CLINICIAN'S CORNER

Intrusion of supra-erupted molars using

miniscrews: Clinical success and root resorption
Farzin Heravi,a Shahin Bayani,b Azam Sadat Madani,c Mehrdad Radvar,d and Najmeh Anbiaeee
Mashad, Iran

Introduction: Conventional orthodontic techniques do not intrude posterior teeth effectively, and almost all
methods result in anterior extrusion rather than posterior intrusion. New absolute anchorages (miniscrews
and miniplates) are said to make posterior tooth intrusion possible. The aim of this study was to evaluate the
clinical success of a new method for molar intrusion with miniscrews and its probable accompanying side effects.
Material and methods: Ten women with overerupted upper first molars participated in this study. Upper molar
bands with brackets were cemented. Two miniscrews were placed, 1 in the mesiopalatal and another in the me-
siobuccal aspect of the upper first molars; a spring made of 0.017 3 0.25-in titanium-molybdenum alloy (TMA)
wire was used to apply 100 g of force through the attachments (50 g each side). Molar intrusion and external
apical root resorption were evaluated by comparing parallel periapical radiographs with bite blocks at 3 intervals:
beginning of treatment (T0), at the end of active treatment (T1), and 6 months after treatment completion (T2).
Results: The mean value of intrusion was 2.1 mm after completion of active treatment. On average, 0.4 6 0.2
mm relapse had occurred during 6 months of retention, and the mean residual intrusion was 1.7mm, which was
statistically significant. Mean root resorption of 0.3 6 0.2 mm for palatal root and 0.4 mm for mesiobuccal and
distobuccal root was measured. Conclusions: Statistically significant intrusion (2.1 6 0.9 mm) was obtained
during active treatment. The mean value of relapse was 0.4 6 0.2 mm, and the mean value for residual intrusion
was 1.7 6 0.6 mm. Minor apical root resorption occurred during treatment. (Am J Orthod Dentofacial Orthop
2011;139:S170-5)

O
verextrusion of maxillary molars usually results
from early loss of antagonistic teeth. The
elongated dentoalveolar process may induce
problems such as functional disturbances and occlusal
interference and cause great difficulty during prosthetic
reconstruction. Conventional options for removing such
interference include coronal reduction of molar crown—
which often requires root canal therapy—and crown
restorations or posterior subapical osteotomy,1 with
the risk of general anesthesia and high cost.
Orthodontic intrusion of molars seemed to be unsuc-
cessful until the development of a skeletal anchorage
From the Mashhad Dental School and Dental Research Center, Mashad University
of Medical Sciences, Mashad, Iran.
a
Associate professor, Department of Orthodontics.
b
Associate professor, Department of Orthodontics, Kerman Dental School.
c
d
Associate professor, Department of Prosthodontics.
Associate professor, Department of Periodontics.
e
Assistant professor, Department of Maxillofacial Radiology.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Shahin Bayani, Senior Resident, Department of Orthodontics,
Mashhad Dental School and Dental Research Center, Mashad University of
Medical Sciences, Mashad, Iran; e-mail, Sh_bayani@kmu.ac.ir.
Submitted, May 2009; revised and accepted, June 2009.
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2009.06.032
S170
system. Conventional techniques2-4 for intrusion
require anchorage reinforcement by incorporating
multiple teeth and using extraoral devices that depend
heavily on patient cooperation and usually result in
extrusion of other teeth rather than posterior intrusion.
Skeletal anchorage, including dental implants,5
surgical miniplates,6 and miniscrews,7,8 is now growing
in popularity because of its ability to provide absolute
anchorage. The literature contains several reports of
molar intrusion accomplished by miniplates9-13 in
patients with anterior open bite or overextruded molars.
However, compared with miniscrews, miniplates have
several disadvantages, including higher cost, limited area
for insertion, and the need for 2 separate insertion and
removal surgeries.8,14
To date, the available literature for molar intrusion
with skeletal anchorage devices, especially miniscrews,
consists mainly of case reports9,15-19 and a few animal
studies.20-24 The literature clearly shows that teeth can
be successfully intruded in variable rates ranging from
1.2 mm in Carillo et al’s study24 to 5 mm in Umemori
et al’s study.9 Intrusion forces also ranged from 50 g
in Carillo et al’s study24 to 500 g in Umemori et al’s
study.9 In some of these studies, elastomeric materials
were used9,15,18,19 for delivering intrusion forces, which
Heravi et al
may have several shortcomings like rapid force degrada-
tion, hygienic problems, and need for patient coopera-
tion. Also, besides elastomeric materials, NiTi coil
springs used in some other studies10,11,23,24 lack the
ability to change force vector, which is sometimes
needed for controlling molar crown torque during
intrusion, and operators were obliged to use lingual or
transpalatal arches or brackets on multiple teeth for
correcting crown torque.9,10,16,19,25
On the other hand, measuring the amount of
intrusion and root resorption in nearly all the human
studies was based on lateral cephalog9,10,12,13,15,17,19,25
or panoramic images,11 which are not accurate enough
for this application.
The purpose of this study was to introduce a new
approach for molar intrusion with miniscrews, with bet-
ter force consistency and force vector control during
treatment, and to evaluate its clinical success and
concomitant root resorption by a more accurate method.
MATERIAL AND METHODS
Participants
Ten female subjects admitted to the orthodontic
department were selected for this study. Their mean
age was 43.6 years (25 to 57 years) and each had at least
overerupted maxillary first molar, which contributed to
prosthodontic replacement of the opposite tooth.
None of them had previous orthodontic treatment or
active periodontal disease in the beginning of treatment.
Materials
For molar intrusion, we used an Absoanchor Mini-
screw Minikit (Dentos Inc, Daegu, Korea), which consists
of long and short hand drivers for miniscrew insertion,
a round bur (1.9-mm diameter, 21-mm length) for
making an indentation in the cortex, and bracket type
miniscrews (1.3-mm diameter, 7-mm length).
Stainless steel bands with .018 3 .030 welded brackets
(Dentaurum, Inspringen, Germany) was banded over ex-
truded teeth. In order to force delivery, a .017 3 0.25-in
titanium-molybdenum alloy (TMA) spring was con-
structed, which was attached to the miniscrew’s head in
1 end and ligated to the bracket in the other end to reach
the predetermined force (Fig I).
Application of intrusive force
Two miniscrews with bracket-type head were inserted:
1 in the mesiobuccal aspect and another in themesiopala-
tal aspect of the selected tooth. After a 2-week interval for
soft tissue healing, bands with brackets were cemented on
the teeth and the .017 3 0.25-in TMA springs were fitted
into the slot on the miniscrew’s head and ligated. The
American Journal of Orthodontics and Dentofacial Orthopedics
S171
other end of the spring was ligated to the bracket that
was welded on the band. In order to have just 1 contact
point, the spring was not engaged in the bracket slot on
the tooth (Fig I). By pulling the occlusal arm of the spring
with a force gauge hook, it could be adjusted in order to
deliver 50 g of force on each side of the tooth. Patients
were visited every 4 weeks for spring adjustments and
observation of treatment progress.
Radiographic evaluation
We used parallel periapical radiographs with bite
blocks to measure the amount of intrusion and root re-
sorption in 3 intervals: at the beginning of treatment
(T0), treatment completion (T1), and 6 months after re-
tention (T2). Film-film holder-tube position should have
remained the same in these 3 intervals in order to make
radiographs comparable. Thus patients’ bite record and
film holder position were registered with polyvinylsilox-
ane material, and at the same time, the horizontal and
vertical angles of the tube were recorded for each patient.
Radiographs were scanned with a high-resolution scan-
ner (700 dpi) by magnification of 1:1 and were saved in
separate files.
In order to have a precise assessment of tooth move-
ment and root resorption, we used a computer software
named PLANMECA Dimaxis Classic (PLANMECA USA,
Roselle, Ill), which could measure the variables by pixel
units and then convert them to millimeters.
Two obvious and distinguishable landmarks in
adjacent teeth (like restoration edge or cusp tip) were
determined, and a line connecting them was used as
the reference axis for further measurements. In order to
measure the amount of intrusion in each root, a perpen-
dicular line was drawn from this axis to each root apex.
The program automatically calculated the distances in
pixel units (Fig 2). The highest intrusion amount between
roots was considered the intrusion amount of tooth.
To measure root resorption, a line passing the
furcation point of the tooth was drawn parallel to the
reference axis, and the perpendicular distance of each
root apex to this line was computed in pixel units in
3 time intervals (Fig 2).
A single calibrated examiner was used throughout the
study period. In a pilot study on 20 variables, the mean
and standard deviation of differences between duplicate
measurements of the examiner were 0.02 6 0.1 mm and
considered to be a reflection of intraexaminer reliability.
Finally, by finishing the active treatment (T0-T1),
patients were referred for prosthetic replacement of the
opposite edentulous area, and during this period they
were supposed to use a maxillary acrylic splint as retainer.
Patients were asked for pain and irritation symptoms
at each visit during treatment.
April 2011  Vol 139  Issue 4  Supplement 1
S172 Heravi et al

Fig 1. TMA spring (.017 3 0.25-in) with 1-point force application.

Fig 2. Assessment of intrusion amount and root resorption by PLANMECA Dimaxis Classic program.
Reference axis connecting 2 distinguishable landmarks in adjacent teeth (restoration edge here) and
line parallel to this axis passing through furcation point of tooth. By comparing perpendicular distances
from root apices to these lines in the 3 time intervals, it is possible to measure intrusion amount and
apical root resorption. The numbers in pixels denote these distances, which are transformed later to
millimeters.

Statistical analysis Results

A 1-sample Kolmogorov-Smirnov test was used for
determining normality of the data. Changes in tooth po-
sition and root resorption were evaluated by a 1-sample
t test, and finally a Spearman correlation test was used to
assess the correlations between variables.
The maxillary first molars were successfully intruded in
all the patients according to their clinical needs. Mean
treatment duration was 7.7 months and ranged from
4.3 to 11.5 months. Changes in tooth position and root
resorption during active treatment (T0-T1), retention

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Heravi et al S173

period (T1-T2), and total treatment (T0-T2) are shown in

Table I. Mean 6 standard deviation (min, max) of
Table I. The mean intrusion value was 2.1 6 0.9 mm
intrusion amount and root resorption
during active treatment (P\0.001), 0.4 6 0.2 mm relapse
took place during the retention period (P \0.001). The Changes during
average amount of intrusion between T0 and T2 was active Changes during Total
treatment retention change
1.7 6 0.6 mm (P \0.001). Variables (T0-T1) period (T1-T2) (T0-T2)
We found a mean palatal root resorption of 0.2 mm Intrusion (mm) 2.1 6 0.9 0.4 6 0.2 1.7 6 0.6
during active treatment (1.5, 4.5) (0.1, –0.7) (1.1, 2.9)
(P 5 0.08) and further 0.1 mm during retention period P \0.001* P \0.001* P \0.001*
(P 5 0.08). Total palatal root resorption was 0.3 mm Palatal root 0.2 6 0.2 0.1 6 0.2 0.3 6 0.2
resorption (mm) (0, 0.6) (0, 0.5) (0, 0.9)
(P 5 0.045). On average 0.4 mm resorption had occurred P 5 0.08 P 5 0.08 P 5 0.045*
in the mesiobuccal (P 5 0.003) and distobuccal roots Mesiobuccal root 0.4 6 0.3 0 6 0.3 0.4 6 0.4
(P 50.009) from T0 to T2. There was no evidence of re- resorption (mm) (0, 0.9) ( 0.3, 0.4) (0, 0.9)
sorption at the furcation of the first molar regardless of P 5 0.03* P 5 0.22 P 5 0.03*
the amount of intrusion and patient age. The Spearman Distobuccal root 0.2 6 0.3 0.2 6 0.3 0.4 6 0.3
resorption (mm) (0, 0.8) ( 0.2, 0.6) (0, 0.8)
test showed significant correlation between treatment P 5 0.015* P 5 0.076 P \0.009*
duration and mesiobuccal root resorption from T0 to T2
Statistically significant differences between groups are indicated by *.
(r 5 0.83, P 50.000). No significant correlation was Significance was determined at the P\0.05 (1-sample t test). Positive
found between patient age and the amount of intrusion. changes denote tooth intrusion and root resorption, and negative
In addition to evaluation of clinical and radiographic changes indicate tooth extrusion (relapse) and root formation.
variables (Table II), some questions were asked about the
patients’ symptoms after miniscrew insertion. Nine of 10
has the advantage of selective intrusion of the mesial
patients reported a dull pain on the day after surgery,
or distal part of the tooth
and the pain continued to the second day for 6 of
 Perfect control of the labiolingual position of the
them. Most patients required pain medication during
tooth during intrusion by altering the force in buccal
this period. All the patients reported tongue irritation
or palatal springs, in contrast to others that are ob-
caused by the palatal miniscrew, which lasted for about
liged to use extra devices like TPA, lingual arches,
a week. There was no need for local anesthesia during
or conventional fixed appliances to control tooth
screw removal for 14 of 20 miniscrews.
buccolingual position9,10,16,19,25
DISCUSSION Intrusion was finished when the tooth was leveled
with the neighboring teeth. Therefore, the amount of in-
Intrusion by conventional methods usually is accom-
trusion ranged from 1.5 to 4.5 mm in this research,
panied by extrusion of the anchorage unit, based on the
which was reasonable considering the different amount
law of action and reaction. Preventing this side effect is
of overeruption of teeth in each patient.
the key of successful intrusion. In existing methods,
To avoid root resorption, intrusive force levels should be
many brackets have to be bonded or an extra oral
kept optimal.26 Although an optimal force has not yet been
appliance designed in order to reinforce the anchorage
suggested for intrusion with miniscrews, forces greater than
unit. However, despite these efforts, efficient intrusion
what is generally accepted for intrusion in conventional
of molars is still difficult to accomplish.
treatments are reported to be applied with miniscrews and
In contrast to traditional methods, intrusion of molars
miniplates. Umemori et al9 used 500 g, Paik et al27 used
has been facilitated by inserting miniscrews to minimize
150 to 250 g, Jeon et al17 used 400 g, Erverdi et al13 used
extrusion of adjacent teeth. We used a new, simple
200 g, Xun25 used 150 g, Park et al15 used 200 to 300 g,
approach for molar intrusion with a .017 3 0.25-in TMA
and Kanzaki et al22 used 100 g. We preferred 100 g force
spring and bracket-type miniscrews, which had some ad-
(50 g per miniscrew) to intrude the teeth in this study, which
vantages over other methods for posterior intrusion using
was the lowest among the above-mentioned studies.
miniscrews including:
Intrusion amounts also varied in the literature according
 Lighter and more continuous force in contrast to to clinical needs. Umemori et al9 achieved 3.5 and 5 mm;
elastic materials used for force delivery used in Erverdi et al,10,13 2.6 and 3.6 mm; Kuroda et al,12 3 mm;
some studies9,15,18,19 Kanzaki et al22 1.7 to 2.3 mm; Carillo et al,24 1.2 to 2.3
 Excellent control of force vector by altering the mm; and Xun et al,25 1.8 mm. In our study, the amount
horizontal extension of the occlusal arm of the spring of intrusion was between 1.5 and 4.5 mm, which was in
or ligating it to different wings of the bracket, which a similar range as other studies.

American Journal of Orthodontics and Dentofacial Orthopedics April 2011  Vol 139  Issue 4  Supplement 1
S174 Heravi et al

Table II. Pearson test (correlation coefficient and P value) for determining correlation between variables throughout
total treatment (T0-T2)
Treatment Intrusion Palatal root Mesiobuccal root Distobuccal root
Variables duration Age amount resorption resorption resorption
Treatment duration — 0.11 0.05 0.37 0.83 0.20
0.76 0.9 0.32 0.00* 0.61
Age 0.11 — 0.28 0.16 0.21 0.30
0.76 0.46 0.68 0.58 0.44
Intrusion amount 0.05 0.28 — 0.40 0.30 0.21
0.89 0.46 0.28 0.57 0.59
Palatal root resorption 0.37 0.16 0.40 — 0.22 0.63
0.32 0.68 0.28 0.57 0.07
Mesiobuccal root resorption 0.83 0.21 0.30 0.22 — 0.31
0.00* 0.58 0.57 0.57 0.41
Distobuccal root resorption 0.20 0.30 0.21 0.63 0.31 —
0.61 0.44 0.59 0.07 0.41
Statistically significant differences between groups are indicated by *. Significance was determined at P \0.05.

The root resorption in our study was 0.3 to 0.4 mm
on average, which was statistically but not clinically
significant. The amount of root resorption was approx-
imately similar to other studies,20,21,23,24 except for
Ari-Demirkaya’s11 study, which had reported higher
root resorption than our study (0.8 mm) maybe because
he used OPG images to assess root resorption which can
overestimate resorption amount28. According to small
amount of root resorption in our study we can suggest
this new technique for intrusion with the confidence
of little side effects.
We also found a small amount of crest resorption in all
our cases during active intrusion. As the crest resorption
was not comparable to the amount of intrusion, final
root coverage was improved at the end of treatment.
By reviewing the literature, it was noticed that in all
human studies on molar intrusion with skeletal anchor-
age, an accurate method for calculating the amount of
intrusion and root resorption was not used. Most of
them used pretreatment and posttreatment lateral ceph-
alograms9,10,12,13,15,17,19,25 to assess these variables, and
1 of them used OPG11 for this purpose. We used parallel
periapical radiographs with Rinn X-C-P film holders and
bite registering material for obtaining a reproducible
film-tube-film holder position. Also, precise computer
software was used in this study that could accurately
estimate variables.
According to our study, some relapse (extrusion) oc-
curred during the retention period, which was in line with
Sugawara et al’s,29 Erverdi et al’s,13 and Park et al’s16 results
and was in contrast to Kurroda et al’s12,19 studies, which
reported good stability after posterior intrusion. Paying
attention to controversies in this subject, more complete
and perfect studies with greater sample size are needed
to determine effective factors in relapse, time needed for
stabilization of treatment outcomes, and best retention
appliance after posterior intrusion.
CONCLUSIONS
1. The amount of intrusion during active treatment
(T0-T1) was 2.1 6 0.9 millimeter, relapse during re-
tention period (T1-T2) was 0.4 6 0.2 mm, and the
remaining intrusion was 1.7 6 0.6 mm throughout
the entire treatment (T0-T2), which was statistically
significant in all these periods.
2. Total amount of resorption was 0.3 mm for palatal
root and 0.4 mm for mesiobuccal and distobuccal
roots, which was statistically but not clinically
significant.
3. There was a significant correlation between treat-
ment duration and mesiobuccal root resorption. No
significant correlation was found between patient
age and the amount of root resorption and intrusion.
4. Almost all the patients reported a dull pain about 2
days after screw insertion, which needed pain
medication. Tongue irritation also was seen, which
disappeared after about a week.
We would like to thank the Vice Chancellor for
research of Mashhad University of Medical Sciences for
financial support.
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