The use of anterior bite raisers in deep bite cases: a clinical report

Introduction

Bite-raising appliances are widely used auxiliary tools in orthodontic treatment, intended to expand the dental arches and temporarily facilitate tooth movement. By creating an artificial occlusal interface that prevents complete intercuspation, these devices increase the vertical dimension of occlusion and reduce interferences that may hinder orthodontic mechanics. This temporary disarticulation enhances treatment efficiency, particularly during the initial phases, and reduces the risk of bracket failure caused by excessive occlusal contacts. [1–3]

Bite raisers can be classified according to their location, design, function, and material. They may be positioned in either the anterior or posterior segments and can be removable, fixed, or semi-fixed, depending on the clinical objectives. From a functional standpoint, they can also be distinguished as passive or active bite raisers, respectively, either not favoring mandibular shift (passive) or guiding mandibular movement during occlusion (active). [4] In terms of materials, several have been introduced over time, including removable acrylic bite plates, metal bite raisers, and composite ones.

Traditional acrylic bite plates were originally used to disarticulate the posterior dentition and facilitate deep bite correction; however, their effectiveness depended on patient compliance and required frequent clinical adjustments. [1,5]

These limitations have led to the development of metal- and resin-fixed bite raisers, which are typically bonded to the palatal surfaces of the maxillary central incisors. [1,6]

The first metal anterior bite raisers were the so-called Bite Turbos, introduced by Mayes, driving greater clinical control during treatment. [4]

They were frequently used in deep overbite cases, especially when associated with reduced lower facial height. Further developments led to the first generation of BiTurbos 1 in 2014, followed by BiTurbos 2, designed by Dr. John Voudouris, which demonstrated effectiveness in controlling the vertical dimension and facilitating rapid deep-bite correction. [6]

The current design presents the following features:

• a vertical groove in the long axis to ease the placement of the device and its detachment;
• dimples for tweezers, which are useful during positioning;
• an 80-gauge mesh on the bonding pad that raises bond strength;
• bulbous ends that favor patient comfort;

a sliding plane that can favor a slight forward repositioning of the mandible in Class II cases. [6] (Fig.1)

Based on existing literature and clinical practice, anterior bite raisers can be positioned in different locations depending on treatment objectives and overjet characteristics. They are typically bonded to incisors. [1]

In case of increased overjet (>3mm), it is preferable to bond them on the palatal surface of canines. In case of occlusal cant, their unilateral placement on the lateral incisor, canine, or both has been described in the literature. [7]

The aim of the case series herein is to show how anterior bite raisers can be an effective tool in the management of deep-bite scenarios, both symmetric and asymmetric.

Clinical Report

CASE 1

A 7-year-old male presented with early mixed dentition. Intraoral examination showed a Class II tendency, with an increased overbite. The upper and lower midlines were not coincidental. As a matter of fact, the lower midline was deviated towards the right side, probably due to a mandibular shift. The arches were neither crowded nor skeletally constricted. However, there was a crossbite between elements 26 and 36, probably due to the extreme palatal position of the upper-left first molar. Upon extra-oral examination, a rightward deviation of the chin was observed, confirming the mandibular shift previously diagnosed. (Fig.2)

This first phase of interceptive treatment consisted of the following objectives:

• Correction of the deep bite;
• Re-centering of the lower midline with the upper one;
• Correction of the cross bite.

To adequately correct the deep overbite, were bonded on the palatal surfaces of the maxillary central incisors. (Fig.3)

This created a gap between the arches, in which posterior teeth would be free to extrude, thus allowing for an increase in vertical dimension. Consequently, dental disarticulation resulted in a prompt re-centering of the midlines. By eliminating any pre-contacts and occlusal interferences, the mandible spontaneously repositioned properly, and asymmetry was resolved. After two months of treatment, the posterior teeth were in contact. (Fig.4)

The upper and lower midlines t remained coincident while the class molar relationship improved. At this stage of treatment, the palatally positioned upper left molar had to be vestibularized. The crossbite was corrected by applying a criss-cross elastic from the palatal surface of the upper left molar to the buccal area of the lower left one. After another three months, the crossbite was solved. (Fig.5)

The device was maintained for six further months to stabilize the achieved occlusion in a symmetric position. Overall, this first treatment phase lasted 11 months. The patient is meant to be monitored during dental exfoliation, and a second phase of treatment will be considered during the late mixed dentition phase.

CASE 2

A 10-year-old female presented with late mixed dentition. Intraoral examination revealed an end-to-end Class II, with an increased overbite. The upper and lower midlines were coincidental. The lower arch showed mild crowding, whereas the upper arch was neither crowded nor skeletally constricted. (Fig.6)

This first phase of interceptive treatment aimed to:

• Correct the deep bite;
• Improve the class molar relationship.

During the first appointment, was bonded on the palatal surfaces of the maxillary central incisors to correct the deep overbite. (Fig.7)

This created a gap between the arches, allowing posterior teeth to extrude, thereby increasing vertical dimension. Meanwhile, the anterior slide plane favored a forward positioning of the mandible. After one month of treatment, the posterior teeth were in contact. (Fig.8)

Therefore, a glass ionomer was added to the device to increase the degree of disclusion and gradually correct the deep bite. (Fig.9)

After 4 months of treatment, the overbite was within normal ranges, and the class molar relationship had improved. (Fig.9)

CASE 3

A 12-year-old female presented with permanent dentition. Intraoral examination showed a Class II subdivision malocclusion with a half-cusp Class II relationship on the right side, a Class I relationship on the left side, and bilateral Class II canine relationships. (Fig. 10)

The upper and lower midlines were coincident. The upper arch presented mild crowding, and the overbite was increased. Both overjet and overbite values were increased. (Fig.10)

The treatment objectives consisted of:

• arch alignment;
• arch leveling;
• arch coordination;
• correction of the deep overbite;
• achievement of a Class I relationship on both sides.

The treatment plan comprised the combined use of a fixed appliance and intermaxillary elastics.

During the first phase of treatment, self-ligating brackets with Bidimensional prescription [8] were bonded in the lower arch, and a nickel-titanium archwire was inserted for alignment and leveling purposes.

After two months, was bonded on the palatal surfaces of the maxillary central incisors to achieve posterior disclusion. This would have promoted deep-bite resolution and improved molar-class relationships while avoiding the risk of lower bracket detachment. (Fig. 11)

At the same time, self-ligating brackets were bonded in the upper arch.

To achieve a stable Class I relationship, short Class II intermaxillary elastics (4 mm, 6 oz) attached from the lower first molars to the upper canines were prescribed to be worn 14–18 hrs/day. (Fig.12)

Once a Class I molar relationship was achieved on both sides, the finishing phase was performed.

Overall, the treatment lasted 18 months.

At the end of treatment, Class I molar and canine relationships were achieved, along with normal overbite and overjet. (Fig. 13)

Discussion

In the present case series, anterior bite raisers were used to temporarily modify the occlusal relationship between the dental arches and facilitate orthodontic treatment. By creating posterior disclusion, these devices can simplify orthodontic mechanics and enable efficient tooth movement in patients with deep overbite or occlusal interferences.

On the one hand, posterior disclusion enables controlled eruption or extrusion of posterior teeth, contributing to the leveling of the curve of Spee and the correction of excessive overbite. At the same time, anterior teeth may undergo relative intrusion as orthodontic mechanics progress. Hence, the combination of posterior extrusion and anterior intrusion represents one of the main mechanisms involved in deep bite correction. [6,1,9,5].

Dental disarticulation also prevents excessive occlusal contacts that often occur while using orthodontic appliances, thereby protecting brackets and allowing treatment mechanics to proceed more efficiently during the early phases of treatment. [1–2,9].

Deep overbite is a common malocclusion characterized by excessive vertical overlap of the anterior teeth. It is often associated with dentoalveolar factors such as a pronounced curve of Spee, infraeruption of the posterior teeth, or increased eruption of the anterior teeth. [10–12]

Its correction frequently requires modification of the vertical dimension and minimization of occlusal interferences that may restrict tooth movement. [13]

Within this context, anterior bite raisers represent an effective tool.

Beyond their role in terms of deep bite correction, the findings of the present case series suggest that anterior bite raisers can also be particularly useful in the management of asymmetric malocclusions, such as Class II subdivision cases. A unilateral Class II molar relationship characterizes these malocclusions and frequently involves dentoalveolar and/or skeletal asymmetries, including midline discrepancies and asymmetric occlusal contacts. [14]

Their correction is often challenging, as it requires not only sagittal correction but also the re-establishment of symmetry between the dental arches. On one hand, conventional treatment strategies typically rely on asymmetric mechanics - such as intermaxillary elastics, distalization protocols, or extraction approaches – and require consistent patient compliance, the lack of which can imply undesired effects in turn. [15]

On the other hand, anterior bite raisers, such as, can provide a relevant biomechanical advantage during the early phases of treatment without implying strict patient compliance. By inducing posterior disclusion, these devices minimize occlusal interferences that can hinder asymmetric correction mechanics, allowing for mandibular repositioning and a more predictable dentoalveolar response. [1–2,7]

Moreover, early occlusal disengagement can promote a spontaneous improvement of asymmetric molar relationships. In the cases presented herein, the application of was associated with a rapid reduction in the severity of the Class II malocclusion, favoring a transition toward a Class I relationship even before the full implementation of orthodontic mechanics. This observation is consistent with the concept that removal of occlusal constraints enhances dentoalveolar adaptability and facilitates sagittal correction. [16–17]

From a functional standpoint, the increase in vertical dimension induced by anterior bite raisers may also contribute to improved neuromuscular balance. The literature suggests that modifications in occlusal conditions are associated with changes in masticatory muscle activity and functional adaptation of the stomatognathic system, potentially reducing functional shifts that can exacerbate asymmetry. [18–19].

An additional finding emerging from this case series is the versatility of anterior bite raisers across different stages of dental development. In particular, Case 3 involved a patient in permanent dentition, whereas Cases 1 and 2 were treated during mixed dentition. Despite these differences, anterior bite raisers proved to be effective in both clinical scenarios, suggesting that their application is not limited to a specific dentition stage. In the mixed dentition scenarios (Cases 1 and 2), early occlusal disclusion facilitated interceptive correction by minimizing functional interferences and promoting favorable dentoalveolar adaptation during growth, when tissues are typically more responsive to functional and mechanical forces. A rapid improvement in the asymmetric molar relationship and midline discrepancy was observed in Case 1 following anterior bite raiser placement, even before the initiation of the second phase of treatment. In Case 2, the anterior sliding plane of favored a forward repositioning of the mandible, allowing for early Class II correction. In the permanent dentition scenario (Case 3), anterior bite raisers provided effective vertical control, facilitated the asymmetric malocclusion correction, and drove the achievement of a stable Class I relationship with the normalization of the overbite.

Finally, in all the illustrated cases, anterior bite raisers remained stable during the early phases of orthodontic treatment and effectively maintained posterior disclusion without significant debonding or mechanical complications.

Conclusions

The cases presented in this series demonstrate the clinical utility of auxiliary tools in managing occlusal interferences during orthodontic treatment. By inducing posterior disclusion, they facilitate orthodontic mechanics, improve treatment efficiency, and contribute to effective deep-bite correction.

In addition to vertical control, may also play a relevant role in the management of asymmetric malocclusions, such as Class II subdivision, as shown in cases 1 and 3. Alongside, in Class II malocclusion with slight overjet, anterior bite raisers can favor the forward repositioning of the mandible as occurred in case 2. In the patients presented, early occlusal disclusion was associated with a reduction in the severity of asymmetry and facilitated the achievement of a Class I relationship.

Furthermore, the use of proved effective in both mixed and permanent dentition, supporting its versatility as a clinical tool applicable to interceptive and comprehensive orthodontic treatment.

Nevertheless, this clinical report has several limitations. As a case series with a limited number of patients, it does not allow for definitive conclusions, and further research will be essential to determine the efficacy of anterior bite raisers.