Journal of Oral Rehabilitation
Journal of Oral Rehabilitation 2014
Comparison of molar intrusion efficiency and bone density
by CT in patients with different vertical facial morphology
W.H. DING, W. LI, F. CHEN, J. F ZHANG, Y. LV, X.Y. CHEN, W.W. LIN, Z. FU &
J . J . S H I Department of Orthodontics, School of Stomatology affiliated to Medical College, Zhejiang University, Hangzhou City, China
SUMMARY The purpose of this study is to examine
the relationship between molar intrusion
efficiency and bone density in patients with
different vertical facial morphology. Thirty-six
female patients, with overerupted upper first
molars, were divided into two groups according to
mandiblular plane angle (FH-MP): hyperdivergent,
FH-MP>30° (G1), hypodivergent, FH-MP<22° (G2).
Mini-screw implants with elastic chains were used
to intrude upper first molars. Spiral CT was used
to measure the intrusion degree of upper first
molar and bone density, and molar intrusion
efficiency was calculated as amount/duration
(mm month 1). In addition, each tooth was
divided into three portions (cervical, furcation and
apical) to measure the bone density. It was found
in this study that treatment duration was 3
13 and
4
71 months in G1 and G2 and that the intrusion
Introduction
Overeruption of maxillary molars usually results from
early loss of antagonistic teeth. In addition, upper pos-
terior dental height is greater in patients with anterior
open bite than others (1). Molar intrusion with
implants becomes a good solution for patients with
overerupted maxillary molars and anterior open bite
(2–5). There have been many researches concerning
on molar intrusion with implant anchorage. The
results indicate that significant true intrusion of
molars could be obtained using implants as bony
anchorage. However, the distance and time of molar
intrusion are different in previous studies (6–8). Sher-
wood et al. (7) found that upper molar was intruded
by 4
1 mm in 6
5 month, while they indicated in
© 2014 John Wiley & Sons Ltd
efficiency was 1
57 and 0
81 in G1 and G2 with
significant difference (P < 0
05). There were
significant differences in cervical, furcation and
apical bone density between two groups (P < 0
05).
The bone density was significantly reduced after
molar intrusion. In addition, the bone density
change was greater in G1 than in G2 (P < 0
05). It
was concluded that molars were more easily to be
intruded in hyperdivergent than in hypodivergent
patients. The difference of bone density and bone
density changes during intrusion may account for
the variation of molar intrusion efficiency.
KEYWORDS: molar intrusion efficiency, bone density,
computed tomography, vertical facial morphology,
mandibular plane angle, bite force
Accepted for publication 16 November 2014
another study that molar was intruded 2 mm in
5
5 month. Furthermore, Park et al. (8) found molar
intrusion rate was 0
5–1 mm per month. Therefore,
molar intrusion efficiency varies in patients. However,
little was known about the factors related to molar
intrusion efficiency. It was suggested that bone struc-
ture and density have an influence on orthodontic
tooth movement (9). Thus, it is inferred that molar
intrusion efficiency is associated with bone quality
including bone structure and density. However, no
evidence shows definite relationship between bone
density and molar intrusion efficiency.
Facial morphology could be divided into three cate-
gories vertically according to mandibular plane angle:
short face, average face, and long face. There are soft
and hard tissue differences among these individuals,
doi: 10.1111/joor.12261
2 W . H . D I N G et al.
including anatomic feature of masticatory muscle,
alveolar bone thickness and teeth inclination etc. The
buccal and lingual cortical bone was thicker in short-
faced individuals than in average and long-faced
groups (10, 11). However, to our best knowledge, no
conclusion could be drawn on the relationship
between bone density and vertical facial morphology.
In addition, it is unknown whether intrusion effi-
ciency varies in patients with different vertical facial
morphology.
Several non-invasive methods can be used to mea-
sure the alveolar bone density, including digital image
analysis of microradiographs, dual energy X-ray
absorptiometry and ultrasound (12–15). However, all
of these approaches have inherent limitations, such as
non-availability of three-dimensional information and
the evaluation being only qualitative. The introduc-
tion of maxillofacial cone beam computed tomogra-
phy (CBCT) has made 3D imaging more readily
available for dental use. Though most CBCT devices
showed a good overall correlation with CT numbers,
large errors can be seen when using the grey values
in a quantitative way. Computed tomography values
(Hounsfield units: HU) and bone mineral density
(BMDs) obtained by medical CT were used to assess
the bone density of jaws. Within the range of CT val-
ues, the density of air was equal to 1000 HU, that of
water was 0 HU and that of mandibular cancellous
bone was from 500 to 850 HU in the posterior region
and more than 850 HU in the anterior region. There-
fore, medical CT was used to measure bone density in
this study. The purpose of this study is to compare
molar intrusion efficiency and bone density in
patients with different vertical facial morphology, and
explore the relationship of molar intrusion, bone den-
sity and facial morphology.
Materials and methods
Patient selection and molar intrusion
The present research has been conducted in full
accordance with ethical principles including the
World Medical Association Declaration of Helsinki.
This study was independently reviewed and approved
by local ethical committee of Zhejiang University
(Hangzhou, China). Written consent of each subject
was also obtained. A total of 40 consecutively finished
female adult patients (ages, 20–42 years; mean  s.d.,
28
93  7
55) from 2008 to 2012 with overerupted
upper first molars were selected in this study. They
were divided into two groups according to mandibular
plane angle: hyperdivergent, FH-MP>30° (G1), hypo-
divergent, FH-MP<22° (G2), every group has 20
patients. The inclusion criteria were as follows: no
patients <18 years old to minimise the effects of
growth; no bone metabolic disease; no previous
orthodontic treatment; no active periodontal disease
at the beginning of treatment; no metal crowns, den-
tal bridges and dental implants to avoid beam-harden-
ing effect; all female patients to minimise the effects
of sex differences. Mini-screw implants were placed
under local anaesthesia in buccal region between first
and second molars and palatal region between second
premolar and first molar (Fig. 1). Sufficient distance
was left between root apex and mini-screw implants
to avoid interference with the intended intrusive
tooth movement. After initial healing of soft tissue
around mini-screw implants in 2 weeks, intrusion
force of 100 g was applied with elastic chains (Fig. 1).
The duration of molar intrusion was recorded. We
found mini-screw implants loosened in two hyperdi-
vergent patients and two hypodivergent patients. The
four patients were excluded from this study; thus, 36
patients were included and every group had 18
patients. Eighteen hyperdivergent and 18 hypodiver-
gent adult female patients without molar intrusion
were selected as control groups.
Bone density measurement by CT
Before CT scanning, the patients were placed in a
lying position with the head horizontally positioned.
A multislice unit* was used, and helical scanning was
performed using a tube voltage of 120 kV and a tube
current of 200 mA. The occlusal plane of each patient
was set perpendicular to the floor base using ear rods.
Computed tomography images of 40 patients were
obtained before and after molar intrusion using the
same condition. Once collected, the CT raw data were
converted into DICOM format. This DICOM formatted
data was exported into Mimics 10.01 software† to
analyse and to determine bone density by grey scale
value (HU). Prior to measuring bone density, 3D
*GE Yokogama Medical System, Tokyo, Japan.
†
Materialise, Leuven, Belgium.
© 2014 John Wiley & Sons Ltd
 INTRUSION EFFICIENCY AND BONE DENSITY
(a)
Fig. 1. The intra-oral photos of the
mini-screw implants and intrusion
force applied. (a) The mini-screw
implant was placed in buccal region
between upper first and second
molars. (b) The mini-screw implant
was placed in palatal region
between upper first molar and
second premolar.
model was resliced to obtain new CT slices of teeth
that were perpendicular to the longitudinal axes of
teeth using the ‘reslice’ function in the software pro-
gram. The slice number was set as 3 (Fig. 2). Bone
density around the teeth was assessed at three levels:
cervical, furcation and apical portions (Fig. 3). The
cervical portion was set as parallel to alveolar crest.
The furcation portion was set as 1 mm above the root
furcation, and the apical portion was set as parallel to
buccal root apex. Before measuring bone density, the
following steps (Fig. 4) were executed: (i) segmenting
the area of tooth from the CT image using threshold
value of cementum; (ii) expanding by one voxel to
include PDL using the morphology operation; (iii)
expanding by a further three voxel to include sur-
rounding bone using the morphology operation; (iv)
subtracting tooth and PDL from tooth, PDL and sur-
rounding bone. The volumes of the areas and their
density values are also demonstrated (Fig. 4).
Molar intrusion efficiency measurement
The axial images of CT were imported into Mimics
10.01 software†. A 3D virtual model was created.
Using axial, coronal and sagittal views, the midsagittal
plane of the model was oriented vertically, the trans-
porionic line was oriented horizontally and the Frank-
fort horizontal plane (FH plane) was oriented
horizontally. The measurement of molar position
(DB-FH: distal buccal cusp-FH plane and MB-FH:
mesial buccal cusp-FH plane) was shown in Fig. 5.
The amount of molar intrusion was calculated as the
difference of (DB-FH+MB-FH)/2 before and after
intrusion, and the intrusion efficiency was calculated
as amount/duration (mm month 1).
Measurement reliability
For the evaluation of the intra-examiner error, the
grey scale value and pre-treatment molar position
© 2014 John Wiley & Sons Ltd
3
(b)
measurement procedure were repeated by the same
person 4 weeks later. The method error was calcu-
lated from the equation: Sx = √∑D2/2N, where Sx is
the error of the measurement, D is the difference
between duplicated measurements and N is the num-
ber of double measurements (16). The errors of the
measurements were 0
11 mm and 29
35 Hu, respec-
tively. The reliability coefficients were 0
91 and 0
88,
respectively.
Statistical analysis
All statistical analyses were performed using SPSS
software packages (SPSS for windows XP, version
13.0‡). The mean and s.d. for each value were deter-
mined. Independent and paired t-tests were used to
determine the statistical significance of the value in
two groups. The statistical significance was deter-
mined at 0
05 levels of confidence.
Results
Comparison of molar intrusion efficiency in hyperdivergent
and hypodivergent patients
The maxillary first molars were successfully intruded
in all the patients according to their clinical needs.
Mean molar intrusion was 4
57 and 3
64 mm in G1
and G2 with no significant difference (P > 0
05).
Mean treatment duration was 3
13 and 4
71 months
in G1 and G2 with significant difference (Table 1)
(P < 0
05). In addition, the intrusion efficiency was
1
57 and 0
81 mm in G1 and G2 with significant dif-
ference (P < 0
05), which means upper molars was
more easily intruded in hyperdivergent patients than
in hypodivergent patients.
‡
SPSS, Chicago, IL, USA.
4 W . H . D I N G et al.
Pre-treatment and post-treatment bone density in
hyperdivergent and hypodivergent patients
The pre-treatment and post-treatment bone density of
three portions including cervical, furcation and apical
were calculated (Table 2). There were significant
differences in cervical, furcation, apical bone density
of pre-treatment and post-treatment between G1 and
G2 (P < 0
05). Bone density is lower in hyperdiver-
gent patients than in hypodivergent patients, which
means bone density is associated with vertical facial
morphology.
Fig. 2. Prior to measuring bone
density, 3D model was resliced to
obtain new CT slices of teeth that
were perpendicular to the
longitudinal axes of teeth using the
‘reslice’ function in the software
program. The slice number was set
as 3.
Fig. 3. The bone density was
assessed at three levels: cervical,
furcation and apical portions. The
cervical portion was set as parallel
to alveolar crest. The furcation
portion was set as 1 mm above the
root furcation, and apical portion
was set as parallel to buccal root
apex.
Bone density change in hyperdivergent and hypodivergent
patients
The bone density of three portions was significantly
reduced after intrusion both in G1 and G2 (P < 0
05).
Significant difference was found in the bone density
change between patients with molar intrusion and
without molar intrusion (Table 3) (P < 0
05). In addi-
tion, the reduction of bone density was greater in G1
than in G2 (Table 2) (P < 0
05), which means bone
density change is also associated with vertical facial
morphology.
© 2014 John Wiley & Sons Ltd
 INTRUSION EFFICIENCY AND BONE DENSITY 5

(a) (b)

Fig. 4. The bone density

measurement. (a) segmenting the
(c) (d)
area of the tooth from the CT image
using the threshold value of the
cementum; (b) expanding by one
voxel to include the PDL using the
morphology operation; (c)
expanding by a further three voxel
to include the surrounding bone
using the morphology operation; (d)
subtracting the tooth and PDL from
the tooth, PDL and surrounding
bone. The volumes of the areas and
their density values are also
demonstrated.

(a) (b)

Fig. 5. The measurement of molar

position. The measurement of molar
position was defined as DB-FH:
distal buccal cusp-FH plane and
MB-FH: mesial buccal cusp-FH
plane. (a) The frontal view of molar
position measurement. (b) The
lateral view of molar position
measurement.

was no study concerning on the factors affecting molar

Discussion
It is observed in this study, absolute molar intrusion,
ranged from 2 to 6 mm, could be achieved by mini-
screw implants. There was no significant difference
in the amount of molar intrusion among patients of
different vertical morphology. However, significant
difference was found in duration and efficiency of
molar intrusion between hyperdivergent and hypodi-
vergent patients. To the best of our knowledge, there
intrusion efficiency. Previous study has found that
complex relationship exists between structures of the
mandibular body and facial types (11). However, no
research has been studying the relationship between
facial type and bone density. Therefore, the purpose of
this study is to explore the relationship of molar intru-
sion efficiency, bone density and facial type.
Clinical application of CBCT in the field of dento-
maxillofacial radiology is gaining importance and

© 2014 John Wiley & Sons Ltd

6 W . H . D I N G et al.

Table 1. The amount, duration and efficiency of molar intrusion

Hyperdivergent Hypodivergent
Sample numbers
18 patients per group Mean SD Mean SD P Significance

Intrusion (mm) 4
57 0
98 3
64 1
25 0
147 NS

Duration (month) 3
13 0
90 4
71 1
50 0
033*
Efficiency (mm month 1) 1
57 0
51 0
81 0
21 0
003*

NS, not significance.

*P < 0
05.

Table 2. Bone density (HU) of pre-treatment and post-treatment and the bone density change of two groups

Hyperdivergent Hypodivergent
Sample numbers
18 patients per group Mean SD Mean SD P Significance

Pre-treatment
Cervical 367
55 51
24 500
40 56
54 0
013*
Furcation 503
16 56
42 626
53 48
17 0
016*
Apical 262
45 33
69 337
70 43
84 0
035*
Post-treatment
Cervical 299
58 52
44 453
10 55
29 0
007*
Furcation 431
33 58
71 582
99 57
95 0
010*
Apical 214
45 33
04 284
95 46
31 0
048*
Change
Cervical 67
98 8
88 47
30 6
92 0
010*
Furcation 71
83 12
63 43
54 10
56 0
014*
Apical 48
00 8
10 52
75 14
10 0
580 NS

NS, not significance.

*P < 0
05.

spreading widely. However, CBCT data have a larger
amount of scattered X-rays than conventional spiral
CT. This may enhance the noise in reconstructed
images and thus affect the low contrast detectability
(17). Because of scatter and artefacts, HU values in
CBCT are not valid, and therefore, the method of cor-
relating BMD to HU values from CBCT is not ideal.
Moreover, the scatter and artefacts in CBCT get worse
around inhomogenous tissues with reduced HU values
up to 200 HU (18), which confirms that the HU in
CBCT is not a valid method for bone density assess-
ment. Therefore, medical CT was used to measure
bone density in this study.
Bone density of cervical, furcation and apical parts
of upper first molars was lower in hyperdivergent
patients than in hypodivergent patients. The results
provide evidence that bone density is associated with
vertical facial type. Furthermore, it was found in this
study that molar intrusion efficiency was greater in
hyperdivergent than in hypodivergent patients, which
is consistent with the results of bone density. There
were no differences of age, sex and orthodontic force
in the two groups, which might affect orthodontic
tooth movement (19, 20). Therefore, it is indicated
that the difference of bone density account for the
distinct molar intrusion efficiency. What is the cause
of difference of bone density in patients with various
vertical skeletal facial type? Tsunori et al. (21) found
that complex relationship exists between the structure
of mandible body and facial type. The buccal and
lingual cortical bone was thicker in short-faced indi-
viduals than in average and long-faced groups. Fur-
thermore, the mandible is short, wide, strong and
square in short-face pattern. The difference of mandi-
ble shape and structure may result from the bite force
or masticatory function caused by masticatory muscle.
Kubotga measured bone mineral content in the first
molar of mandible using dental radiographs and
reported that the density was higher in molars with a
stronger bite force (22). Van Limborgh classified the

© 2014 John Wiley & Sons Ltd

 INTRUSION EFFICIENCY AND BONE DENSITY 7

Table 3. The bone density change (HU) in intrusion or non-intrusion groups (control group)

Intrusion Non-intrusion
Bone density change
18 patients per group Mean SD Mean SD P

Hyperdivergent
Cervical 67
98 8
88 4
15 19
90 0
001*
Furcation 71
83 12
63 5
35 15
38 0
001*
Apical 48
00 8
10 7
08 14
40 0
003*
Hypodivergent
Cervical 47
30 6
92 10
35 10
74 0
001*
Furcation 43
54 10
56 14
73 19
55 0
002*
Apical 52
75 14
10 1
35 13
43 0
001*

*P < 0
05.

various factors involved in the growth and develop-
ment of bones into genetic factors and showed that
they interact (23). Jawbones receive physical stimula-
tion from biting and chewing throughout life.
Mechanical stress applied to bone influences bone
volume and structure by controlling bone remodel-
ling, and it is generally agreed that application of
mechanical stress to bone is necessary to maintain
bone volume and structure. Sato et al. (24) found that
bone density in cancellous bone was reduced by
38
1% in the root apex and 16
7% on the lingual side
as a result of lost masticatory function. Therefore, the
different bite force caused by masticatory muscle may
account for the variance of bone density in patients
with distinct vertical facial type.
Some studies have focused on the bone response to
orthodontic tooth movement in animals and found
bone fraction and mineral density are reduced during
tooth movement using histomorphometric methods.
Hus et al. (25) found in a clinical study that bone den-
sity around teeth reduced significantly after applica-
tion of orthodontic forces 7 months. In this study, we
found that bone density was reduced in the cervical,
furcation and apical region of upper first molar after
intrusion movement. The intrusion force was trans-
ferred from teeth to periodontal ligament and alveolar
bones, and many layers of networked reaction were
involved in the transduction of mechanical force into
molecular events (signal transduction) and orthodon-
tic tooth movement (26). Orthodontic tooth move-
ment is associated with bone remodelling, which
consists of bone resorption and apposition, induced
by osteoclasts and osteoblasts. It was found in this
study that bone density were greatly reduced in hy-
perdivergent patients, which was most likely due to
the differences in periodontal ligament and bone cell
populations, genomes, and protein expression pat-
terns. Furthermore, bone metabolism may be faster
in hyperdivergent patients than in hypodivergent
patients, and the difference of activity and number of
osteoclasts may account for the variation in bone
density change (27). This could also account for the
difference of molar intrusion efficiency in hyperdiver-
gent patients and hypodivergent patients.
Some limitation of this study should be considered.
First, the bone density measurement was only limited
in upper first molar. The further study will explore
the bone density of entire region of jawbone includ-
ing maxilla and mandible. Second, only 20 patients
were included in every group;thus, further study will
expand the patient samples and male patients will be
included.
Conclusions
Absolute molar intrusion could be achieved by mini-
screw implant in patients with different mandibular
plane angle. The molars were more easily to intrude
in hyperdivergent than in hypodivergent patients.
The difference of bone density and bone density
change during intrusion may account for the varia-
tion of molar intrusion efficiency. The bite force
caused by masticatory muscle may account for the
difference of bone density in patients with distinct
vertical facial type.
Acknowledgment
This study was sponsored by Medical Science and
Technology Fund of Zhejiang Province, PR China

© 2014 John Wiley & Sons Ltd

8 W . H . D I N G et al.
(2013KYA118) and Technological Research for Public
Welfare and Social Development Project of Science
and Technology Agency of Zhejiang Province, PR
China (2013C33154) and National Natural Science
Foundation of China (2013 81301669).
Disclosure
No conflict of interests declared.
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Correspondence: Jiejun Shi, Department of Orthodontics, School of
Stomatology affiliated to Medical College, Zhejiang University,
Hangzhou City 310006, China. E-mail: sjiejun2013@163.com
© 2014 John Wiley & Sons Ltd