Comprehensive orthodontic management of skeletal Class II division 2 deep overbite malocclusion with severe alveolar bone defect: A case report with two-year follow-up

doi:10.21203/rs.3.rs-5312390/v1

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Case Report

Comprehensive orthodontic management of skeletal Class II division 2 deep overbite malocclusion with severe alveolar bone defect: A case report with two-year follow-up

https://doi.org/10.21203/rs.3.rs-5312390/v1

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Background

Deep overbite is a vertical developmental anomaly of the upper and lower jaws and/or dental arches, often accompanied by sagittal and horizontal abnormalities in three-dimensional space. It can lead to restricted mandibular movement, discomfort in temporomandibular joint and masticatory muscles, and, in severe case, damage to hard tissue of the teeth and periodontal structures.

Case presentation

This case report details the orthodontic treatment of a 27-year-old female with a severe anterior alveolar bone defect, Class II skeletal malocclusion, severe crowding, a pronounced anterior deep overbite, and posterior scissor bite. The treatment aims to alleviate the deep overbite through lingual root movement and intrusion the upper anterior teeth, combined with crown reduction, while carefully managing the intrusion and labial tipping of the lower anterior teeth. Strategic asymmetric tooth extractions and a comprehensive sequential orthodontic approach such as auxiliary intrusive arch, power arms, segmental arch-wires, and mini-screws were employed. After 29 months treatment, both deep overbite and arch width discrepancies were corrected, resulting in significantly improved facial aesthetics, harmonious tooth alignment, a balanced occlusal relationship, and enhanced stability of upper and lower anterior teeth. The treatment outcomes remained stable during a two-year follow-up.

Conclusions

This case demonstrates that for adult with severe deep overbite, skeletal class II division 2 malocclusion, and poor periodontal condition, a carefully tailored treatment plan with sequential and comprehensive orthodontic management— incorporating the use of auxiliary intrusive arches, mini-screws, power arms, segmental arch-wires, and crown reduction—can successfully achieve a camouflage strategy with stable and lasting results.

Deep overbite

Severe alveolar bone defect

Skeletal Class II division 2 malocclusion

Deep overbite, a complex malocclusion, can profoundly impact teeth, the entire dentition, alveolar bone, mandibular position, temporomandibular joint and even facial aesthetics [1, 2]. Severe cases of deep overbite often manifest with reduced lower facial height, imbalanced anterior and posterior upper jaw height, and discrepancies in heights of anterior alveolar and basal bone [1–4]. These deep overbites may not only involve abnormal vertical development but also exists three-dimensional spatial irregularities, such as maxillary protrusion and/or mandibular retrusion in sagittal plane, and discrepancies in the width of the upper and lower dental arches and/or jaws in horizontal plane [2]. Additionally, deep traumatic overbite, often associated with Class II div. 2, can lead to hard tissues and periodontal damage [4–7]. This malocclusion has been associated with restricted lower jaw movement, increased condyle rotation angle, posterior condyle displacement, anterior disc dislocation, temporomandibular joint discomfort, or masticatory muscles issues [8–11].

Orthodontic treatment, once contraindicated in severe adult periodontitis cases, is now considered feasible and may enhance the preservation and restoration of compromised dentition [12]. However, there are complexities to consider. Periodontal issues can complicate orthodontic treatments, potentially influencing tooth movement [6, 13]. Orthodontic treatment can pose risks like exacerbating bone fenestration, dehiscence, or root resorption and increasing acidogenic biofilm production. Moreover, intrusion, a vital protocol for deep bite treatment, in cases with extensive periodontal support loss, may lead to unfavorable crown-root ratios and root resorption risks [13]. Conversely, extrusion might aid periodontists and prosthodontists in future alveolar bone utilization and soft-tissue architecture improvement [13]. The decision between intrusion and extrusion, minimizing reciprocal tooth movement, and achieving lasting effects pose challenges for orthodontists.

In current orthodontic practices, treatment objectives expand beyond aesthetics to prioritize long-term health and stability, including addressing function concerns [14]. Deep overbite cases, particularly Class II div. 2, often present temporomandibular joint morphology and functionality abnormalities, potentially causing discomfort in chewing muscles and influencing diagnosis [11, 14–16]. Selecting a reference jaw position (RP) for treatment diagnosis remain a debated topic. While some scholars advocate for reconstructing occlusion in centric relation, others prioritize the adaptative centric position that has already taken shape or the musculoskeletal stable position perceived as relatively ideal [14, 17]. Clinicians may face uncertainties: Will the condylar position remain stable? Is repositioning necessary? Might occlusal jaw position stability be affected during the treatment? Addressing these queries necessitates comprehensive patient jaw position assessment and personalized treatment planning.

Severe deep overbite, complicated by three-dimensional spatial abnormalities, periodontal symptoms, dental pulp, temporomandibular joint, or muscle issues, poses a challenge in orthodontic treatment [5, 6]. Correcting deep overbite typically involves incisor intrusion, posterior protrusion, or a combination, along with upper anterior teeth labial inclination [1]. However, there isn’t a universal procedure for all these scenarios. Precise diagnosis, personalized treatment plans, and an efficient treatment protocol are essential for optimal correction [4, 5].

This article presents a challenging case of severe skeletal Class II div. 2 malocclusion with three-dimensional directional anomalies and significant alveolar bone deficiency. Successfully treatment employed an asymmetric extraction camouflage strategy, alongside sequential and comprehensive orthodontic management, resulting in satisfactory and stable outcome.

Diagnosis and etiology

The patient, a 27-year-old female, presented with concerns regarding irregular teeth alignment, chewing difficulties, and looseness in the lower front teeth. Over the past few years, the looseness of the lower front teeth has gradual worsened. The patient recently underwent full-mouth cleaning and periodontal maintenance. She reported no clear recollection of any history of joint clicking or pain and no history of trauma or family issue related to these concerns.

The Frontal view presented overall facial symmetry with a shorter lower facial third (Fig. 1). The lateral view displayed a low-angle profile with mild protrusion of both the upper and lower lips beyond the E-Line and a distinct deepening of the mentolabial groove. Intraoral examination and model analysis (Fig. 2) demonstrated significant lingual inclination of the upper and lower anterior teeth, with a distal relationship of the canines and first molars. A severe overbite was observed, with Spee curve depths of 12mm on the right and 8mm on the left, along with a pronounced deviation in the upper occlusal plane. The square, wider upper arch contracted with a smaller lower arch, which exhibited lingual inclination of the lower left posterior teeth and a scissor bite in the left premolar region. Moderate crowding was present in upper arch, while the lower arch showed severe crowding. The maxillary midline was centered, with a Bolton’s anterior teeth ratio of 76.5%. The lower incisors exhibited exposed roots and Grade II mobility and tooth 25 had residual crown with pulp involvement. Furthermore, bilateral TMJ examination indicated no clicking, noise, or pain during opening and closing with no significant deviation in mouth opening.

CBCT imaging revealed significant abnormalities related to the deep overbite, including extensive overlap of the upper and lower anterior teeth in panoramic CT scans. The labial alveolar bone plate in the anterior tooth regions were extremely thin, with apical one-third bone fenestration on the upper anterior teeth, while severe bone deficiency were showed on the lower incisors (Fig. 3). Coronal views indicated arch width discrepancies, though no skeletal width discrepancies were noted¹⁸. Temporomandibular joint imaging showed asymmetry in the size and shape of the condyles on either side, but the cortical bone remained smooth and continuous, with relatively posterior condyle positioning.

The cephalometric radiograph measurements indicated a typical skeletal Class II malocclusion with maxillary protrusion and mandibular retrusion (Fig. 3e, Table 1). Reduction in mandibular plane inclination resulted in a relatively low mandibular angle and occlusal plane angle (FH-MP = 20.1°, OP-FH = 3.6°). Excessive vertical development of upper anterior teeth and insufficient vertical height of lower posterior teeth was noted. Pronounced lingual inclination was observed in both upper and lower anterior teeth, and a significant increase in interincisal angle between the upper and lower anterior teeth (U1- L1 = 184.2°).

As previously mentioned, the patient was diagnosed with skeletal class II, angle class II division 2 malocclusion, a hypodivergent facial pattern, dental arch width discrepancies, and crowding. Additional finding included a significantly thin alveolar bone plate in upper anterior region and an alveolar bone defect on the labial side of the lower anterior teeth, accompanied by gingival recession and exposed tooth roots, as well as residual crown in tooth 25. The mandible was found to be in an adaptive centric position, which can serve as the reference mandibular Position (RP) [17].

Table 1

Pretreatment and Posttreatment Cephalometric Measurements (Downs + Steiner + Alveolar height)
Measurements	Pretreatment	Posttreatment	Norm(mean ± SD)
SNA	80.9	79.0	83 ± 4.0
SNB	73.3	70.2	80 ± 3.9
ANB	7.6	8.8	3 ± 2.0
SN-OP	11.6	21.0	16 ± 5.0
GoGn-SN	25.8	30.6	33 ± 5.2
FH-NPo	83.7	80.0	86 ± 3.7
NA-Apo	12.6	15.9	6 ± 4.4
AB-NPo	16.2	-16.8	-4.5 ± 2.8
FMA (FH-MP)	20.1	25.9	27 ± 6.1
SGn-FH	60.3	64.9	66 ± 4.3
OP-FH	3.6	13.2	12 ± 4.4
U1-NA(mm)	6.3	0.9	5 ± 2.4
U1-NA	-13.3	11.8	23 ± 5.7
L1-NB(mm)	1.2	8.7	7 ± 2.1
L1-NB	1.4	36.6	30 ± 5.8
U1-L1	184.2	122.8	124 ± 8.2
L1-OP	96.56	125.4	112 ± 6.0
IMPA (L1-MP)	80.0	112.7	97 ± 7.1
U1-APo	0.7	6.6	7 ± 2.2
U1-PP (mm)	31.6	29.5	28 ± 2.0
U6-PP (mm)	20.3	22.3	22 ± 2.0
L1-MP (mm)	42.6	39.3	48 ± 3.4
L6-MP (mm)	27.4	31.3	34 ± 4.0

Treatment alternatives

For the patient who cannot undergo orthognathic surgery, compensatory treatment was necessary. Given the skeletal factors, thin alveolar bone plates of the anterior teeth, and poor periodontal conditions, a moderate movement amount and cautious approaches were essential to avoid excessive inclination and reciprocal movement.

In the sagittal direction, we aimed address the lingual inclination of the upper and lower anterior teeth, centralize the roots within the alveolar bone, and intrude the upper anterior teeth through controlled lingual root movement. While the lower anterior teeth also required vertical intrusion control, existing bone defects and root exposure necessitated limiting the degree of intrusion and performing crown truncation to achieve a balanced crown-root ratio and a normal overbite, which may require root canal treatment. Additionally, considering the unpredictability of treatment outcomes due to severe periodontal issues, post-treatment procedures such as soft and hard tissue augmentation was planned to optimize enhance periodontal health and aesthetics of the anterior teeth. In the horizontal direction, we must correct the scissor bite and coordinate arch width.

Given the improvement in the patient’s aesthetic preference for tooth alignment and overall profile, along with a strong desire to retain as many natural and healthy teeth as possible, we planned to extract Tooth 14, the residual Tooth 25, and loose Tooth 32, while addressing Bolton discrepancy through minor interproximal enamel reduction.

Treatment Progress

In the initial orthodontic phase, Teeth 14 and 25 were extracted. and partial maxillary orthodontic brackets were affixed, and mini-screws were placed buccally mesial to Tooth 16 and 26 to enhance posterior anchorage. These screws enabled direct force to move Teeth 13 and 23 distally and intrusively, while also applying distal force to Tooth 24. To address the distal inclination of Tooth 24, a 0.018 x 0.025-inch stainless steel power arm auxiliary arch was applied, generating a clockwise moment (Fig. 4). Additionally, a 0.018 x 0.025-inch stainless steel segmental intrusive arch, combined with a 0.012-inch nickel-titanium segment archwire for the upper incisors, facilitated the intrusion and positioning adjustment of the anterior teeth.

Subsequently, the transition of nickel-titanium segment archwires for the upper incisors progressed from 0.012-inch to 0.014-inch and 0.016-inch, in conjunction with the gradual force from the segmental intrusive arch, resulting in the alignment, intrusion and labial movement of these teeth. Following the distalization and intrusion of the upper canines, as well as the correction of Tooth 24’s axial inclination, the upper arch transitioned to a full-archwire configuration. The archwires were then further changed from 0.014-inch to 0.016-inch, progressing to 0.018-inch, 0.017-inch*0.025-inch, and then to 0.019-inch*0.025-inch nickel-titanium wires, which progressively aligned and leveled the upper dental arch (Fig. 5). During the alignment, the upper mini-screws were removed due to its loosen.

During this process, Tooth 32 was extracted to facilitate natural drift of the lower incisors. Bilateral lower molar blankets were placed to correct the scissor bite on the left side through reciprocal traction. Continuous monitoring was conducted to ensure a stable jaw position and no abnormal muscle tension. Once the scissor bite was resolved, a sequence of 0.014-inch, 0.016-inch, and 0.018-inch nickel-titanium wires was used to align and level the lower dental arch (excluding the anterior teeth) and to coordinate the width of the bilateral posterior teeth.

After establishing bilateral posterior teeth contact and a slight natural drift of the lower anterior teeth, root canal treatment and crown truncation were performed on the incisors. To create the necessary space for the planned position of the lower anterior teeth, minimal enamel removal was conducted on the lower premolars and canines. Additionally, the rotations and inclinations of the lower canines were corrected.

Following those steps, the lower anterior braces were installed and suspendly ligated to a 0.012-inch nickel-titanium auxiliary arch, gradually aligning lower anterior teeth. Once the target dental arch curvature was nearly achieved, a sequence of 0.012-inch, 0.014-inch, and 0.016-inch nickel-titanium wires were used for further alignment. To centralize the roots within the alveolar bone while avoiding reciprocal movement, and square archwires were not utilized to avoid excessive lip protrusion (Fig. 6).

Due to the loosen of the mini-screws, an extraoral arch and headgear were utilized to reinforce posterior anchorage, while a 0.018 x 0.025-inch stainless steel wire with a reverse curve of Spee was employed for the progressive retraction of the upper anterior teeth. Close monitoring of anterior teeth was conducted to prevent interference and maintain periodontal health throughout the retraction process. Continuous assessment of the patient's jaw position and TMJ stability was performed using CBCT imaging and clinic examination to ensure consistency at the RP.

For fine adjustments, positive torque was applied to the stainless steel archwire in the upper arch to control the root positions of the upper anterior teeth. Meanwhile, the lower anterior teeth were aligned and leveled using a round wire, without intermaxillary traction. The orthodontic treatment concluded with the closure of the maxillary gaps, achieving proper alignment of the anterior teeth within the alveolar bone, and establishing optimal occlusal relationships.

The comprehensive treatment lasted 29 months. Post-orthodontic treatment, the patient's facial proportions are more harmonious, with increased lower facial height and an enhanced overall appearance. Intraoral assessment shows correction of the deep overbite, and the dentition is well-aligned, establishing favorable relationships between the anterior and posterior teeth. Periodontal examination indicates improved stability in the lower anterior teeth, with only minimal mobility observed (Fig. 7 and Fig. 8). Due to the improved stability of the lower anterior teeth, the patient was satisfied and temporarily decided not to proceed with the pre-planned soft and hard tissue augmentation surgery. So the periodontist bonded a periodontal fiber splint to the lingual side of the teeth, which serves both as a retainer and provides additional stability. The patient was advised to follow up regularly for monitoring.

Post-treatment CBCT analysis confirms that, although the alveolar bone plates of the upper and lower anterior remain thin, the roots of these teeth are now centralized within the alveolar bone. Additionally, the condyle-joint fossa relationship has been maintained without alteration. Comparative evaluation of lateral cephalograms and X-ray cephalometric measurements shows a clockwise rotation of the mandibular plane. This rotation correlates with a noticeable compensatory inclination of both upper and lower anterior teeth and significant intrusion of both, accompanied by minor elongation of the lower posterior teeth (Fig. 9 and Fig. 10).

Based on the one- and two-years follow-up assessments, the overall appearance, dental alignment, and occlusal stability have remained satisfactory condition, with no noticeable increase in mobility of the lower anterior teeth (Fig. 11 and Fig. 12). The two-year post-treatment CBCT analysis indicates that the position of the condyles has not significantly changed, and the status of the tooth roots and alveolar bone remains consistent (Fig. 13).

This case presents a skeletal Class II, Angle Class II division 2 malocclusion with a skeletal deep overbite. The etiology is associated with skeletal hypo-divergence, characterized by the shortened anterior lower facial height, flattened mandibular plane angle, smaller gonial angle, and more horizontal occlusal planes, along with infraocclusion of the maxillary and mandibular posterior teeth [1, 19].The protrusion of the maxilla and retrusion of the mandible disrupted the eruption balance of the anterior teeth, resulting in supraeruption of both upper and lower anterior segments [8]. Additionally, the inward inclination of the upper incisors likely caused a corresponding lingual inclination of the lower anterior teeth, altering their growth pattern and contributing to the formation of a deep Spee curve in the lower jaw, alongside an abnormal maxillary curve. Furthermore, the lack of coordination in the width of the upper and lower dental arches, coupled with a posterior scissor bite, led to inadequate support for the height of the posterior teeth and alveolar bone, exacerbating in excessive development of the anterior teeth and alveolar height due to the counterclockwise rotation of the lower jaw [8].

The deep bite position restricted the mandibula’s forward and lateral movements, which eventually caused the temporomandibular joint to shift backward, reducing the joint's posterior space [1, 3, 11, 15]. Over time, the patient adapted to this jaw position, displaying no obvious joint symptoms during clinical examination. However, the prolonged deep bite and the forced posterior positioning of the lower jaw resulted in unusual bite trauma on the labial side of the lower anterior teeth, leading to alveolar bone defects [7, 19]. It is theorized that the degree of these defects closely correlates with the severity of the deep overbite, the extent of inward inclination, and the duration of the condition.

In addressing this case, it was essential to craft a treatment plan that carefully considered various factors, including the malocclusion, periodontal health, alveolar bone condition, joint positioning, patient preferences, and long-term stability [8]. The objectives included uprighting the lower posterior teeth, coordinating the width of the upper and lower molars, and establishing a functional occlusal relationship among the posterior teeth [7, 20]. Additionally, the aim was to procline the upper and lower anterior teeth, creating a harmonized occlusal plane to enhance facial aesthetics from both frontal and profile perspectives [1, 2, 21]. Centralizing the roots of the front teeth within the alveolar bone and ensuring proper contact between the upper and lower anterior teeth were critical for achieving functional balance and long-term stability [7, 8]. However, considering skeletal factors, the thin labial and lingual bone plates of the anterior teeth, and poor periodontal conditions, a cautious approach was necessary to avoid excessive lingual inclination and proclination, emphasizing the importance of moderation.

The presence of periodontal issues significantly complicated orthodontic treatment. The extensive alveolar bone defects in the lower anterior teeth added challenged the treatment strategy. Considering this compromised periodontal condition, it was crucial to avoid reciprocal movement. The complete dentistry emphasizes the preservation of teeth whenever possible, aiming for enhanced oral health, function, and aesthetics through minimal intervention [22]. Thus, to meet these objectives and to limit movement in the lower anterior teeth, Tooth 32, which exhibited significant mobility and severe alveolar bone defects, was extracted. Reducing the crown length of the lower front teeth for balancing the crown-root ratio is key for maintaining periodontal bone health. This adjustment lowers the risks associated with tooth movement, lessens orthodontic challenges, and boosts the periodontal outlook. For individuals presenting with alveolar bone loss and deep overbite in the anterior teeth, this approach stands a favorable option [13, 23].

From the initial gathering of medical history, radiographic examinations, and clinical assessment of jaw relations, no apparent signs of joint discomfort were noted in the patient. While CBCT revealed a reduction in the right condylar posterior space, the condyle’s anterior slope aligned with the posterior slope of the joint fossa, positioned at the uppermost area within the fossa. Additionally, despite indications of limited during protrusive and lateral excursion, palpation of the masticatory muscles and temporomandibular joint showed no anomalies. According to Dawson's theory, we consider the initial jaw position to be in the adaptative centric position, serving as the RP for treatment [17].

The step-by-step planning of the treatment process was essential, emphasizing gradual progression and avoiding haste.

The treatment approach for addressing the deep overbite primarily concentrated on intruding the upper anterior teeth while considering tooth alignment, anterior teeth’s function, and lip-tooth relationships [12]. This process was divided into phases, starting with the distal movement and intrusion of the upper canines to create space for aligning and leveling the upper anterior teeth. Simultaneously, carefully management was employed for the controlled intrusion and labial tipping of the upper incisors. Due to the thin labial alveolar bone, traditional segmental intrusive arch mechanics were preferred over mini-screws for controlled incisor intrusion. Orthodontic expert Burstone’s recommendations suggested that this method, with careful force management, could achieve true incisor intrusion [13, 21]. The incorporation of small loops design in medio of upper first molars aimed to regulate appropriate intrusive forces. Segmental intrusive arch mechanics induced labial tipping of the upper incisors and extrusion of the posterior teeth, suiting Class II Division 2 deep overbite cases [24]. The labially applied intrusive forces gradually tip the crowns labially and the roots lingually, aligning the anterior teeth’s axis with the alveolar bone direction and reducing the risk of root resorption [13, 21]. During the initial stages of incisor intrusion, single-point contacts was employed to avoid substantial torque from the square archwires on the already lingually tipped upper incisors, which could pose challenges to periodontal health, root integrity, and increase the risk of posterior anchorage loss [21].

The treatment strategy involved extracting the residual crown of Tooth 25, which complicated matters due to the distal inclination of Tooth 24. To address this, a Power Arm was used to extend the force arm towards the root and apply a distally directed force towards the mini-screw. Therefore, Tooth 24 underwent double-track forces where the force on the root-oriented generated a clockwise rotational moment, while the force on the crown, driven by distal movement of Tooth 23, produced counterclockwise moment around the impedance center (Refer to the schematic diagram in Fig. 3 for details). The root experienced a relatively greater displacement than the crown. Clinical observations showed that this double-track method resulted a relatively favorable outcome.

Following the installation of full-arch fixed orthodontic appliances in the upper jaw, reciprocal traction was applied to upright the lower posterior teeth. This rectified width discrepancy established the occlusal relationship on that side, and created room for extruding the posterior teeth on the right side. Extrusion of both sides of the posterior teeth proved advantageous in correcting the deep overbite in the anterior teeth.

Following the removal of Tooth 32, braces weren’t immediately installed on the lower anterior teeth. This allowed natural drifting due to the available ample space and utilized the extraction space to refine the lower dental arch and reposition the canines. Further steps involved interproximal enamel reduction on lower premolars and canines to address the Bolton index discrepancy resulting from the asymmetry extraction, aiming to minimize reciprocal movement of the lower front teeth.

Recognizing the impact of occlusion contact patterns and dynamic tooth relationships on the masticatory system’s stability, Okeson’s recommended bilateral manual manipulation technique was consistently employed throughout the orthodontic process to monitor the jaw position and ensure its stability [14]. This vigilance was particularly critical during the vertical alignment of the lower left posterior teeth and the retraction of the upper anterior teeth, for these procedures might trigger occlusal interferences leading mandibula’s lateral shifts or further retraction [25]. Additionally, regularly monitoring of the alveolar bone condition of the upper anterior teeth using CBCT scans was conducted. Adjustment of movement of both anterior and posterior teeth was undertaken as needed, prioritizing the centralization of the roots of the anterior teeth within the alveolar bone to improve their inclination without applying excessive retraction force. The objective was to eliminate any posterior interferences during protrusive and lateral excursions while ensuring harmonious canine guidance. This was essential for maintaining the patient's jaw position and preserving their periodontal health [7, 17].

Regarding treatment outcomes, significant improvements in facial aesthetics and dental occlusion were observed in both the front and posterior teeth, along with notable enhancements in the stability of the lower front teeth. The reduction in tooth mobility is likely attributed to the centralization of the roots within the alveolar bone, with increased interdental alveolar bone between the roots enhancing stability. Considering the insufficient alveolar bone during tooth movement, PAOO (Periodontally Accelerated Osteogenic Orthodontics) can be performed, and in cases of gingival recession, soft tissue augmentation procedures such as root coverage may be necessary [26]。However, the patient’s preferences must be taken into account. Fortunately, the treatment outcome was satisfactory, and periodontal condition have improved. Although the two-year post-treatment CBCT showed minor cortical bone regeneration in the upper anterior region, and the roots of both upper and lower anterior teeth remained centralized within the alveolar bone, contributing to tooth stability, argumentation surgery is still recommended for long-term stability. Proper periodontal care forms the foundation for orthodontic treatment in patients with compromised periodontal conditions, which in turn positively influences periodontal tissue health [27]. Looking ahead, advancements in oral materials and clinical techniques offer hope for improved bone regeneration materials and methods, promising better prospects for patients with labial and buccal bone defects.

Despite not achieving an ideal facial profile and tooth inclination, this case yielded favorable results considering its complexity and treatment difficulty, attributed to thorough diagnosis and a well-structured treatment plan.

In managing complex traumatic deep overbite cases, addressing three-dimensional concerns is essential. Coordinating posterior width and securing vertical bite support are critical for correcting deep overbite, while establishing a favorable anterior sagittal relationship is key for long-term stability post-correction. What’s more, pay attention to treatment details, such as using various segmental and auxiliary arches alongside anchorage support, employing a step-by-step strategy, vigilant monitoring and timely intervention in periodontal and joint conditions, collectively contribute to effectively and healthily controlling tooth movement.

CBCT Cone-beam computed tomography

TMJ Temporomandibular joint

RP Reference mandibular Position

Ethics approval and consent to participate

The study participant provided written informed consent.

Consent for publication

The patient provided written consent for the publication of this case report and accompanying images.

Competing interests

The authors declare that they have no competing interests.

Author Information

Yan Lin ¹; Minrui Xu²; Yingzi Xiao³; Quan Zhong⁴; Linyu Xu⁵

Associate Chief Physician of Orthodontics, Department of Orthodontics, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China
Associate Chief Physician of Prosthodontics, Dental Department of Fujian Province Governmental Hospital, Fuzhou, China
Resident Physician of Orthodontics, Department of Orthodontics, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China
Associate Chief Physician of Periodontics, Department of Periodontics, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China
Chief Physician and Doctoral Supervisor of Orthodontics, Director of Orthodontics Department, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China

Author Contribution

YL performed the major patient clinical operations, analyzed and interpreted the patient data, and was a major contributor in writing the manuscript. MRX performed some patient clinical operation and partial manuscript writing. YZX was involved in image analysis and partial manuscript writing. QZ performed some patient clinical operation. LYX proposed and agreed with the patient clinical treatment and participated in the final review of manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors thank all the researchers for their participation in this study and the Fujian Medical University Affiliated Stomatological Hospital for providing a good clinical working environment and equipment.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article.

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No competing interests reported.

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Comprehensive orthodontic management of skeletal Class II division 2 deep overbite malocclusion with severe alveolar bone defect: A case report with two-year follow-up

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Background

Case presentation

Diagnosis and etiology

Treatment alternatives

Treatment Progress

Discussion

Conclusions

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Data availability

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