortening the lower segment of the face, strengthening the supramental folds, external protrusion of the lower lip. Sometimes this type of face is spoken “like a bird”. Among the oral signs are the following: the lower front row is overlapped by the upper, the depth of the oral vestibule decreases, the upper jaw dominates the lower. With a pronounced deep bite, the patient can often develop stomatitis, gingivitis, periodontitis, etc.

The violation is often accompanied by a weakening of the tone of the chewing muscles, which entails dysfunction and arthrosis of the jaw system. The patient has aching pains, discomfort and a crack in the joints, pain in the head. [6]

The deep bite in children, unfortunately, is often ignored. But it is precisely in childhood that such a violation can be corrected much easier and faster. In general, doctors determine such basic stages of development that affect the formation of bite features:

• the period from newborn to six months of age;
• from six months to three years (in this period, a temporary bite is formed against the background of teething of temporary teeth);
• from three to six years (there is an active development of the jaw system, which is preparing for the next stage of eruption);
• from six to twelve years (against the background of a mixed bite, a gradual replacement of temporary teeth with permanent ones occurs);
• from twelve to fifteen years (a permanent bite is finally formed).

By about the age of 15, the child completes the final formation of dental arches. Normally, complete closure of the upper and lower rows during chewing should be noted. An exception is the first lower incisors (wisdom teeth appear later). A deep bite in a teenager can develop with any violation of the course of any one of the listed stages. It is important that parents pay attention to the problem in a timely manner, because the child rarely himself indicates discomfort and makes any complaints about the teeth. It is optimal to visit a pediatric dentist every six months, who will accurately determine pathological changes and be able to take appropriate measures in time.

Forms

Dentists have identified two options for the manifestation of the violation - this is the dentition and skeletal form of a deep bite. Dental symptoms are the same in two situations. However, when the dentition changes outwardly, the patient's face looks normal, and with a skeletal form has a disproportionate appearance. A deep skeletal bite is less common and requires complex treatment, which should be started as early as childhood, during the period of active formation of the osteo-maxillary system. If you do not start treatment procedures in time, then only surgery can help.

Deep bite is subdivided according to the type of overlapping of the front row into horizontal and vertical type.

In addition, the violation is of two varieties: distal and neutral.

A deep distal bite always attracts attention regardless of the age of the patient: the chin is reduced and beveled, facial proportions are broken. If such a person smiles, then the exposure of the gum surface is noticeable. In turn, the distal bite is divided into two subtypes:

• fan-shaped teeth against a background of narrowing of the lateral row;
• the upper crowns are as inclined as possible, there is no gap between them.

Another variety is a deep neutral bite, which is almost invisible externally and does not cause violations of facial proportionality. Nevertheless, the supramental fold deepens; when the mouth is opened, overlapping of the lower row by the upper one is revealed. Already at a young age, abrasion of tooth enamel is noticeable, inflammatory processes are often worried.

Other forms of pathology are of the following types:

• A deep open bite is characterized by the appearance of a gap in the lower-upper direction, which is explained by the non-closure of the lateral and frontal teeth.
• A deep traumatic bite is accompanied by a strong overlapping of the crowns, which leads to their touching the cutting edges to the soft tissues (which, accordingly, are injured).
• Deep incisal bite is the last stage of deep non-closure, in which there is a complete coronal overlap.
• A deep cross bite is a broken jaw ratio due to the curvature of specific crowns, or the entire jaw. There are two options for cross-bending:
• deep anterior bite (upper jaw descends into the lower);
• posterior bite (upper jaw covers the lower).
• Deep prognathic bite suggests an incorrect jaw ratio, in which the upper protrudes anteriorly in relation to the lower, and there is no contact between the incisors. Such a defect is attributed to anomalies of the sagittal plane.

Complications and consequences

The most common negative consequence of a deep bite is a violation of the chewing load, as some of the teeth experience an increased load against the background of inaction of others. Overloaded teeth are more prone to various diseases. By about 35 years old, patients with a deep bite begin to notice a noticeable worsening of their condition: there is increased dental mobility, exposure of the roots, enamel erasing, and bleeding gums. The temporomandibular mechanism also suffers, which becomes more vulnerable. There are pains in the head, spine (especially in the cervical region), discomfort occurs during eating or sleeping.

With a deep bite, external unaesthetic disturbances can be detected - for example, hollowness of the cheeks, a change in the shape of the lower jaw, early formation of wrinkles. In turn, such changes often become the causes of depression, neurosis, isolation of patients.

The load on the digestive organs increases, which is associated with insufficient chewing of food. The risk of developing infectious and inflammatory diseases increases (a deep bite sometimes makes it difficult to adequately clean teeth from plaque).

In addition, with a malocclusion in a patient, the dentist often has difficulty performing manipulations on treatment and prosthetics.

In general, we can list the most common negative consequences of a deep bite:

• frequent mucosal injuries, chronic stomatitis;
• improper chewing, swallowing and respiratory function;
• increased vulnerability and abrasion of enamel coating;
• frequent periodontal disease;
• joint diseases, pain in the back and head;
• digestive tract problems;
• psychological and physical discomfort.

Diagnostics of the deep bite

To diagnose and identify types of deep bite, the dentist determines:

• an indicator of the width of the crowns of the lower and upper incisors, their localization relative to the axis (correct position, tendency to retrusion or protrusion);
• the severity of the dental superior incisor tubercles;
• contacting the front teeth;
• mutual relation of fangs with the first permanent molars to the sagittal side (dentition closed in the usual position);
• premature destruction or loss of temporary or permanent posterior teeth;
• mesial inclination, or a shift of the row to a free place as a result of the destruction or removal of other teeth;
• the severity of morphofunctional disorders (Siebert-Malygin method) and the complexity of their correction (Malygin-Bely method). [7]

Appropriate measurements should be made and calculated:

• mesiodistal indicator of crowns of the lower and upper incisors, their total number;
• the degree of correspondence of the totality of mesiodistal indices for the crowns of the lower and upper incisors according to the Ton index (1.35 mm);
• an indicator of the depth of overlap with cutters;
• the size of the sagittal space between the central incisors above and below;
• an indicator of the length of the anterior segment of the dental arches (Korkhaus method);
• an indicator of the width of the dental arches (Pona method, Linder and Hart corrections).

The diagnosis is made based on the results of clinical studies, the study and measurement of the jaws, the metric assessment of photographic facial images from different angles. [8]

In addition, tele-roentgenography is performed - an x-ray of the skull in different projections. The procedure is carried out from a large distance, which allows you to get a picture that is close in size to the original object. For TRG, a special orthopantomograph device is used.

Differential diagnosis

In dentistry, there are several forms of malocclusion, and they must be distinguished. The orthognathic closure is considered optimal when the upper dentition overlaps the lower one quite a bit: this condition is the norm and contributes to optimal chewing function.

Other, incorrect types of closures are as follows:

• distal - it is characterized by excessive maxillary development compared with the underdevelopment of the lower jaw;
• mesial - characterized by an anterior jaw extended forward;
• open - observed when the vast majority of the teeth of both jaws are not closed;
• cross - is characterized by the underdevelopment of one of the dentitions;
• dystopic - a violation with the wrong arrangement of teeth that are in the wrong row.

They say about a deep bite if the upper dentition overlaps the lower by more than 50% of the height of the teeth. [9]

Treatment of the deep bite

Treatment with a deep bite is considered more effective if it is started even during periods when temporary teeth erupt, either the first or second permanent molars, or when temporary incisors are replaced by permanent ones. The doctor sets himself the following tasks:

• neutralization of the root cause that led to the violation;
• correction of the shape of the dental arches and the position of individual teeth;
• stabilization of the mandibular position, normalization of the jaw development.

For correction, various methods and techniques are used, taking into account the initial provoking causes, the period of formation of a broken bite.

If we are talking about a temporary deep bite, it is recommended to explain to children the need to chew solid foods (crackers, raw fruits and vegetables) to stimulate adequate jaw development, normal formation of alveolar processes and the dentition. If caries is found that affects temporary molars, then they are restored as much as possible. They try to eradicate bad habits, such as biting the lips, sucking a finger, etc. This should be done as early as possible, since such habits are not harmless to form a bite.

In the period of an active bite change - from about 5.5 to 9 years - they begin intensive orthodontic correction. It is at this time that lateral tooth decoupling occurs, which leads to dentoalveolar elongation and contact with the corresponding teeth, so the incisal overlap becomes smaller. If a neutral deep bite is diagnosed, then for removable lateral dental separation, special removable plates are used that are installed on the upper jaw and have a bite area for an anterior denture, clasps and other fixators. Such a plate is made on a wax basis, is modeled on the upper jaw and has a thickening in the front, which serves to separate the lateral teeth by a couple of millimeters more than with a physiological calm state. The plate is fixed using clasps, vestibular arcs, or other fixing devices. In order for the lower jaw not to move anteriorly, left or right, the bite area should have imprints of cutting incisal edges and tubercles of the fangs of the second jaw. In some cases, the plate is provided with a spring mechanism or an expander screw.

Sometimes orthodontic eliners are used to correct a deep bite. These transparent mouthguards help to correct the violation invisibly to others, but they are not always shown. They can be used only in patients with a simple displacement. Many experts draw attention to the fact that the effect of treatment with braces and aeliners with a deep bite is almost the same. However, wearing eliners is more comfortable - both psychologically for the patient himself and practically.

Correction with mugs tolerates a deep bite: special pads are made of elastic transparent polymer material, which does not injure soft tissues and is practically not felt in the oral cavity. Mouthguards can solve many orthodontic problems at almost any age.

And yet, most often, experts recommend correcting the deep bite with braces, or the so-called bracket systems. The special design provides the necessary pressure, helping to restore the correct position of the dentition. With a deep bite, you can use any kind of braces - lingual, vestibular, metal, ceramic or ligature. Which type will be more suitable for a particular person, the doctor decides.

Surgery

Often with a pronounced deep bite, conventional treatment does not bring the desired result. In this case, doctors are advised to seek help from orthodontic surgeons.

Invasive orthognathic surgery includes a number of methods and techniques that make the intervention extremely gentle. All manipulations to correct a deep bite and bone defects in an adult patient are performed through the oral cavity, with a minimum intensity of movements of the surgeon and with a minimum incision. [10]

After orthognathic surgery, facial scars do not remain, and the result can be observed immediately after completion of the intervention. The preparation period takes about a month: during this time, the doctor, using special programs, pre-models the necessary manipulations that will be used during surgical treatment. This minimizes the likelihood of risks, as well as shortens the term operation. [11], [12]

What do deep bite patients need to know about possible surgery?

• The operation to correct a deep bite can be performed from the age of 18, at the end of the period of bone growth.
• The operational period lasts approximately 1-6 hours, which depends on the complexity of the problem.
• Intervention is performed under general anesthesia.
• In the postoperative period, orthodontic therapy will be prescribed with the mandatory wearing of braces. The duration of this wearing is determined in a specific order.

After the operation, the patient is given an individual rehabilitation plan and further orthodontic treatment. [13]

Exercises

In the uncomplicated form of a deep bite, the use of various aids is allowed, which, in particular, are special exercises.

Dentists have developed a set of classes that is suitable for independent use at home. Classes should be held regularly, as the success of the event completely depends on this. Optimally, this complex is suitable for children and adolescents, since their maxillofacial system is still at the formation stage. Children are encouraged to perform exercises under the supervision of adults.

To correct a deep bite, you need to carry out such manipulations daily three times a day:

• Open your mouth wide, then gradually rhythmically, applying short translational movements, close it.
• Touch the sky with the tip of the tongue and push the tongue as far back as possible. Keeping your tongue in this position, open and close your mouth.
• Put the elbow of one hand on the table, rest your chin on the palm of the put hand. In this position, open and close the mouth (the head should move, but not the lower jaw).
• Repeat the first exercise.

The above exercises are repeated one after another six times. In addition to classes, one should not forget to load the jaw, regularly chewing hard plant products, which also helps to improve the dentition.

Also, such an exercise should be practiced daily. The patient becomes straight, hands wound behind his back, chin lifts up. It extends the lower jaw as far away as possible, after which it returns to its original position. The exercise is repeated three times a day for fifteen times.

Any such exercises are carried out very carefully, because too intense movements can harm and even lead to the need for urgent medical attention.

Myogymnastics with a deep bite

In childhood, malocclusion is often associated with abnormal function of the maxillofacial muscles. In order for the child to chew, swallow, breathe and speak normally, the muscles of the mouth and face must be balanced. For example, if the baby constantly breathes with his mouth, his mouth is open. This entails excessive tension of the masticatory muscles, a change in the width of the jaws and improper bite formation. Or, when the process of swallowing changes with mimic hyperactivity, the child forms a gap between the front teeth, which entails problems with speech quality. Such examples clearly demonstrate the interconnectedness of the work of human organs.

With a deep bite, doctors often prescribe myogymnastics, which is a kind of training of the facial muscles. We suggest you consider the basic exercises used for such a correction.

• The lower jaw is gradually advanced anteriorly until the lower incisors are in front of the upper. They fix the position for ten seconds, after which they also gradually return to their original position.
• They take a wooden stick, pull a rubber tube over it, place it between the front teeth. The patient alternately clenches and unclenches the jaw.

To achieve the effect, classes are carried out twice a day for about 12-14 times, daily. However, before proceeding to gymnastics, you should first consult your dentist.

Prosthetics with a deep bite in adults

If the question arises about prosthetics, then patients with a deep bite are first sent to the orthodontist - to "raise" the height of the bite.

Prosthetics will be performed after orthodontic therapy. In this case, teamwork is used, during which the orthopedic surgeon is responsible for the overall medical concept. He consults with the orthodontist, discussing the necessary result. The orthodontist, in turn, analyzes how it can be implemented. Next, the orthopedist draws up a diagram of the movement of teeth and passes it to the orthodontist.

If the patient already has any orthopedic devices (veneers or crowns) in the oral cavity, then braces can be placed on them. But, after the completion of the period of orthodontic correction, such devices are most often replaced, due to a change in the occlusion and the shape of the dentition.

After completion of the preliminary treatment, previously established temporary crowns are replaced by permanent ones, taking into account the changed occlusion.

The orthodontic splint - the retainer - is not glued to the orthopedic structure. The exception is veneers: in this situation, the inside of the tooth is not involved, and the tire will be clearly fixed. Ceramic crowns are a poor basis for gluing a retainer, so in this case they use a holding cap. During the year after treatment, the mouthpiece will ease the load on the front teeth, which stabilizes the therapeutic effect.

Prevention

The formation of an incorrect, in particular, deep bite starts in early childhood. Therefore, the first rule of prevention should be addressed to parents. And this is especially important if the family has a hereditary predisposition to such violations. Parents should be careful and consult a doctor at the first sign of a malfunction.

Pregnant women should not only protect their own health, but also remember that the processes of dental mineralization in the unborn baby occur at about 20 weeks of gestation. Therefore, the second trimester of pregnancy is the period when it is necessary to ensure an adequate intake of calcium and fluoride in the body.

Starting from the moment a baby is born, its nutrition should be extremely balanced and complete. The priority, of course, is breastfeeding. During the first months after the birth of the baby lower jaw is still at the stage of pre-formation, therefore, it is smaller than the upper. Breast sucking causes jaw muscles to work intensively, resulting in a gradual alignment of the jaw size. Artificial feeding does not give the muscles the necessary load, since it is much easier to “get” milk from the nipple.

It is equally important to pay attention that the growing baby adheres to nasal breathing, does not have such bad habits as sucking a finger, a dummy, etc.

And another universal means of preventing the appearance of a deep bite at any age is a regular visit to the dentist. The doctor will always pay attention to any violation, monitor the tendency to change the bite, recommend the necessary treatment.

Forecast

The length of the correction period for a deep bite depends on at what age the treatment was started, how pronounced the violation was, whether there were other abnormalities or dental deformities, or whether there were general developmental disorders.

In general, the prognosis is considered favorable, especially if corrective measures were taken at the initial stage of a temporary or permanent bite, and during treatment it was possible to get rid of morphological and functional disorders. The worst prognosis is expected if a deep bite is a genetic feature.

The duration of the further use of various restraining (retention) devices after the end of orthodontic therapy depends on what methods of treatment were used, whether unresolved functional impairments remained, what positive results were achieved, and also on the age of the patient. If it was possible to achieve high-quality dental closure against the background of adequate functioning, further retention may not be required. In case of incomplete elimination of the problem, the patient is prescribed the appropriate holding devices, which are selected depending on the expected most probable dental displacement. The duration of use of such devices is individual.

Deep bite and army

Can a person go to serve in the army with a deep bite? Most recruits think that the quality of the bite does not affect their ability to serve. However, this is not entirely true: some young people are indeed refused a call if their deviation is complex and requires medical correction.

So, regardless of the form of the broken bite (deep, distal, etc.), with a strong deviation of the indicators from the norm, the recruit can be exempted from the need for military service. For example, this is possible:

• with a deep bite of the II degree and a divergence of 5-10 mm against a background of reduced chewing ability (less than 60%);
• with a deep bite of the II - III degree, with a discrepancy of more than 10 mm.

In the latter case, it is especially difficult to go to serve in the army. In most cases, such a conscript is sent for treatment, having previously granted a deferment from service. Completely exempt from conscription men with pronounced intermaxillary discrepancy.

If controversial issues arise at the doctors of the military commissariat, then the suitability category is determined after additional diagnostics. Research is needed to assess the degree of development of the disorder and the quality of the function of chewing products. If the pronounced deep bite is confirmed, then the category “B” is assigned to the conscript and a deferment is given for medical and corrective measures.