Options for treating excess overjet graphic 1The treatment for excess overjet must consider several factors in addition to identifying the original etiology that caused the problem. It is also important to realize that in many patients the excess overjet actually presents as a deep overbite from over-eruption of the anterior teeth with minimal overjet.

In these patients a special challenge exists; if the anterior teeth are repositioned to correct the over-eruption, an anterior open bite will likely result displaying the excess overjet that led to the over-eruption.  

No treatment: When the excess overjet is not accompanied by any symptoms with regards to the TMJs, muscles, or teeth, the patient may choose no treatment. This is especially true in adult patients who have demonstrated that the excess overjet has been well tolerated

Orthodontics: In some patients the excess overjet is not from a skeletal problem or missing teeth, but rather mal-aligned or mal-positioned anterior teeth. In these patients orthodontics alone is the ideal choice.

Orthodontics and selective extraction: A frequent option for the correction of excess overjet is to shorten the maxillary arch by removing the maxillary first premolars and retracting the maxillary anterior teeth. This can be used when the patient has a mandibular deficiency or when the patient has a short mandibular arch from missing mandibular teeth.

treating excess overjetThis approach has several potential negative consequences including, creating an unattractive facial profile and smile from the maxillary anterior retraction, or the inability to create an acceptable anterior occlusal relationship depending upon the patients skeletal relationship. Having said that, for many patients, especially those whose facial profile would have benefitted from premolar extraction, this option can be a very good choice.

Orthodontics and tooth replacement: Excess overjet typically is due to either a skeletal problem from a mandibular deficiency or a short mandibular arch from missing mandibular teeth such as missing mandibular second premolars. Instead of removing maxillary teeth and retracting the maxillary anterior teeth, this approach uses orthodontics to open the spaces where the missing teeth should have been. This has the effect of lengthening the mandibular arch to eliminate the excess overjet while leaving the maxillary teeth in an ideal position. Today the missing mandibular teeth would then commonly be replaced with implants.

Orthodontics and orthognathic surgery: For patients whose excess overjet is due to a deficiency in mandibular development this option is often the ideal choice. The orthodontist will position the maxillary teeth ideally for the best esthetics The surgeon will then advance the mandible to an ideal anterior occlusal relationship. Finally the orthodontist will correct and refine the occlusion For many patients with a Class II skeletal relationship that is responsible for their excess overjet, this provides the most ideal occlusal and esthetic result.

Even though the therapies above are ideal, many patients are unwilling to go through having braces and surgery.

Build a dual bite: This approach is unusual but can be very effective for patients who won’t agree to an orthodontic and surgical correction. This involves creating two different intercuspal positions that the patient can comfortably slide between.

The first occlusion is designed with the mandible in a retruded position to have even contact on as many teeth as possible, but not the anteriors due to the excess overjet. This occlusion is also designed to have guidance in left and right excursive movements on the most anterior teeth that touch in the retruded position, typically the first or second premolars.

The other intercuspal position exists in a more anterior mandibular position where anterior tooth contact can be achieved. In this position all the anterior and posterior teeth are in contact, but when the patient moves left, right, or forward the anterior teeth provide guidance separating the posterior teeth. The key to this treatment is to create a smooth balanced slide from the more retruded position to the more anterior position.

Although it sounds complicated to achieve, this approach can be well managed if an articulator is used which allows accurate recording and repositioning of the mounted models to the desired positions and in between. This approach does often involve the restoration of a significant number of maxillary teeth and also results in fairly flat posterior tooth form.


Comments

John Sweeney
February 27th, 2013
Thanks for the post Frank, this is great information. I have a patient that will need to be restored with the dual bite you mentioned above. It will be my first case like this so it was great to see your thoughts. It will definitely help. On another note, I have successfully been able to treat minor excess overjet with interproximal reduction (ipr)of .2mm to .4mm between the upper 6 anteriors and sometimes the premolars followed by retraction of the upper anteriors without doing extractions. It has been a great tool to get the anteriors closer to coupling prior to restorative work. But as you mentioned with flattening of the upper anterior arch, you also have to be careful with this approach and make sure their profile can take those type of movements. Thanks again for the post!
John Sweeney
March 6th, 2013
Frank, Is it a good treatment option to add composite to the lingual surfaces of the upper anterior teeth to gain coupling in patients who don't require restorative treatment in the upper? I'm wondering if you could wax up a case adding wax only to the lingual surfaces of the upper anteriors and then use a matrix to bond composite to these teeth. I guess the biggest potential problem with this could be speech depending on how much you had to add. Any thoughts? John
Ed Lipskis
March 19th, 2013
I find it surprising that there is no mention of airway and whether or not the tongue retracts into the airway, potentially reducing the airway volume. This should always be a consideration before deciding on retractive mechanics. Facial form also should be a significant factor. Is treatment successful when the dental alignment is considered acceptable, but the patient's face looks significantly worse? Very few patients that are not of African or Asian Indian ethnic backgrounds have maxillas that are prognathic. in fact statistically, most often in cases of excessive overjet, the maxilla is not normal or prognathic, it is retrognathic. With todays treatment options, it seems problematic to take a maxilla that is retrognathic and use retractive mechanics. It is certainly simpler, but I wouldn't want my children treated that way.
Bill Smith
March 23rd, 2013
I like Ed's comments. His findings are the same as mine. Has anyone considered that perhaps the lower posterior teeth are inadequately erupted, rather than the anterior teeth supra-erupted? I find that if the mandible is repositioned down and forward several good things frequently happern. The patient is now dental Class I; the airway is improved; the facial appearance is improved; the patient now has a nice chin; the TMJ condyles are in a more healthy position in the fossa. TMJ problems decrease. Another thought about Ed's comments. More people have died from a limited airway than from crowded teeth. We need to consider the patient's airway in our dental treatment plans.
Domingo Martin
December 23rd, 2013
you forgot about vertical control either using skeletal anchorage or dental implants….frank whenever you want would love to share my material with your group merry christmas domingo san sebastian spain