ORIGINAL ARTICLE

Deepbite correction with incisor intrusion in adults: A long-term cephalometric study

u  r Tu zc l Onur Alpakan,b and C rko Selin Kale Varlk,a Od ag Ankara, Turkey

Introduction: The purpose of this study was to investigate the long-term stability of deep overbite correction with mandibular incisor intrusion with utility arches in adult patients. Methods: Pretreatment, posttreatment, and 5-years postretention lateral cephalograms of 31 patients (mean age, 26.8 years; range, 24.1-30.9 years) with Class II Division 1 malocclusion and deepbite, treated by maxillary rst premolar extraction and mandibular incisor intrusion, were traced and measured. Results: Signicant decreases in overjet and overbite (6.4 6 1.2 and 3.9 6 0.7 mm, respectively), signicant retroclination (17 6 1.9 ) and retraction (3.8 6 1.1 mm) of the maxillary incisors, and signicant increases in protrusion (0.8 6 1.5 mm), proclination (0.6 6 0.9 ), and intrusion (2.6 6 1.4 mm) of the mandibular incisors were observed at posttreatment. At postretention, there were statistically signicant but clinically unimportant increases in overjet and overbite (0.4 6 0.2 and 0.8 6 0.4 mm, respectively) and extrusion of the mandibular incisors (0.8 6 1.1 mm). Conclusions: Correction of deepbite in nongrowing patients by mandibular incisor intrusion with a utility arch can be considered effective and stable. (Am J Orthod Dentofacial Orthop 2013;144:414-9)

orrection of deepbite is often a challenging step in orthodontic treatment. Untreated deepbite can cause increased anterior crowding, maxillary dental aring, periodontal problems, and temporomandibular joint problems and can interfere with lateral and anterior mandibular movements.1-3 Deepbite can be treated orthodontically by intrusion or aring of the incisors, extrusion or passive eruption of the buccal segments, or a combination of these.4-6 The choice of treatment depends on several factors. Extrusion of the posterior dentition, although an effective method of bite opening in growing patients,7,8 is not indicated in patients with normal incisor display or normal or long lower facial height; its stability is questionable in nongrowing patients with average to low mandibular plane angles.6,9-14 Intrusion of the maxillary incisors is indicated in patients with excessive incisor and gingival display and a large interlabial
a

gap.13-15 Considering these facts, mandibular incisor intrusion is the most suitable deepbite treatment for adults with normal incisor and gingival display and a normal or high mandibular plane angle. Although many studies have examined the stability of deepbite treatment, most included growing subjects. In some studies, different malocclusions or different treatment methods were assessed together, and in others the follow-up durations were short.16-19 Two studies of nongrowing subjects did not include information about long-term follow-up results and treatment stability.20,21 The purpose of this study was to investigate the longterm stability of deepbite correction with mandibular incisor intrusion with utility arches in adult patients. The null hypothesis was that dental deepbite correction with mandibular incisor intrusion in adults is stable.
MATERIAL AND METHODS

Associate professor, Department of Orthodontics, Faculty of Dentistry, Gazi University, Ankara, Turkey. b Private practice, Ankara, Turkey. c Assistant professor, Department of Orthodontics, Faculty of Dentistry, Gazi University, Ankara, Turkey. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conicts of Interest, and none were reported. Reprint requests to: Selin Kale Varlk, Gazi University, Faculty of Dentistry, Bis kek Cd. 1. Sok. No: 4 06510 Emek, Ankara, Turkey; e-mail, kaleselin@yahoo.com. Submitted, February 2013; revised and accepted, April 2013. 0889-5406/$36.00 Copyright 2013 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2013.04.014

In this retrospective longitudinal study, pretreatment (T1), posttreatment (T2), and postretention (T3) lateral cephalograms of 31 patients (24 women, 7 men) with Class II Division 1 malocclusion treated with a 1-phase maxillary rst premolar extraction protocol by either of the rst 2 authors were used. Their mean age at the beginning of treatment was 26.8 years (range, 24.1-30.9 years). The inclusion criteria were (1) standardized lateral cephalograms available at 3 time periods, T1, T2, and T3; (2) deepbite of at least 4.5 mm; (3) normal vertical dimension represented by

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lower face height of 47 6 3 ; (4) 3 to 4 mm or less of maxillary incisor display at rest; (5) overjet of at least 6 mm; and (6) 4 mm or less crowding in the maxillary and mandibular arches. Because of the retrospective nature of the study and because no additional x-rays were taken, ethical approval was not needed; informed consent had been obtained at T1 from all patients as the routine protocol. The treatment protocol included intrusion of the mandibular incisors to correct the deepbite and extraction of the maxillary rst premolars to correct the overjet. All patients had transpalatal arches on the maxillary rst molars before the extractions. All patients had 0.018-in slot preadjusted metal brackets with the Roth prescription. In the maxillary arch, after alignment, the canines were retracted with nickel-titanium coil springs (Sentalloy; GAC International, Central Islip, NY) exerting 150 g of force on 0.016 3 0.022-in stainless steel archwires (Accuform; GAC International). The incisors were retracted by 0.017 3 0.025-in betatitanium alloy archwires (Resolve; GAC International) with mushroom loops. The mandibular incisors and premolars were leveled by 0.016-in nickel-titanium segments if necessary. After leveling, custom-made mandibular utility arches (0.016 3 0.022-in Blue Elgiloy wires; Ormco, Glendora, Calif), activated to exert 40 g of force, were used for incisor intrusion. During this period, 0.016 3 0.022-in stainless steel stabilizing sections extending from the rst molars to the rst premolars were placed. The intrusive force of 40 g was checked before tying the archwire, and the force levels were checked every 4 weeks. Intrusion was considered complete when a 2-mm overbite was achieved, and a 0.016 3 0.022-in Blue Elgiloy stabilization utility arch was placed. At this point, the mandibular canines were tied to the stabilizing utility arch with elastic thread if their intrusion was necessary; 0.017 3 0.025-in stainless steel wires were used for nishing in both arches. The mean active treatment time was 2.7 years (range, 2.4-3 years). Immediately after debonding, maxillary and mandibular wraparound retainers were delivered. The patients were instructed to wear the retainers 24 hours a day for the rst year and only at night after that. The retention period lasted 1.5 years. The same author (S.K.V.) hand-traced the lateral cephalograms and identied all landmarks. All handtracings were scanned with a scanner at 200 dpi, and Dolphin software (version 10; Dolphin Imaging & Management Solutions, Chatsworth, Calif) was used to obtain the cephalometric measurements. The measurements are shown in the Figure and Table I. The center of resistance (a point located at one-third of the distance

Fig. Cephalometric landmarks.

of the root length apical to the alveolar crest) was used to evaluate the vertical positions of both the mandibular and maxillary central incisors.22 Sixty randomly chosen lateral cephalograms were retraced and redigitized, and method error was calculated with Dahlbergs formula.23
Statistical analysis

Statistical analysis was completed using the Statistical Package for Social Sciences (version 13; SPSS, Chicago, Ill). Because the Shapiro-Wilks test showed that all data were normally distributed, treatment (T2-T1), postretention (T3-T2), and overall changes (T3-T1) were compared by repeated measurements analysis of variance (ANOVA), followed by multiple comparisons with the Bonferroni adjustment. The signicance level was set at P \0.05.
RESULTS

The method error ranged from 0.15 mm (U1CR to PP) to 0.55 mm (L6 to MP) for the linear measurements, and from 0.25 (L1 to MP) to 0.45 (U1 to L1) for the angular measurements. Because the sample size was 31 subjects and the 0.8-mm change in overbite in postretention period was statistically signicant, the power of the study at a signicance level of 0.05 was 0.86.

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Table I. Cephalometric measurements

SN to MP ( ) ANS to Xi/Xi-PM ( ) Overbite (mm)


Table II. Cephalometric measurements at the 3 evalu-

Overjet (mm)

U1CR to PP (mm)

U1 to PP ( ) U1 to APg (mm)

U6 to PP (mm) L1CR to MP (mm)

L1 to MP ( ) L1 to APg (mm)

L6 to MP (mm) U1 to L1 ( )

Angle formed by the sella-nasion line and mandibular plane* (MP) Angle formed by the line extending from anterior nasal spine to Xiy and corpus axis (Xi-PMz) Distance between incisal edges of maxillary and mandibular central incisors, perpendicular to occlusal plane (OP) Distance between incisal edges of maxillary and mandibular central incisors, parallel to OP Perpendicular distance between the center of resistancek (CR) of maxillary central incisor and palatal plane (PP) Angle formed by the long axis of maxillary central incisor and palatal plane Perpendicular distance from maxillary incisor incisal edge to A-pointpogonion line Perpendicular distance from the mesiobuccal cusp tip of maxillary rst molar to PP Perpendicular distance between the CR of mandibular central incisor and mandibular plane (MP) Angle formed by the long axis of mandibular central incisor and MP Perpendicular distance from mandibular incisor incisal edge to A-pointpogonion (APg) line Perpendicular distance from the mesiobuccal cusp tip of mandibular rst molar to MP Angle formed by the long axes of maxillary and mandibular incisors

ations
Pretreatment Posttreatment Postretention Measurement Mean 6 SD 32.7 6 2.4 SN to MP ( ) 47.1 6 1.9 ANS to Xi/Xi-PM ( ) Overbite (mm) 5.9 6 0.7 Overjet (mm) 8.6 6 1.3 U1CR to PP (mm) 12.9 6 1.8 132.2 6 5.4 U1 to PP ( ) U1 to APg (mm) 8.1 6 1.4 U6 to PP (mm) 28.5 6 4.1 L1CR to MP (mm) 28.2 6 2.9 94.2 6 2.8 L1 to MP ( ) L1 to APg (mm) 2.1 6 0.9 L6 to MP (mm) 36.0 6 2.5 110.2 6 3.8 U1 to L1 ( ) Mean 6 SD 33.2 6 2.6 47.3 6 1.2 2.0 6 0.1 2.1 6 0.3 12.6 6 2.1 115.2 6 5.1 4.3 6 0.7 28.4 6 3.9 26.4 6 2.1 94.6 6 2.5 2.8 6 0.8 36.9 6 2.7 131.7 6 3.9 Mean 6 SD 33.4 6 2.3 47.3 6 1.9 2.8 6 0.4 2.3 6 0.2 12.8 6 1.6 115.3 6 5.4 4.3 6 0.6 28.6 6 3.9 27.3 6 2.9 94.4 6 2.6 2.8 6 0.6 36.5 6 2.6 131.6 6 4.1

*Mandibular plane (MP): formed by a line through menton, tangent to the lower border of the angle of the mandible; yXi: the geometric center of the ramus of the mandible; zPM: protuberance menti point selected at the anterior border of the symphysis between Point B and pogonion where the curvature changes from concave to convex; Occlusal plane (OP): formed by a line bisecting the overlapping cusps of the rst molars and the incisal overbite; kCenter of resistance (CR): a point located at one-third of the distance of the root length apical to the alveolar crest.

The mean values for the cephalometric measurements at T1, T2, and T3 are shown in Table II, and the treatment, postretention, and overall changes and their comparisons are shown in Table III. Of the treatment changes (T2-T1), overjet and overbite signicantly decreased by 6.4 6 1. and 3.9 6 0.7 mm, respectively (Table I). Signicant retroclination (17 6 1.9 ) and retraction (3.8 6 1.1 mm) of the maxillary incisors were observed. There were signicant increases in the protrusion (0.8 6 1.5 mm) and proclination (0.6 6 0.9 ) of the mandibular incisors. The interincisal angle increased by 21.5 6 5.1 . There were no signicant changes in the vertical positions of the maxillary incisors and rst molars. In the

mandibular arch, signicant intrusion of the incisors (2.6 6 1.4 mm) and extrusion of the molars (0.8 6 0.6 mm) were observed. The SN to MP and ANS to Xi/Xi-PM angles did not change signicantly. Among the postretention (T3-T2) changes, there were signicant increases in overjet and overbite (0.4 6 0.9 and 0.8 6 0.4 mm, respectively). In the mandibular arch, signicant extrusion of incisors (0.8 6 1.1 mm) was observed. Other variables did not show any changes. During the overall period (T3-T1), the maxillary incisors were retroclined (16.9 6 0.4 ) and retracted (3.7 6 1 mm), and the mandibular incisors were protruded (0.7 6 1.1 mm) signicantly; these changes contributed to a signicant decrease in overjet (6.3 6 1.2 mm) and an increase in the interincisal angle (21.4 6 5.2 ). The mandibular molars were extruded, and the mandibular incisors were intruded signicantly; these changes resulted in a signicant reduction in overbite. The vertical positions of the maxillary incisors and molars and the proclination of the mandibular incisors had no signicant changes from T1 to T3.
DISCUSSION

The aim of this study was to evaluate the long-term stability of deepbite correction in adults with mandibular incisor intrusion using the bioprogressive sectional arch technique. The null hypothesis was that dental deepbite correction with mandibular incisor intrusion in adults is stable; based on our results, the null hypothesis was not rejected. The mean overbite correction at T2 was 3.9 mm, which corresponded to 66.1% of the pretreatment overbite. This ratio is higher than the ratio reported in the study of Weiland et al20 using adult patients. In that

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Table III. Descriptive statistics and statistical comparisons of the treatment, postretention, and overall changes
Treatment changes (T2-T1) Measurement SN to MP ( ) ANS to Xi/Xi-PM ( ) Overbite (mm) Overjet (mm) U1CR to PP (mm) U1 to PP ( ) U1 to APg (mm) U6 to PP (mm) L1CR to MP (mm) L1 to MP ( ) L1 to APg (mm) L6 to MP (mm) U1 to L1 ( ) Mean 6 SD 0.5 6 1.6 0.2 6 3.7 3.9 6 0.7 6.4 6 1.2 0.3 6 0.9 17.0 6 1.9 3.8 6 1.1 0.1 6 0.8 2.6 6 1.4 0.6 6 0.9 0.8 6 1.5 0.8 6 0.6 21.5 6 5.1 Sig NS NS * * NS * * NS * * * * * Postretention changes (T3-T2) Mean 6 SD 0.2 6 1.3 0.1 6 3.7 0.8 6 0.4 0.4 6 0.9 0.1 6 0.6 0.2 6 0.8 0.1 6 1.3 0.2 6 0.6 0.8 6 1.1 0.2 6 0.9 0.1 6 1.3 0.3 6 0.5 0.1 6 1.7 Sig NS NS * * NS NS NS NS * NS NS NS NS Overall changes (T3-T1) Mean 6 SD 0.6 6 1.6 0.2 6 3.8 3.1 6 0.8 6.3 6 1.2 0.2 6 0.9 16.9 6 0.4 3.7 6 1.0 0.1 6 0.8 2.1 6 0.9 0.3 6 0.8 0.7 6 1.1 0.5 6 0.6 21.4 6 5.2 Sig NS NS * * NS * * NS * NS * * *

Sig, Signicance; NS, not signicant. *P \0.001.

study, 2 different mechanics were used, and the correction values were 3.17 and 3.56 mm, corresponding to 58.8% and 58.1%, respectively. The difference could be because in our study, the posttreatment overbite value was slightly lower than that reported by Weiland et al. In our study, a statistically signicant but clinically insignicant relapse of 0.8 mm was observed at T3, and the mean overbite (2.8 mm) at T3 was acceptable. In previous studies, either similar or higher relapse values ranging from 0.1 to 2.1 mm were reported.7,8,16,17,2427 However, when our results were compared with those of previous studies, there are differences in terms of factors that were previously reported to have affected overbite stability, such as the subjects' growth potential, growth pattern, muscle strength, adaptation capacity, follow-up and retention durations, initial overbite value, and retainer type.8,14,21,26-31 We used incisor centroid as a reference point and evaluated true intrusion, as was proposed by Ng et al.32 At the end of the treatment, 2.6 mm of mandibular incisor intrusion was achieved. Similar mean intrusion values between 1.1 and 3 mm were reported in previous studies where deepbite correction was accomplished by only mandibular incisor intrusion with segmental or sectional arches.10,33,34 An important consideration with regard to centroid while evaluating the mean incisor intrusion value is that although it was claimed to be independent of any change in the axial inclination, the possibility that centroid can slightly move apically because of proclination of the incisors, resulting in somewhat higher than actual intrusion values, cannot be ruled out.14,32 In this study, an 0.8-mm relapse was observed at T3. Although this relapse was statistically signicant, it was not

clinically important because the overbite value at T3 was well within the normal range, and the overall intrusion value of 2.1 mm was quite remarkable. The interincisal angle is believed to play a critical role in the stability of deepbite correction. Berg28 suggested that the interincisal angle should be less than 140 at the end of treatment for stability of deepbite treatment. According to Houston,35 an approximate interincisal angle of 135 inhibits incisor overeruption and thus has an impact on the stability of deepbite treatment. In this study, the mean interincisal angle, which was below the normal range at T1, increased signicantly after treatment mainly because of retraction of the maxillary incisors; it approached the norm values proposed by several authors and did not change at T3.36-38 The substantial stability of overbite correction in this study seems to support the validity of the interincisal angle values suggested for stability by Berg and Houston. An intrusive force that is labial to the center of resistance of the incisors would intrude them but also tip them labially.12 Labial tipping tends to decrease overbite because it inuences the vertical incisal edge position, and depending on the original inclination of the incisors, it can be advantageous in deepbite correction.33,34,39,40 However, aring has been associated with an increased incidence of relapse.8,10,13,17 In this study, statistically signicant increases in both proclination and protrusion of the mandibular incisors were observed after treatment. The mean increases in L1 to APg and L1 to MP were 0.8 mm and 0.6 , respectively. Although statistically signicant, these values were much lower than the values reported in other studies in which intrusion utility arches were used.10,34,39 Less

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incisor aring could be due to the use of 0.016 3 0.022in utility arches in this study, thus providing better torque control. Relapse of proclined incisors is thought to be related to distortion of the perioral neuromuscular balance13 or the tendency of incisors that were upright at the beginning of treatment to return to their original positions.8 The changes in the sagittal position of the mandibular incisors in our study were stable in the postretention period. The reason for no relapse might be that the L1 to APg and L1 to MP measurements were within normal ranges at T1; despite some aring, they remained within the normal ranges at T2 and therefore caused no neuromuscular imbalance. This study involved nongrowing patients with normal vertical dimensions; therefore, prevention of posterior extrusion that could result in relapse and opening rotation of mandible was intended. To this end, sectional arches were used for intrusion, and stabilization sections were used to enhance the vertical anchorage of the mandibular molars and premolars.41,42 Still, despite these measures, extrusion of 0.8 mm occurred in the mandibular molars. This value was lower than reported in other studies in which mandibular incisor intrusion was performed with segmental or sectional arches. In the study of Dake and Sinclair,10 when the mandibular incisors were intruded with utility arches, they reported 2.6 mm of mandibular molar extrusion. Al Buraiki et al16 used lever arches and reported 1.6 mm of mandibular molar extrusion. One explanation for the lower value in our study could be that these 2 studies were conducted with growing subjects who had a likelihood of continuing molar eruption.31 Moreover, the intrusion force used in this study was lower than that was used by Dake and Sinclair; an intrusion force of 40 g might not have affected the posterior vertical anchorage. According to Nanda and Kuhlberg,13 1 mm of maxillary or mandibular molar extrusion effectively reduces incisor overlap by 1.5 to 2.5 mm. In our study, the mean overbite reduction was 3.9 6 0.7 mm, and the mean mandibular incisor intrusion was 2.6 6 1.4 mm. That is, together with the modest increases in the proclination and protrusion of the mandibular incisors, molar extrusion might have contributed to overbite correction. Seemingly, 0.8 mm of mandibular molar extrusion did not result in mandibular posterior rotation because the mandibular plane and lower facial height angles did not change at either T2 or T3. The molars retained their new vertical positions in the postretention period; thus, the 0.8-mm relapse in overbite cannot be attributed to a posttreatment change in molar position. Similarly, Burzin and Nanda14 also found no relationship between molar extrusion and overbite relapse.

This study had some limitations because of its retrospective design without randomization. Although consecutively treated subjects were included without regard to treatment and postretention outcomes and 2 orthodontists with similar experience provided the orthodontic treatment, adhering strictly to treatment and retention protocols, the potential for selection bias still exists. Therefore, these ndings must be regarded with some caution.
CONCLUSIONS

1.

2.

3.

With mandibular intrusion utility arches, 2.6 mm of true incisor intrusion was obtained. Only 0.8 mm of molar extrusion was observed. Five years after the end of the retention period, a statistically signicant but clinically unimportant relapse of 0.8 mm (which corresponded to approximately 30% of the total intrusion amount) was observed in mandibular incisor intrusion and overbite. Deepbite treatment with mandibular incisor intrusion with utility arches was effective and appeared to be stable in nongrowing patients.

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