CLINICIAN’S CORNER
Selective alveolar corticotomy to intrude
overerupted molars
Dauro Douglas Oliveira,a Bruno Franco de Oliveira,b Helio Henrique de Araújo Brito,c
Margareth Maria Gomes de Souza,d and Paulo José Medeirose
Belo Horizonte and Rio do Janeiro, Brazil
Orthodontic intrusion of overerupted molars in adults is challenging for most clinicians. Efficient intrusion can
be achieved by combining selective alveolar corticotomies with a modified full-coverage maxillary splint to
reduce surgical risks, treatment time, and costs for both orthodontists and patients. (Am J Orthod Dentofacial
Orthop 2008;133:902-8)
O
rthodontic treatment of overerupted molars
has always been considered challenging for
most orthodontists. Pure intrusion can only be
achieved when an adequate anchorage system supports
light and continuous forces that are directed through the
tooth’s center of resistance.1,2 This approach is partic-
ularly difficult when posterior teeth must be intruded in
adults. The lack of compensation through growth3 and
the slower biologic response to orthodontic forces,
when compared to younger patients,4,5 increase the
complexity of this procedure. More adults now seek
orthodontic care. Consequently, clinicians might see
patients who need molar intrusion more often.
The correction of supraerupted molars with conven-
tional fixed appliances can lead to undesirable extrusion
of the adjacent teeth that function as anchor units,
lengthening the overall treatment time and compromis-
ing the results.6 Various approaches have been pro-
posed to intrude overerupted molars, including vertical-
pull headgears,7 removable appliances with elastics,8
modified palatal arches,9 elastomeric chains,10 mag-
nets,11 and skeletal anchorage systems.12,13 The need
for patient cooperation for long time periods and the
difficulties in applying well-controlled force systems
have been suggested as limitations of these early
methods of molar intrusion.14 Although the use of
a
Program director, Orthondontic Graduate Program, Pontifical Catholic Uni-
versity, Belo Horizonte, Brazil.
b
Private practice, Belo Horizonte, Brazil.
c
Adjunct professor, Pontifical Catholic University of Minas Gerais, Belo
Horizonte, Brazil.
d
Adjunct professor, Federal University of Rio de Janeiro, Rio de Janeiro,
Brazil.
e
Adjunct professor of oral surgery, Federal University of Rio de Janeiro, Rio de
Janeiro, Brazil.
Reprint requests to: Dauro D. Oliveira, Av Cristóvão Colombo, 550/404, Belo
Horizonte, MG, Brazil, 30140-150; e-mail, dauro.bhe@terra.com.br.
Submitted, June 2006; revised and accepted, July 2006.
0889-5406/$34.00
Copyright © 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.07.030
902
mini-titanium screws solved most anchorage problems
when intrusion of posterior teeth is required, individual
anatomical variations might impose limitations for
adequate implant placement in some patients.15 Unsat-
isfactory implant positioning can result in undesired
sequelae, such as root perforations,16 or lead to inap-
propriate direction of intrusive forces, compromising
treatment efficiency.
Tooth movement efficiency can be increased when
well-planned force systems are applied to bony tissues
that offer less resistance against the desired move-
ment.1,17 Therefore, faster orthodontic movement takes
place, and treatment goals can be achieved in a shorter
time, without compromising the results. Since treat-
ment efficiency is always a concern in adult orthodon-
tics, how can it be achieved when molar intrusion is
needed? Overall, orthodontic tooth movement is accel-
erated when performed under increased bone turnover
conditions18 caused by either pharmacologic modula-
tion19,20 or hormonal alterations.21,22 However, these
possibilities have not yet reached routine application in
the daily orthodontic practice. The physiologic alter-
ations observed when the bony tissues respond to a
traumatic stimulus might help to elucidate an alterna-
tive approach that could create a localized area of
increased bone turnover and, consequently, decreased
resistance to tooth movement.
When responding to a traumatic stimulus, the bony
tissues initially have a biologic stage called regional
acceleratory phenomenon characterized by a transient
increase in bone turnover and a decrease in trabecular
bone density.23 After fractures or surgical osteotomies,
the regional acceleratory phenomenon significantly
stimulates healing and tissue reorganization by a tem-
porary burst of localized tissue remodeling.24 Alveolar
corticotomies are surgical interventions limited to cor-
tical bone that were suggested as an alternative to
facilitate the treatment of complex occlusal problems
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 6
combined with orthodontic therapy.25 Although no
studies have directly investigated whether corticoto-
mies result in alveolar bone regional acceleratory phe-
nomena or how they influence tooth movement, clinical
reports have shown that orthodontic movement was
potentiated when started shortly after selective alveolar
corticotomies.26,27
The initial reports on combining orthodontic ther-
apy and alveolar corticotomies suggested that treatment
was facilitated because the bone blocks limited by the
surgical cuts could be moved individually by using the
crowns of the teeth as handles to which orthodontic
forces were applied.25-28 Wilcko et al29 questioned
these statements, implying that the healing stimulus
generated by the corticotomy leads to increased bone
turnover and a less dense trabecular bone. The authors
suggested that decreased trabecular bone density and
not movement of independent bone blocks would better
explain the effects of alveolar corticotomies on orth-
odontic therapy. Despite these opposing points of view,
all clinical reports showed increased treatment effi-
ciency. This article describes the combination of selec-
tive alveolar corticotomies and a modified full-cover-
age maxillary splint to efficiently intrude overerupted
molars in adult patients.
Surgical procedure
The surgeries were performed with the patients
under local anesthesia. Full-thickness flaps were raised
on both buccal and lingual surfaces to expose the
alveolus surrounding the overerupted maxillary first
molars. Cortical bone was removed by using a #701
surgical bur under continuous and abundant irrigation
with cold sterile saline solution. Vertical cuts were
made on both mesial and distal interproximal areas
starting 2 to 3 mm above the alveolar crest and
extending 2 to 3 mm past the estimated root apices. A
horizontal corticotomy was performed connecting the
interdental cuts. Several small round perforations
equivalent to the bur diameter were also made inside
the areas circumscribed by those cuts (Fig 1) to increase
the healing stimulus. All surgical cuts were made in the
cortical plate, barely penetrating the trabecular bone.
After careful irrigation, the gingival flaps were reposi-
tioned and sutured appropriately. Antibiotics and anti-
inflammatories were prescribed from 24 hours before to
3 days postsurgery.
Intrusion appliance design
Maxillary and mandibular alginate impressions
were taken, and the working models obtained with
stone were mounted in a hinge axis articulator. A
full-coverage flat-plane maxillary splint was fabricated
Oliveira et al 903
Fig 1. Selective alveolar corticotomy.
with acrylic. Ball clasps were added between the first
premolars and the canines to increase appliance reten-
tion, and small J-hooks were placed on both buccal and
lingual surfaces of the first molars. The acrylic covering
the maxillary first molars’ occlusal surfaces was re-
moved to allow intrusion force delivery. Closed Sen-
talloy coils (GAC International, Islandia, NY) were tied
to the J-hooks with steel ligatures (Fig 2) to allow
constant 100-g intrusive forces apically through the
center of resistance of the molars.
PATIENT 1
A 36-year-old woman was referred to the Depart-
ment of Orthodontics of the Pontifical Catholic Univer-
sity of Minas Gerais in Brazil for an evaluation about
the chances of intruding overerupted maxillary right
and left first molars. The patient reported losing all
mandibular first and second permanent molars in early
adolescence. These teeth had never been replaced,
resulting in overeruption of both maxillary first molars
(Fig 3, A).
Three treatment options to level her maxillary
occlusal plane were presented: (1) restorative leveling
with full crowns and possible need for root canal
treatment, as well as periodontal surgery to obtain
appropriate cemento-enamel junction dimensions; (2)
subapical osteotomies for immediate bone-block intru-
sion; and (3) selective alveolar corticotomies followed
by orthodontic treatment to intrude the maxillary first
molars. The patient was informed of the risks, advan-
tages, and disadvantages of all therapeutic approaches.
She decided to undergo orthodontic treatment after
corticotomies and signed a consent form assuming all
responsibilities for her decision.
Seven days after surgery, orthodontic forces were
applied with the modified maxillary splint previously
described. The patient reported mild postcorticotomy
discomfort, describing it as similar to the soreness she
felt after previous tooth extractions. She followed the
904 Oliveira et al American Journal of Orthodontics and Dentofacial Orthopedics
June 2008

Fig 2. Modified maxillary splint with superelastic nickel-titanium springs.

Fig 3. Patient 1. Intraoral photographs: A, pretreatment; B, 2.5 months after intrusive force
application; C, 6 months postcorticotomy.

recommendations for full-time appliance wear, except
during meals and oral-hygiene procedures. Two and a
half months after the force application, the maxillary
first molars were fully intruded (Fig 3, B). At this point,
fixed appliances were placed to continue treatment,
and, 3 months later, progress records were obtained for
reevaluation (Fig 3, C). Cephalometric superimposition
before treatment and 6 months into treatment showed
complete and pure intrusion of the overerupted molars
(Fig 4, A), without commonly seen side effects, such as
clockwise rotation of the mandible and anterior bite
opening. Comparison of the periapical radiographs
showed improvement in the crown-to-root ratios, no
adjacent tooth extrusion, and no root resorption (Fig 4, B).
PATIENT 2
A 39-year-old man sought prosthodontic care to
restore his edentulous regions and improve mastication.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 6
Fig 4. Patient 1. A, Pretreatment and 6-month progress overall and maxillary cephalometric
superimpositions; B, periapical radiograph evaluation, pretreatment and postintrusion.
He prematurely lost all mandibular molars due to
carious lesions. Consequently, the maxillary first and
second permanent molars on both the right and left
sides overerupted. Intrusion of these molars was re-
quired for prosthetic reestablishment of appropriate
function. The patient did not want either extracting and
substituting the overerupted molars by implants or
subapical surgery for immediate molar repositioning.
He decided to undergo selective alveolar corticotomies
and orthodontic intrusion.
The extension of the surgical cuts was the only
difference in relation to the surgical technique de-
scribed above. Surgical cuts surrounded both molars on
the labial surface and the proximity to the palatine
artery limited the vertical cuts lingually. One week
postsurgery, orthodontic forces were applied with the
modified full-coverage maxillary splint. The maxillary
third molars contributed to appliance stability. After 4
months of full-time wear, occlusal plane leveling was
observed (Fig 5).
DISCUSSION
Posterior teeth that are supraerupted due to early
loss of their antagonists are commonly seen in adults
Oliveira et al 905
without access to dentistry during childhood and ado-
lescence. Conventional treatment options to correct
overerupted molars include crown reduction followed
by full-coverage restorations30,31 or posterior segmen-
tal osteotomy to impact the elongated segments.32
Although still used, both clinical approaches have
disadvantages. While the first method usually removes
sound tooth structures frequently requiring endodontic
treatment and periodontal surgery, the second has the
risks associated with general anesthesia and higher
costs. Thus, orthodontic intrusion of overerupted mo-
lars would increase the quality of the multidisciplinary
treatment needed to restore appropriate function in
these patients.
Orthodontic treatment efficiency is especially im-
portant when treating adults. These patients have spe-
cific demands and usually want to achieve their treat-
ment goals as soon as possible to reduce the negative
effects of orthodontic appliances in their social and
professional lives. An ideal scenario for efficient tooth
movement combines well-planned force delivery sys-
tems1 and decreased alveolar trabecular bone density
where the resistance against the desired movement is
reduced.17 The optimum force system for molar intru-
906 Oliveira et al
Fig 5. Patient 2. A, Surgical procedure; B, intrusion appliance; C, pretreatment model; D, progress
model after 4 months of intrusion.
sion is obtained when low and continuous forces are
applied apically through the tooth’s center of resistance
from both the buccal and lingual sides.33 Adequate
anchorage units are also required to eliminate or min-
imize undesired side-effects from the reactive forces.2
The previously reported orthodontic approaches for
molar intrusion fulfill only some of these requirements.
The modified full-coverage maxillary splint we
propose might overcome some limitations of the early
methods described for orthodontic intrusion of
overerupted molars. Vertical-pull headgears deliver
intrusion forces only from the molar buccal surface,
and a tipping moment is created.34 The application of
intrusive forces with elastics8 or elastomeric chains10
requires frequent reactivations due to early force deg-
radation35,36; this can be impractical for both patient
and orthodontist. We suggest superelastic nickel-tita-
nium springs, which permit constant force application
over a wide range of activation without requiring
frequent checkups.37 The modifications in maxillary
splint design allow the intrusive forces from both the
buccal and lingual surfaces, eliminating the tipping
moment noticed with high-pull headgears.
Although skeletal anchorage systems solved the
need for patient cooperation, anatomical variations can
limit ideal micro-titanium screw placement in some
patients who require molar intrusion.15 When mini-
implants are not placed correctly, the resultant line of
intrusion force passes away from the molar’s center of
resistance, generating uncontrolled rotational moments
and decreasing intrusion efficiency. The intrusion ap-
American Journal of Orthodontics and Dentofacial Orthopedics
June 2008
pliance shown in this article might be a viable alterna-
tive when ideal implant positioning is risky or impos-
sible. During appliance construction, the hooks that
serve as points of force application are positioned to
create a line of force directed apically through the
center of resistance of the molars. In addition, the use of
the entire occlusion as the anchorage unit for molar
intrusion has been successfully reported.8,33 However,
the dependence on patient cooperation is a disadvan-
tage of the suggested approach. To overcome this
limitation, selective corticotomies were performed to
increase alveolar bone response, reducing treatment
time and consequently diminishing the demand for
overall appliance wear.
The successful clinical application of corticotomy-
facilitated orthodontics has been shown to reduce
treatment time in adults26,27 as an intermediate therapy
between orthognathic surgery and conventional orth-
odontics to correct moderate skeletal malocclusions,38
and before the application of orthodontic forces on
overerupted molars.6,39 Mostafa et al6 described suc-
cessful molar intrusion combining corticotomy and
fixed edgewise appliances. Although they did not
mention the amount of force applied, rapid movement
of the tooth-bone segment without anchorage loss was
reported. Hwang and Lee39 demonstrated the correction
of supraerupted molars after performing localized cor-
ticotomies and applying orthodontic forces with full-
time wear of magnetic appliances and night use of a
vertical-pull chincup. Despite earlier reports that ap-
proximately a force of 90 g per tooth is required for
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 6
molar intrusion,40 a force of more than 90 g was exerted
with repelling magnets because the authors believed
that heavier forces were necessary to move the bone
block with the tooth. The theory of bone-block move-
ment has been used to explain orthodontic movement
after alveolar corticotomies since the introduction of
this therapeutic approach.25-28 However, the postsur-
gery increase in regional bone turnover was suggested
as a more adequate explanation for this phenomenon.41
While the influence of corticotomy on alveolar bone
physiology and tooth movement has not been directly
investigated, indirect evidence might support the in-
creased bone turnover theory. Animal studies showed
that orthodontic tooth movement is faster under in-
creased alveolar bone turnover conditions.18-22 In ad-
dition, the initial bony-tissue response to a traumatic
injury is an increase in bone turnover.23,24 Based on this
evidence, we decided to use orthodontic forces in the
range needed for tooth intrusion, applying 100 g per
tooth to be intruded.
The results reported here showed 4 mm of intrusion
on the maxillary right and left molars within 2.5 months
in 1 patient and 3 to 4 mm in 4 months on both the
maxillary right first and second molars on the second
patient. These findings are similar to those reported by
Hwang and Lee.39 Other orthodontic treatment ap-
proaches obtained molar intrusion without previous
selective corticotomies. However, the average active
treatment time required for complete intrusion was
longer. Yao et al13 used skeletal anchorage to obtain an
average of 3 to 4 mm of intrusion in 7.6 months.
Sherwood et al42 obtained 4 mm of intrusion in 6.5
months using mini-titanium plates, and Enacar et al9
registered approximately 4 mm of intrusion in 8.5
months using a modified transpalatal arch. The results
in our patients reported here indicate that the healing
stimulus caused by the corticotomies might reduce the
overall treatment time required to intrude overerupted
molars. However, animal studies and further research
with larger clinical samples are needed to better under-
stand how corticotomies affect alveolar bone metabo-
lism and orthodontic tooth movement.
This treatment approach combines a simple and
low-cost modified maxillary splint designed to deliver
ideal intrusive forces. The use of Sentalloy coils allows
constant force exertion over longer periods of time, and
the transparent appliance might not compromise esthet-
ics. Incorporating localized corticotomies shortly be-
fore orthodontic treatment appears to decrease bony-
tissue resistance against the intrusion forces, increasing
treatment efficiency and reducing the demand for over-
all appliance wear and patient cooperation.
Oliveira et al 907
This therapeutic approach might be a viable option
when skeletal anchorage has risks to the patient or
restricts the application of adequate intrusion force
direction. It should also be considered if the patient
desires a shorter treatment time.
CONCLUSIONS
Successful intrusion of overerupted molars is a signif-
icant clinical challenge to orthodontists. Although pros-
thetic leveling of the occlusal planes might restore sound
teeth, subapical interventions for immediate repositioning
have surgical risks and higher costs. Therefore, an inter-
mediate alternative to increase treatment efficiency and
minimize patient discomfort would be welcome. Our
patients demonstrated that combining selective alveolar
corticotomies with a full-coverage splint modified to
incorporate superelastic nickel-titanium coils can be a
viable alternative to efficiently intrude overerupted max-
illary molars and reduce surgical risks, treatment time, and
costs for both orthodontists and patients.
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