THE KOREAN JOURNAL of

Original Article ORTHODONTICS

pISSN 2234-7518 • eISSN 2005-372X

https://doi.org/10.4041/kjod.2018.48.6.367

Evaluation of changes in the maxillary alveolar

bone after incisor intrusion

Ezgi Atik Objective: This study was performed to investigate the changes in alveolar bone
Hande Gorucu-Coskuner after maxillary incisor intrusion and to determine the related factors in deep-bite
Bengisu Akarsu-Guven patients. Methods: Fifty maxillary central incisors of 25 patients were evaluated
Tulin Taner retrospectively. The maxillary incisors in Group I (12 patients; mean age, 16.51 ±
1.32 years) were intruded with a base-arch, while those in Group II (13 patients;
mean age, 17.47 ± 2.71 years) were intruded with miniscrews. Changes in the
alveolar envelope were assessed using pre-intrusion and post-intrusion cone-
beam computed tomography images. Labial, palatal, and total bone thicknesses
Department of Orthodontics, Faculty were evaluated at the crestal (3 mm), midroot (6 mm), and apical (9 mm)
of Dentistry, Hacettepe University,
levels. Buccal and palatal alveolar crestal height, buccal bone height, and the
Ankara, Turkey
prevalence of dehiscence were evaluated. Two-way repeated measure ANOVA
was used to determine the significance of the changes. Pearson’s correlation
coefficient analysis was performed to assess the relationship between dental
and alveolar bone measurement changes. Results: Upper incisor inclination and
intrusion changes were significantly greater in Group II than in Group I. With
treatment, the alveolar bone thickness at the labial bone thickness (LBT, 3 and 6
mm) decreased significantly in Group II (p < 0.001) as compared to Group I. The
LBT change at 3 mm was strongly and positively correlated with the amount of
upper incisor intrusion (r = 0.539; p = 0.005). Conclusions: Change in the labial
inclination and the amount of intrusion should be considered during upper
incisor intrusion, as these factors increase the risk of alveolar bone loss.
[Korean J Orthod 2018;48(6):367-376]

Key words: Alveolar bone change, Cone-beam computed tomography, Intrusion,

Maxillary incisor

Received January 29, 2018; Revised March 12, 2018; Accepted April 21, 2018.

Corresponding author: Ezgi Atik.

Assistant Professor, Department of Orthodontics, Faculty of Dentistry, Hacettepe
University, Sihhiye 06100, Ankara, Turkey.
Tel +90-312-3052290 e-mail ezgibaytorun@hotmail.com

How to cite this article: Atik E, Gorucu-Coskuner H, Akarsu-Guven B, Taner T.

Evaluation of changes in the maxillary alveolar bone after incisor intrusion. Korean J
Orthod 2018;48:367-376.

© 2018 The Korean Association of Orthodontists.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License
(http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and
reproduction in any medium, provided the original work is properly cited.

367
 Atik et al • Intrusion and alveolar bone

INTRODUCTION MATERIALS AND METHODS

The bone morphology of the patient and the biome- This retrospective study was approved by the Ethics
chanics used during treatment are important factors that Committee of Hacettepe University, with institutional
must be taken into account before orthodontic treat- review board number GO 17/13-11. The present study
ment.1 If there is an imbalance between the resorption included patients’ CBCT images obtained between 2010
and apposition of the alveolar bone during orthodontic and 2011 for a previous study, which had been con-
tooth movement, the tooth will move out of the alveolar ducted prospectively to evaluate the skeletal and dental
envelope in a “through-the-bone” manner.2 Therefore, effects, treatment period, and amount of root resorption
orthodontic forces can lead to different tissue responses, observed when 4 maxillary incisors were intruded with
such as alveolar bone loss, gingival inflammation, root miniscrew or base-arch approaches.18
resorption, and pulpal reactions.3,4 In that previous study, the patients had been random-
Anterior deep-bite is a common complaint among ly assigned to either of the 2 treatment modalities. The
orthodontic patients. The main treatment steps of ante- sample size for the present study was calculated based
rior deep-bite and retroclined maxillary incisors involve on a significance level of 0.05 and a power of 80% to
incisor protrusion and intrusion mechanics. Intrusion detect a significant difference of 0.78 mm with standard
of the maxillary incisors is particularly indicated in pa- deviation of 0.72, according to the results of another
tients with excessive incisor and gingival display.5,6 An study19 that evaluated changes in alveolar bone width.
intrusive force would also tip the incisor teeth labially, The power analysis showed that the minimum sample
because of the position of the force vector according to size should be 11 in each group.
the center of resistance of the incisors.7 The effects of The CBCT images were selected from the database
both intrusion and protrusion movements on the alveo- of the department according to the following inclusion
lar bone surrounding the incisors have previously been criteria: (1) post-adolescent patients (older 15 years); (2)
evaluated. Steiner et al. 8 and Batenhorst et al. 9 have anterior deep-bite ≥ 4 mm; (3) Class II or Class I maloc-
experimentally demonstrated that marginal bone loss is clusion (2o < ANB < 6o) with a hypodivergent growth
associated with incisor proclination. Thongudomporn et pattern (sella-nasion-mandibular plane < 32o); (4) no
al.10 investigated maxillary alveolar bone thickness after history of trauma to the maxillary anterior teeth; (5) a
maxillary incisor proclination and extrusion, and found treatment plan including the intrusion of the maxil-
statistically significant decreases in the palatal and total lary incisors for correcting deep-bite malocclusion, by
bone thickness at the mid and apical levels of the root. means of either conventional mechanics (base-arch) or
Additionally, a recent study11 revealed that alveolar bone miniscrews; (6) no evidence of periodontal or gingival
height and thickness decreased in response to different problems at the start of orthodontic treatment; (7) CBCT
intrusion mechanics. Orthodontists may be unaware of scans available at the pre-intrusion phase (T0) as well as
the detrimental effects of the tooth movement, such as after achieving normal overbite (T1).
irreversible hard tissue changes, since the clinical ob- CBCT scans had been acquired previously, using an
servations may not reflect the underlying periodontal Iluma CBCT Scanner (3M IMTEC, Ardmore, OK, USA),
structures.12 with a voxel size of 0.3 mm at 3.8 mA, and 120 kVp.
Because of the limitations of two-dimensional lateral The data were recorded in Digital Imaging and Commu-
cephalograms in terms of investigating alveolar bone nication in Medicine & Management Solutions format
changes, particularly in the anterior region,13,14 cone- and were evaluated using Dolphin 3D Imaging software
beam computed tomography (CBCT) is the preferred tool v. 11.5 (Dolphin Imaging, Chatsworth, CA, USA).
for evaluating the alveolar bone qualitatively and quanti- Group I consisted of the CBCT images of 12 patients
tatively.15-17 To our knowledge, only one previous study11 (8 female, 4 male) with a mean age of 16.51 ± 1.32
has used CBCT to evaluate changes in the alveolar bone years, while Group II consisted of the CBCT images of
after incisor intrusion using 2 different segmented arches. 13 patients (6 female, 7 male) with a mean age of 17.47
Given this lack of information, the primary purpose of ± 2.71 years. These patients had been treated previ-
the present study was to evaluate the effect of maxillary ously with the 0.018-inch Roth prescription preadjusted
incisor intrusion on alveolar bone height and thickness, brackets (Dentsply Sirona, York, PA, USA), applied to
using CBCT scans. The secondary purpose of the study the maxillary central and lateral incisors, in combination
was to investigate dehiscence around the maxillary cen- with intrusion mechanics. Intrusion was started when
tral incisors. The null hypothesis was that there would leveling and alignment of the 4 maxillary incisors were
be no significant difference in terms of alveolar bone completed with 0.016 and 0.016 × 0.016-inch nitinol
changes between the use of base-arch and of miniscrew arch-wires. In Group I, the 0.017 × 0.025-inch titanium
intrusion mechanics. molybdenum alloy Burstone-base-arch was applied to

368 https://doi.org/10.4041/kjod.2018.48.6.367 www.e-kjo.org

Atik et al • Intrusion and alveolar bone

the maxillary incisors on a 0.016 × 0.016-inch segmen- measured to calculate the rate of incisor intrusion and
tal stainless steel arch-wire and the arch was inserted proclination, respectively. The labial, palatal, and total
into the molar tubes with a gable-bend at the posterior alveolar bone thicknesses for each maxillary central inci-
segment with cinching-back. The active anterior part of sor were measured in 3 slices, separated by 3 mm, at the
the base-arch was adjusted to apply 100 g, as measured widest point of the labiopalatal root along the long axis
with a force gauge, and was connected to the anterior from the cementoenamel junction (CEJ). These measure-
region between the lateral and central incisors bilaterally. ments were defined as the labial bone thickness (LBT 3,
In Group II, 1.4-mm diameter and 8-mm length mini- LBT 6, and LBT 9 mm), palatal bone thickness (PBT 3,
screws (DEWIMED; Medizintechnik GmbH, Tuttlingen,
Germany) were inserted, using a self-drilling method,
between the central and lateral incisors, bilaterally. An Axial slice
intrusion force was obtained by using nickel-titanium
(Ni-Ti) coil springs from the segmental 0.016 × 0.016-
inch stainless steel arch-wire to the miniscrews. In both
treatment groups, a total of 100 g intrusion force (50 g LBT 1.9 mm

to the right and 50 g to the left segment) was applied TBT

between the central and lateral incisors. Reactivations 9.3 mm

were applied every 4 weeks until adequate overbite was

1.6 mm
achieved. PBT
T0 and T1 CBCT images were used to evaluate chang-
es in the alveolar bone of 50 maxillary central incisors (26
teeth from Group I and 24 teeth from Group II). The in-
trusion duration was 0.39 ± 0.10 years for Group I, and
0.37 ± 0.07 years for Group II. The T1 CBCT was taken
at a minimum of 6 months after the T0 CBCT.
The perpendicular distance from the incisal edge of Figure 1. Location of alveolar bone thickness measurements.
the maxillary central incisor to the palatal plane (PP) LBT, Labial bone thickness; TBT, total bone thicknesses;
and the maxillary incisor inclination to the PP were PBT, palatal bone thickness.

Figure 2. Orientation of all 3 planes of space on cone-beam computed tomography.

www.e-kjo.org https://doi.org/10.4041/kjod.2018.48.6.367 369

 Atik et al • Intrusion and alveolar bone

PBT 6, and PBT 9 mm), and total bone thickness (TBT Sagittal slice
3, TBT 6, and TBT 9 mm) (Figure 1). The alveolar thick-
ness of each side and the level of the maxillary right and
left incisors were averaged to obtain the mean thickness.
The measurements were made by two authors (E.A. and
H.G.C.) in a sectional slice of 0.5-mm thickness (Figure
2), in a darkened room, according to the protocol of Ti-
mock et al.12
When the distance from the CEJ to the bone crest was
greater than 2 mm, an alveolar bone defect was record- PACH 1.8 mm BACH
ed, and it was classified as alveolar bone dehiscence.20 1.8 mm

The prevalence of dehiscence in each treatment group

for each incisor was carefully observed by two examiners 13.1 mm

(E.A. and H.G.C.). BBH

On the sagittal-cross section of the maxillary incisors,
labial and palatal aspects were measured as the distance
from the most apical portion of the CEJ to the most
coronal portion of the marginal alveolar bone crest, de- Figure 3. Location of alveolar bone height measurements.
fined as the buccal alveolar crestal height (BACH) and PACH, Palatal alveolar crestal height; BACH, buccal
the palatal alveolar crestal height (PACH), respectively. alveolar crestal height; BBH, buccal bone height.
Buccal bone height (BBH) measurements were defined
as the linear distance between the most incisal point of

A C

Figure 4. Cone-beam com-

puted tomography images of
a representative case. A, B,
B D Pretreat­ment. C, D, Post-treat­
ment.

370 https://doi.org/10.4041/kjod.2018.48.6.367 www.e-kjo.org

Atik et al • Intrusion and alveolar bone

the tooth’s crown to the buccal alveolar crest along the were significantly greater than those observed in Group
long axis of the tooth (Figure 3). Pre- and post-treat- I (both p < 0.05). In Group I, LBT at 9 mm significantly
ment CBCT images of a representative case from Group increased with treatment (0.48 ± 0.17; p = 0.009); how-
II are shown in Figure 4. ever, this increase did not differ from that seen in Group
II. The TBT values did not show significant changes in
Statistical analysis either of the groups after treatment (Table 2).
Statistical calculations were performed with IBM-SPSS
for Windows software, version 21 (IBM Co., Armonk, Bone height measurements
NY, USA). Independent t -tests were used to evaluate the BACH and BBH significantly increased in Group II
demographic differences (age and intrusion duration) from T0 to T1 (5.77 ± 0.62 and 5.92 ± 0.57 mm, respec-
between the groups. Wilcoxon’s signed-rank test was tively; both p < 0.001) and these changes were signifi-
used to compare the initial (T0) measurements between cantly greater in Group II than in Group I (both p < 0.05).
the groups. Statistical comparison of alveolar thickness Changes in PACH measurement were not significant in
and heights in the different groups were conducted us- the treatment groups, and no differences were found in
ing two-way repeated-measures ANOVA. Bonferroni these changes between the groups (Table 2).
adjustment was applied to avoid Type I error due to
multiple testing. Statistical significance level was set at Prevalence of dehiscence
p < 0.05. The prevalence of dehiscence was defined as The frequency of dehiscence around the maxillary
frequency-%. Pearson’s correlation coefficient analysis incisors is shown in Table 3. Twenty-four maxillary inci-
was used to assess the relationship between the dental sors from Group I and twenty-six maxillary incisors from
and alveolar measurement changes. Group II were evaluated. The prevalence of dehiscence at
To evaluate reproducibility, 25 teeth from the total T1 (with no dehiscence at T0) for the maxillary right and
sample were randomly selected for remeasurements at left central incisors were, respectively, 16.7% and 25% in
T0 and T1 at an interval of 30 days. The intraclass cor-
relation coefficients were between 0.756 and 0.981.
Table 1. Comparison of initial measurements between the
RESULTS groups
Variable Group I Group II p -value
The pretreatment group differences are presented in
Table 1. The two groups were generally similar at T0, U1-PP (o) 101.04 ± 1.92 94.47 ± 1.85 0.022*
and there were no statistically significant differences be- U1-PP (mm) 29.06 ± 0.84 29.14 ± 0.80 0.948
tween the groups, except for upper central incisor (U1)- LBT-3 (mm) 1.15 ± 0.07 1.23 ± 0.027 0.414
palatal plane (PP)o (p = 0.022), and PBT-3 mm (p = LBT-6 (mm) 0.81 ± 0.09 0.69 ± 0.09 0.357
0.033) (Table 1).
LBT-9 (mm) 0.56 ± 0.10 0.62 ± 0.10 0.669
Dental and alveolar bone changes between T0 and T1
and comparison of these changes between the groups PBT-3 (mm) 2.34 ± 0.14 1.90 ± 0.14 0.033*
are presented in Table 2. PBT-6 (mm) 3.85 ± 0.35 3.33 ± 0.33 0.282
PBT-9 (mm) 5.97 ± 0.50 4.94 ± 0.48 0.153
Dental measurements
TBT-3 (mm) 9.37 ± 0.23 9.17 ± 0.22 0.533
Overbite significantly decreased with treatment in both
groups (p < 0.05). The upper incisor inclination in rela- TBT-6 (mm) 10.40 ± 0.41 9.94 ± 0.39 0.426
tion to the palatal plane (U1-PPo) significantly increased TBT-9 (mm) 11.38 ± 0.51 10.77 ± 0.49 0.397
with treatment in both groups (p < 0.05). There was a BACH (mm) 1.74 ± 0.11 1.66 ± 0.11 0.604
statistically significant decrease in the U1 to PP distance PACH (mm) 1.55 ± 0.15 1.82 ± 0.15 0.213
in Groups I and II of −2.58 mm and −3.40 mm, respec-
BBH (mm) 13.44 ± 0.26 13.02 ± 0.25 0.241
tively (p < 0.05). The treatment-induced increase in U1-
PPo and the decrease in U1-PP distance measurements Values are presented as mean ± standard deviation.
were significantly greater in Group II than in Group I (p Group I, Intrusion with a base arch; Group II, intrusion with
miniscrews; U1, upper central incisor; PP, palatal plane; LBT,
< 0.05) (Table 2).
labial bone thickness; PBT, palatal bone thickness; TBT, total
bone thickness; BACH, buccal alveolar crestal height; PACH,
Bone thickness measurements palatal alveolar crestal height; BBH, buccal bone height.
LBT at 3 mm and 6 mm decreased significantly in The p -value was analyzed by Wilcoxon test, comparison
Group II from T0 to T1 (−1.12 ± 0.12 and −0.47 ± 0.09 of pre-treatment measurements between the groups; the
mm, respectively; both p < 0.001) and the decreases significance level was *p < 0.05.

www.e-kjo.org https://doi.org/10.4041/kjod.2018.48.6.367 371

 Atik et al • Intrusion and alveolar bone

Table 2. Pre- (T0) and post-intrusion (T1) dental and alveolar measurements and comparison of changes during
treatment in each group
Variable T0 T1 p -valuea Change p -valueb
Overbite (mm) Group I 4.7 (4.1 to 6.7) 0.9 (0.0 to 2.2) 0.002* −3.8 (−4.5 to 2.6) 0.270
Group II 5.4 (4.2 to 8.2) 0.9 (0.0 to 2.5) < 0.001* −4.5 (−8.2 to 2.1)
U1-PP (o) Group I 101.04 ± 1.92 111.32 ± 1.99 < 0.001* 10.28 ± 2.03 0.008*
Group II 94.47 ± 1.85 112.86 ± 1.92 < 0.001* 18.39 ± 1.95
U1-PP (mm) Group I 29.06 ± 0.84 26.49 ± 0.80 < 0.001* −2.58 ± 0.94 0.039*
Group II 29.14 ± 0.80 25.74 ± 0.77 < 0.001* −3.40 ± 0.26
LBT-3 (mm) Group I 1.15 ± 0.07 0.97 ± 0.12 0.181 −0.18 ± 0.13 0.000*
Group II 1.23 ± 0.027 0.11 ± 0.12 < 0.001* −1.12 ± 0.12
LBT-6 (mm) Group I 0.81 ± 0.09 0.73 ± 0.10 0.396 −0.08 ± 0.10 0.008*
Group II 0.69 ± 0.09 0.22 ± 0.10 < 0.001* −0.47 ± 0.09
LBT-9 (mm) Group I 0.56 ± 0.10 1.05 ± 0.19 0.009* 0.48 ± 0.17 0.280
Group II 0.62 ± 0.10 0.85 ± 0.18 0.184 0.22 ± 0.16
PBT-3 (mm) Group I 2.34 ± 0.14 2.25 ± 0.27 0.685 −0.00 ± 0.22 0.038*
Group II 1.90 ± 0.14 2.49 ± 0.26 0.011* 0.59 ± 0.21
PBT-6 (mm) Group I 3.85 ± 0.35 3.93 ± 0.31 0.817 0.07 ± 0.30 0.726
Group II 3.33 ± 0.33 3.55 ± 0.30 0.458 0.22 ± 0.29
PBT-9 (mm) Group I 5.97 ± 0.50 5.58 ± 0.41 0.317 −0.40 ± 0.39 0.810
Group II 4.94 ± 0.48 4.68 ± 0.39 0.482 −0.27 ± 0.37
TBT-3 (mm) Group I 9.37 ± 0.23 9.45 ± 0.31 0.739 0.08 ± 0.22 0.735
Group II 9.17 ± 0.22 9.14 ± 0.30 0.877 −0.03 ± 0.021
TBT-6 (mm) Group I 10.40 ± 0.41 10.11 ± 0.41 0.284 −0.29 ± 0.26 0.974
Group II 9.94 ± 0.39 9.64 ± 0.39 0.246 −0.30 ± 0.26
TBT-9 (mm) Group I 11.38 ± 0.51 10.88 ± 0.44 0.114 −0.50 ± 0.31 0.965
Group II 10.77 ± 0.49 10.25 ± 0.42 0.089 −0.52 ± 0.30
BACH (mm) Group I 1.74 ± 0.11 2.17 ± 0.68 0.508 0.43 ± 0.65 0.000*
Group II 1.66 ± 0.11 7.43 ± 0.65 0.000* 5.77 ± 0.62
PACH (mm) Group I 1.55 ± 0.15 1.52 ± 0.17 0.838 −0.03 ± 0.12 0.742
Group II 1.82 ± 0.15 1.85 ± 0.16 0.793 0.03 ± 0.12
BBH (mm) Group I 13.44 ± 0.26 13.78 ± 0.68 0.572 0.34 ± 0.59 0.000*
Group II 13.02 ± 0.25 18.93 ± 0.66 0.000* 5.92 ± 0.57
Values are presented as median (range) or mean ± standard deviation.
Group I, Intrusion with a base arch; Group II, intrusion with miniscrews; U1, upper central incisor; PP, palatal plane; LBT,
labial bone thickness; PBT, palatal bone thickness; TBT, total bone thickness; BACH, buccal alveolar crestal height; PACH,
palatal alveolar crestal height; BBH, buccal bone height.
a
Comparison of pre-treatment and post-treatment measurements within groups and bcomparison between groups; the
significance level was *p < 0.05; two-way repeated-measure ANOVA, Bonferroni correction for subgroups.

Group I and 100% and 84.6% in Group II. In Group II, p = 0.005). The change in TBT at 9 mm was negatively
only 1 tooth showed dehiscence at both T0 and T1. correlated with the change in the upper incisor inclina-
Correlation coefficients (r) between dental alveolar tion (r = −0.436; p = 0.029) and with the initial TBT at
changes/initial bone thickness and alveolar bone mea- 9 mm (r = −0.507, p = 0.010).
surement changes are presented in Table 4. The LBT
change at 3 mm was strongly and positively correlated
with the amount of upper incisor intrusion (r = 0.539;

372 https://doi.org/10.4041/kjod.2018.48.6.367 www.e-kjo.org

Atik et al • Intrusion and alveolar bone

Table 3. Dehiscence distribution (frequency-%) in Group I and Group II

Side Absence of dehiscence at Presence of dehiscence at
Dehiscence Group (number of teeth) T0, number of teeth (%) T1, number of teeth (%)
Absence of dehiscence at T0 Group I Right (12) 10 (83.3) 2 (16.7)
Left (12) 9 (75.0) 3 (25.0)
Group II Right (13) 0 13 (100)
Left (13) 1 (7.7) 11 (84.6)
Presence of dehiscence at T1 Group I Right (12) 0 0
Left (12) 0 0
Group II Right (13) 0 0
Left (13) 0 1 (7.7)
Group I, Intrusion with a base arch; Group II, intrusion with miniscrews; T0, pre-intrusion; T1, post-intrusion.

Table 4. Correlation between dental and alveolar bone measurement changes

Variable LBT-3 (mm) D TBT-9 (mm) D BACH D
U1-PP (mm) D 0.539 (0.005*) −0.199 (0.339) −0.312 (0.129)
U1-PP (o) D −0.396 (0.050) −0.436 (0.029*) 0.209 (0.315)
a
LBT-3 (mm) T0 −0.382 (0.059) × –
TBT-9 (mm) T0a × −0.507 (0.010*) –
Values are presented as r (p ) value.
LBT, Labial bone thickness; TBT, total bone thicknesses; BACH, buccal alveolar crestal height; U1, upper central incisor; PP,
palatal plane.
a
Pearson correlation coefficient analysis; the significance level was *p < 0.05.

DISCUSSION in limiting the excessive labial tipping of the anterior

teeth. However, in the miniscrew group, segmental arch-
In orthodontics, the main treatment goals are to wire, including only the 4 maxillary incisors, was used,
maximize the desired tooth movement and to minimize which may be the reason for the greater labial tipping
the undesirable side effects on the periodontal struc- of incisors in the miniscrew group. The biomechanical
ture surrounding the teeth. For optimal stability of the explanation for the different amounts of incisor intru-
teeth and periodontal health, alveolar bone support is sion may be related to the use of continuous force (Ni-
an important factor to consider in orthodontic treat- Ti coil in the miniscrew group) vs. a linear decrease of
ment. Currently, using CBCT images is a highly accurate force in the base-arch group. Tian et al.22 showed that
measuring method for evaluating the alveolar bone di- lingual-inclined maxillary central incisors had less bony
mensions with a high degree of accuracy between direct support and a greater frequency of alveolar bone defects
measurements and CBCT.12,21 This retrospective CBCT than normally inclined maxillary incisors. In the present
study was performed to evaluate the alveolar bone loss study, the lingual inclination of the maxillary incisors at
around the maxillary central incisors that is induced by the T0 was greater in the miniscrew group, which might
two different intrusion mechanics (base-arch or minis- be a factor in the greater labial alveolar bone loss in this
crew), after the leveling and aligning stage. group.
We found a statistically significant decrease in labial However, our results showed that total alveolar bone
alveolar bone thickness at the crestal and midroot levels thickness did not change, but was maintained in both
in the miniscrew group (Group II). Significantly greater treatment groups. This suggests that the rate of labial
changes were observed in the miniscrew group than in alveolar bone resorption was relatively higher than the
the base-arch group (Group I), which might be related rate of apposition on the lingual aspect in the miniscrew
to greater changes in inclination and intrusion of the group, which may lead to a decrease in the LBT at the
maxillary incisors. In the base-arch group, the arch-wire crestal level. Similarly, the findings of different stud-
was extended into the molar tube with cinching-back ies19,23-25 showed a significant decrease in bone thickness
and a gable bend, and these mechanics may play a role in the direction of tooth movement. However, Thon-

www.e-kjo.org https://doi.org/10.4041/kjod.2018.48.6.367 373

 Atik et al • Intrusion and alveolar bone

gudomporn et al.10 investigated changes in maxillary there was a weak negative correlation between facial
alveolar bone thickness after maxillary incisor extrusion vertical bone recession and the pretreatment cortical
and proclination and did not find significant changes bone thickness at the apex level of the mandibular ante-
in LBT in the direction of tooth movement. In contrast, rior teeth.
they found significant changes in palatal and total al- Some caution should be taken while intruding the
veolar bone thicknesses at the mid and apical levels of upper incisors. For example, miniscrews can be placed
the root. Kaied and Tanielian11 evaluated the effects of distally to the canines to reduce the degree of labial
incisor intrusion using segmented and utility arches and tilting of the upper incisors, in order to minimize the
found significant decreases in alveolar bone thickness in possible stress at the alveolar ridge. Cho et al.31 recently
both treatment groups. However, in the present study, performed a three-dimensional finite element study, and
the base-arch group did not show a significant decrease reported that, when an intrusion force was applied distal
in alveolar bone thickness. The differences between the to the lateral incisors, the amount of displacement of
studies may arise from the different type of biomechan- the anterior teeth was low and stresses were distributed
ics used, different force magnitudes, and individual re- across all anterior teeth, regardless of the alveolar bone
sponse differences in terms of the bone remodeling rate. loss.
The results of this study showed that the percentage Considering our findings, it would be beneficial to
of dehiscence at the maxillary right and left incisors was assess the prerequisite bone morphology prior to initiat-
significantly greater in the miniscrew group than in the ing orthodontic treatment. Careful analysis of the bone
base-arch group; in accordance with this result, the loss structure around the maxillary upper incisors, particu-
of the alveolar crestal height and bone height on the la- larly in adult deep-bite patients who require both incisor
bial side in the miniscrew group was significantly greater proclination and intrusion, could be considered as an
than those in the other treatment group. However, clini- important pretreatment assessment step before planning
cally, no occurrence of gingival recession was encoun- the treatment protocol. The current study showed that
tered in the miniscrew group. the decrease in bone thickness and bone height and the
Tooth movements, which decentralize the teeth from prevalence of dehiscence after labialization and intrusion
the alveolar ridge, may be a critical factor for developing were significantly greater in the miniscrew group than
bone dehiscence.26 In the present study, the upper an- in the base-arch group. This suggests that conventional
terior alveolar bone was subjected to an intrusion force intrusion mechanics, such as an intrusion utility arch or
with upward and forward direction, which might lead base-arch in which cinching-back of the arch-wire can
to concentration of stress and deformation on the labial be incorporated or miniscrew-assisted intrusion (with
alveolar ridge crest.27 Similarly, Bimstein et al.28 indicated the miniscrew placed more distally) on a continuous
that the change in alveolar bone height of protruded arch-wire, rather than a segmental anterior wire, should
mandibular incisors may be influenced by the change be considered. This is particularly true for patients who
in both the inclination and intrusion of the central inci- have less favorable periodontal structure around the
sors. However, there is no direct association between incisors at the beginning of the intrusion. Therefore,
buccal movement of the incisors and the occurrence of from a clinical perspective, the clinician should take
gingival recession.29 The periodontal status, such as the cognizance of the individual’s biological characteristics
amount of keratinized gingiva, mucogingival problems, before choosing the type of the biomechanics used dur-
and harmful habits of the patients are other factors that ing the orthodontic treatment. Furthermore, light forces
must be considered at the pretreatment phase as risk and long-term activations during orthodontic treatment
factors of gingival recession.30 would be useful to eliminate or reduce marginal alveolar
The extent of intrusion and the inclination of the bone loss by providing more time for alveolar bone re-
maxillary incisors showed positive and negative correla- modeling.
tion with changes in LBT at 3 mm and TBT at 9 mm, It has been indicated that, when alveolar bone thick-
respectively. This may be because increased intrusion ness is larger than the voxel size, measurements might
and decreased inclination can be expected to trigger in- be overestimated; in contrast, when it is smaller than
creased labial alveolar bone changes at the crestal level voxel size, measurements may be underestimated.32 In
and decreased total alveolar bone changes at the apical the present study, statistically significant alveolar bone
level, respectively, during upper incisor intrusion. changes were greater than the voxel size of the CBCT
The pretreatment total alveolar bone thickness was images, which may be a limitation of the current study.
negatively correlated with the change in the TBT at 9 This study was also limited by its retrospective study
mm. This suggests that a greater decrease in bone thick- design. Further longitudinal follow-up investigations
ness may occur if the TBT at the level of the maxillary are necessary to reveal the exact alveolar bone response
incisor apex is thinner. Garlock et al.3 also found that once treatment is completed. This would reveal the

374 https://doi.org/10.4041/kjod.2018.48.6.367 www.e-kjo.org

Atik et al • Intrusion and alveolar bone

course of bone remodeling over time. Another limita- Saunders; 1993.

tion of this study is that CBCT images at T0 were taken 7. Burstone CJ. Biomechanics of deep overbite correc-
before leveling and aligning of the incisors; thus, this tion. Semin Orthod 2001;7:26-33.
study showed the effect of both proclination and intru- 8. Steiner GG, Pearson JK, Ainamo J. Changes of the
sion, rather than purely the effect of intrusion. marginal periodontium as a result of labial tooth
movement in monkeys. J Periodontol 1981;52:314-
CONCLUSION 20.
9. Batenhorst KF, Bowers GM, Williams JE Jr. Tissue
The null hypothesis of the study was rejected. When changes resulting from facial tipping and extrusion
the same intrusion force was applied with the 4 maxil- of incisors in monkeys. J Periodontol 1974;45:660-
lary anterior teeth being intruded as a segment either 8.
with a base-arch or miniscrews, the degree of labial tilt- 10. Thongudomporn U, Charoemratrote C, Jearapong-
ing and intrusion of the anterior teeth increased in both pakorn S. Changes of anterior maxillary alveolar
treatment groups, and to a greater extent in the mini- bone thickness following incisor proclination and
screw group. The degree of labial alveolar bone thick- extrusion. Angle Orthod 2015;85:549-54.
ness and bone height decrease were also greater in the 11. Kaied IB, Tanielian RH. Comparative radiographic
miniscrew group. The degree of change in labial inclina- evaluation of the alveolar bone support changes
tion and intrusion should be taken into account during after incisal intrusion. Orthodontics (Chic.) 2012;13:
upper incisor intrusion, as these factors may increase 60-71.
the risk of alveolar bone loss. The data on morphology 12. Timock AM, Cook V, McDonald T, Leo MC, Crowe J,
of the alveolar bone as analyzed by means of CBCT can Benninger BL, et al. Accuracy and reliability of buc-
guide the orthodontic treatment plan and indicate the cal bone height and thickness measurements from
limits of tooth movement. cone-beam computed tomography imaging. Am J
Orthod Dentofacial Orthop 2011;140:734-44.
CONFLICTS OF INTEREST 13. Handelman CS. The anterior alveolus: its importance
in limiting orthodontic treatment and its influence
No potential conflict of interest relevant to this article on the occurrence of iatrogenic sequelae. Angle Or-
was reported. thod 1996;66:95-109; discussion 109-10.
14. Vardimon AD, Oren E, Ben-Bassat Y. Cortical bone
REFERENCES remodeling/tooth movement ratio during maxillary
incisor retraction with tip versus torque movements.
1. Nauert K, Berg R. Evaluation of labio-lingual bony Am J Orthod Dentofacial Orthop 1998;114:520-9.
support of lower incisors in orthodontically untreat- 15. Ludlow JB, Laster WS, See M, Bailey LJ, Hershey
ed adults with the help of computed tomography. J HG. Accuracy of measurements of mandibular anat-
Orofac Orthop 1999;60:321-34. omy in cone beam computed tomography images.
2. Verna C, Zaffe D, Siciliani G. Histomorphometric Oral Surg Oral Med Oral Pathol Oral Radiol Endod
study of bone reactions during orthodontic tooth 2007;103:534-42.
movement in rats. Bone 1999;24:371-9. 16. Kim Y, Park JU, Kook YA. Alveolar bone loss around
3. Garlock DT, Buschang PH, Araujo EA, Behrents RG, incisors in surgical skeletal Class III patients. Angle
Kim KB. Evaluation of marginal alveolar bone in the Orthod 2009;79:676-82.
anterior mandible with pretreatment and posttreat- 17. Lee KM, Kim YI, Park SB, Son WS. Alveolar bone loss
ment computed tomography in nonextraction pa- around lower incisors during surgical orthodontic
tients. Am J Orthod Dentofacial Orthop 2016;149: treatment in mandibular prognathism. Angle Orthod
192-201. 2012;82:637-44.
4. Melsen B. Biological reaction of alveolar bone to 18. Karagöz A. Derin örtülü kapanışlı olgularda üst keser
orthodontic tooth movement. Angle Orthod 1999; intrüzyonunun konik ışınlı bilgisayarlı tomografi ile
69:151-8. incelenmesi. Ankara, Turkey: Hacettepe University;
5. Nanda R, Kuhlberg A. Management of deep overbite 2013.
malocclusion. In: Nanda R, ed. Biomechanics and 19. Sarikaya S, Haydar B, Ciğer S, Ariyürek M. Changes
esthetic strategies in clinical orthodontics. 1st ed. St. in alveolar bone thickness due to retraction of an-
Louis: Elsevier Saunders; 2005. p. 131-55. terior teeth. Am J Orthod Dentofacial Orthop 2002;
6. Burzin J, Nanda R. The stability of deep overbite 122:15-26.
correction. In: Nanda R, Burstone CJ, eds. Reten- 20. Persson RE, Hollender LG, Laurell L, Persson GR.
tion and stability in orthodontics. Philadelphia: WB Horizontal alveolar bone loss and vertical bone de-

www.e-kjo.org https://doi.org/10.4041/kjod.2018.48.6.367 375

 Atik et al • Intrusion and alveolar bone

fects in an adult patient population. J Periodontol odontal remodeling during orthodontic treatment.
1998;69:348-56. Semin Orthod 2002;8:23-8.
21. Mischkowski RA, Pulsfort R, Ritter L, Neugebauer J, 27. Cobo J, Argüelles J, Puente M, Vijande M. Dento-
Brochhagen HG, Keeve E, et al. Geometric accuracy alveolar stress from bodily tooth movement at dif-
of a newly developed cone-beam device for maxillo- ferent levels of bone loss. Am J Orthod Dentofacial
facial imaging. Oral Surg Oral Med Oral Pathol Oral Orthop 1996;110:256-62.
Radiol Endod 2007;104:551-9. 28. Bimstein E, Crevoisier RA, King DL. Changes in the
22. Tian YL, Liu F, Sun HJ, Lv P, Cao YM, Yu M, et al. morphology of the buccal alveolar bone of pro-
Alveolar bone thickness around maxillary central truded mandibular permanent incisors secondary
incisors of different inclination assessed with cone- to orthodontic alignment. Am J Orthod Dentofacial
beam computed tomography. Korean J Orthod Orthop 1990;97:427-30.
2015;45:245-52. 29. Kalha A. Gingival recession and labial movement of
23. Yodthong N, Charoemratrote C, Leethanakul C. Fac- lower incisors. Evid Based Dent 2013;14:21-2.
tors related to alveolar bone thickness during upper 30. Aziz T, Flores-Mir C. A systematic review of the as-
incisor retraction. Angle Orthod 2013;83:394-401. sociation between appliance-induced labial move-
24. Ahn HW, Moon SC, Baek SH. Morphometric evalu- ment of mandibular incisors and gingival recession.
ation of changes in the alveolar bone and roots Aust Orthod J 2011;27:33-9.
of the maxillary anterior teeth before and after en 31. Cho SM, Choi SH, Sung SJ, Yu HS, Hwang CJ. The
masse retraction using cone-beam computed to- effects of alveolar bone loss and miniscrew position
mography. Angle Orthod 2013;83:212-21. on initial tooth displacement during intrusion of the
25. Picanço PR, Valarelli FP, Cançado RH, de Freitas KM, maxillary anterior teeth: Finite element analysis. Ko-
Picanço GV. Comparison of the changes of alveolar rean J Orthod 2016;46:310-22.
bone thickness in maxillary incisor area in extraction 32. Sun Z, Smith T, Kortam S, Kim DG, Tee BC, Fields
and non-extraction cases: computerized tomogra- H. Effect of bone thickness on alveolar bone-height
phy evaluation. Dental Press J Orthod 2013;18:91- measurements from cone-beam computed tomogra-
8. phy images. Am J Orthod Dentofacial Orthop 2011;
26. Fuhrmann R. Three-dimensional evaluation of peri- 139:e117-27.

376 https://doi.org/10.4041/kjod.2018.48.6.367 www.e-kjo.org