See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/24203928

Miniscrews for upper incisor intrusion

Article in The European Journal of Orthodontics · April 2009

DOI: 10.1093/ejo/cjn122 · Source: PubMed

CITATIONS READS

94 2,007

3 authors:

Omur Polat-Ozsoy Ayça Arman Ozcirpici

Izmir Tinaztepe University and Private Practice Başkent University
56 PUBLICATIONS 1,407 CITATIONS 89 PUBLICATIONS 1,736 CITATIONS

SEE PROFILE SEE PROFILE

Firdevs Senel
Beykent University
25 PUBLICATIONS 384 CITATIONS

SEE PROFILE

All content following this page was uploaded by Omur Polat-Ozsoy on 07 March 2016.

The user has requested enhancement of the downloaded file.

European Journal of Orthodontics 31 (2009) 412–416 © The Author 2009. Published by Oxford University Press on behalf of the European Orthodontic Society.
doi:10.1093/ejo/cjn122 All rights reserved. For permissions, please email: journals.permissions@oxfordjournals.org.
Advance Access publication 16 March 2009

Miniscrews for upper incisor intrusion

Omur Polat-Ozsoy*, Ayca Arman-Ozcirpici* and Firdevs Veziroglu**
Departments of *Orthodontics and **Oral and Maxillofacial Surgery, Baskent University, Ankara, Turkey

SUMMARY The aim of this study was to investigate if true incisor intrusion can be achieved using miniscrews.
Eleven patients (three males and eight females; mean age: 19.8 ± 4.8 years) with normal vertical dimension
showing a pre-treatment deep bite of 5.9 ± 0.9 mm and a ‘gummy’ smile were enrolled in the study. After
levelling of the maxillary central and lateral incisors with a segmental arch, an intrusive force of 80 g using
closed coil springs was applied from two miniscrews placed between the roots of the lateral and canine
teeth. The amount of incisor intrusion was evaluated on lateral cephalometric headfilms taken at the end
of levelling (T1) and at the end of intrusion (T2). Statistical analysis of the data was performed using a
paired t and Wilcoxon signed rank tests. A significance level of P < 0.05 was predetermined.
The mean upper incisor intrusion was 1.92 mm and the mean overbite decrease 2.25 ± 1.73 mm in 4.55
months. Upper incisor angulation resulted in a 1.81 ± 3.84 degree change in U1-PP angle and a 1.22 ± 3.64
degree change in U1-NA angle. However, these were not statistically significant (P > 0.05).
True intrusion can be achieved by application of intrusive forces close to the centre of resistance using
miniscrews. However, studies with a larger number of subjects and long-term follow-up are necessary.

Introduction
Miniscrews are used in orthodontics as a stable anchorage

Downloaded from by guest on January 4, 2016

A deep bite is a complex orthodontic problem that is a unit. Due to their small dimensions, they can be placed in
common feature of many malocclusions (Al-Buraiki et al., interdental areas where traditional implants cannot be
2005). A decrease in vertical skeletal growth, axial inserted (Carillo et al., 2007). The orthodontic literature is
inclinations of the upper and lower anterior teeth, vertical lacking controlled studies on the effects of miniscrew-
positions of the anterior (Wolfson, 1938; Dermaut and supported incisor intrusion. This study aimed to investigate
Vanden Buckle, 1976; Karlsen, 1994) and posterior (Schudy, the effects of incisor intrusion obtained with the aid of
1968; Karlsen, 1994) teeth, and loss of periodontal support miniscrews. The null hypothesis investigated is that true
(Melsen et al., 1989) are among the factors that contribute incisor intrusion can be achieved using miniscrews.
to the development of deepening of the bite. Correction of a
deep bite is an important part of orthodontic treatment due Subjects and methods
to the potential deleterious effects on the temporomandibular
This study was approved by the Medical Scientific Ethics
joint (Alexander et al., 1984) and periodontal health and
Committee of Baskent University. Informed consent was
facial aesthetics (Janzen, 1989; Lindauer et al., 2005).
obtained from the patients and/or parents. The patients were
Non-surgical correction of a deep bite involves extrusion
selected according to the following criteria:
of posterior teeth, intrusion of the incisors, or both (Burstone,
1977; Otto et al., 1980; Hans et al., 1994; Davidovitch and 1. A deep bite of at least 4 mm.
Rebellato, 1995; Weiland et al., 1996; Nanda, 1997). The 2. Excessive gingival display on smiling.
treatment of choice depends on a variety of factors such as 3. Normal vertical dimensions, represented by a GoGnSN
smile line, upper lip length, incisor display, and vertical angle of 32 ± 6 degrees.
dimension (Lindauer et al., 2005). For instance, in subjects Eleven patients (three males and eight females; mean
with a normal vertical dimension, intrusion of the anterior age: 19.79 ± 4.79 years; mean overbite: 5.9 ± 0.9 mm) who
teeth is recommended. Conventional methods for incisor met the selection criteria and agreed to the placement of
intrusion usually involve 2 × 4 appliances or reverse curved miniscrews participated in the study. Prior to insertion of
arches. Labial tipping of anterior teeth is commonly the the miniscrews, brackets were bonded to the four maxillary
outcome of these arches that gives the impression of deep incisor teeth only and the teeth were levelled with 0.016 and
bite correction due to the change in vertical incisal edge 0.016 × 0.016 nickel titanium (NiTi) segmental wires. After
position (Barton, 1972; Engel et al., 1980; Otto et al., 1980; completion of levelling, a 0.016 × 0.022 stainless steel wire
Hans et al., 1994; Davidovitch and Rebellato, 1995; Weiland was bent to the maxillary anterior segment with small hooks
et al., 1996). Only a few studies that show true incisor at the distal ends of the wire for intrusion.
intrusion can be found in the orthodontic literature (Hans et al., Two miniscrews (Absoanchor; Dentos, Taegu, Korea),
1994; Weiland et al., 1996; Kinzel et al., 2002). 1.2 mm in diameter and 6 mm in length, were placed distal
MINISCREWS FOR UPPER INCISOR INTRUSION 413

to the maxillary lateral incisors under local anaesthesia. The Periapical radiographs were obtained for each patient at
implants were inserted at the mucogingival junction into the T2 to determine any signs of root resorption.
bone without drilling. Placement of the implants was carried
out by an oral surgeon. Statistical analysis
One week after insertion, the screws were loaded with
One week after the initial evaluation, six radiographs were
medium superelastic NiTi closed coil springs and an
retraced by the same investigator to determine the method
intrusion force of 80 g was applied. The patients were
error. Spearman rho correlation coefficients were calculated
recalled every 4 weeks and the screws were checked for
for repeatability, and the coefficients were found to be close
signs of mobility or infection.
to 1.00.
In five patients, brackets (Victory series; 3M Unitek,
Descriptive statistics for age, duration of treatment, mean
Monrovia, California, USA) were bonded to teeth in the
differences, standard deviations, and minimum and maximum
lower arch.
values were calculated between T2 and T1. After checking
for normal distribution of the data, a paired t or a Wilcoxon
Records and measurements
signed rank test was performed for the assessment of treatment
Two lateral cephalometric headfilms of the patients, one at changes. A significance value of 0.05 was predetermined.
the end of levelling (T1) and the other at the end of intrusion
(T2), were obtained. All cephalograms were traced by the
Results
same investigator (OPO) over a negatoscope in a dark room
using a 0.3 mm lead pencil. Fifteen landmarks were located A total of 22 screws were inserted. One screw was replaced
and 16 measurements (seven angular and nine linear) were due to close proximity to one of the lateral roots, and two
made on the cephalometric tracings (Figure 1). The centre due to post-operative infection and mobility.
of resistance (CR) of the maxillary central incisor was Upper intrusion was achieved in 4.55 ± 2.64 months. The
determined for each patient rather than the CR of the anterior mean rate of intrusion was 0.42 mm/month.

Downloaded from by guest on January 4, 2016

segment due to its ease of location and high reproducibility The mean overbite at T1 was 5.54 ± 1.38 mm. The mean
(Van Steenbergen et al., 2005). The CR of the maxillary intrusion of the upper anterior segment was 1.92 ± 1.19 mm
central incisor was taken as a point located at one-third of (CR-PP distance) and the mean change in overbite
the distance of the root length apical to the alveolar crest 2.25 ± 1.73 mm (Table 1). Vertical movement and overbite
(Burstone, 1962). A horizontal reference plane (palatal change were statistically significant (P < 0.05).
plane) and a vertical reference plane (a line perpendicular to The sagittal position of the upper incisors showed
palatal plane from point A) were used. minimal changes (U1-NA angle 1.22 ± 3.64 degrees; U1-NA

Figure 1 (a–c) Skeletal and dental measurements used in the study. (1) SNA (degree), angle formed between sella
nasion and nasion point A planes; (2) SNB (degree), angle formed between sella nasion and nasion point B planes; (3)
ANB (degree), angle formed between nasion point A and nasion point B planes; (4) GoMe-SN (degree), angle between
the mandibular and sella nasion planes; (5) N-ANS (mm), distance between nasion and anterior nasal spine; (6)
ANS-Me (mm), distance between anterior nasal spine and menton points; (7) S-Go (mm), distance between sella and
gonion points; (8) 1-NA (degree), angle formed between the upper incisor axis and nasion point A plane; (9) 1-NA
(mm), distance between the labial point of the upper incisor and nasion point A plane; (10) 1-PP (degree), angle formed
between the upper incisor axis and the palatal plane; (11) IMPA (degree), angle formed between the lower incisor axis
and the mandibular plane; (12) Cr-PP (mm), vertical distance between the centre of resistance (CR) of the upper
incisor and the palatal plane; (13) Cr-PFA (mm), horizontal distance between the CR of the upper incisor and the point
of force application on the upper incisor where the bracket is bonded; (14) 1-Ls (mm), vertical distance between the
upper incisor tip and upper lip stomion; (15) overjet (mm), horizontal distance between the tips of the upper and lower
central incisors; and (16) overbite (mm), vertical distance between the tips of the upper and lower central incisors.
414 O. POLAT-OZSOY ET AL.

Table 1 Pre-treatment (T1) and post-treatment (T2) cephalometric values and results of the statistical evaluation.

T1 T2 T2 − T1 P value

82.81 ± 3.51 81.63 ± 3.09 −3.00 ± −1.18 0.029

SNB (°) 75.68 ± 1.40 76.40 ± 1.95 −0.72 ± 1.00 0.039
ANB (°) 6.31 ± 1.90 5.95 ± 1.63 −0.36 ± 0.97 NS
GoGnSN (°) 32.80 ± 4.20 33.00 ± 4.56 0.20 ± 1.15 NS
N-ANS (mm) 55.77 ± 3.93 55.93 ± 3.37 0.16 ± 1.01 NS
ANS-Me (mm) 67.13 ± 5.44 67.48 ± 6.20 0.34 ± 1.88 NS
S-Go (mm) 84.63 ± 5.12 85.00 ± 5.31 0.36 ± 1.34 NS
1-NA (°) 11.31 ± 8.71 12.54 ± 9.42 1.22 ± 3.64 NS
1-NA (mm) 0.50 ± 3.79 1.36 ± 3.82 0.86 ± 1.28 NS
1-PP (°) 101.50 ± 9.19 103.31 ± 8.95 1.81 ± 3.84 NS
Cr-PP (mm) 15.42 ± 2.85 13.51 ± 2.73 −1.92 ± 1.19 0.007
Cr-PFA (mm) 5.13 ± 1.50 5.27 ± 1.61 0.13 ± 1.05 NS
1-Ls (mm) 4.54 ± 1.98 3.38 ± 2.28 −1.16 ± 1.01 NS
Overjet (mm) 4.54 ± 1.98 3.38 ± 2.28 −0.27 ± 1.21 0.004
Overbite (mm) 5.54 ± 1.38 3.29 ± 1.44 −2.25 ± 1.73 0.002
IMPA (°) 96.95 ± 5.85 95.54 ± 4.86 1.40 ± 3.61 NS

NS, not significant.

distance 0.86 ± 1.28 degrees; and U1-PP angle 1.81 ± 3.84 intrusion is the treatment of choice. Conventional intrusion
degrees); however, these changes were not significant mechanics frequently cause labial tipping of incisors, a
(P > 0.05). A change in the distance between the point of situation which does not always give favourable treatment

Downloaded from by guest on January 4, 2016

intrusive force application and the CR of the maxillary outcomes (Barton, 1972; Engel et al., 1980; Otto et al.,
central incisor was also found not to be statistically 1980). Melsen et al. (1989) indicated that the segmented
significant (0.13 ± 1.05 mm, P > 0.05). arch technique is the treatment of choice for patients with
The lower incisors were slightly protruded but the extent elongated incisors or periodontal bone loss. However, since
of the protrusion was not significant (1.40 ± 3.61 degrees, conventional arches are connected to the posterior teeth
P > 0.05). A significant decrease in overjet was observed during intrusion, the presence of counteracting moments is
(0.27 ± 1.21 mm, P < 0.05). frequently inevitable (Burstone, 2001). Direct application
Skeletal measurements showed significant changes in of intrusive forces from miniscrews offers an efficient
SNA and SNB (P < 0.05); however, all vertical measurements alternative to 2 × 4 arches and true intrusion can be achieved.
remained unchanged (P > 0.05). However, to date, no clinical studies have evaluated the
When periapical radiographs were examined for signs of effects of miniscrews used for incisor intrusion. The aim of
resorption, slight blunting of only one central incisor root this study was to investigate whether true incisor intrusion
was seen. Figure 2a,b shows the intraoral records of a patient can be achieved with the use of miniscrews.
with incisor intrusion. Recently, the focus of the orthodontic literature has been on
the evaluation of the smile and the effect of incisor display
during smiling (Janzen, 1989; Lindauer et al., 2005; Sarver
Discussion and Ackerman, 2005). It has been speculated that overbite
Correction of a deep overbite is one of the primary goals of correction with maxillary incisor intrusion will lead to a
orthodontic treatment. In patients with an excessive gingival flattening of the smile arc and a reduction in smile attractiveness
display and a normal vertical dimension, maxillary incisor (Lindauer et al., 2005). The patients selected for this study

Figure 2 Frontal intraoral views of a patient treated with miniscrews: (a) pre-intrusion and (b) post-intrusion.
MINISCREWS FOR UPPER INCISOR INTRUSION 415

showed a gummy smile and incisor intrusion was the preferred In some of the patients, the lower arch was bonded for
choice of treatment. However, no overcorrection was carried levelling during upper incisor intrusion. As a result, the
out and bite opening was to be achieved by intrusion not only lower incisors showed minimal, non-significant protrusion.
of the maxillary but also of the mandibular incisors. The minimal increases in axial inclination of the upper and
In vitro studies using different methods such as the lower incisors resulted in a significant decrease in overjet.
laser reflection technique and holographic interferometry Root resorption is one of the most serious consequences of
(Dermaut and Vanden Buckle, 1976), photoelastic stress orthodontic treatment and intrusion is one type of tooth
analysis (Matsui et al., 2000), and the finite element method movement that has been suggested as a possible cause of root
(Reimann et al., 2007) as well as in vivo studies have been resorption. DeShields (1969) and Kaley and Phillips (1991)
performed to determine the CR of the incisors (Sia et al., found no correlation with upper incisor intrusion and root
2007). The results show that the CR of the four incisor teeth resorption. Conversely, McFadden et al. (1989) found 1.8 mm
lies 8–10 mm apical and 5–7 mm distal to the lateral incisors root shortening in patients treated with utility arches.
(Dermaut and Vanden Buckle, 1976; Matsui et al., 2000; Costipoulos and Nanda (1996) noted negligible amounts of
Turk et al., 2005; Reimann et al., 2007; Sia et al., 2007). resorption with intrusion and concluded that intrusion with low
Thus, application of intrusive forces mesial to the lateral forces can be effective in reducing overbite without significant
incisors would result in their proclination. The miniscrews root resorption. In this study, any possible sign of root resorption
used in the present sample were placed between the incisor was checked on the periapical radiographs and slight blunting
and canine roots in order to minimize forward movement of of only one central incisor was detected. Intrusion was
the incisors. The records were taken at the end of levelling undertaken with continuous forces via closed coil springs and
and intrusion; therefore, any protrusion occurring during the use of continuous forces might have favoured root
levelling was omitted from the measurements. continuity. Thus, force levels were within the limits
The use of the incisal edge or root apex for the evaluation recommended by Burstone (2001). However, controlled
of intrusion is not recommended because these points do not studies on the effects of incisor intrusion using miniscrews on
depend on any change in inclination (Ng et al., 2005). root resorption with a larger sample size should be performed.

Downloaded from by guest on January 4, 2016

Burstone (1962) reported that the CR of an upper incisor
was located at one-third of the distance of the root length, Conclusions
apical to the alveolar crest. The CR of the central incisor was
1. True intrusion of upper incisors can be achieved using
the reference point of choice in the present study due to the
miniscrew anchorage.
fact that it is easily identified and its reproducibility is high.
2. During the application of intrusive force, the axial
Thus, it is unaffected by the change in tooth inclination.
inclination of the upper incisors showed minimal change,
The mean upper incisor intrusion in the present study was
which was considered to be clinically acceptable.
1.92 mm. The amount of intrusion was determined not only
3. Root resorption was not seen as a consequence of
by the extent of the overbite but also by the amount of the
incisor intrusion.
upper incisors displayed during smiling and the smile line.
The amount of intrusion found was slightly higher than that Address for correspondence
reported by Weiland et al. (1996) and Kinzel et al. (2002)
who evaluated the amount of true intrusion, using the CR or Dr Omur Polat-Ozsoy
incisor centroid. However, those studies evaluated the effects Baskent University
of conventional segmented arches. There exists only one Faculty of Dentistry
case report on the use of miniscrews for upper incisor 11. Sokak No: 26 06490
intrusion. Kim et al. (2006) used one screw placed at anterior Bahcelievler
nasal spine in a Class II division 2 subject and although Ankara
protrusion was favourable in that case, measurements for Turkey
determining the amount of intrusion were not carried out. E-mail: omurorto@yahoo.com
The axial inclination of incisors in the present investigation
showed a minimal increase during intrusion that was not Funding
significant. As stated above, the CR of the upper four incisors
lies 8–10 mm apical and 5–7 mm distal to the lateral incisors Baskent University Research Foundation (D-KA06/07).
(Dermaut and Vanden Buckle, 1976; Matsui et al., 2000;
Turk et al., 2005; Reimann et al., 2007; Sia et al., 2007). The References
point of force application in this study was close to the CR Al-Buraiki H, Sadowsky C, Schneider B 2005 The effectiveness and long-term
and the amount of force applied was within recommended stability of overbite correction with incisor intrusion mechanics. American
Journal of Orthodontics and Dentofacial Orthopedics 127: 47–55
limits. The moments that would normally be produced
Alexander T A, Gibbs C H, Thompson W J 1984 Investigation of chewing
with conventional intrusion arches did not occur since the patterns in deep bite malocclusions before and after orthodontic
segmented arch used did not extend to the posterior teeth. treatment. American Journal of Orthodontics 85: 21–27
 416 O. POLAT-OZSOY ET AL.

Barton K A 1972 Overbite changes in the Begg and edgewise techniques. Lindauer S J, Lewis S M, Shroff B 2005 Overbite correction and smile
American Journal of Orthodontics 62: 48–55 aesthetics. Seminars in Orthodontics 11: 62–66
Burstone C J 1962 The biomechanics of tooth movement. In: Kraus B S McFadden W M, Engström C, Engström H, Anholm J M 1989 A study of
(ed.) Vistas in orthodontics Lea & Febiger, Philadelphia, pp. 197–213. the relationship between incisor intrusion and root shortening. American
Burstone C R 1977 Deep overbite correction by intrusion. American Journal of Orthodontics and Dentofacial Orthopedics 96: 390–396
Journal of Orthodontics 72: 1–22 Matsui S, Caputo A A, Chaconas S J, Kiyomura H 2000 Center of resistance
Burstone C J 2001 Biomechanics of deep overbite correction. Seminars in of anterior arch segment. American Journal of Orthodontics and
Orthodontics 7: 26–33 Dentofacial Orthopedics 118: 171–178
Carillo R, Buschang P H, Opperman L A, Franco P F, Rossouw E P 2007 Melsen B, Agerbaek N, Markenstam G 1989 Intrusion of incisors in adult
Segmental intrusion with mini-screw implant anchorage: a radiographic patients with marginal bone loss. American Journal of Orthodontics and
evaluation. American Journal of Orthodontics and Dentofacial Dentofacial Orthopedics 96: 232–241
Orthopedics, 132: 576.e1–e6 Nanda R 1997 Correction of deep overbite in adults. Dental Clinics of
Costipoulos G, Nanda R 1996 An evaluation of root resorption incident to North America 41: 67–87
orthodontic intrusion. American Journal of Orthodontics and Dentofacial Ng J, Major P W, Heo G, Flores-Mir C 2005 True incisor intrusion attained
Orthopedics 109: 543–548 during orthodontic treatment: a systematic review and meta-analysis.
Davidovitch M, Rebellato J 1995 Two-couple orthodontic appliance American Journal of Orthodontics and Dentofacial Orthopedics 128:
systems utility arches (a two-couple intrusion arch). Seminars in 212–219
Orthodontics 1: 25–30 Otto R L, Anholm J M, Engel G A 1980 A comparative analysis of intrusion
Dermaut L R, Vanden Buckle M M 1976 Evaluation of intrusive mechanics of incisor teeth achieved in adults and children according to facial type.
of the type ‘segmented arch’ on a macerated human skull using the laser American Journal of Orthodontics 77: 437–446
reflection technique and holographic interferometry. American Journal Reimann S, Keilig L, Jäger A, Bourauel C 2007 Biomechanical
of Orthodontics 69: 447–454 finite element investigation of the position of the centre of resistance of
DeShields R W 1969 A study of root resorption in treated Class II, division the upper incisors. European Journal of Orthodontics 29: 219–224
1 malocclusions. Angle Orthodontist 39: 231–245 Sarver D M, Ackerman M B 2005 Dynamic smile visualization and
Engel G, Cornforth G, Damerell J M, Gordon J, Levy P, McAlpine J 1980 quantification and its impact on orthodontic diagnosis and treatment
Treatment of deep-bite cases. American Journal of Orthodontics 77: 1–13 planning. In: Romano R, (ed.) The art of the smile. Quintessence
Publishing Co, Ltd, New Malden, UK, pp. 101–139.
Hans M G, Kishiyama C, Parker S H, Wolf G R, Noachtar R 1994
Cephalometric evaluation of two treatment strategies for deep overbite Schudy F F 1968 The control of vertical overbite in clinical orthodontics.

Downloaded from by guest on January 4, 2016

correction. Angle Orthodontist 64: 265–274 Angle Orthodontist 38: 19–39
Janzen E K 1989 A balanced smile—a most important treatment objective. Sia S, Kog Y, Yoshida N 2007 Determining the center of resistance of
American Journal of Orthodontist 96: 275–280 maxillary anterior teeth subjected to retraction forces in sliding
Kaley J, Phillips C 1991 Factors related to root resorption in edgewise mechanics. Angle Orthodontist 77: 999–1003
practice. Angle Orthodontist 61: 125–132 Turk T, Elekdag-Turk S, Dincer M 2005 Clinical evaluation of the centre
Karlsen A T 1994 Craniofacial characteristics in children with Angle Class of resistance of the upper incisors during retraction. European Journal of
II division 2 malocclusion combined with extreme deepbite. Angle Orthodontics 27: 196–201
Orthodontist 64: 123–130 Van Steenbergen E, Burstone C J, Prahl-Andersen B, Aartman I H 2005
Kim T W, Kim H, Lee S J 2006 Correction of deep overbite and gummy The influence of force magnitude on intrusion of the maxillary segment.
smile by using a mini-implant with a segmented wire in a growing Class Angle Orthodontist 75: 723–729
II division 2 patient. American Journal of Orthodontics and Dentofacial Weiland F J, Bantleon H P, Droschl H 1996 Evaluation of continuous arch
Orthopedics 130: 676–685 and segmented arch leveling techniques in adult patients—a clinical
Kinzel J, Aberschek P, Mischak I, Droschl H 2002 Study of the extent of study. American Journal of Orthodontics and Dentofacial Orthopedics
torque, protrusion and intrusion of the incisors in the context of Class II, 110: 647–652
division 2 treatment in adults. Journal of Orofacial Orthopedics 63: Wolfson A 1938 Deepbites in adults. American Journal of Orthodontics
283–299 and Oral Surgery 24: 120–128

View publication stats