Original Article

Cephalometric evaluation of deep overbite correction using anterior bite

turbos
Sherif G. Elbarnashawya; Marissa C. Keeslerb; Samer Mosleh Alanazic; Howard E. Kossoffd; Leena
Palomoe; Juan Martin Palomof; Mark G. Hansg

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/93/5/507/3259042/i1945-7103-93-5-507.pdf by Peru user on 11 August 2024

ABSTRACT
Objectives: To evaluate the outcome of treating deep overbite (OB) using anterior bite elevators
concurrently with a pre-adjusted edgewise appliance.
Materials and Methods: The Case Western Reserve University (CWRU) cephalometric analysis
was used to isolate tipping movement of upper (TUI) and lower incisors (TLI), bodily tooth
movement of upper (BUI), and lower incisors (BLI), as well as vertical skeletal changes in the
anterior region of the maxilla (MXSK) and mandible (MNSK). Thirty treated subjects were examined
at pretreatment (T1) and posttreatment (T2) and compared to an untreated control group matched
on age, sex, and Angle malocclusion from the Bolton Brush Growth Study Collection (CWRU,
Cleveland, Ohio).
Results: Overbite (OB) in the treated group was decreased significantly (P , .001) (5.6 mm)
compared to controls. Statistically significant (P , .001) changes were found for BUI (0.7 mm),
TUI (0.9 mm), TLI (1.4 mm), BLI (1.1 mm), and MNSK (1.6 mm). Most of the overbite correction
was in the lower arch and included tipping and intrusion of the lower incisors along with an increase
in lower vertical facial height.
Conclusions: Deep OB correction was achieved efficiently using anterior bite elevators with pre-
adjusted edgewise appliance. Correction using bite turbos would be a treatment option for
individuals presenting with decreased lower facial height and deep bite. (Angle Orthod.
2023;93:507–512.)
KEY WORDS: Deep bite; Anterior bite elevators; CWRU analysis; Bite turbos; Cephalometrics

INTRODUCTION both jaws is controlled by molar drift toward the

occlusal plane along with incisor bodily movement
Deep overbite (OB) correction has always been
considered a challenging objective of comprehensive and/or tipping, and vertical skeletal growth of the
orthodontic treatment. The etiology of deep OB is maxilla and the mandible.1,2
believed to develop from multiple factors, hence, the Since the introduction of the orthodontic biteplate, it
various methods and differing appliances designed to has been used as an adjunct in treatment of deep OB.
‘‘open the bite.’’ Ultimately, the vertical discrepancy in A two-phase treatment protocol using removable

a
Former Resident, Department of Orthodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio.
b
Orthodontist, Private Practice, Neenah, Wis.
c
Research Fellow, Department of Orthodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio.
d
Professor, Department of Orthodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio.
e
Professor and Chair, Ashman Department of Periodontology & Implant Dentistry, College of Dentistry, New York University, New
York, NY.
f
Professor and Program Director, Department of Orthodontics, School of Dental Medicine, Case Western Reserve University,
Cleveland, Ohio.
g
Professor and Chair, Department of Orthodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio.
Corresponding author: Mark G. Hans, DDS, MSD, Professor and Chair, Department of Orthodontics, School of Dental Medicine, Case
Western Reserve University, 10900 Euclid Ave., Cleveland, Ohio, 44106-7401
(e-mail: [email protected])
Accepted: March 2023. Submitted: June 2022.
Published Online: May 8, 2023
Ó 2023 by The EH Angle Education and Research Foundation, Inc.

DOI: 10.2319/061622-432.1 507 Angle Orthodontist, Vol 93, No 5, 2023

508 ELBARNASHAWY, KEESLER, ALANAZI, KOSSOFF, PALOMO, PALOMO, HANS

biteplates on deep bite patients demonstrated the of radiographs, (2) not in the range of 10–14 years of
improvement of OB was a result of upper and lower age, (3) use of any functional orthopedic appliances,
incisor proclination.3 More recently, a similar study (4) extractions or missing teeth (excluding third
conducted on prepubertal vs pubertal patients revealed molars), (5) use of intrusion arch mechanics or reverse
that treatment in the permanent dentition leads to a curve of Spee (RCS) wires or temporary anchorage
more favorable outcome through dentoalveolar chang- devices, (6) craniofacial disorders, Angle Class III, or
es with no significant skeletal modification.4 Most orthognathic surgery. Thirty untreated controls,
authors agree that removable biteplates allow the matched for age, sex, and Angle malocclusion were
posterior teeth to erupt into occlusion without intrusion selected from the Bolton Brush Growth Study collection
of the lower incisors, thus, increasing lower vertical (Cleveland, Ohio).12

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/93/5/507/3259042/i1945-7103-93-5-507.pdf by Peru user on 11 August 2024

facial height.5–11
In the last 10 years there has been an increase in the Image Collection
use of anterior bite elevators, also known as ‘‘turbos,’’
All treatment radiographs were taken on a single
in deep bite cases. Considering their small size, ease
machine (CS 8100SC, Carestream Dental LLC, Atlan-
of fabrication, and ease of use, turbos present a
ta, Ga) with patients in natural head position and
convenient alternative to conventional removable
maximum intercuspation. The magnification of the
biteplates. Because turbos are attached to the lingual
lateral cephalograms was consistent at 8% and all
surface of the upper incisors, patient compliance is not
images were de-identified prior to digitization by the
a concern.
investigator (SE). Control group lateral cephalograms
The purpose of this study was to determine the
were retrieved from the digital library of the Bolton
effects of anterior bite turbos in combination with
Brush legacy collection after being scanned via film
pretorqued pre-angulated orthodontic brackets in
digitizer (VIDAR DosimetryPRO Advantage, Vidar
growing patients. The Case Western Reserve Univer-
Systems Corp., Herndon, Va). All orientations and
sity (CWRU) vertical pitchfork cephalometric analysis
measurements were performed by the same investi-
was used to isolate tipping and bodily tooth move-
gator.
ments of the maxillary and mandibular incisors as well
as the vertical skeletal changes.
Technical Details
MATERIALS AND METHODS All images were digitally traced by one investigator
(SE) using commercially available imaging software
Subjects
(Dolphin version 11.95, Patterson Dental Supply INC.,
The Institutional Review Board of Case Western St. Paul, Minn). Six linear landmarks were identified on
Reserve University (IRB #2017-2179) approved this each cephalogram (anterior nasal spine [ANS], center
study, which retrospectively examined the cephalo- of rotation of the maxillary, and mandibular central
metric records of 57 patients treated by a single incisors [CRU1 and CRL1], incisal edges of the
orthodontist in private practice (Marissa Keesler, maxillary and mandibular central incisors [IEU1 and
Neenah, WI). Each patient was treated with anterior IEL1], and Menton [Me]). The images at T1 and T2
bite elevators, 3 or 5 mm in size, fixed on the lingual were digitally superimposed for the best fit of the
surfaces of the maxillary central incisors, and 0.022 3 greater wing of the sphenoid, planum sphenoidale, and
0.028-inch self-ligating brackets. A combination of the anterior wall of Sella. This method of superimpo-
round, square, and rectangular archwires was used sition is a digitally modified version of a cephalometric
for each patient. Wires included (012, 014, 016, 018) analysis that has been used in previous studies13–15
nickel titanium, (18 3 18, 18 3 25, 20 3 20, 21 3 28, 21 and is considered highly accurate because, after 7
3 25) BF, (16 3 22, 19 3 25, 21 3 25) stainless steel, years of age, the registered landmarks are extremely
and (19 3 25) titanium-molybdenum alloy. Short double stable.16 The software created a Cartesian coordinate
elastics were only used to correct Class II molar system and the superimposition of the two tracings
discrepancy. resulted in the 0,0 point in both tracings to be
Thirty sets of lateral cephalograms met the inclusion coincident. This is a modification of the use of a
criteria: (1) pretreatment (T1) and posttreatment (T2) fiducial line employed in traditional lightbox acetate
cephalograms of diagnostic quality, (2) orthodontic tracings in previously published studies that used the
treatment using anterior bite elevators, (3) OB at T1 5 CWRU analysis.11,13–15
mm, (4) 10–14 years of age at T1, (5) Angle Class I or The CWRU analysis results in six linear and two
II malocclusion, and (6) positive anterior/posterior angular variables. Figure 1 shows a schematic diagram
overjet. The excluded subjects had at least one of of the skeletal, dental, and angular variables. Maxillary
the following criteria: (1) inadequate diagnostic quality skeletal change (MXSK) is the vertical change of ANS

Angle Orthodontist, Vol 93, No 5, 2023

DEEP BITE CORRECTION USING ANTERIOR BITE TURBOS 509

bite were assigned a positive sign (þ). For example,

bodily movement of the maxillary incisor (BUI) away
from the occlusal plane (ie, intrusion) would receive a
negative sign. The net changes in the linear variables
were used to calculate the change in overbite using the
following equation where D stands for the net change:
D Overbite (OB) ¼ D MXSK þ D MNSK þ D BUI þ D TUI
þ D BLI þ D TUI.

Statistical Analysis

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/93/5/507/3259042/i1945-7103-93-5-507.pdf by Peru user on 11 August 2024

All data were analyzed with the Statistical Package for
the Social Sciences personal computer version (SPSS,
Chicago, Ill). Shapiro-Wilks test was used to test for
normal distribution of each parameter. Descriptive
statistics (means, standard deviations, and ranges) were
calculated to assess the effects of sex, race, and age
matching as well as to determine the presence of any
Figure 1. Schematic diagram of the skeletal, dental, and angular dentoalveolar changes between the treated and control
variables.
individuals. Two-tailed paired t-tests were used to
evaluate the statistical significance between means of
from T1 to T2. Bodily movement of the maxillary incisor both groups. Alpha was 0.05 and Beta 0.2 for all tests.
(BUI) is the distance between ANS and the center of To assess investigator tracing and measurement
rotation of the upper incisor (CRU1). Tipping move- error, 10 random subjects at T1 and T2 (five treated
ment of the maxillary incisor (TUI) is the distance and five control) were retraced and the six linear and
between CRU1 and the incisal edge of the upper the two angular variables were remeasured. The
central incisor (IEU1). Tipping movement of the second set of tracings and measurements were
mandibular incisor (TLI) is the difference between compared with the first set by using intraclass
center of rotation of the lower central incisor (CRL1) correlation coefficients.
and the incisal edge of the lower central incisor (IEL1).
Bodily movement of the mandibular incisor (BLI) is the RESULTS
distance between the CRL1 and Menton. Mandibular Thirty treated subjects, 15 male and 15 female
skeletal change (MNSK) is the vertical distance Caucasians, met the inclusion criteria. The mean age
between ANS and Menton. Gonial angle (Ga) is the at T1 was 12.9 years of age and 14.8 years at T2. The
angle between the inferior border of the mandible and average treatment time was 22.8 months, and the
the posterior border of the ramus. Mandibular plane mean duration of anterior bite elevator placement was
angle was measured between the Sella-Nasion plane 12.2 months. Nineteen patients were Angle Class II,
and the mandibular plane (SN-MPA). and 11 were Class I. The control group was selected
from the Bolton Brush Growth Study Collection and
Convention of Signs matched on age, gender, and Angle class with the
treated group (Table 1).
A negative sign () was assigned to dental and
At T1, only one variable, TUI, showed a statistically
skeletal movements that reduced the vertical overbite,
significant difference between the groups (P  .001).
whereas movements that increased the vertical over-
TUI was greater in the treated group (22.8 mm)
compared to the control (21.3 mm), indicating that the
Table 1. Description of Treated and Control Groups
incisors were more upright in the treatment group.
Treated Control Apart from that, there were no other significant
Total sample 30 30 differences between the groups (Table 2).
Girls 15 15 Assessment of the post-treatment skeletal and
Boys 15 15
Angle Class I 11 11
dental changes showed that six variables (MXSK,
Angle Class II 19 19 BUI, TUI, TLI, MNSK, and MPA) met the parametric
Age at T1 (y) 12.9 6 1.1 13 6 1.1 assumptions based on the Shapiro-Wilk test. There-
Age at T2 (y) 14.8 6 1.2 14.8 6 1.1 fore, two-tailed paired t-tests were used to detect
Time interval (mo) 19 6 6 19 6 7 significant differences between those variables. A
Time with turbos (mo) 12.2 6 3.6 0
Mann-Whitney test was used for the remaining three

Angle Orthodontist, Vol 93, No 5, 2023

510 ELBARNASHAWY, KEESLER, ALANAZI, KOSSOFF, PALOMO, PALOMO, HANS

Table 2. Comparison Between Treated and Control Groups at T1a,b

Variable Treated Means Control Means P Value Significance
MXSK 24.3 6 2.1 25.1 6 2.4 .25 NS
BUI 11.3 6 1.3 10.7 6 1.0 .012 NS
TUI 22.8 6 1.6 21.3 6 1.3 ,.001 ***
TLI 15.1 6 0.9 14.7 6 1.1 .14 NS
BLI 23.6 6 1.6 23.1 6 1.1 .2 NS
MNSK 62.1 6 2.4 61.2 6 1.8 .07 NS
OB 6.2 6 0.6 7.0 6 0.8 .83 NS
Ga 123.3 6 3.6 122.7 6 3.5 3.5 NS
SN-MPA 32.9 6 2.0 33.6 6 1.4 1.43 NS

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/93/5/507/3259042/i1945-7103-93-5-507.pdf by Peru user on 11 August 2024

a
BLI indicates bodily tooth movement of lower incisors; BUI, bodily tooth movement of upper incisors; Ga, Gonial angle; MNSK, vertical
skeletal changes in the anterior region of the mandible; MXSK, vertical skeletal changes in the anterior region of the maxilla; NS indicates not
significant; OB, overbite; SN-MPA, mandible plan angle of Sella-Nasion plane and the mandibular plane; TLI, tipping movement of lower incisors;
TUI, tipping movement of upper incisors.
b
All measures are in millimeters except SN-MPA and Ga, which are in degrees.
*** P , .001.

variables (BLI, OB, and GA), which were not normally the correction of deep overbite. This allows the clinician
distributed according to the normality test. Results are to create a decision matrix based on the pretreatment
shown in Table 3. characteristics of the patient and the documented
In summary, in the treated subjects, all variables effects of various biomechanical systems to choose a
except MXSK and GA contributed to a reduction in treatment option that will achieve the most beneficial
overbite. The net OB change was a net change of 5.6 facial and dental changes for that patient.
mm due to a significant 5.2 mm decrease in overbite Previously, the effects of cervical headgear and
in the treated group compared to a slight increase (0.4 tandem mechanics, removable appliance therapy
mm) in overbite in the control group. The mean (bionator), nonextraction treatment with preadjusted
intraclass correlation coefficients of the repeated edgewise appliances and continuous arch mechanics,
measurements were between 0.908 and 0.958. extraction of first premolars with preadjusted edgewise
appliances and continuous arch mechanics, and
DISCUSSION extraction of first premolars using Tweed mechanics
were reported.11,13,14 In addition, this analysis has been
This study evaluated the relative contributions to deep used to study open bite correction with extraction of
overbite correction of skeletal and dental components of first molars15 and the effects of the active vertical
growing adolescents treated with anterior bite turbos corrector. All of these studies isolated the changes in
and a pre-adjusted edgewise appliance. As observed in the same six variables that contributed to the final
previous studies, an increase in lower vertical facial orthodontic result. The results of the present study
height (MNSK) during orthodontic treatment of growing were most similar to those seen with nonextraction
patients was a major factor in decreasing OB.11,13 The continuous arch mechanics using an edgewise appli-
CWRU analysis allows practitioners an easy way to ance system. In both strategies, the majority of
compare the effects of different treatment strategies for correction was due to increased vertical mandibular

Table 3. Comparison of Changes Between Treated and Control Groups at T2a,b

Variable Treated Means (T ) Control Means (C ) P Value Significance Difference (T-C)
MXSK 2.3 6 0.7 2.4 6 0.7 .65 NS 0.1
BUI 1.0 6 0.3 1.7 6 0.4 ,.001 *** 0.7
TUI 0.6 6 0.4 0.3 6 0.2 ,.001 *** 0.9
TLI 1.0 6 0.6 0.4 6 0.2 ,.001 *** 1.4
BLI 1.4 6 0.6 2.5 6 0.8 ,.001 *** 1.1
MNSK 6.0 6 1.0 4.4 6 0.9 ,.001 *** 1.6
OB 5.2 6 0.7 0.4 6 0.4 ,.001 *** 5.6
Ga 1.0 6 1.0 1.2 6 0.6 .70 NS 0.1
SN-MPA 1.9 6 0.9 0.9 6 0.7 ,.001 *** 2.8
a
BLI indicates bodily tooth movement of lower incisors; BUI, bodily tooth movement of upper incisors; Ga, Gonial angle; MNSK, vertical
skeletal changes in the anterior region of the mandible; MXSK, vertical skeletal changes in the anterior region of the maxilla; NS indicates not
significant; OB, overbite; SN-MPA, mandible plan angle of Sella-Nasion plane and the mandibular plane; TLI, tipping movement of lower incisors;
TUI, tipping movement of upper incisors.
b
All measures are in millimeters except SN-MPA and Ga, which are in degrees.
*** P , .001.

Angle Orthodontist, Vol 93, No 5, 2023

DEEP BITE CORRECTION USING ANTERIOR BITE TURBOS 511

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/93/5/507/3259042/i1945-7103-93-5-507.pdf by Peru user on 11 August 2024

Figure 3. Percentage contribution of change in variables to overbite
correction.
Figure 2. Schematic diagram illustrating the net difference between
both groups (treated minus control).
changes over the course of the treatment period
growth. However, there was less lower incisor procli- compared to the control subjects. There was relative
nation using the bite turbos, and small, but significant, intrusion of the lower incisors and additional overbite
relative intrusion of the upper and lower incisors. The correction due to labial tipping.
only appliance system studied to date that did not The treated subjects obtained a net 5.6 mm of OB
achieve overbite correction by increasing vertical correction, which was predominantly achieved by
mandibular growth was the Tweed system in which increasing lower anterior facial height (MNSK) via
overbite was corrected primarily by intrusion of the extrusion of the posterior teeth (Figure 2). This was
upper and lower incisors. similar to the effect of a removable bite plane as
described by Bahador et al., who also found an
It has been widely believed that facial types have a
increase in vertical facial height.5 Thus, the advantages
strong relationship with dental overbite and, hence,
of the bite turbos were ease of use and elimination of
require different treatment approaches.17–19 Using a
patient compliance issues sometimes found with a
digitized method of the described technique to analyze
removable appliance.
the cephalograms, only one of the variables showed
significant differences at T1, TUI. The treated sample
Limitations
was categorized to have an average lower facial height
of 62 mm that coincided with the norms (64 mm 64) A limitation of this study design was that the increase
and a SN-mandibular plane angle average recorded at in lower facial height could have been the result of
32.98. Both values suggested that the treated group as maxillary or mandibular molar eruption or a combina-
well as the matched control were normodivergent with tion of both.
normal facial growth patterns. This suggested that, in
cases of extreme hypodivergence, the effects of the CONCLUSIONS
bite turbos may be different.  Anterior bite turbo mechanics should be considered
As might be expected, the effect of the bite turbos on
in patients with deep anterior overbite, especially
vertical downward growth of MXSK was negligible. The
individuals with decreased lower facial height.
maxillary incisors, on the other hand, had 0.6-mm  Significant bodily and tipping movements of maxillary
relative intrusion compared to controls, and labial
and mandibular incisors contributed to overall over-
tipping resulting in an additional 0.9 mm of overbite
bite reduction (Figure 3).
correction caused by forward movement of the upper
incisors. These findings were different when compared
to Forsberg et al., who concluded that the anterior fixed REFERENCES
bite plane resulted in anterior rotation of the maxilla 1. Engel G, Cornforth G, Damerell JM, et al. Treatment of deep-
and reduction in vertical development of the upper face bite cases. Am J Orthod. 1980;77(1):1–13. doi:https://doi.
height.10 The lower incisors also showed significant org/10.1016/0002-9416(80)90220-1

Angle Orthodontist, Vol 93, No 5, 2023

512 ELBARNASHAWY, KEESLER, ALANAZI, KOSSOFF, PALOMO, PALOMO, HANS

2. Simons ME, Joondeph DR. Change in overbite: a ten-year 12. Hans MG, Broadbent Jr BH, Nelson SS. The Broadbent-
postretention study. Am J Orthod. 1973;64(4):349–367. Bolton Growth Study–past, present, and future. Am J Orthod
3. Franchi L, Baccetti T, Giuntini V, Masucci C, Vangelisti A, Dentofacial Orthop. 1994;105(6):598–603.
Defraia E. Outcomes of two-phase orthodontic treatment of 13. Hans MG, Kishiyama C, Parker SH, Wolf GR, Noachtar R.
deepbite malocclusions. Angle Orthod. 2011;81(6):945–952. Cephalometric evaluation of two treatment strategies for
4. Baccetti T, Franchi L, Giuntini V, Masucci C, Vangelisti A, deep overbite correction. Angle Orthod. 1994;64(4):265–
Defraia E. Early vs late orthodontic treatment of deepbite: a
274.
prospective clinical trial in growing subjects. Am J Orthod
14. Bazzucchi A, Hans MG, Nelson S, Powers M, Parker S.
Dentofacial Orthop. 2012;142(1):75–82. doi:https://doi.org/
10.1016/j.ajodo.2012.02.024 Evidence of correction of open bite malocclusion using
5. Bahador MA, Higley LB. Bite opening: a cephalometric active vertical corrector treatment. Semin Orthod. 1999;5:
analysis. J Am Dent Assoc. 1944;31(5):343–352. 110–120.

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/93/5/507/3259042/i1945-7103-93-5-507.pdf by Peru user on 11 August 2024

6. Belger I. Cephalometric analysis of growth in subjects using 15. Hans MG, Groisser G, Damon C, Amberman D, Nelson S,
bite plate. Angle Orthod. 1956;26(1):42–49. Palomo JM. Cephalometric changes in overbite and vertical
7. Atherton JD. The effect of removable appliance therapy on facial height after removal of 4 first molars or first premolars.
the facial pattern. Br Dent J. 1963;114:512–514. Am J Orthod Dentofacial Orthop. 2006;130(2):183–188.
8. Richardson A, Adams CP. An investigation into the short and 16. Melsen B. The cranial base: the postnatal development of
long term effects of the anterior bite plane on the occlusal the cranial base studied histologically on human autopsy
relationship and facial form. Trans. Europ. Orthod. Soc. material. Acta Odontol Scand. 1974;32(62):9–126.
1963:375–383. Published online. 17. Wylie WL. The relationship between ramus height, dental
9. Menezes DM. Changes in the dentofacial complex as a
height, and overbite. Am J Orthod Oral Surg. 1946;32(2):57–
result of bite plane therapy. Am J Orthod. 1975;67(6):660–
67.
676.
10. Forsberg CM, Hellsing E. The effect of a lingual arch 18. Schudy FF. Vertical growth versus anteroposterior growth as
appliance with anterior bite plane in deep overbite correc- related to function and treatment. Angle Orthod. 1964;34(2):
tion. Eur J Orthod. 1984;6(1):107–115. 75–93.
11. Hans MG, Teng CM, Liao CC, Chen YH, Yang CY. An 19. Creekmore TD. Inhibition or stimulation of the vertical growth
evidence-based approach to treatment of open bite and of the facial complex, its significance to treatment. Angle
deep bite. World J Orthod. 2007;8(1)45–64. Orthod. 1967;37(4):285–297.

Angle Orthodontist, Vol 93, No 5, 2023