ORIGINAL ARTICLE

Treatment effects of intrusion arches and

mini-implant systems in deepbite patients
€ rkkahramanb
Neslihan Ebru Şenışıka and Hakan Tu
Isparta, Turkey

Introduction: The purpose of this study was to compare the skeletal and dental effects of 2 intrusion systems
involving mini-implants and the Connecticut intrusion arch in patients with deepbites. Methods: The study sam-
ple consisted of 45 adults (26 women, 19 men) with deepbites. They were divided into 3 groups: 2 treatment
groups and 1 untreated control group (15 subjects in each group). The Connecticut intrusion arch and the implant
groups underwent maxillary incisor intrusion with Connecticut intrusion arches and a mini-implant system,
respectively. During the 7-month study period, no other treatment was performed with the exception of
maxillary incisor intrusion. Results: The mean amounts of genuine intrusion were 2.20 mm (0.31 mm per month)
in the Connecticut intrusion arch group and 2.47 mm (0.34 mm per month) in the implant group. No statistically
significant differences were found in the extent of maxillary incisor intrusion between the 2 intrusion systems
(P .0.05). Both systems led to protrusion and intrusion of the maxillary incisors (P \0.05), and protrusion
and extrusion of the mandibular incisors (P \0.05). In the Connecticut intrusion arch group, the maxillary molars
were extruded by moving the crown distally and the root mesially. The 2 intrusion systems were statistically dif-
ferent in the extent of alterations in the axial inclinations of the maxillary molars (P \0.05). Conclusions: Both
the Connecticut intrusion arch and the mini-implant intrusion systems successfully intruded the 4 maxillary
incisors. Although the movement of the maxillary molars led to the loss of sagittal and vertical anchorages
during intrusion of the incisors in the Connecticut intrusion arch group, these anchorages were maintained in
the implant and control groups. (Am J Orthod Dentofacial Orthop 2012;141:723-33)

D
eepbites can affect a person’s esthetic appear-
ance and smile.1 Anterior deepbites caused by
overeruption of the maxillary incisors can be de-
termined by using lateral cephalometric radiographs. If
the lower lip covers more than 4 mm of the maxillary
central incisors on a patient’s lateral cephalometric
radiographs, it is the result of maxillary incisor overerup-
tion.2
Depending on the diagnosis and treatment objectives,
a deep overbite can be corrected by intruding the incisors,
extruding the buccal segments, or combining these treat-
ments.1,3 Extrusion of posterior teeth drops the mandible
From the Department of Orthodontics, School of Dentistry, Suleyman Demirel
University, Isparta, Turkey.
a
Assistant professor.
b
Professor and department chair.
This study is a doctoral thesis by the first author and was supported by the Suley-
man Demirel University Research Fund (research number 1598-D-08). Ethical
approval was obtained from the Suleyman Demirel University, Faculty of Medi-
cine, Research Ethics Committee (decree number 2007-10/07).
Reprint requests to: Neslihan Ebru Şenışık, Department of Orthodontics, School
of Dentistry, Suleyman Demirel University, 32040 Cunur, Isparta, Turkey; e-mail,
nebuydas@yahoo.com.
Submitted, July 2011; revised and accepted, December 2011.
0889-5406/$36.00
Copyright Ó 2012 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2011.12.024
downward and backward, and the condyle assumes a new
position in the temporomandibular joint articulation. If
equilibrium is achieved between function, muscles, and
the temporomandibular joint after orthodontic
treatment by remodeling and readaptation, the
extrusion of the posterior teeth and the successful
treatment of the deep overbite remain stable. In adults,
however, the mastication muscles and altered occlusion
might move the extruded posterior teeth back to the
original positions until equilibrium between the soft
and hard tissues is obtained again and relapse occurs.4
Therefore, in adults, the skeletal discrepancy can be
compensated for only by dentoalveolar orthodontic
methods with fixed appliances.5,6 Maxillary incisor
intrusion should be the preferred treatment in
nongrowing patients with anterior deepbites caused by
overeruption of the maxillary incisors.4
Intrusion arches are frequently used to treat deep
overbites.7 However, undesirable side effects such as ex-
trusion of the posterior teeth or flaring of the anterior
teeth limit treatment efficiency.3,8 Moreover, vertical
forces can easily be heavier than desired and change
the balance between intrusion of the incisors and
extrusion of the molars.9 Anchorage control, especially
723

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724
Table I. Distributions of chronologic ages of study subjects and treatment durations for the groups
CTA (n 5 15)
Groups Mean 6 SD Min
Chronologic age (y) 20.32 6 3.22 15.70
Treatment duration (mo) 6.88 6 0.95 5.10
CTA, Connecticut intrusion arch; Min, minimum; Max, maximum.
in the vertical dimension, is most important if an effective
bite opening is to be created by genuine intrusion of the
anterior teeth.10 Although extraoral appliances provide
sufficient anchorage, they require excessive patient co-
operation.11
Maximizing desired tooth movements and minimizing
undesirable side effects are important goals of orthodontic
treatment.9 Mini-implants were recently used as anchor-
age devices to intrude maxillary incisors, indicating that
effective incisor intrusion can be achieved with few side
effects.12-19 Furthermore, intrusion with mini-implants
increases treatment efficiency with minimal dependence
on patient cooperation. Most of these studies were case
reports, and, although case reports contribute consider-
able information about treatment outcome, individual
variations can affect the results.10,12-14 Even though there
are few studies that eliminate the effect of individual
variations by good sample sizes, none has compared the
skeletal and dental effects of the 2 maxillary intrusion
systems involving mini-implants and Connecticut intrusion
arches.16-19 Therefore, we aimed this prospective study at
comparing the 2 maxillary intrusion systems involving
mini-implants and Connecticut intrusion arches used
as intraoral intrusion systems. The treatment efficiency
of these 2 intrusion systems with different anchorage
zones during maxillary incisor intrusion was evaluated.
The null hypothesis was that there are no statistically sig-
nificant differences in the treatment effects of these 2
maxillary intrusion systems involving mini-implants
and Connecticut intrusion arches on the dental and skel-
etal structures of young adult patients.
MATERIAL AND METHODS
In this prospective clinical study, the inclusion criteria
for participants were (1) all permanent teeth present and
fully erupted, (2) minimal crowding in the maxillary an-
terior segment, (3) Class II Division 2 malocclusion with
increased overbite ($4 mm), (4) lower lip covering more
than 4 mm of the maxillary central incisors on the lateral
cephalometric radiographs, (5) no periodontal disease or
extremely flared incisors, and (6) chronologic age of 16
years or more.
Forty-five patients (26 women, 19 men) fulfilling the
criteria were selected from those referred for orthodontic
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Implant (n 5 15) Control (n 5 15)
Max Mean 6 SD Min Max Mean 6 SD Min Max
25.40 20.13 6 2.48 16.90 24.30 20.49 6 2.80 15.40 25.40
8.50 6.93 6 1.17 5.70 10.70 6.90 6 1.01 5.60 9.60
treatment between January and September 2008. They
did not receive any other orthodontic treatment during
the maxillary incisor intrusion. Hand-wrist radiographs
were used to assess skeletal maturity, if required. All
participants were informed of the purpose of the study,
and they signed informed consent forms.
The participants were divided into 3 groups with 15
subjects in each group by block randomization: the
Connecticut intrusion arch group, comprising 6 men
and 9 women, had intrusion with Connecticut intrusion
arches; the implant group, comprising 6 men and 9
women, had intrusion with a mini-implant system; and
the control group of 7 men and 8 women had no treat-
ment. The mean ages of these groups are shown in
Table I.
In the Connecticut intrusion arch group, 0.018 3
0.025-in brackets (series 2000; Ormco, Glendora, Calif)
were placed on the patients’ 4 maxillary incisors. Lace-
back ligatures were placed on the brackets of the 4 max-
illary incisors. Aligning and leveling were not performed.
A passive 0.016-in round segmental archwire (Ortho
Organizers, Carlsbad, Calif) was bent for each patient
to maintain the initial position of the 4 maxillary inci-
sors.
The maxillary molars were banded, and a 0.016 3
0.022-in maxillary long Nitanium intrusion arch (Ortho
Organizers) was placed. The Connecticut intrusion arch
was cinched back to prevent facial tipping of the inci-
sors.20 On the incisor segment, the Connecticut intrusion
arch was tied behind the lateral incisor brackets to indi-
vidual archwires (Fig 1). The initial intrusive force of the
Connecticut intrusion arches was totally 60 g, and it was
checked and reactivated monthly with a Tweed loop and
helix forming pliers (02-209; Pin Tech Instruments,
Sialkot, Pakistan) after controlling the intrusive force.
In the implant group, 0.018 3 0.025-in brackets (se-
ries 2000; Ormco) were placed on the patients’ 4 maxil-
lary incisors. Laceback ligatures were placed on the
brackets of the 4 maxillary incisors. Aligning and leveling
were not performed. A passive 0.016-in round segmen-
tal archwire (Ortho Organizers) was bent for each patient
to maintain the initial position of the 4 maxillary inci-
sors. Two self-drilling mini-implants (diameter, 1.3
mm; length, 5 mm) (Absoanchor; Dentos, Daegu, South
Korea) were inserted into the alveolar bone between the
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Fig 1. Connecticut intrusion arch.
Fig 2. Implant.
roots of the lateral incisors and canines at the mucogin-
gival junction.17,18 The intrusion force was delivered by
nickel-titanium coil springs, which were placed between
the hooks of the passive arch and the mini-implants
(Fig 2), and maintained at approximately 90 g (mini-
mum, 35 g; maximum, 50 g) per side during the study.
The magnitude of the intrusive force was measured
with a calibrated Dontrix gauge (Correx; Ortho Care,
Saltaire, United Kingdom) and checked at every appoint-
ment. The mini-implants were loaded immediately.
The control group was observed for 7 months (Fig 3).
A lateral cephalometric radiograph and orthopantomo-
graph (Planmeca, Helsinki, Finland), a set of impressions
with a wax bite, and extraoral and intraoral photographs
were obtained from each patient before intrusion (T0)
and after intrusion (T1). To compare the intrusion rates
and the treatment efficiencies of the 2 intrusion systems,
treatment time was limited to 7 months (Table I). If re-
quired, maxillary incisor intrusion was continued after
the study period. The cephalograms were traced, verified
for landmark locations, and superimposed by an
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Fig 3. Control.
Fig 4. Cranial base superimposition and angular mea-
surements: 1, Ax: sagittal position of Point A; 2, Ay: verti-
cal position of Point A; 3, Bx: sagittal position of Point B; 4,
By: vertical position of Point B; 5, SN-GoGn angle; 6, SN-
OP angle; 7, Ax-Bx: distance between Points A and B; 8,
U1-L1 angle; 9, overjet; 10, overbite. The nasion line was
accepted as the x-axis, and a line perpendicular to the
sella-nasion line at sella was defined as the y-axis.
investigator (N.E.Ş). The tracings were analyzed by using
an imaging system (Dolphin Imaging, Chatsworth, Calif).
From each set of lateral cephalograms, cranial base super-
impositions (Figs 4 and 5) and mandibular regional
superimpositions (Fig 6) were made according to the
method of Bj€ ork and Skieller.21 Maxillary regional super-
imposition was based on the best-fit method (Fig 7). After
the superimpositions, the locations of all anatomic
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Fig 5. Cranial base superimpositions: 1, anterior face
height (AFH); 2, posterior face height (PFH); 3, anterior
lower face height (ALFH); 4, PFH/AFH; 5, ULx: sagittal po-
sition of the upper lip; 6, ULy: vertical position of the upper
lip; 7, LLx: sagittal position of the lower lip; 8, LLy: vertical
position of the lower lip; 9, U1(tip)-Stm: the distance be-
tween the tip of the upper incisor and stomion superioris.
landmarks were determined by using an x-y coordinate
system. In the cranial base superimposition, the sella-
nasion line was accepted as the x-axis, and a line
perpendicular to the sella-nasion line at sella was defined
as the y-axis (Figs 4 and 5). In the mandibular regional
base superimposition, the gonion-gnathion line was ac-
cepted as the x-axis, and a line perpendicular to the
gonion-gnathion line at gonion was defined as the
y-axis (Fig 6). In the maxillary regional base superimposi-
tion, the anterior nasal spine-posterior nasal spine line
was accepted as the x-axis, and a line perpendicular to
that line at the posterior nasal spine was defined as the
y-axis (Fig 7). The centers of resistance of the central inci-
sors22 and the maxillary molars23 were used to determine
the genuine intrusion and positional changes of the
maxillary teeth. The center of resistance points were deter-
mined on the initial cephalograms of each patient and
transferred to the final cephalograms by individual tem-
plates. The crown of the tooth was used while placing
the individual tooth templates to prevent any influence
of root resorption. Maxillary intermolar width (the distance
between the mesial cusps of the maxillary first molars) was
measured with a digital caliper on the plaster models.
Data were collected by assessing 35 measurements
on the lateral cephalogram radiographs and 1
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Fig 6. Mandibular superimposition and angular mea-
surements: 1, L1x: sagittal position of the tip of the lower
incisor; 2, L1y: vertical position of tip of the lower incisor;
3, L6x: sagittal position of mesial tip of the lower first mo-
lar; 4, L6y: vertical position of the mesial tip of the lower
first molar; 5, L1-GoGn angle; 6, L6-GoGn angle. The
GoGn line was accepted as the x-axis, and a line perpen-
dicular to the GoGn line at Go was defined as the y-axis.
measurement on the plaster models before and after in-
trusion (Figs 4-7).
Statistical analysis
After a 2-week interval, 30 study models and 30
cephalograms were randomly selected and remeasured
for reproducibility of the measurements. Reproducibility
was assessed by the Pearson correlation coefficient, and
it was nearly 1.00 (r minimum 5 0.992). Homogeneity of
variances was tested by using the Levene test for equality
of variances. Repeated measures analysis of variance
(ANOVA) was used to compare the results of the different
treatment modalities, determine the significance levels
for the study groups (Connecticut intrusion arch, im-
plant, and control) and the treatment periods (T0, be-
fore; T1, after), and examine the interactions between
the study periods and the groups. The Duncan test was
used for multiple comparisons of the 3 groups at T0
and T1 (version 9.0; SAS Institute, Cary, NC). Values of
P \0.05 were considered significant.
RESULTS
Of the 30 mini-implants that were inserted in the im-
plant group, 3 loosened in the first month of orthodontic
force loading; these were replaced immediately. The new
insertion place of the mini-implants was 1 mm above the
first insertion place. Self-drilling mini-implants 1.3 mm
in diameter and 5 mm in length provided sufficient an-
chorage for maxillary incisor intrusion. The overall
success rate was 90%.
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Fig 7. Maxillary superimposition and angular measure-
ments: 1, U1(cr)x: sagittal position of the center of resis-
tance of the upper incisor; 2, U1(cr)y: vertical position of
the center of resistance of the upper incisor; 3, U1(tip)x:
sagittal position of the incisal tip of the upper incisor; 4,
U1(tip)y: vertical position of the incisal tip of the upper in-
cisor; 5, U6(cr)x: sagittal position of the center of resis-
tance of the upper first molar; 6, U6(cr)y: vertical position
of the center of resistance of the upper first molar; 7,
U6(tip)x: sagittal position of the mesial tip of the upper first
molar; 8, U6(tip)y: vertical position of the mesial tip of the
upper first molar; 9, U6(distal ridge)-U1(tip): distance
from the incisal edge to the distal side of the upper first mo-
lar; 10, U1-PP angle; 11, U6-PP angle. The ANS-PNS line
was accepted as the x-axis, and a line perpendicular to the
ANS-PNS line at PNS was defined as the y-axis).
After the treatment, the mean amounts of genuine in-
trusion were 2.20 mm in the Connecticut intrusion arch
group and 2.47 mm in the implant group (Tables II-IV;
Figs 8 and 9). The center of resistance of the maxillary
incisors significantly moved upward and backward, and
the tip of the maxillary incisors significantly moved
upward and forward in both groups (P \0.05). The axial
inclination of the maxillary incisors significantly
increased, and the distance between the incisor tip and
stomion superioris decreased in both treatment groups
(P \0.05). In the Connecticut intrusion arch group, the
center of resistance of the maxillary molar moved
mesially (0.30 mm), and the mesial tip of the maxillary
molar moved distally (0.83 mm). The mean extrusion
movement of the maxillary molar was 0.80 mm in the
Connecticut intrusion arch group (P \0.05). The axial
inclination of the maxillary molars significantly increased
(tipped distally) in the Connecticut intrusion arch group
(P \0.05). The mandibular incisors moved significantly
upward and forward in both treatment groups
(P \0.05). The axial inclination of the mandibular
incisors significantly increased in both treatment groups
(P \0.05). The mandibular molars moved downward in
the Connecticut intrusion arch group and upward in the
implant and control groups (P \0.05). The interincisal
angle and overbite significantly decreased in the both
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treatment groups (P \0.05). Arch length significantly
increased and the occlusal plane angle significantly
decreased in both treatment groups (P \0.05). After
treatment, backward movement of Point A was
statistically significant in the groups (P \0.05).
No statistical significance was observed in face
height, soft tissue, or plaster model changes after treat-
ment (P .0.05).
At T0, no statistically significant intergroup differ-
ences were observed among the groups (P .0.05)
(Tables II-IV).
At T1, the vertical movement of the maxillary incisor
tip was statistically significant in the implant group com-
pared with the control group (P\0.05). The axial inclina-
tion of the maxillary incisor significantly increased (tipped
buccally) in the Connecticut intrusion arch and implant
groups more than in the control group (P\0.05). The in-
clination of the maxillary molars significantly increased
(tipped distally) in the Connecticut intrusion arch group
(P \0.05). The occlusal plane angle significantly de-
creased in the Connecticut intrusion arch group compared
with the control group (P \0.05). The interincisal angle
significantly decreased in the implant group compared
with the control group (P \0.05).
Overbite significantly decreased in the Connecticut
intrusion arch and implant groups compared with the
control group (P \0.05; Tables II-IV)
DISCUSSION
Maxillary incisor intrusion is essential in adults with
deep overbites, especially in those with gummy
smiles.7,24-26 In this prospective study, we aimed at
comparing the effects of 2 maxillary intrusion systems
involving Connecticut intrusion arches and mini-implants.
The only applied force was the maxillary intrusion
force to evaluate the genuine treatment efficiency of
the 2 intrusion systems. Therefore, the participants were
selected with an inclusive criterion of minimal crowding
in the maxillary anterior segment in order not to perform
aligning and leveling. Aligning and leveling before intru-
sion could produce vertical forces and moments that
could alter the axial inclinations of the incisors.27 Addi-
tionally, the deepbite, the maxillary plane of the occlu-
sion, and the natural root and crown positions of the
maxillary incisors could alter during aligning and leveling.
Rigid (large rectangular) stabilizing arch wires must
be used for consolidation during incisor intrusion so
that the centers of resistance of the incisors move closer
to each other.27 Therefore, undesirable side effects such
as protrusion could be eliminated during incisor intru-
sion. In this study, leveling was not performed to con-
serve the initial amount of deepbite and the initial
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Table II. Descriptive statistics and statistical comparisons of the 3 groups for the skeletal measurements at T0 and T1
CTA (n 5 15) Implant (n 5 15)

T0 T1 T1-T0 T0 T1 T1-T0

Measurements Mean 6 SD Mean 6 SD Mean 6 SD Mean 6 SD Mean 6 SD Mean 6 SD

Ax (mm) 62.87 6 4.46A 62.67 6 4.60B 0.20 6 0.25 61.73 6 4.87A 61.60 6 4.93B 0.13 6 0.22
Ay (mm) 63.27 6 3.95 63.50 6 3.82 0.23 6 0.50 64.33 6 5.39 64.33 6 5.56 0.00 6 0.38
Bx (mm) 48.13 6 6.71 48.20 6 6.77 0.70 6 0.18 46.77 6 5.70 46.80 6 5.67 0.03 6 0.13
By (mm) 98.27 6 5.23 98.33 6 5.17 0.70 6 0.26 98.40 6 7.76 98.43 6 7.77 0.03 6 0.13
SN-GoGn ( ) 29.63 6 6.35 29.93 6 6.22 0.30 6 0.70 30.63 6 6.48 30.60 6 6.51 0.03 6 0.55
SN-OP ( ) 15.17 6 3.57A 12.43 6 3.30Bb 2.73 6 1.50 17.23 6 4.71A 14.47 6 4.33Bab 2,77 6 1.64
Ax-Bx (mm) 14.73 6 3.92 14.47 6 3.94 0.27 6 0.32 14.97 6 3.26 14.80 6 3.0 0.17 6 0.31

Intragroup differences (within group) are indicated with capital letters, A and B. Intergroup differences (between group) are indicated with
lower-case letters, a and b.
CTA, Connecticut intrusion arch; NS, nonsignificant.
*P \0.05 (interaction of period * group).

Table III. Descriptive statistics and statistical comparisons of the measurements at T0 and T1
CTA (n 5 15) Implant (n 5 15)

T0 T1 T1-T0 T0 T1 T1-T0

Measurement Mean 6 SD Mean 6 SD Mean 6 SD Mean 6 SD Mean 6 SD Mean 6 SD

U1(cr)x (mm) 48.83 6 3.93A 47.93 6 4.11B 0.90 6 0.83 47.50 6 4.17A 46.57 6 4.41B 0.93 6 0.56
U1(cr)y (mm) 15.27 6 2.17A 13.07 6 2.54B 2.20 6 0.90 14.70 6 2.81A 12.23 6 2.62B 2.47 6 0.81
U1(tip)x (mm) 50.50 6 4.40A 51.40 6 4.38B 0.90 6 1.28 49.07 6 3.68A 50.90 6 3.80B 1.83 6 1.26
U1(tip)y (mm) 30.23 6 3.03A 27.90 6 3.74Bab 2.33 6 1.01 29.70 6 3.88A 26.90 6 3.86Bb 2.80 6 0.82
U6(cr)x (mm) 21.13 6 5.09A 21.43 6 4.88B 0.30 6 0.56 18.80 6 4.23A 18.80 6 4.23B 0.00 6 0.00
U6(cr)y (mm) 13.97 6 2.28A 14.63 6 2.21B 0.67 6 0.36 12.97 6 2.70A 13.00 6 2.71B 0.03 6 0.13
U6(tip)x (mm) 23.20 6 4.76A 22.37 6 4.90B 0.83 6 0.90 21.00 6 4.35A 21.00 6 4.35B 0.00 6 0.00
U6(tip)y (mm) 24.43 6 3.30A 25.23 6 2.83B 0.80 6 0.65 24.00 6 3.02A 24.00 6 3.02B 0.00 6 0.00
U6-U1(tip) (mm) 37.60 6 3.07A 38.93 6 2.62B 1.33 6 1.55 37.83 6 3.26A 38.97 6 2.74B 1.13 6 1.08
U1-PP ( ) 98.87 6 7.92A 103.73 6 8.14Ba 4.87 6 5.64 99.57 6 9.50A 107.67 6 7.56Ba 8.10 6 5.17
U6-PP ( ) 92.73 6 5.56A 102.57 6 6.56Ba 9.83 6 3.53 92.00 6 4.25A 92.00 6 4.25Bb 0.00 6 0.00
U1(tip)-Stm (mm) 9.97 6 3.55A 9.20 6 3.49Ba 0.77 6 1.21 9.93 6 3.58A 9.03 6 2.98B 0.90 6 1.39
L1x (mm) 68.23 6 6.02A 68.57 6 6.17B 0.33 6 0.65 67.77 6 5.79A 68.93 6 5.78B 1.17 6 0.67
L1y (mm) 38.90 6 3.63A 39.13 6 3.72B 0.23 6 0.32 38.87 6 5.82A 39.30 6 5.88B 0.43 6 0.42
L6x (mm) 46.30 6 5.68 46.27 6 5.69 0.03 6 0.13 44.93 6 5.37 44.93 6 5.37 0.00 6 0.00
L6y (mm) 30.53 6 3.46 30.43 6 3.51 0.10 6 0.21 30.43 6 5.22 30.57 6 5.23 0.13 6 0.30
L1-MP ( ) 93.87 6 6.40A 95.07 6 7.16B 1.20 6 3.00 95.70 6 7.79A 97.90 6 7.49B 2.20 6 2.07
L6-MP ( ) 91.43 6 5.93 91.43 6 5.93 0.00 6 0.00 91.87 6 4.62 91.87 6 4.62 0.00 6 0.00
U1-L1 ( ) 149.87 6 10.23A 143.40 6 11.50Bab 6.47 6 8.61 147.43 6 12.83A 137.33 6 10.48Bb 10.10 6 6.36
Overjet (mm) 2.80 6 1.84 3.17 6 1.50 0.37 6 1.23 3.23 6 0.98 3.83 6 1.28 0.60 6 0.66
Overbite (mm) 6.83 6 1.03A 4.73 6 1.65Bb 2.10 6 1.20 7.13 6 2.21A 4.87 6 2.17Bb 2.27 6 0.59

Intragroup differences (within group) are indicated with capital letters, A and B. Intergroup differences (between group) are indicated with
lower-case letters, a and b.
CTA, Connecticut intrusion arch; NS, nonsignificant.
*P \0.05 (interaction of period * group).

positions of the maxillary incisors. It was impossible in
practice to apply a rigid (large rectangular) stabilizing
archwire onto incisors that were not level. Because this
arch would not be passive, bending and applying a large
rectangular archwire would alter the incisors’ root posi-
tions. All patients had retruded incisors. Additionally, the
intrusion force was placed through the center of resis-
tance of the maxillary incisors. A passive 0.016-in round
wire during intrusion produced protrusion of the maxil-
lary incisors (5 in the Connecticut intrusion arch group,
8 in the implant group), but protrusion of the incisors
was preferred because of their initial retruded position.

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Table II. Continued

Control (n 5 15)

T0 T1 T1-T0

Mean 6 SD Mean 6 SD Mean 6 SD P

61.67 6 4.21A 61.67 6 4.21B 0.00 6 0.00 *
64.40 6 3.31 64.40 6 3.31 0.00 6 0.00 NS
47.87 6 6.16 47.90 6 6.14 0.03 6 0.13 NS
96.83 6 5.35 97.03 6 5.51 0.20 6 0.56 NS
30.23 6 5.32 30.20 6 5.50 0.03 6 0.48 NS
15.77 6 2.82A 15.90 6 3.07Ba 0.13 6 0.48 *
13.80 6 3.83 13.77 6 3.83 0.03 6 0.13 NS

Table III. Continued

Control (n 5 15)

T0 T1 T1-T0

Mean 6 SD Mean 6 SD Mean 6 SD P

50.03 6 4.03A 50.03 6 4.03B 0.00 6 0.00 *
14.57 6 3.21A 14.57 6 3.21B 0.00 6 0.00 *
50.83 6 6.12A 50.83 6 6.12B 0.00 6 0.00 *
30.53 6 3.96A 30.53 6 3.96Ba 0.00 6 0.00 *
21.50 6 3.33A 21.50 6 3.33B 0.00 6 0.00 *
14.23 6 3.09A 14.23 6 3.09B 0.00 6 0.00 *
23.77 6 3.58A 23.77 6 3.58B 0.00 6 0.00 *
24.97 6 3.17A 25.00 6 3.15B 0.03 6 0.13 *
37.87 6 3.50A 38.00 6 3.67B 0.13 6 0.48 *
95.50 6 8.57A 95.33 6 8.65Bb 0.17 6 0.94 *
93.13 6 4.43A 93.13 6 4.43Bb 0.00 6 0.00 *
10.33 6 3.33A 10.46 6 3.20B 0.13 6 0.81 *
65.70 6 7.91A 65.70 6 7.91B 0.00 6 0.00 *
38.60 6 4.85A 38.60 6 4.85B 0.00 6 0.00 *
43.97 6 5.25 43.97 6 5.25 0.00 6 0.00 NS
30.40 6 3.77 30.47 6 3.74 0.03 6 0.13 *
93.63 6 7.22A 93.53 6 7.31B 0.10 6 0.85 *
91.67 6 7.61 91.67 6 7.61 0.00 6 0.00 NS
151.23 6 11.46A 151.47 6 11.55Ba 0.23 6 0.78 *
2.17 6 1.52 2.17 6 1.52 0.00 6 0.00 NS
6.97 6 1.41A 6.97 6 1.41Ba 0.00 6 0.00 *

It is suggested that an intrusive force should be con-
stant, and low load-deflection mechanisms should be
used during incisor intrusion.27 The Connecticut
intrusion arch is fabricated from a nickel-titanium alloy
to provide light, continuous force distribution. The Con-
necticut intrusion arch remains active at a constant force
level for a long period of time.20 Our subjects were checked
every month, and we observed that, in the Connecticut in-
trusion arch group, the initial intrusive force (total, 60 g)
decreased to 40 g in 1 month. At the end of 1 month,
the Connecticut intrusion arch was reactivated to 60 g.
But, in the implant group, the initial intrusive force (total,

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Table IV. Descriptive statistics and statistical comparisons of the 3 groups for face height, soft tissue, and plaster
model measurements at T0 and T1
CTA (n 5 15) Implant (n 5 15)

T0 T1 T1-T0 T0 T1 T1-T0

Measurement Mean 6 SD Mean 6 SD Mean 6 SD Mean 6 SD Mean 6 SD Mean 6 SD

AFH (mm) 122.47 6 7.55 122.67 6 7.37 0.20 6 0.44 124.57 6 10.53 124.50 6 10.49 0.07 6 0.32
PFH (mm) 83.90 6 7.82 84.07 6 7.48 0.17 6 0.96 84.07 6 10.56 84.07 6 10.73 0.00 6 0.46
ALFH (mm) 67.50 6 5.73 67.62 6 5.71 0.12 6 0.32 66.70 6 8.00 66.63 6 7.71 0.07 6 0.37
PFH/AFH (%) 68.55 6 5.42 68.57 6 5.17 0.02 6 0.65 67.45 6 5.66 67.46 6 5.64 0.02 6 0.33
ULx (mm) 76.17 6 6.27 76.57 6 6.62 0.40 6 1.24 76.07 6 7.08 76.07 6 7.61 0.00 6 2.02
ULy (mm) 78.10 6 3.89 78.03 6 4.30 0.07 6 1.07 80.37 6 6.00 80.43 6 6.14 0.07 6 0.90
LLx (mm) 70.67 6 6.98 70.43 6 6.98 0.23 6 1.77 70.53 6 5.23 70.10 6 4.89 0.43 6 1.57
LLy (mm) 90.20 6 4.05 89.43 6 4.61 0.77 6 1.78 91.77 6 8.64 91.43 6 9.04 0.33 6 1.64
RU6-LU6 (mm) 51.40 6 3.24 51.40 6 3.24 0.00 6 0.00 51.20 6 2.70 51.26 6 2.63 0.06 6 0.25

Intragroup differences (within group) are indicated with capital letters, A and B. Intergroup differences (between group) are indicated with
lower-case letters, a and b.
CTA, Connecticut intrusion arch; NS, nonsignificant.

Fig 8. Schematic illustration of dentoalveolar treatment Fig 9. Schematic illustration of dentoalveolar treatment
changes in the Connecticut intrusion arch group. changes in the implant group.

90 g) delivered by the nickel-titanium coil springs de-
creased to almost 0 g after 1 month. This force was reac-
tivated monthly. To eliminate the different types of force
between the 2 intrusion systems, different force magni-
tudes were applied to the groups.
Repeated measures ANOVA showed no statistically
significant intergroup differences in the values of max-
illary incisor intrusion between the Connecticut intru-
sion arch and the implant groups after the study. Both
intrusion systems led to intrusion and protrusion of
the maxillary incisors. Conflicting results exist in the
literature regarding the Connecticut intrusion arch28,29
and mini-implant treatments10,13,14,16-18 for the mean
levels of genuine maxillary incisor intrusion. Several
factors such as different mini-implant localizations,13,14
force magnitudes,13,16,18,28,29 force directions applied
during maxillary incisor intrusion,13,14,18 treatment
durations,13,14,16 and methods10,13,14,16,18,29 used to deter-
mine the amounts of maxillary incisor intrusion might
have accounted for the different incisor intrusion rates.
In this study, the center of resistance of the maxillary
incisors moved backward. As a result, retraction of the

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Table IV. Continued
Control (n 5 15)
T0 T1
Mean 6 SD Mean 6 SD
123.77 6 6.68 124.10 6 6.88
84.27 6 6.02 84.57 6 5.96
68.17 6 5.09 68.20 6 5.30
68.10 6 4.24 68.20 6 4.21
76.13 6 5.08 76.60 6 5.32
79.17 6 4.41 79.70 6 4.69
69.80 6 6.09 69.90 6 6.08
90.90 6 4.09 91.57 6 4.51
50.96 6 2.47 50.96 6 2.47
maxillary incisors was obtained during maxillary incisor in-
trusion. The possible reason for the maxillary incisor retrac-
tion could be the direction of the intrusion force, which
was applied through the center of resistance of the 4 inci-
sors in the implant group and the cinching back of the
Connecticut intrusion arch in that group. Our study results
agree with those of recent studies.16,28,30
Protrusion of the maxillary incisors might be an
undesirable side effect of maxillary incisor intrusion.4
Because all subjects had retruded incisors according to
the characteristics of Class II Division 2 malocclusion in
this study, treatment inducing labial movement of the
incisal edge of the maxillary incisors would provide
a much more stable outcome.2 Protrusion of the incisors
during intrusion was reported with intrusion
arches3,5,8,28-31 as well as mini-implants.10,13,17 In
contrast, both Deguchi et al16 and Saxena et al18
achieved retrusion of the maxillary incisors during max-
illary incisor intrusion. In these studies, an additional
force in the posterior direction was applied with the in-
trusive force; thus, during intrusion, retrusion of the
maxillary incisors was obtained.
As mentioned by Burstone,27 the undesirable side
effect is primarily a tip-back action, with the crown mov-
ing distally and the root mesially. Additionally, steepening,
extrusion, and narrowing of the buccal segments were re-
cently reported as side effects of intrusive arches.3,8 In our
study, the only significant difference between the
Connecticut intrusion arch and the implant groups was
the change in axial inclination of the maxillary molars
after the study period. The effect of the Connecticut
intrusion arch treatment on the maxillary molars
differed from that of the mini-implant system because
of the side effects of the Connecticut intrusion arch.
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T1-T0
Mean 6 SD P
0.33 6 0.59 NS
0.30 6 0.53 NS
0.03 6 0.40 NS
0.10 6 0.24 NS
0.47 6 0.97 NS
0.53 6 1.58 NS
1.10 6 0.83 NS
0.67 6 1.54 NS
0.00 6 0.00 NS
Mesial movement of the center of resistance of the max-
illary molar indicated anchorage loss in the Connecticut
intrusion arch group after treatment. The Connecticut in-
trusion arch was cinched back to prevent facial tipping of
the maxillary incisors. Cinching back the intrusion arch
creates a force to move the incisors lingually, and a mo-
ment of this force opposes the moment of the intrusion
force. Additionally, a force to move the molar mesially is
created, along with a moment to tip the molar mesially.31
Mesial forces created by cinching the intrusion arches
might be responsible for the observed anchorage loss. Po-
sitional change in the molars was also reported in recent
studies with Connecticut intrusion arches.3,8,28,29 In
agreement with previous studies, our study showed that
both sagittal and vertical anchorages were conserved in
the mini-implant system.10,16,17
Spontaneous extrusion and protrusion of the man-
dibular incisors obtained in this study might have oc-
curred because of the increased amount of maxillary
incisor intrusion. Similar to our results, Kim et al14
reported the same result after intrusion of the maxillary
incisors. In the mandibular molar area, molar extrusion
induced by alveolar eruption was observed in both the
implant and control groups. Conversely, spontaneous
intrusion, instead of extrusion, of the mandibular molars
was observed in the Connecticut intrusion arch group af-
ter treatment. In the Connecticut intrusion arch group,
the maxillary molars were extruded by the Connecticut
intrusion arch because of distal tipping of the maxillary
molars. The reciprocal influence of maxillary molar ex-
trusion might have caused the intrusion of the mandib-
ular molars in the Connecticut intrusion arch group.9
Arch length is affected by both inclination of the inci-
sors32,33 and distal tipping of the molars.3,11 In our study,
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732
the maxillary arch length increased because of distal
tipping of the maxillary molars and proclination of the
maxillary incisors in the Connecticut intrusion arch
group, whereas the maxillary arch length increased
solely because of proclination of the maxillary incisors in
the implant group. Thus, an increased maxillary arch
length was observed mostly in the Connecticut intrusion
arch group. To our knowledge, there are no reports in
the literature on the therapeutic effects of incisor
intrusion with mini-implants on arch length.
Overbite was significantly reduced with both Con-
necticut intrusion arch and implant treatment, but the
mean amount of overbite remained stable in the control
group after the study period. In the implant group, over-
bite reduction was obtained by both maxillary incisor in-
trusion and protrusion. In the Connecticut intrusion arch
group, however, overbite reduction was achieved by the
combined effect of maxillary incisor intrusion, protru-
sion, and molar extrusion.28 If incisor intrusion is ob-
tained by molar extrusion in adults, the muscles of
mastication and altered occlusion might move the ex-
truded posterior teeth back to their original positions un-
til soft and hard tissue equilibrium is obtained again, and
relapse occurs.8 Incisor intrusion treatment with mini-
implants only affects the maxillary incisor area.16,17
The position of the maxillary molars is maintained
during incisor intrusion with mini-implants10,17; thus,
stability of the results depends on successful retention
of the incisor intrusion with the mini-implant system.
In this study, similar treatment effects were achieved
by both the Connecticut intrusion arch and the mini-
implant intrusion systems with the exception of alter-
ation in the axial inclination of the maxillary molars.
The differences in the treatment effects of the 2 maxillary
intrusion systems were statistically significant. Therefore,
the null hypothesis was rejected. Further studies should
confirm these important findings and investigate the
posttreatment stability of these techniques.
CONCLUSIONS
1. The maxillary incisor intrusion rates of the Connect-
icut intrusion arch and the mini-implant systems
were similar.
2. Both maxillary intrusion systems led to protrusion
and intrusion of the maxillary incisors, and protru-
sion and extrusion of the mandibular incisors.
3. Although movement of the maxillary molars led to
loss of sagittal and vertical anchorage during intru-
sion of the incisors in the Connecticut intrusion arch
group, these anchorages were conserved in the im-
plant group.
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4. Self-drilling mini-implants 1.3 mm in diameter and
5 mm in length provided sufficient anchorage for
maxillary incisor intrusion. The overall success rate
was 90%.
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