1

INTRODUCTION

Subject of smile and facial animation as it relates to

communication and expression of emotion should greatly influence

orthodontist. Frush and Fischer12 studied denture esthetics and

proposed that curvature of the incisal edges of upper anterior teeth and

curvature of the incisal edges of upper anterior teeth and curvature of

the upper border of the lower lip should be in harmony

Most orthodontist come across cases with excessive incisor exposure

and increased overbite in their clinical practice. These patients require

a comprehensive treatment plan, which establishes how the incisor

exposure should be reduced and deep overbite, corrected depending on

the cause.

Correction of the deep overbite can be can be accomplished in a

number of ways depending on the initial diagnosis and treatment

objectives. Deepbite can be corrected by various tooth movements,

which include the following 2.

a) Extrusion of posterior teeth

b) Uprighting of posterior teeth

c) Increasing the inclination of incisors

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d) Intrusion of anterior teeth

e) Combination of one or two of the above tooth movements

Extrusion of the posterior teeth will result in increased lower facial

height, steepening of the occlusal plane, downward and backward

rotation of the mandible, resulting in worsening of the class II skeletal

relationship. The long-term stability of the correction is questionable

unless suitable growth occurs. Deep overbite correction by intrusion of

anterior teeth offers a number of advantages including, simplifying

control of vertical dimension and allowing forward rotation of the

mandible. Intrusion of anterior teeth to correct deep overbite may be

indicated in patients with unaesthetic excessive maxillary incisor

showing at rest position of the lip (5-8mm), and deep mandibular curve

associated with long lower facial height 30.

The amount of incisors that show at rest is a crucial esthetic parameter,

and can be due to a number of hard tissue and soft tissue factors 30.

a) Short upper lip philtrum height- which results in children due to

incomplete lip growth, in adults short lip is simply an anatomic

variable.

b) Vertical maxillary excess

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c) Excessive clinical crown height

d) Detorqued maxillary incisors.

Numerous methods have been described for incisor intrusion, and all of

the employ the same principle, a tipback bend at the molars, or a V

bend in the posterior region of the arch to provide an intrusive force at

he incisors. Wire material used for the intrusion are diverse, but all

recognize the need for light continuous force

DEFNITION

Marcotte 23
defines intrusion as the” tooth movement that occurs in an

axial (apical) direction and whose center of rotation lies at infinity. It is

an axial type of translation”

Nicolai 27
as “ Translational form of tooth movement directed apically

and parallel to the long axis”

Burstone 4 as “ Apical movement of the geometric center of the root in

respect to the occlusal plane or a plane based on the long axis of the

tooth”
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ROLE OF INTRUSION

It is wise to intrude the maxillary incisors to a significant degree prior

to any retraction. If this is accomplished, several advantages are

immediately gained

1. Bite opening is achieved by moving maxillary incisors into the

alveolus

2. The potential for increasing a gummy smile is minimized

3. The unfavorable tipping of the occlusal cant will not be as

common

4. It will minimize the chances of moving the apices into

juxtaposition against the dense cortical bone

5. There will be a reduction in the total amount of class II elastics

that will be required

6. The torquing requirements will be reduced, and when needed

will be accomplished within a more adequate anatomical area,

and not restricted by the lingual cortical plate.

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BIO-MECHANICS OF INTRUSION

Analysis of biomechanical situation 26

True intrusion is obtained when an intrusive force is directed

through the center of resistance of the anterior teeth. Unfortunately

this is difficult to accomplish; spatial relationship between center of

resistance (CR) and point of application (P.F.P) varies depending on

labiolingual inclination of upper incisors. Intrusive force is normally

applied to the labial surface of the incisors, this produces a moment

which tends to flare the crowns forward and move the roots lingually.

In cases where incisors are markedly proclined, an intrusive

force creates a large moment. In these cases incisors should be

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retracted first to improve their axial inclination before intrusive

mechanics are initiated.

Thus the key to successful intrusion is light continuous force, which is

directed towards the root apex of incisors.

BIOMECHANICS OF INTRUSION ARCHES

Law of equilibrium states that for every force there is an equal

and opposite reactive force, but also that sum of the moment in any

plane is equal to zero. In other words, moments as well as forces

generated by an orthodontic appliance must be equal to zero. Analysis

of equilibrium can be stated in an equation form

 Horizontal forces = 0

 Vertical forces = 0
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 Transverse forces = 0

and

 Moment (horizontal axis) = 0

 moment (vertical axis) = 0

 moment (Transverse axis) = 0

ONE COUPLE AND TWO COUPLE SYSTEMS 21,28

Determinate systems in orthodontics are those in which a couple

is created at one end of an attachment with only a force (no couple) at

the other. This constitutes the one couple system; which means that

the wire, that will serve as a spring, can be inserted into a tube or

bracket at one end, but must be tied so that there is only one point of

contact on the other.

When more is tied into the bracket on both ends – a statistically

indeterminate two couple system has been created.

ONE COUPLE SYSTEM

In orthodontic applications, one couple systems are found, when two

conditions are met.

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1) Cantilevers spring or auxillary arch wire is placed into a bracket

or tube. It typically attaches to a tooth or teeth that is part of the

stabilized segment.

2) Other end of cantilever spring or auxillary arch wire is tied to

teeth that are to be moved with a single point of force

application like an intrusion arch.

INTRUSION ARCHES 21,28

Major use of one couple system is for intrusion, typically of

incisors that have erupted too much. For intrusion, light force against

the teeth to be intruded is critical. Intrusion arch typically employs

posterior anchorage against two or four incisors. Because the intrusive

force must be light, the reaction force against the anchor teeth is also

light, well below the force levels needed for extrusion and tipping that

would be the reactive movement of the anchor teeth. Tying the molar

teeth together with a rigid lingual arch prevent buccal tipping of

molars.
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Two factors in the action of the intrusion arch are the relationship of

the point of force application relative to the center of resistance of the

incisor segment, and whether the incisors are free to tip facially as they

intrude or whether the arch is cinched back to produce the lingual root

torque.

A).

A) An intrusion arch can be tied at any point along the incisor

segment. If it is tied behind the lateral incisor bracket, the force is

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applied in line with the center of resistance, and there is no moment

to rotate the incisors facio-lingually

B)

B) If the intrusion arch were tied in the mid line and cinched back so

that it would not slide in the forward in the molar tube, the effect

would be lingual root torque on the incisors as they intrude.

Equilibrium requires that both moments and forces be balanced, so the

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moment on the incisors would be balanced by similar moments on the

anchor molars. Each would receive a 100 gm-mm moment to bring the

crown mesially, which would require a 10gm force at the distal of the

molar tube, if the distance from the tube to the molars center of

resistance were 10mm

6
TWO COUPLE SYSTEM

The effect of tying an intrusion arch into the brackets changes the

bio – mechanical aspect of the appliance from a one couple system to

an indeterminate two couple system. Utility arch popularized by

Ricketts and used frequently for incisor intrusion, makes this change.

Like a one-couple intrusion arch, it is formed from rectangular wire so

that it will not roll in the molar tube, and it bypasses the canine and

premolar teeth. The resulting long span provides excellent load

deflection properties so that light force necessary for intrusion can be

created. Difference comes when utility arch is tied into the incisor

brackets.

Utility arch often is an intrusion arch in a two couple configuration,

created by tying the intrusion arch into the slots of the brackets. When
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this is done, the precise magnitude of the force and couples cannot be

known.

a) Activating the utility arch, by placing it into the brackets creates

the intrusive force, with a reactive force of the same magnitude

on the anchor molar and a couple to tip the crown distally. At the

incisors, a moment to tip the crown facially (M f) is created by

the distance of the brackets forward from the center of

resistance, and an additional moment in the same direction is

created by the couple within the bracket (M c) as the inclination

of the wire is changed as it is brought to the brackets. The

moment of the couple cannot be known, but is clinically

important as it affects the magnitude of the intrusion force

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b) Placing a torque bend in the utility arch creates a moment to

bring the crown lingually, controlling the tendency for the tooth

to tip facially as they intrude, but it also increases the magnitude

of the intrusive force on the incisor segment and the extrusive

force and the couple on the molar.

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c) Cinching back the utility arch creates a force to bring the

incisors lingually, and a moment of this force opposes the

moment of the intrusive force. At the molar, a force to bring the

molar mesially is created along with a moment to tip the molar

mesially. Especially if the torque bend is present it is difficult to

be certain which of the moments will prevail, or whether the

intrusive force is appropriate. With this two couple system,

vertical forces easily can be heavier than desired, changing the

balance between intrusion of incisors and extrusion of molars.

OPTIMAL INTRUSIVE FORCE FOR INTRUSION

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A movement of intrusion must be performed carefully in adults,

laminadura of adult teeth in the apical region is frequently denser and

periodontal ligament is somewhat narrower than in children’s teeth. A

careful examination of radiograph is always important for intrusion 33.

Loading diagram, of intrusive force shows that force is concentrated

over a small area at the apex. For this reason extremely light forces are

needed to produce appropriate pressure within the periodontal ligament

during intrusion 28.

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An optimal force is one that produces a rapid rate of tooth movements,

without discomfort to the patient or ensuing tissue damage. Optimal

force range for intrusion has been a long time controversy 33.

Dellinger7 in 1967, demonstrated intrusion histologically and

cephalometrically for the first time on monkey premolars when he

applied 50 grams of force and found very little resorption with good

intrusion.

Stenvik and Mjor 38 in 1970 investigated the effect of intrusion on pulp

and dentine on human premolars and found that force above 150 to 200

grams caused stasis in pulp vessels.

Reitan in 1974 32, did studies on the intrusion of human premolars and

concluded that force around 80 to 90 grams range caused apical root

resoprtion while any force not exceeding 30 grams did not result in any

damage.

Burstone 4
in 1977, suggested 50 grams of intrusive force for upper

central incisors, 100 grams for central and laterals and 200 grams for

six upper anteriors. He advocated use of 40 grams for four lower

incisors and 160 grams for all six lower anteriors.

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Bench, Gugino and Hilgers 1 in 1978, advocated intrusive force of 15

to 20 grams per lower incisor and 60 to 80 grams for all four lower

incisors.

Ricketts 36
in 1980 advocated use of 125 to 160 grams of force for

upper incisor intrusion and 60 to 75 grams for lower incisors.

Lui and Herschelb 22 in 1981 suggested use of 80 to 100 grams of force

for four incisors intrusion.

Nicolai 27
in 1985 suggested that intrusive force should be 60 grams /

cm2 of occlusoapical projection of root surface area.

Kesling 20
in 1985 suggested 35 grams of net force for six upper

anterior intrusion, 14 grams for lower six anteriors.

Proffit 28
in 1993 suggested 15 grams of force needed for incisor

intrusion.

Siatkowski 38
in 1997, based on the work of Dermaut suggested 10-15

grams of force for upper central incisor where as 5-10 grams for lower

lateral and 15-25 grams for canines.

Though there has been many opinions regarding an ideal force for

intrusion, all recognize the need for light continuous force.

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MAJOR PRINCIPLES OF INTRUSION`4

Six major principle of intrusion should be followed; if genuine

intrusion and greater control of force system is needed.

1. CONTROLLING FORCE MAGNITUDE AND

CONSTANCY.
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2. ANTERIOR SINGLE POINT CONTACTS.

3. POINT OF FORCE APPLICATION.

4. SELECTIVE INTRUSION.

5. CONTROL OF REACTIVE UNITS.

6. AVOIDING EXTRUSIVE MECHANICS.

1. CONTROLLING FORCE MAGNITUDE AND CONSTANCY

It is important to use the lowest magnitude of force that is

capable of intruding incisors. If the magnitude of force are too great;

rate of intrusion will not increase and rate of resorption will increase as

demonstrated by Dellingers 7 research on monkeys.

Too great a force will have reciprocal effect on posterior anchorage,

posterior teeth will feel a vertical force which will tend to extrude the

buccal segment and a moment which in upper arch will steepen the

plane of occlusion and in the lower arch flatten it. If only a single

tooth, as the 1st molar is attached to an intrusive spring, the undesirable

side effect is only a tip back action with the crown moving distally and

root mesially. Loss of anchorage during intrusion is primarily

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produced by moment rather then by force since occlusal forces tend to

negate eruptive tendency.

Inorder to maintain a constant force during intrusion, wire with a

low load deflection rate should be used. If a high load deflection

spring is used for intrusion as teeth moves, a rapid drop in force

magnitude occurs, so that optimal force may be only momentarily

reached.

Suggested force levels are based on clinical experience and the

clinician learns that inorder to accomplish optimum intrusion, force

should be delivered constantly. A low load deflection rate spring

makes it practical for the clinician to determine the magnitude of force,

since activation is not so critical and as intrusion proceeds there will

not be marked reduction in force magnitude.

2. ANTERIOR SINGLE POINT CONTACTS

Anterior single point contact is needed in the anterior segment so that a

constant force is produced and genuine intrusion is produced in the

anterior segment.

By having a single point of force application on the incisors, the

clinician knows more positively the full force system acting at the
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incisor segment and buccal tube, thereby producing a statically

determinant system. By placing the intrusive arch into the brackets

produces a statically indeterminant system, which prevents the

orthodontist from knowing exactly what type of force he is delivering.

Intrusive arch is not placed directly into the brackets of anterior

teeth; because anterior torque may be present in the arch even if no

torque is present as the intrusive arch works; torque can be introduced.

If inadvertently or purposely labial root torque is placed into the

incisors; intrusive forces are increased on anterior teeth, the added

intrusive force is not needed and can produce anchorage loss of

posterior teeth.

Undesirable curvatures are formed in the wire during activation

if the intrusive arch is placed directly into the anterior segment.

Anterior single point contact allows for placement of series of

anterior alignment arch directly into the bracket.

An exception in which intrusive arch may be placed into the

brackets of incisors can be found in the example of central incisor

intrusion alone. If the intrusive arch is placed into the incisors, it is

necessary to round the wire so that no torque is produced. Rounding

the anterior segment of an intrusive arch going into four incisors may
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be a problem since torque can still be produced because of curvature in

anterior part of the arch.

3. POINT OF FORCE APPLICATION

An intrusive force placed through the center of resistance of the

incisors will intrude the teeth and not produce any labial or lingual

rotation of teeth. Center of resistance of an anterior segment can be

estimated to be at the geometric center of roots of the incisors to be

intruded.

Vanden Bulke, Dermaut 9

on his investigation using laser

reflection technique and holographic interferometry on dry human

skull, defined the center of resistance of various units of anterior

segments.

a. For an anterior segment comprising of two central incisors,

center of resistance was located on a projection line parallel

to mid saggital plane on a point situated at distal half of the

canine.
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b. For an anterior segment that included the four incisors, center

of resistance was situated on a projection line, perpendicular

to occlusal plane between canines and 1st premolar.

c. For rigid anterior segment that included the six anterior

teeth, center of resistance was situated in a projection line

perpendicular to occlusal plane distal to the Ist premolar.

d. Center of resistance of anterior segments incorporating two

or four anterior teeth were within 2mm of each other,

however inclusion of canines in anterior segment resulted in

center of resistance moving distally by approximately one

premolar width (7mm).

e. No appreciable shift in location of center of resistance of

various segments was studied as varying magnitude of

intrusive force was applied.

In maxillary intrusion, intrusive arch is normally placed slightly

anterior to labial surface of incisors as it is attached to the anterior

segment. This produces a moment which tends to flare, the crowns

forward and move the roots distally. It is therefore important to tie the

intrusive arch back to prevent the incisors from protruding. When the

intrusive arch is placed anterior to center of resistance during intrusion,

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root retraction simultaneously occurs and minimizes the need in many

class II patients for root movement to be accomplished in a later stage.

4. CONTROL OF REACTIVE UNITS

Best control over the posterior teeth, is the minimization 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 control

of posterior teeth.

Posterior teeth are joined together to form the posterior

anchorage unit. Whenever possible atleast the Ist molars and IInd

premolars should be used and addition of other teeth would enhance

anchorage. The potential wire used for stabilizing the buccal segments

should be atleast .018" square in crossection for 0.022" slot brackets

and in addition the right and left buccal segments are joined with a

trans-palatal arch in maxilla and lingual arch in the mandible.

Two basic side effects should be anticipated from intrusive

mechanics

1. From the lateral view a moment is created which tends to alter

the plane of occlusion of the buccal segment and therefore in the upper
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arch, the plane is steepened. To minimize these changes a number of

principle are used in the intrusive mechanics that have been described,

the force are kept as low as possible, teeth in the buccal segment are

rigidly connected and the right and the left buccal stabilizing segment

are connected by a trans-palatal arch in the maxilla and by lingual arch

in the mandible. Finally as an added precaution occipital head gear can

be used in the upper arch.

2. Second major side effect produced by an intrusive arch can be

seen from the frontal view with an intrusive force acting on the

incisors, there is an equal and opposite extrusive force acting at the

molars and since the extrusive force is acting buccaly at the tube, a

moment is created that tends to tip the crowns lingually and roots

buccally. One of the functions of the lingual arch is to resist side

effects and to prevent any undesirable change in axial inclination of

molars or change in width.

5. AVOIDING EXTRUSIVE MECHANICS

Extrusive mechanics should be avoided if one is to accomplish

genuine intrusion. Examples of extrusive mechanics include use of

class II and class III intermaxillary elastics, cervical headgear with

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outerbows placed above the occlusal plane and placement of reverse

curve of spee in lower arch to extrude premolars.

One of the classic situations for inadvertently erupting incisors,

which have been intruded or are going to be intruded is placement of

continuous arch wire. If the arch wire is placed into the canine bracket,

it will lie occlusal and hence will produce extrusion of incisors.

Incisors make very poor anchorage for distal root movement of canine,

since eruption occurs much more easily than distal root movement. It

is therefore preferable to bypass canines during canine root movement

or in certain situation canine root movement should be completed,

before incisors are joined to rest of the arch.

6. SELECTIVE INTRUSION

Taking advantage of geometry of anterior segment is one of the key

concepts in producing genuine intrusion. In class II division 2 cases,

occluso-gingival steps are seen in the position of the incisors as upper

central incisors project occlusally to the lateral incisors. It is desirable

to intrude just the two central incisors to the level of lateral incisors

before joining all four incisors together for further intrusion. When

one works on two incisors alone, lower forces can be used, and

undesirable side effect that are present with continuous arch are
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avoided. A continuous arch placed through the brackets not only

produces vertical forces but, unfortunately creates moments which alter

axial inclination as result of which extrusion and steepening of

maxillary plane would occur, which results in deepening of overbite.

In a similar way class II division I patients may require intrusion

of four incisors, both maxillary and mandibular, to the level of canines.

Many times canines that are in infraocclusion should not be extruded

but the four anterior teeth should be intruded to the level bypassing the

canines.

Indiscriminate leveling of anterior segment with a continuous

wire may make it impossible to employ intraoral mechanics.

APPLIANCE REQUIREMENT FOR UNIFORM INTRUSION

Appliances, which are used, for intrusion should fulfill two important

criteria

1) It should deliver a constant moment to force ratio to maintain the

center of rotation of incisors

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2) Appliances should have low load deflection rate with long range

of activation so that greater force constancy over the activation

range can be achieved

One or more of the following ways can reduce load deflection, in the

appliance

1) Reducing the cross section of the wire

2) Increasing the inter bracket distance

3) Wire material

1) Reducing the cross section of the wire

Reducing the diameter of the wire is commonly use to improve the

force constancy and reduce the load deflection rate, however as the

cross section of the wire gets smaller, less control is expressed on the

tooth in all three planes of space

2) Increasing the inter bracket distance

Large inter bracket distance reduces the load deflection rate and helps

deliver a constant force magnitude, providing a better directional

control of tooth movement

3) Wire material
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Material are available which have lower modulus of elasticity than

stainless steel and reduction in the modulus of elasticity translates into

almost 1:1 reduction in the load deflection rate of the arch wire

BASIC DESIGN OF AN INTRUSION ARCH 3

There are two basic designs for an intrusion arch

1) Continuous arch

2) Three piece intrusion arch

1) CONTINUOUS ARCH

Continuous arch consist of a relatively rigid anchorage unit connecting

the teeth of the posterior segment . The cuspid is bypassed by placing a

small step in the region of the cuspid or eliminating the cuspid bracket

entirely. Anterior teeth are connected together within an incisor

segment. A 0.017 x 0.025 – inch or 0.016 x 0.022 – inch TMA alloy,

Intrusion arch from an auxiliary tube places the intrusive force on the

incisors. As the wire is brought down to the central incisors or the

lateral incisors, only single forces are directed in an intrusive direction.

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2) THREE PIECE INTRUSION ARCH

It is similar to the continuous arch in that it requires a stable

anchorage unit for the posterior teeth and separate anterior segment.

Instead of a continuous wire separate tip-back springs are applied on

the right and left side. Bent hook shown in the figure delivers an

intrusive force distal to the bracket of the lateral incisors. When the

force is directed at 90 degrees, its point of attachment can be placed

through the center of resistance of the incisors so that no flaring of

teeth occurs.

The following Intrusion arches are reviewed in these

discussions.

1. UTILITY ARCH

2. CONNECTICUT INTRUSION ARCH

3. BURSTONE INTRUSION ARCH

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4. TIP-BACK SPRINGS (INTRUSION SPRINGS)

5. THREE-PIECE INTRUSION ARCH

6. KALRA SIMULTANEOUS INTRUSION

RETRACTION

7. MULLIGANS INTRUSION ARCH

8. INTRUSION ARCHES IN BEGG MECHANICS

a) JYOTHINDRA KUMAR’S POWER ARM

b) JAYADE’S PALATAL ELASTICS

UTILITY ARCH 24,34

Utility arch designed by Robert M. Ricketts in the early 1950’s

and has been popularized as an integral part of bioprogressive therapy.

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One of the most versatile auxiliary arch wires that can be used in

either mixed or permanent dentition treatment, is the utility arch.

Utility arch is a continuous wire that extends across both buccal

segments, but engages only the 1st permanent molars and four incisors

It was developed originally to provide a method for leveling the curve

of spee in the mandible but through the incorporation of loops, has

been adapted to perform additional functions in addition to incisor

intrusion in both arches.

BASIC COMPONENTS

Regardless of the presence or absence of loops, all utility arches have a

common design, which consist of:

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A. Molar segment

B. Posterior vertical segment

C. Vestibular segment

D. Anterior vertical segment

E. Incisal segment.

A. MOLAR SEGMENT

It extends into the tube on the 1 st molar. This segment may be

cut flush with the end of the tube or may be bend gingivally if the

utility arch is to be tied back. When utility arches are used in

combination with full arch appliances, it is necessary to have auxiliary

tubes located in the gingival portion of the 1st molar bands.

B. POSTERIOR VERTICAL SEGMENT

It is formed by making a 90° bend with 142 arch forming pliers.

Posterior step typically is 3-4mm in length in the mandible and 4 –

5mm in maxilla. It is often necessary to place a 3 rd order bend at the

function of molar segments and posterior vertical segment to avoid

impingement of utility arch on adjacent gingiva..

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C. VESTIBULAR SEGMENT

Vestibular segment is formed by placing a right angle bend at

the inferior portion of posterior vertical segment. The wire then passes

antero-inferiorly along gingival margin.

D. ANTERIOR VERTICAL SEGMENT

Anterior vertical segments should be about 4-5mm in length

when the utility arch is used in the mandible and about 5-8mm in

length, when the arch is used in the maxilla. Depth of the maxillary

and mandibular vestibules of the individual patients , along with the

design of the fixed appliances used during treatment, determine

specific length of both vertical segments.

E. INCISAL SEGMENT

Final 90° bend creates the incisal segment that should lie passively

in the brackets of anterior teeth.

WIRE SELECTION

As advocated by Ricketts 34
, utility arches are fabricated from

chrome – cobalt wires. In contrast to stainless steel wire, chrome –

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cobalt wire is manipulated easily and loops can be formed in the wire

with little difficulty.

With regard to selection of appropriate size of wire for 0.018"

slot appliance, recommended wire for mandibular utility arch is either

0.016" x 0.022" or 0.016" x 0.016" wire. For maxillary arches 0.016"

x 0.022" wire is recommended, with 0.022" slot, 0.019" x 0.019" wire

can be used in either arch. Generally rectangular wire is preferable to

round wire to control torque and prevent unwanted tipping of incisors.

TYPES OF UTILITY ARCHES

Although many configuration for utility arch have been

described, four types of utility arches can be defined , based on their

use.

1. PASSIVE UTILITY ARCH

It is ideal for stabilization or space maintenance in either mixed

permanent dentition.

2. INRUSION UTILITY ARCH

It is used mainly to intrude anterior teeth and will be discussed

later in much detail.

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3. RETRACTION UTILITY ARCH

These type is used both in the mixed and permanent dentition to

achieve retraction and intrusion of incisors.

4. PROTRACTION UTILITY ARCH

It is used to procline and intrude maxillary and mandibular

incisors.

INTRUSION UTILITY ARCH

Intrusion utility arch is similar in design to passive utility arch,

except that the posterior vertical segments do not lie flush against the

auxillary tube on the 1st molar bracket. Arch is activated to intrude the

anterior teeth. After activation, the vestibular segments and the anterior

and posterior vertical segments, which serve as the long lever arm from

the molar to the incisors, deliver a light continuous force.

FORCE LEVEL
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Utility arch should produces 60 –100 grams of force on the

mandibular incisors, force level considered ideal for mandibular incisor

intrusion.

FABRICATION

As with the passive arch, intrusion arch is stepped gingivally at

the molars, passes through the buccal vestibule, and then is stepped

occlusally at the incisors to avoid distortion from occlusal forces. In

contrast to the passive utility arch, posterior vertical segment is atleast

5mm, anterior to the auxillary tube of molar.

ACTIVATION
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Intrusion of anterior teeth can be produced in one of the two ways:

1. First the utility arch can be bent passively to fit the existing

occlusion. After ligating the utility arch into the anterior brackets, an
 39

intrusive force can be produced by placing an occlusally directed gable

bend in the posterior portion of the vestibular segment of the arch wire.

2. Bench 1 has advocated an alternative method of activation of utility

arch to produce intrusion. This type of activation involves placing a

tip – back bend in the molar segment .Tip-back bend causes the molar

segments of the arch wire to lie in the vestibular sulcus. Intrusive force

is created by placing the incisal segment of the utility arch into the

bracket of the incisors; however placing a tip back bend can

occasionally lead to unintentional posterior tipping of 1 st molars which

in the maxillary arch can be minimized by concurrent use of trans –

palatal arch. Thus activating the Utility arch by placing a gable bend in

the posterior aspect of the vestibular segment seems to avoid unwanted

tipping.

CONCLUSION

Utility arch is an integral part of interceptive as well as

comprehensive orthodontic treatment. It is efficient in intruding upper

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and lower incisors and is especially effective in protruding and

retruding anterior teeth.

CONNECTICUT INTRUSION ARCH 31

Connecticut Intrusion arch introduced by Ravindra Nanda is

fabricated from Nickel – Titanium alloys as it is the material of choice

for delivering continuous forces under large activation. These alloys

have high memory and low load deflection rate producing small

increments of deactivation over time and thus reducing the number of

reactivation appointment.
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APPLIANCE DESIGN

Connecticut Intrusion arch incorporates the characteristics of

utility arch as well as those of Conventional Intrusion arch. C.T.A is

preformed with the appropriate bends necessary for easy insertion and

use.

Two wire sizes are available 0.016" x 0.22" and 0.017" x 0.025"

Maxillary and mandibular versions have anterior dimensions of 34 mm

and 28mm respectively. The by pass, located distal to lateral incisors

is available in two different length to accommodate for extraction, non-

extraction and mixed dentition cases.

MECHANICS

C.T.A’s basic mechanism of force delivery is a V bend

calibrated to deliver approximately 40 –60 g of force. Upon insertion

the V bend lies just anterior to the molar brackets. When arch is

activated, a simple force system results consisting of vertical force in

the anterior region and a moment in the posterior region.

Incisor intrusion requires about 50g of force directed apically

along the center of resistance. Although the C.T.A is calibrated for this

purpose, slight difference in placement may alter the force system

 42

during activation. Moment created at the molar will also vary,

according to the amount of force at the incisors multiplied by the

distance to the molars. These minor changes can be measured with a

spring gauge when the arch is inserted and necessary adjustments can

be made to ensure proper force delivery.

About 1mm of intrusion can be expected every six weeks. Head

gears may be worn to counter-act the side effect on the molars.

INCISOR INTRUSION

With proper diagnosis and treatment planning CTA can rapidly

correct a deep bite and Class II molar relationship, requiring a minimal

number of appliance adjustment.

A pure intrusion arch would have a point contact at the incisors.

Insertion of wire into the incisor bracket however will tend to flare the

incisors, which may not be desirable. During intrusion of flared

incisors C.T.A’s point of force application is anterior to center of

resistance, which will flare the incisors even more unless the length of

wire between them and the molar is fixed. A tight inch back will

prevent incisor flaring during intrusion and produce some retraction of

incisors as well,
 43

Other various used of C.T.A are

a) Simultaneous Class II molar correction

b) Correction of incisors flaring

c) Correction of anterior occlusal cant

d) Correction of minor open bite

C.T.A will remain active at a constant force level for a long period of

time, allowing long intervals between appointments and virtually

eliminating the need for adjustments. Its simplicity of design and

minimal requirement for auxiliary hardware makes it an ideal addition

to the armamentarium of busy clinician.

 44

BURSTONE INTRUSION ARCH 4

In the 1950’s Burstone developed the segmented arch technique, which

had different crossection of the wire within the same arch and wires

that did not run continuously from one bracket to the adjacent bracket.

Burstone concluded that one of the limitations of the continuous arch

therapy is its inability to produce genuine intrusion.

Basic mechanism of Burstone intrusion arch consist of

 45

1. Posterior anchorage unit

2. Anterior segment

3. Intrusive arch spring.

Posterior anchorage

To increase the stability of the posterior segment, wires that

are .018" x .025" or .021" x 0.25" Stainless steel can be placed,

(depending upon whether it is .018 or .022 slot) following initial

alignment and maintained in placed through out treatment.

When alignment is completed in the posterior segment, right and left

buccal segments are joined together across the arch by means of trans-

palatal arch in maxilla and low lingual arch in mandible.

Intrusive Spring

Intrusive arch consist of an 0.018" x 0.022" or 0.018" x .025" wire

with a 3mm helix wound 2½ times placed mesial to the auxiliary tube.

Curvature in placed in the intrusive arch, so that the incisal portion lies

gingival to the central incisors. When the arch is tied to the level of the

incisors, an intrusive force is developed. Inorder that the arch does not

increase its length during the activation, a gentle curvature should be

 46

placed with the amount of curvature increasing as one approaches the

helix. In this way the activated arch wire will appear relatively straight,

and as it works out during intrusion arch length will decrease and no

anterior flaring is produced.

Anterior segment

Intrusive spring is not tied directly into the incisor bracket. An

anterior alignment arch or anterior segment is placed in the central

incisor or the four incisors and intrusive arch is either tied labially,

incisally or gingivally to that wire.

TIP-BACK SPRINGS (INTRUSION SPRINGS) 35

Originally proposed by Burstone, these springs are made of

0.017" x 0.025" inch.T.M.A wire. The upper and lower arches have to

be leveled and aligned and rigid stainless steel wire, preferably of

0.017 x 0.025 inch dimension should be engaged.

 47

Anchor molars should be re–inforced with a T.P.A in the upper and a

lingual holding arch in the lower arch. The intrusion springs are made

from 0.017" x 0.025" TMA wire without a helix or 0.017" x 0.025"

stainless steel wire with a helix so that forces can be made optimal for

intrusion. The wire is bent gingivally mesial to the molar tube and then

a helix is formed. The mesial end of the spring is bent into a hook and

is engaged on to the main archwire distal to lateral incisor, which

according to Burstone 4 is the approximate center of resistance of the

four incisors.
 48

Mesial end of the spring lies passively at the height of mesio – buccal

fold and spring is activated by pulling the hook down and engaging it

on to the arch wire.

These springs are indicated in cases requiring true intrusion of incisors

and can be used in the following conditions.

9. Growing patients with forward growth rotation.

10.For a very deep curve of spee in the lower arch

11.Cases with deep overbite due to extrusion of incisors.

12.For a steep natural plane of occlusion

THREE PIECE INTRUSION ARCH 37

The Three piece Intrusion arch consist of the following parts

1. The anterior segment with posterior extension

2. Posterior Anchorage unit

3. Intrusion Cantilevers
 49

POSTERIOR ANCHORAGE UNIT

After satisfactory alignment of the pre-molars and molars, passive

segmented wire (.017 x .025” stainless steel) are placed in the right and

left posterior teeth for stabilization. A precision stainless steel trans-

palatal arch (.032 x .032 ) placed passively between the first maxillary

molars consolidates the posterior unit now consisting of right and left

posterior units. Canines may be retracted separately and incorporated

into the buccal segment.

 50

ANTERIOR SEGMENT

The anterior segment is bent gingivally distal to the laterals and then

bent horizontally creating a step of approximately 3mm. The distal part

extends posteriorly to the distal end of the canine bracket where it is

formed into a hook. The anterior segment should be made of (.017

x .025 inch SS or larger) to prevent side effects created by bending of

wire during force application.

INTRUSION CANTILEVER

The intrusion cantilever is fabricated from .017 x .025 inch T.M.A.

The wire is bent gingivally mesial to the molar tube and a helix is

formed. The mesial end of the cantilever is bend into a hook. The

cantilever is then activated by making a bend mesial to the helix at the

molar tube, such that the anterior end with the hook lies passively in

the vestibule. This is then brought down and engaged onto the

horizontal portion of the anterior segment. This allows further distal

placement of the intrusive forces, that is , lateral to the lateral incisor,

so that the resultant forces are made to pass through the center of

resistance of anterior teeth. An elastic chain can be attached to the

 51

hook to facilitate simultaneous intrusion and retraction or to redirect

the forces more parallel to the long axis of incisors.

However to achieve true intrusion of anterior teeth it is always

necessary to balance the effective force of intrusion

MULLIGANS INTRUSIVE ARCH 25

Introduced by Thomas F.Mulligan.

Intrusion arch is made from .016 SS round arch wire in a .018/.022

slot. Both the upper molars are banded and the four incisors are bonded

that is why it is called a 2 x 4 appliance. Intrusive force is created by an

asymmetrical V bend which is intrusive at the incisors and extrusive at

the molars. Archwire is cinched back tightly at the molars.

Mulligans intrusive arch finds its major application in the mixed

dentition stage, where it can be used not only to intrude but also to

retract and upright the molars.

KALRA SIMULTANEOUS INTRUSION RETRACTION

The K- SIR 19 archwire is a modification of segmented loop mechanics
 52

of Nanda and Burstone.

APPLIANCE DESIGN

It is a continuous .019" x .025" TMA archwire with closed 7mm x

2mm U loop at the extraction site.

To obtain bodily movement and prevent tipping of teeth into the

extraction space a 90° V bend is placed in the arch wire at the level of

U-loop. This V-bend, when centered between the Ist molar and the

canine during space closure, produces two equal and opposite moments

to counter the moments caused by activation force of closing loop.

An off centered 60° V bend located posterior to the interbracket

distance produces an increased posterior clockwise moment on the Ist

molar which augments the molar anchorage as well as intrusion of

anterior teeth.

To prevent the buccal segment from rolling mesiolingually due to force

produced by loop activation, a 20° anti-rotation bend is placed in the

archwire just distal to each U-loop.

ACTIVATION
 53

A trial activation of the arch wire is performed outside the mouth.

Trial activation releases the stress built up in bending the wire and thus

reduces severity of the V bend.

After the trial activation, the neutral position of each loop is

determined with the legs extended horizontally.In the neutral positon,

the U-loop is about 3.5mm wide and the archwire is inserted into the

auxiliary tube of the Ist molar and engaged in the six anterior brackets

It is activated about 3mm so that the mesial and distal legs of the loop

are barely apart. IInd premolars are bypassed to increase the

interbracket distance between the two ends of the attachment, which

increases the efficacy of the off enter V bend.

When the loops are first activated, the tipping moments generated by

the retracting force will be greater than the opposing moments

generated by the V bend in the arch wire. This will initially cause

controlled tipping of the teeth into the extraction space.

As the loops deactivate and force decreases; the moment to force ratio

will increase to first cause bodily and then root movement of teeth. The

archwire should therefore be not reactivated at short intervals, but only

every 6-8 weeks until all the space have closed.

 54

CONTROL OF REACTIVE FORCES

The Off-centered V- bend will generate an extrusive force on the

molars, which is usually undesirable. One of the keys to preventing

unwanted side effects of an appliance is to keepthe reactive force at a

minimum, while exerting an optimum level of force on the teeth to be

moved.

Force on the anterior segment

K-.SIR exerts about 125g of intrusive force on the anterior segment,

and a similar amount of extrusive force , distributed between the two

buccal segments-generally the 1st permanent molar and the 2nd

premolars, connected by segments of TMA wire.

Reactive extrusive force on the buccal segment is countered by force of

occlusion and mastication, adding teeth to anchorage unit, and banding

the 2nd molar will increase anchorage in the antero-posterior direction.

DISCUSSION
 55

The main indication of K-SIR is for retraction of anterior teeth in

a 1st premolar extraction patient who has a deep overbite and excessive

overjet, and who require intrusion of anterior teeth, and maximum

molar anchorage.because the intrusion of the six anterior teeth occur at

the same time as their retraction , K-SIR shortens the tratment time

compared to conventional edgewise mechanics.

 56

INTRUSION ARCHES IN BEGG MECHANICS

Lack of true intrusion of maxillary incisors was one of the major

weaknesses of traditional Begg . Bite opening occurred mainly on

16

account of molar extrusion and some intrusion of lower incisors.

Whether upper incisors intruded, remained at the same level or

extruded was a debated issue.

Anchorage bend provides the main source of intrusion for the Begg

mechanics. Intrusive force from bite opening bend in an arch wire acts

through the bracket that are placed on the labial aspect of the incisor

crowns. Hence it causes the labial crown\ lingual root tipping. Such

displacement is undesirable except in class II div 2 cases and round

arch wire employed in begg does not have capability on their own to

counter labial flaring of upper incisors.

Therefore , this displacement is resisted in begg treatment by use of

Class II elastics. The interplay between intrusive and elastic forces

determines the magnitude and direction of net resultant force acting on

the teeth. The other important consideration is the site for placing the

bite opening bends in the arch wire.

 57

Kesling 20
analyzed the conventional bite opening mechanism. Anchor

bend in the upper .016” arch wire generated approximately 45 grams of

force on each side, while the extrusive component was of Class II

elastics was about 30 grams, thus the net resultant force on each side

was 15 grams. This force magnitude spread over 3 teeth amount to 5

grams on each tooth, was too little for active intrusion.

Jayade 16
reported that these same combination of bite opening bend

and Class II elastics were used at all time irrespective of upper incisor

inclination. Therefore, while the direction of resultant force remains

more or less fixed, the way it related to the incisors were quite variable.

Only in a few instances it passed close to the long axis of the incisor

teeth, and it did not happen most of the time.

In refined Begg 15
, excess proclination or retroclination is corrected

initially in the substage 1A. Then the intrusive and Class II elastic

forces are varied as described depending on the changing incisor

inclination, so that the orientation of the resultant is kept close to the

center of resistance of the upper incisors and more or less parallel to

their long axis.

1) Initially the intrusive force is about 45 gm while the class II

force is about 60 gm in case of severely proclined incisors,

 58

which is similar to conventional mechanics. The resultant of the

two passes little behind the center of resistance and slightly

diverging away from the long axis of the teeth. It mainly reduces

the proclination of teeth but causes very little intrusion.

2) As the inclination improves the intrusive force is gradually

increased to about 60gm while the class II force is reduced till it

reaches to about 30 grams on each side. This combination

produces a resultant that is a little more vertically oriented, and

hence lies more parallel to their long axis and closer to C.res. It

brings about some more correction of inclination and some more

intrusion.

3) As the incisors become more upright, the elastic application is

changed to amore oblique direction. The resultant from such

combination gets oriented even more vertical and thus more

parallel to the long axis of the teeth. It not only reduces the

incisor inclination by controlled tipping, but is also adequate in

magnitude ( 15 –20 gms on each tooth) to bring about active

intrusion of incisors.

A gradual increase in the magnitude of intrusive forces, described

above is obtained by increasing the anchor bend from about 30 0 to 500

 59

in the .016” arch wire over 2-3 visits, and afterwards bu using

the .018” arch wire with similar enhanced anchorbend. The elastic

force is reduced by using them for longer periods ( 3 –5 days) instead

of changing them frequently or switching from the yellow(5/16”) to the

road runner elastics (3/8”).

USE OF ELASTICS FROM TRANSPALATAL ARCH (Palatal

Elastics) 15
 60

Proposed by Dr. V.P.Jayade, Transpalatal arch carries hooks

that are bent or are soldered to it, and which lie in line with the lateral

incisor. An additional oval shaped wire soldered to the T.P.A in the

center; kept slightly lower away from the palate, rest on the dorsum of

the tongue. This helps in generating a constant intrusive force on the

entire assembly, which neutralizes the extrusive component of the

palatal elastic on upper molars.

Four additional brackets are bonded on the palatal aspect of the

upper incisors as gingivally as possible with slots facing incisally.

 61

Sectional stainless steel 0.016" stain less steel wire contoured to follow

the general curvature of the arch; with ends bend, us pinned in four

palatal brackets. High hat pins may be used on the engagement of the

palatal elastic on lateral incisor.

Light elastics are applied from the hooks on the T.P.A to the

high hat pins. No elastics on the buccal aspects. Mechanism of palatal

elastics are ideal for intrusion because it involves using forces on both

the labial and the palatal side of incisors thereby giving a better control

over orientation of the resultant.

MECHANICS OF PALATAL ELASTICS 15

By anchorage bend provides a labially acting intrusive force:

elastic force acts palatally and the resultant force magnitude and
 62

direction can be controlled so that it passes close to the C Res of the

teeth.

This can be done precisely with the help of a cephalogram,

which helps in constrochry a parallelogram to estimate amount of

intrusive force and elastic force.

POWERS ARMS FOR INTRUSION

Proposed by Jyothendra Kumar: Small sections of rectangular wires in

0.018" x 0.025" are bend in the form of hooks and are soldered on

buccal aspect of upper molars gingival to the tubes. Elastics run on the

buccal side from power arm to cuspid circle.

 63

TISSUE RESPONSE DURING INTRUSION

Intrusion requires careful control of force magnitude. Light forces are

required because forces are concentrated in a small area at the tooth

apex. A light and continuous force, has proved favorable for intrusion

in young patients. In other cases, the alveolar bone may be closer to the

apex, increasing the risk of apical root resorption. If the bone of the

apical region is fairly compact, as in some adults, a light interrupted

force may be preferable. This provides time for cell proliferation to

start, and direct bone resorption may prevail when the arch is

reactivated after the rest period.

Intruded teeth in young patients undergo only minor positional changes

after treament. Relapse usually does not occur, partly because the free

gingival fibres become slightly relaxed. Stretch is exerted primarily on

the principal fibres. An intruding movement may therefore cause

formation of new bone spicules in the marginal region. These new

bone layers occasionally become slightly curved as a result of tension

exerted by stretched fibre bundles. Such tension is seen in the middle

third of the roots. Rearrangement of the principal fibres occurs after a

retention period of 2-3 months. In the young patients, the intruded teeth
 64

remains fairly stable. In adults, however relapse after intrusion may

occur, particularly when the retention period has been too short.

IAROGENIC RESPONSE FOLLOWING INTRUSION

One of the most common iatrogenic complication following intrusion

of tooth is the loss of root length apically. A frequent observation is

that after a successful initial period, adult teeth may be intruded

without any perceptible shortening of roots.

Intrusion has been reported to alter cemento-enamel junction and

angular crestal relationship and to creae only epithelial attachment to

roots; therefore a periodontally susceptible patient is at a greater risk of

periodontal breakdown. Tooth movement when properly executed,

improves periodontal conditions and is beneficial to periodontal health.

Intrusive movements may also cause certain changes in the pulp tissue.

As demonstrated by Stenvik and Mjor , vacuolization of the

odontoblastic layer constitutes the most characteristic tissue alteration.

After intrusion of teeth in young individuals, it was shown that a force

of 90cN would cause a marked reaction with apical resorption and pulp

alteration. In Reitan’s material, it was found that a difference existed

when the apical root portion was fully developed. Less vacuolization
 65

occurred in these cases and less marked pulpal reaction was observed

after tooth movement with interrupted forces.

The reparative properties of the pulp are known to be extensive.

Orthodontic tooth movement in adolescents causes no increased risk of

damage to the pulp. However the pulpal response to tooth movement in

adults may be different.

On the basis of what has been observed experimentally, it is likely that

all teeth moved with fixed appliance undergo certain pulpal alteration.

In all instances a boderline may be drawn between the small groups of

teeth that will become devitalized and all the other teeth that inspite of

pulp alteration remain vital. Devitalization may occur when the pulp

structures have become degraded after insertion of deep cavity filling

or when the teeth moved orthodontically have been subjected to trauma

or severe pressure before the treatment period.

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CONCLUSION