AmericanJournalof ORTHODONTICS

Volume 72, Nu,ntberL, July,1977

ORIGINAL ARTICLES

Deepouerbi,tecorrectionby intrusion
Chorles R. Burstone
Farm'ington, Conn.

/-\
LJr. of the major challenges of Class If treatment is the correction of
deep overbite. Unfortunately, it is still common for the correction to be deter-
mined by the system of nechanics that an orthodontist will employ, rather than
the nature of the discrepancy. fn most instances this correction is produced by
the extrusion of posterior teeth, with the greatest successassociated with patients
who exhibit eonsiderable mandibular growth.
Differential treatment planning for the Class II patient requires that the
relative amount of anterior intrusion and posterior extrusion be determined be-
fore treatment and that differential mechanics be utilized to produce the desired
correction.''The amount of intrusion required will vary from patient to patient;
however, some trends in treatment planning should be noted in the average Class
II situation. Many Class II casesare characterized either by an A-B (apical base)
discrepancy or by a greater-than-average vertical d.imension.
I-rip length may be relatively short in relation to the vertical dimension. It is
not desirable to increase the vertical dimension, since it would tend to make the
A-B relationship more Class II and increase an abnormally large lower face. A
great deal has been written about the undesirability of rotating a mandible open
in the steep mandibular plane case; the same precautions concerning rotation
should. also be employed in a patient with a large A-B discrepancy. Fig. 1 shows
a patient in whom deep overbite lvas corrected by the extrusion of primarily
lower premolars and molars associated with leveling the curve of Spee in the
lower arch and the use of Class II elastics.
The bony Class II relationship measured at points A and B has becomemore
severe as the mandible has swung downward and backward. The vertical dimen-
sion has increased, creating an even longer lower face and potential instability in

Department of Orthoclontics, School of Dental Medicine, University of Connecticut

Health Center.
 2 Burstone Am. J. Orth,od..
Juta tg77

Fig. l. Correction of deep overbite by exfrusion of lower first molors ond premolors os.
socioted with Closs ll elosticsond leveling of the lower curve of Spee. An undersiroble
increose in verticol ond fcciql convexity hos .occurred. (Solid line-before; dotted line-
ofier treotmenl.)

the overbite correction. Extrusive mechanics has worsened the skeletal pattern
since minimal mandibular growth has occurred. during treatment. patients J. Z.
and M. H. were treated with the intrusion mechanics which are described in this
article (Figs. 2 to 5). Even though these patients are characterized by minimal
mandibular growth, it should be noted that the mandible has not exhibited a
clockwise rotation during treatment; actually, the Y axis angle has been reduced.
This control of vertical dimension ensures that one has not encroached on the
interocclusal space during d.eep overbite correction and thus increases stability.
ft makes it easier for the patient to close his lips and improves the A-B relation-
ship.l If our objective in a high percentage of Class fI easesis to reduce or hold
vertical dimension rather than to'increase it, conection of deep overbite becomes
more difficult for it requires genuine intrusion of the anterior teeth. Although
intrusion may complicate the mechanieal treatment of the patient, it is necessary
for the achieving of an optimal result.
The decision as to the proper cant an<l level of the occlusal plane should not
be determined as an accident of meehanics but should be carefully evaluated at
the beginning of treatment. The usual factors that should be considered. are the
natural plane of occlusion (the original axial inclinations and alignment of the
posterior teeth), anterior esthetics (the relationship of the incisor to the upper
lip), the amount of attached gingiva present in the mandibular incisor region,
and the A-B discrepancy. rf one were to genera,lize,most Class rr patients require
Yolunte 72 Deep ouerbitecorrection 3
Nunxber L

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Figs.2 to 5. Correctionof deep overbiie by intrusion of incisors.Anterior croniol bose

superpositionond seporote moxillory ond mondibulor superpositionsore shown. (Super-
M.H,d
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&
position of moxillo is on polotol plone ot ANS; mondible is superposedot symphysis
ond onterior ihird of lower border.) Note genuine intrusion of moxillory incisorsond re-
duction in fociol convexity.(Solid block teeth-ofter treotment.)
4 Burstone Am. J. Orthoil
JulA L977

a relatively flat occlusalplane that tends to coincide with the natural plane.of
occlusion of the posterior teeth. The plane should not allow more than 3 mm. of
the incisors to show belowthe upper lip.
ff we acceptthis conceptof an occlusalplane, it is apparent that more intru-
sion of the upper ineisor than of the lower incisor is required. Once again, this
complicatestreatment since it is much easierto intrude lower incisors becauseof
their smaller root massand the commonpresenceof a curve of Speein the lower
arch. For optimal treatment, however,more intrusion is required in the upper
arch than in the lower. It should be noted that in Patients J. Z. and.M. H.
genuine intrusion of the upper ineisor is shown in the maxillary superposition
which is greater than the intrusion shown in the mandibular arch.
Every patient with deep overbite requires a comprehensivetreatment plan
which establisheshow the d.eepoverbite should be corrected,either by extrusion
of posterior teeth or inhibition and genuine intrusion of anterior teeth. This
decisionis basedin part on where the clinician desiresto place the occlusalplane,
the amount of mandibular growth anticipated, and the vertical dimensiondesired
at the end of treatment.
It is important to define intrusion, sihce the dental literature suggestsam-
biguity in its use.fntrusion refers to the apical movementof the geomdtriccenter
of the root (centroid) in respect to the occlusalplane or a plane based on the
long axis of the tooth. Labial tipping of an incisor around,its centroid produces
pseudo-intrusion.Although this pseudo-intrusionwould help correct a deep over-
bite in a Class II, Division 2 patient, it should not be confusedwith the genuine
intrusion discussedin this article. Incisal edEesshould.therefore not be used to
evaluate intrusion, since they are easily affected by tipping movementsof the
incisors. Ideaily, a point should be selectedin the center of the root (centroid)
and comparisonshould be basedupon the movementof this point.
The bqsic inlrusivemechonism
In the 1950's I developed an approach to orthodontie therapy which did not
use continuous arches.2 The technique, known as tlte segmented, arch, used dif-
ferent cross sections of wire within the .same arch and wires that did not run
continuously from one bracket to the adjacent bracket.s,n Segmented arch pro-
cedures have a number of advantages in space closure in extraction cases and in
producing tooth alignment with minimum side effects.5 In particular, segmenta-
tion allows for the genuine intrusive movement of the anterior teeth. One of the
limitations of traditional continuous arch therapy has been its inability to pro-
duce genuine intrusion.
The basic mechanism for intrusion consists of three parts: (L) a posterior
anchorage unit, (2) an anterior segment, and (3) an intrusive arch spring
(Fig.6).
Early in treatment the posterior teeth are aligned and joined together with a
buccal stabilizing segment. once a buccal stabilizing segment of at 1east 0.018 by
0.018 inch (0.457 by 0.457 mm.), with or without loops, can be placed, intrusive
mechanics can be begun. (The mechanics described are based upon a 0.022 inch
(0.559 mm.) slot edgewise bracket. Although the cross sections of wire wiII differ
 J

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Volunxe 72 Deep ouerbite correction 7
Number L

not increase and the rate of root resorption will increase. This has been demon-
strated.by Dellinger's research on monkeys.GEven more significant is the recipro-
cal effect on the posterior segments of too great a force. The posterior teeth will
feel a vertical force which will tend to extrude the buccal segments and a moment
or torque which in the upper arch will steepen the plane of occlusion and in the
lower arch flatten it (Fig. 9). If only a single tooth, as af.rst molar, is attached
to an intrusive spring, the undesirable side effect is seen primarily as a tip-back
action, with the crown moving distally and the root mesially. I-rossof anchorage
during intrusion is primarily produced by the moment rather than by the force,
since occlusal forces tend to negate the eruptive tendency. The moment is large
because the distance from the incisors to the posterior teeth is great.?
The recommendecl forces for anterior intrusion are given in Table I. It
should be noted that approximately 25 Gm. of force is delivered to an upper
incisor and approximately half that amoF.nt to a lower incisor. A canine requires
about 50 Gm. of force, on the average, for intrusion. Fig. 10 gives the load-
deflection characteristics of typical 0.018 by 0.025 inch (0.0457 by 0.635 mm.)
intrusive arches. The length of the arch is measured from the mesial aspect of
the auxiliary tube on the molar to the midline of the dental arch parallel to the
midsagittal plane. If the orthodontist desires to intrude four incisors, 100 Gm.
of force midline would be required (25 Gm. per tooth). For a 30 mm. arch, 16.5
mm. of activation is required. (The intrusiye arch is then bent so that its anterior
portion lies 16.5 mm. below the level of incisor brackets.)
The suggested forces are averages based upon clinical experience. They can
be modified if root circumference and length vary from the average. Care shoulcl
be taken, holever, not to increase the magnitudes significantly because of the
possibility of upsetting the posterior anchorage. It is important to make sure
not only that an optimal magnitude of force is employed but that the force
operates rqlatively constantly.
Springs that deliver relatively constant force have low load-deflection rates.
An intrusive arch with a 30 mm. arm (perpendicular distance from the incisor
to the first molar) has a load-deflection rate of 6 Gm. per millimeter. If this
intrusive arch is activated 16.5 mm., 100 Gm. of force is produced in the midline,
50 Gm. per side. As the incisors intrud.e 1 mm., there is a change of force magni-
tude of only 6 Gm.; hence, the delivery of force is relatively constant.
By eontrast, high load-deflection mechanisms, such as some of the loops that
are tried for intrusion, are activated only just a few millimeters; accordingly,
the drop off of force is very dramatic for every millimeter of tooth movement.
With a high load-deflection mechanism, it is not possible to deliver optimum
forces since the activations required to produce the desired forces are in tenths
of a millimeter and the orthodontist does not have the ability to cawy out such
minute activation.8 Furthermore, with a high load-deflection spring rate as the
tooth moves, a rapid drop in force magnitude occurs, so that the optimal force
may be only momentarily reached.
The clinician, therefore, learns that he must use greater than optimal forces
to achieve any appreciable tooth movement. In short, in order to accomplish
intrusion, it is neeessary to deliver an optimal force constantly. A low load-
 Am,. J. Orthod,.
8 Bu,rstone JulA L977

I N T R U S I VBEA S EA R C H E S
W I R Es l Z E :, 0 1x8. 0 2 5 "
DIAMETER OF HELIX =3mm.2!,/2TURNS

-
U
U

L=35mm

ACTIVATION(mm)
Fig. l0 Lood-deflectionchorocteristicsof the intrusiveorch {Lf is the perpendiculordistonce
from the incisor brocket to the mesiol ospect of the molor ouxiliory tube. The totol force
is given on the verlicol oxis. Dqtq ore bosed on overoge orch forms. Activotion con be
determinedfrom this toble, or o force gouge con be used in the mouth.

deflection rate spring makes it practical for the clinician to determine the magni-
tude of the force, since activation is not so critical and assuresthat as intrusion
proceedsthere will not be a marked red.uctionin force magnitude.
Force magnitude can be measuredeither from a force-deflectiongraph (Fig.
10) based on averagearch form or by directly measuring the intrusive arch in
the mouth with the use of a force gauge.The intrusive arch has certain character-
istics which assure a low deflection rate and relative freedom from accidental
permanent deformation under the forces of mastication. Although a wire of
relatively large crosssectionis used,either 0.018by 0.025inch (0.457by 0.635
mm.) or 0.018by 0.A22ine}l (0.457by 0.559mm.), the load deflectionis reducecl
by the long perpendicular length from the incisors to the auxiliary tube of the
first molar. In addition, a helix 3 mm. in diameter is placedat the critical section
immediately mesial to the auxiliary tube on the first molar in which 2.5 turns are
plaeed (Fig. 11). This springis an exampleof how a large cross-sectional wire
can be used in proper designto d.eliveroptimal and constantforceswithout being
so flimsy that permanent deformation can occur under accidentalloading.
Anleriorsingle point conlqcls
The intrusive arch is not placed directly into the brackets of the anterior
teeth. The major reason why one avoid.s bracket engagement of the intrusive
Volutne 72
Number t Deep ouerbite correction 9

F i g . l l . A h e l i x3 m m . i n d i o m e t e w r i t h 2 . 5 t u r n si s p l o c e di m m e d i o i e l m
y e s i o lt o t h e
ouxiliorytube on ihe firstmolor.Thehelix lowersthe forceond deliversit moreconslontly
withoutreducing the orch'sobilityto withstondpermonent deformotion.
F i g . 1 2 , l n t r u s i v eo r c h i s p l o c e di n c i s o li o b r o c k e t sA. s e p o r o f e0 . 0 1 0 b y 0 . 0 2 0 i n c h
(0.254by 0"508mm.)onteriorsegmentioinsthe incisor.
Fig. 13. lf the intrusiveorch is plocedin two incisors,it is necessory to round the wire
so thot no lbrque is produced.

spring is that, inadvertently, anterior torque may be present in the arch. Even if
no torque is present, as the intrusive arch works out, torque can be introduced. If,
purposely or inadvertently, labial root torque is placed into the incisors, the
intrusive forces are increased on the anterior teeth; this added intrusive force is
not needed and can produce anchorage loss of the posterior teeth.
On the other hand, if lingual root torque is present, it will have the effect of
reducing the magnitude of intrusion on the incisors. In fact, if the lingual root
torque is large enough, the direction of the force could reyerse and the incisors
could actually extrude.
The ad.vantage of not tying an intrusive arch directly into the incisor brackets
is that it allows the clinician to know more positively the force system delivered.
By having a single point of force application on the incisors, one knows the full
force system acting at both the incisor point and the buccal tubes. A system of
this type is described as being statically determinant. Placing the intrusive arch
into the brackets produces a statically indeterminant system which prevents the
orthodontist from knowing exactly what tyae of force he is delivering.
Another disadvantage of placing an intrusive arch into the incisors is that un-
 Burstotte Am,. J. Orthoitr.
l0 JulA 1977

desirable curvatures are formed in the wire during activation. This is particu-
Iarly noticeable if small cross sections of wires are used for intrusion.
The anterior single-point contact allows for the placement of a series of
anterior-alignment arches directly into the bracket. The anterior-alignment
arches can include small-cross-sectionbundle or straight wires or wires with loops
(Fig. 12). One can gradually work up to larger cross sections that can stabilize
the anterior segment.
An exception in rn'hich the intrusive arch may be placed in the brackets of the
incisors can be found in the example of central incisor intrusion alone (Fig. 13).
If the intrusive arch is placed into the incisors, it is necessary to round the wire
so that no torque is produced. Round.ing the anterior segment of an intrusive arch
going into four incisors may be a problem since torques can still be produced be-
cause of the curvature in the anterior part of the arch.

Pointof forceo.pplicotion
An intrusive force placed through the center of resistanceof the incisors will
intrude the center of resistance and not produce any labial or lingual rotation of
the teeth. The center of resistance of an anterior segment can be estimated to be
at the geometric center of the roots of the incisors to be intruded 1Fig. i+) .
In maxillary intrusion, the intrusive arch is normally placed slightly anterior
to the labial surface of the incisors as it is attached to the anterior segment. This
produces a moment which tends to flair the crown forward and move the root
distally (Fig. 1a). It is important, therefore, to tie the intrusive arch back to
prevent the incisors from protruding. When the intrusive arch is placed anterior
to the center of resistance during intrusion, root retraction simultaneously occurs
and minimizes the need in many Class II patients for root movement to be
accomplished at a later stage.
fn those patients who have markedly protruded incisors, an intrusive force
placed on the labial surface of an incisor will produce a moment that is very large
and hence more effective in producing lingual root movement of the incisor.
Since these protruded incisors do not require this type of lingual root movement,
a slightly different mechanism is used".An anterior segment is made with a pos-
terior extension (Fig. 15). Right and left sectional intrusive arches are con-
structed with a hook that catches on the Dosterior extension so that the force can
be directetl through the center of resistance of the incisors (Figs.15 and 16).
Sectional intrusive springs solve the problem of delivering an intrusive force to
the incisors without producing undesirable change in axial inclination, but they
are not as efficient as intrusive arches applied to teeth with normal axial inclina-
tions' It can be seen that an intrusive force on a flared tooth has a strong anterior
component which tends to translate the root of the incisors labially (Fig. 1?).
Since only a portion of the component force is directed along the long axis of the
tooth, rates of tooth movement are proportionately 1ow.
In the patient requiring extraction it is possible to have a better solution to
the problem of a protruded incisor. The incisors should be uprighted first and,
after they have normal axial inclination, intrusive mechanics is initiated.
In using the intrusion arches and sections,control of the active force system
 VollntLe '12
Nult'Lbel' 1 Deep ouerbite correction II

e C A

N\ #

Fig. I4. As the intrusiveforce is opplied more onteriorly to the center of resistonceof the
incisors,o positivemoment is creofed which tends to move the root linguolly, provided the
i n c i s o ri s r e s i r o i n e df r o m f l c r i n g l o b i o l l y .
F i g . 1 5 . A p o s t e r i o re x t e n s i o nh o s b e e n p l o c e d o n o l o w e r 0 . 0 1 8 b y 0 . 0 2 5 i n c h ( 0 . 4 5 7
by 0.635 mq.) onterior segmenf. Right ond sectionol intrusive springs ore hooked on the
extension.
Fig' 16. Forcesystemof opplionce shown in Fig. i5. Only forces on the teeth qre shown.
\ Note thot the posferior extension ollows force to be directed through the center of
resistonceof the incisor. No incisor tipping will occur.
Fig. 17. A long posterior extension is used to protrusive lower incisorsto prevent floring.
t The hook ot the intrusive section is shown.

on the incisors is the major key to success. This control inciudes delivering
optimai force magnitudes, deiivering these forces eonstantiy, clelivering the intru-
sive force at a single point contact, and controlling the point of force application
rvith respect to the center of resistance of the anterior seEment.

Selectiveintrusion

Indiscriminate leveling with a continuous arch or with sections can produce

undesirable side effects in a patient with cleep overbite. rn tr'ig. 18 a class rr,
Division 2 maxillary arch is depicted. Commonly one would like to intrude the
incisors to the level of the canines or perhaps produce some extrusion of the
posterior teeth without altering the plane of occlusion (Iine A). A straight arch
 l2 Burstone Anr. J. Orthod,
Jula L977

46.nf,)

,l

Fig. 18. A stroight wire ploced in brocketsof o Closs ll, Division 2 cose, insieod of pro-
ducing intrusion(line A), tends to steepenthe plone of occlusion[line B).
Fig. l9' A stroight olignment orch, insteod of intruding incisors,will erupt loterol incisors
ond tends to converge the incisor roots mesiolly.
Fig.2O' Arch widths ore controlled with o linguol orch. Mondibulor linguol orch inserted
from the posterior of the molor tubes is shown. Tronspolotol linguol orch is used on the
moxilloryorch.

wire placed. through the brackets not only produces vertical forces but, un-
fortunately, moments which alter axial inclinations, and thus it is possible that
this maxillary arch could be leveled by not producing any intrusion but by extru-
sion and steepening of the maxillary plane of occlusion (line B). Fig. 1g shows
the anterior segment from the frontal view. Although the central incisors should
be intruded to the level of the lateral incisors, a continuous arch wire produces
primarily extrusion of the lateral ineisors, since extrusive movements can be
accomplished more easily than intrusion. The undesirable moments will tend to
converge the roots toward the midline.
ff one looks at the anterior segment in the Class If, Division 2 case,occlusal-
gingival steps are seen in the position of the incisors as the upper central incisors
project occlusally to the lateral incisors. It is desirable to intrude just the two
central incisors to the level of the lateral incisors before joining all four incisors
Volunxe 72 Deen ouerbite corcection 13
NunLber I

Fig.2I. Occipitol heodgeor ploced onterior to the center of resistonceof the posterior
onchorogeunit. Heodgeor will counteroctmoment ond force of the intrusiveorch.

together for further intrusion. When one works on two incisors alone, lower
forces can be used and, of course, the undesirable side effects that were present
with a continuous arch are avoided. In a similar way, Class II, Division I pa-
tients may require intrusion of four incisors, both maxillary and mandibular, to
the level of the canines. Ifany times eanines that appear in infraocclusion shoulcl
not be extiuded, but the four anterior teeth should be intruded to their level by-
passing the canines.
Taking"pdvantage of the geometry of the anterior segment is one of the key
concepts in producing genuine intrusion. Indiscriminate leveling of the anterior
segment with a continuous wire may make it impossible to employ intraoral
mechanics for intrusion.

Conlrolof lhe reoctiveunits

The best control over the posterior teeth, the reactive unit, is the minimiza-
tion of force magnitude used. for intrusion. Since the moment arm is so large
from anterior to posterior segments, it is necessary to give thought to the control
of the posterior teeth.
As many teeth as possible are joined together to form the posterior anchorage
unit. Whenever possible, at least the first molars and second premolars should be
used and the addition of other teeth would further enhance the anchorage poten-
tial. A1l teeth are joined together by means of a buccal wire to form a buccal unit.
The buccal wires, buccal stabilizing segments,are at least 0.018 inch (0.457 mm.)
square in cross section for 0.022 inch (0.559 mm.) slotted brackets. In addition
to connecting posterior teeth by means of a buccal wire, right and left buccal
segments are joined with a transpalatal arch in the maxilla or a low lingual arch
in the mandible (Fig. 20). One should consid.erthe posterior anchorage unit not
 l4 Burstone 4111. J. Orthod,.
JulA 197'I

Fig.22. The extrusive force on the molor during incisor intrusion tends to tip the crown
l i n g u o l l y .T h i s c o n b e p r e v e n t e db y u s i n g o l i n g u o l o r c h .

as a group of iudividual posterior teeth but as a single posterior tooth composed

of all the individual teeth on the right and left sides of the arch. In segmented
arch mechanics, individual adjustments are not normally made in the buccal
segment of the lingual arch during treatment; adjustments are made between
the auxiliary tube of the first molar and the anterior teeth.
Two basic side effects could be anticipated from intrusive mechanics.Looking
from the lateral view (Fig. 9), a moment is created which tends to alter the plane
of occlusion of the buccai segment; in the upper arch the plane is steepened.To
minimize these changes, a number of principles are used in the intrusive mecha-
nisms that have been described. The forces are kept as low as possible.The largest
nurnber of teeth are present in the buccal segment; these teeth are relatively
rigidly connected by a buccal stabilizing segment and across the arch with a
lingual arch. Finally, as an added precaution, occipital headgear can be used in
the upper arch, designed so that its force is anterior to the center of resistance
(Fig. 21).
The lieadgear produces a moment opposite to the moment produced by the
intrusive arch and thus prevents the sf,eepeningof the maxillary plane of occlu-
sion. rf cooperation is exeellent with this tlpe of occipital gear, this moment may
overwhelm the moment produced by the intrusive arch and the posterior segment
could tip forward. For this reason, it is important to v'atch carefully the effects
of occipital headgear on patients who have already undergone extraction in the
upper arch. Although occipital headgear can heip to control the posterior seg-
ment, prevent their extrusion, and minimize the moment tending to steepen the
plane of occlusion, they should be used only as an adjunct to treatment. Ireadgear
should not cover up basic inadequacies in intraoral mechanics.
The second major side effect produced by an intrusive arch can be seen from
the frontal view (Fig.22). with an intrusive force on the incisors, there is an
equal and opposite extrusive force on the molars. Since the extrusive force is
operating buccally at a tube, it can be seen that a moment is created that tends
to tip the crowns lingually and the roots buccally. one of the functions of the
lingual arch is to prevent any undesirable change in axial inclination of the
 Volume 72
Nunber I Deep ouerbitecorrection t5

Fig.23. PotientR. A. beforetreotment.Deepoverbiteis chorocterized

by overeruption
of
the moxillorycentrolincisors.

molars or change in width. The lingual arch also has the ad.vantage that one
does not have to be that precise in forming the widths of the intrusive arch since
this is adequately controlled by the iingual arch. I-.,ingual arches are not only
helpful during the stage of intrusion, but they also help resist side effects at al-
most any stage of treatment.

Avoiding exlrusivemechonics
rf one is to accomplish genuine intrusion in patients, it would be disappoint-
ing to succeedand then to lose the intrusion by using eruptive mechanics on the
incisors and molars. Extrusive mechanics on the posterior teeth should therefore
be avoided. Examples of extrusive mechanics are the use of Class II and Class
rrr intermaxillary elastics, cervical gear with outer bows placed high applied to
the maxillary arch, and the placement of a reverse curve of spee in the lower
arch wire to extrud.e premolars.
One of the classic situations for inadvertently erupting incisors which have
been intruded. or are going to be intruded is placement of a continuous arch wire,
with or without loops, through a canine which has a crown distal to the root. rf
the arch wire is piaced into the canine bracket, it will lie occlusal and hence will
produce eruption of the incisors. fncisors make very poor anchorage for distal
root movement of a canine, since eruption occurs so much more easily than distal
 LnL. J. Orthoil.
I6 Burston'e Jula !977

i :lii'il
l:1:t$6***tl

Fig.24. Potient R. A. Intrusiveorch in ploce intruding the centrol incisors.

t .A . F o l l o w i n g
F i g . 2 5 .P o t i e nR o f t h e i n c i s o r so,l l s i x i n c i s o rosr e o l i g n e dw i t h o
inirusion
0.010 by 0.020 inch 10.25aby 0.508 mm.)section'

root movement. It is preferable to bypass the canines during canine I'oot move-
ment, or in certain situations canine root movernent should. be completed before
the incisors are joined to the rest of the arch'
The typical patient who requires intrusion also requires minimization of
extrusion of the posterior teeth. An exception is found in some of the patients
with flat mandibular planes who have well-developed musculature. Extrusive
mechanics on posterior teeth can be used.on some of these patients, provided the
cant of the plane of occlusion is controlled.. fntrusion could' be the fina1 result
since the muscles of mastication may intrude the posterior teeth back to their
place
original positions. In these patients, it is necessary to keep the arches in
in
until this intrusion has occurred. Inhibition of the eruption of posterior teeth
the growing patient can be accomplished using a number of procedures. occipital
headgear can be worn to the upper arch, cervicai headgear with high outer bows
to the lower arch. Chin caps can be useful in inhibiting the eruption of posterior
teeth. Although there is not good. documentation, it is possible that temporo-
masseter exercisescould further aid in this inhibition'
Volutne 72
Number I Deep ouerbite comection 17

i#-,:;i..|r

Fig, 25. Potient R, A. ot completion of treqtment.

Treolmenl sequence

Unless the incisors are protruded, intrusion is started during or following the
initial alignment of the posterior segments. Patient R. A. (Fig. 28) exhibited
deep overbite with excessive extrusion of the central ineisors. During the first
appointment an 0.018 by 0.018 inch (0.457 by 0.457 mm.) alignment arch was
placed in the buccal segmentsand an 0.018 by 0.022 inch (0.45? by 0.55g mm.)
intrusive arch was inserted to the central incisor only, bypassing the canines and
Iateral incisors (Fig. 2a). When the central incisors were intruded to the level of
the lateral incisors and canines, a 0.010 by 0.020 inch (0.254 by 0.508 mm.)
anterior arch segment was placed from canine to canine to align the anterior
teeth and to hold the incisor intrusion (Fig.25). Simultaneously, in the lower
arch, tip-back segments were used to remove the lower curve of Spee and to re-
tract the lower posterior segments. Headgear to the upper arch was used to
restrain the buccal segments in order to correct the Class II occlusion produced
by retraction of the lower buccal segments.The occlusion at the time of deband-
ing is shown in Fig. 26. The molar bands have been left in place so that head-
gear worn 6 to 8 hours a day could be used as a retentive appliance.
At the beginning of treatment Patient M. M. showed 100 per cent overbite
and a iateral open-bite tendency (Fig. 27). Since the central incisors were posi-
tioned occlusal to the lateral incisors, an 0.018 by 0.018 inch (0.457 by 0.457
mm.) connector was fabricated joining the central incisors together, bypassing the
canines and lateral incisors (Fig.28). Intensive arches were used until the
 A111. J. Orthod'.
l8 Burstotte Jul.u L977

Eig.27. Potient M. M. before treotment. Deep overbite with loterol open-bite. To ovoid
increoseof verticol ond eruptive incisor relotionshipto upper lip,.no l e v e l i n g o f m o n d i b -
ulor curve of Soee wos olonned.

Fig. 28. Potient M. M. lncisor connectorin ploce before plocement of the intrusive orch.
Fig.29. Potient M. M. Following incisor intrusion ond olignment of the six onterior feeth,
the onterior segment is retrocteden mossewith 0.0'|0 by 0.020 inch {0.254 by 0.508 mm.)
retrqction spring.

Fig, 30. Potient M. M. ot completion of lreotment. Curve of Spee remoins in lower orch.
Deep overbite wos correctedby upper incisor intrusion.
Vol%nxe 72
Nunxber ! Deep ouerbitecoryect'ion 19

))

ft

Fig.3l. Potient M. M. Croniol bose superposition(Dotfed line-Afrer treotment). No mon-

dibulqr rotoiion or increosein verticol dimension hos occurredduring treotment.
Fig. 32. Potient M. M. Moxillory ond mondibulor superpositions.Upper incisorshove been
intruded 7 mm., meosured oi their opices.

central incisors reachedthe level of the lateral incisors,and.then all four incisors
were intruded as a unit. En massespaceclosure of the six anterior teeth was
effectedby an 0.010by 0.020inch (0.254by 0.508mm.) anterior retraction as-
sembly (Fig. 29). The finisheclresult is shownin Fig. 30.
Becauseof the short upper lip, the curve of Speewas maintained.in the lower
arch, with all of the intrusion occurring in the upper incisor region (Figs. 31
and 32). The skeletal pattern with its large vertical height anteriorly, facial
convexity, and steep mandibular plane required treatment that would maintain
the vertical dimension and correct the deep overbite by intrusion. If the lower
curve of Spee had been leveled, the result would have been undesirable; the
vertical dimensionwould have been increased,so that the patient would not close
her lips and too much upper incisor would have shown below the upper lip.
Indiscriminate leveling of the lower arch should not be attempted in this type of
case.
Conine inslrusion

It is usually not possibleto intrude aII six anterior teeth at one time without
producing undesirable axial inclination changein the posterior segment.Using
 Am. J. Orthod.
zy D'I*rtl'0'ne
Jula 1977

Fig. 33. An 0.018 by 0.025 inch (0.457 by 0.635 mm.) conine-intrusionspring. Possive
position.
Fig. 34. Conine-inirusionspring is ociivoted by plocing its onterior end into the verticol
tube of the conine.
F i g . 3 5 . A n 0 . 0 1 8 b y 0 . 0 1 8 i n c h ( 0 . 4 5 7 b y 0 . 4 5 7 m m . ) i n t r u s i v es p r i n g o t t o c h e dt o i h e
ouxiliory fube on the second premolor. This spring is used if molor ouxiliory tube is not
ovoiloble.
Fig. 36, Active stote of spring shown in Fig. 35. Helices lowei lood-deflectionrote ond
reduce unwonted negotive moments on lhe conine.

the suggested force values, typically 100 Gm. of force on a sid.eis required to
intrude the incisors and the canines. Table I shows that 100 Gm. would produce
a moment of 3,000 Gm.-mm. to the posterior segment if the perpendicular distance
from the incisors to the center of resistance of the posterior segment was 30 mm.
Since moments of this magnitude are most effective, tipping of the posterior teeth
will occur more rapidly than the intrusion, and since this tipping is not required,
intrusion mechanics will not be successful. If the posterior segment were backed
up with an occipital headgear in the maxillary arch, it is possible to eliminate
this undesirable moment as well as the eruptive force on the posterior teeth.
Wiihout excellent cooperation from the patient in the wearing of headgear,
intrusion of six anterior teeth simultaneously should not be attempted.
Two types of situation require separate eanine intrusion. In the first the
canine lies bilaterally occlusal to the premolar and the canine must be intruded
separately foilowing auterior intrusion. In the second, the canines have not
erupted symrnetrically and canine intrusion is required on only one side. In
Volume 7 2 Deep ouerb'itecorcection 2l
NunTbel 1

Fig, 37. Conineroot spring.Duringconineroot movementintrusioncan be corriedout

simultoneously.

patients with deep overbite it is usually a mistake to level and extrude infra-
erupted canines. Many of these canines should be left in their original position
and the incisors should be intruded to their level.
Figs. 33 and 34 show a canine-intrusion spring which is aetivated.to produce
50 to 75 Gm. of force. It is fabricated from 0.018 by 0.025 ineh wire inserted into
the auxiliary tube of the first molar ancl into the vertical tube of a canine
bracket. Since the intrusive force lies lateral to the center of resistance of the
canine, it is necessaryto place a slight constrietive force in the spring to keep the
canine from flaring labially. To minimize the chance of producing an undesirable
moment in the canine tube, it is a good idea to round the wire in the portion of
the spring that is placed in the vertical tube of a canine. If the incisors have
already been intruded, it is necessaryto join them to the posterior segments by
an anteripr wire inserted in the auxiliary tubes of the premolars stepped either
occlusally or gingivally around the canine. This wire holds the incisors in place
and adds further anchorage for the intrusion of the canines.
If the auxiliary tube in the first molar is not available for an intrusive spring,
an 0.018 by 0.018 inch (0.457 by 0.457 mm.) spring can be constructed which
inserts into the auxiliary tube of the most anterior premolar (Figs. 35 and 36).
If no auxiliary tubes are available, a continuous segment from molar forward to
canine can be constructed of this design. The 0.018 by 0.018 inch (0.457 by 0.457
mm. ) intrusive spring is a modified rectangular ioop with helices placed mesial
to the brackets. This design reduces the load-deflection rate and, more important,
assures that as the spring works out a vertical force will be delivered without an
undesirable moment being produced on the canine. If a canine is flared, a moment
is produced which flares the canine more; hence, it is necessaryto tie the canine
back on both the buccal and lingual aspects.A buccal tie alone could cause the
canine to rotate with its distal aspect toward the lingual.
In addition to specialized.intrusive springs, separate canine intrusion can be
produced by canine-retraction assembliesor root springs. In Fig. 37 a root spring
is being used.to simultaneously retract the root and intrude the canine.
 Anx. J, Orthoil.
22 Burstone JulU L971

Summory

Not all patients with deep overbite should be treaterl with the same mechanics.
Some patients require intrusion of the anterior teeth, while others require pri-
marily extrusion. This article has discussed the principles of incisor and canine
intrusion and has demonstrated the use of intrusion springs that are capable of
intruding incisors with minimal side effects on the posierior teeth.
Six principles must be considered in incisor or canine intrusion: (1) the use
of optimal magnitudes of force and the delivery of this force constantly with low-
load-deflection springs; (2) the use of a single point contact in the anterior
region; (3) the careful selection of the point of force application with respect to
the center of resistance of the teeth to be intruded; (4) selective intrusion based
on anterior tooth geometry; (5) control over the reactive units by formation of
a posterior anchorage unit; and (6) inhibition of eruption of the posterior teeth
and avoidance of undesirable eruptive mechanics.

REFERENCES
1. Burstone, C. J.: Lip posture and its significance in treatmeut planning, AM. J. ORrHoD.
53t 262-2U, 7967.
2. Rurstone, C. J.: Segmenteclarch teehnique, syllabus, Inclianapolis, 1958, Indiana, University.
3. Burstone, C. J.: The rationale of the segmentedarch, Au. J. Onrnoo. 11: 805-8221 1962,
4. Burstone, C. {.: Mechanics of the segmenteil arch technique, Angle Orthotl. S6: 99-120,
1966.
5. Burstone, C. J., anrl Koenig, H. A.: Force systems from an icleal arch, AM. J. ORTHoD.65:
270-289,1974.
6. Dellinger, X. L.: A histologic anrl cephalometric i:rvestigation of premolar intrusion in the
Maaaca speaiosamonkey, Au. J. Onrnoo. 53: 325-355,1967.
7. Burstone, C. J.: Application of bioengineering to elinical orthoclontics, frn, Graber, T. M,
(editor) : Current orthotlontic concepts and techniques, eil, 2, Philaclelphia, 1975, W. R.
SaunilersCompany pp. 230-258.
8. Burstone, C. J., Baklwin, J. J., ancl Lawless, D. T,: The application of continuous forces
to orthoclontics,Angle Orthod.3l: 1-14,1961.

263 Xarmingtom Aae, (06032)