American Journal of ORTHODONTICS

Volume 72, Number 1, July, 1977

ORIGINAL ARTICLES

Deep overbite correction by intrusion

Charles R. Burstone
Farmington, Conn.

0 ne of the major challenges of Class II treatment is the correction of

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

Department of Orthodontics, SchooI of DentaI Medicine, University of Connecticut

Health Center.

1
2 Bursto?le Am. J. Orthod.
J&y 1977

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1 \ \ I,<,/ ,I ,/ --
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Fig. 1. Correction of deep overbite by extrusion of lower first molars and premolars as-
sociated with Class II elastics and leveling of the lower curve of Spee. An undersirable
increase in vertical and facial convexity has .occurred. (Solid line-before; dotted line-
after treatment.)

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

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Figs. 2 to 5. Correction of deep overbite by intrusion of incisors. Anterior cranial base

superposition and separate maxillary and mandibular superpositions are shown. (Super-
position of maxilla is on palatal plane at ANS; mandible is superposed at symphysis
and anterior third of lower border.) Note genuine intrusion of maxillary incisors and re-
duction in facial convexity. [Solid black teeth--after treatment.)
4 Bursto7le Am. J. Orthod.
July 1977

a relatively flat occlusal plane that tends to coincide with the natural plane of
occlusion of the posterior teeth. The plane should not allow more than 3 mm. of
the incisors to show below the upper lip.
If WC accept this concept of an occlusal plane, it is apparent that more intru-
sion of the upper incisor than of the lower incisor is required. Once again, this
complicates treatment since it is much easier to intrude lower incisors because of
their smaller root mass and the common presence of a curve of Spee in the lower
arch. For optimal treatment, however, more intrusion is required in the upper
arch than in the lower. It should be noted that in Patients J. Z. and M. H.
genuine intrusion of the upper incisor is shown in the maxillary superposition
which is greater than the intrusion shown in the mandibular arch.
Every patient with deep overbite requires a comprehensive treatment plan
which establishes how the deep overbite should be corrected, either by extrusion
of posterior teeth or inhibition and genuine intrusion of anterior teeth. This
decision is based in part on where the clinician desires to place the occlusal plane,
the amount of mandibular growth anticipated, and the vertica1 dimension desired
at the end of treatment.
It is important to define intrusion, since the dental literature suggests am-
biguity in its use. Intrusion refers to the apical movement of the geometric center
of the root (centroid) in respect to the occlusal plane or a plane based on the
long axis of the tooth. Labial tipping of an incisor around its centroid produces
pseudo-intrusion. Although this pseudo-intrusion would help correct a deep over-
bite in a Class II, Division 2 patient, it should not be confused with the genuine
intrusion discussed in this article. Incisal edges should therefore not be used to
evaluate intrusion, since they are easily affected by tipping movements of the
incisors. Ideally, a point should be selected in the center of the root (centroid)
and comparison should be based upon the movement of this point.
The basic intrusive mechanism

In the 1950s I developed an approach to orthodontic therapy which did not

use continuous arches.2 The technique, known as the segmented arch, used dif-
ferent cross sections of wire within the same arch and wires that did not run
continuously from one bracket to the adjacent bracket.39 4 Segmented arch pro-
cedures have a number of advantages in space closure in extraction cases and in
producing tooth alignment with minimum side effects.5 In particular, segmenta-
tion allows for the genuine intrusive movement of the anterior teeth. One of the
limitations of traditional continuous arch therapy has been its inability to pro-
duce genuine intrusion.
The basic mechanism for intrusion consists of three parts: (1) a posterior
anchorage unit, (2) an anterior segment, and (3) an intrusive arch spring
(Fig. 6).
Early in treatment the posterior teeth are aligned and joined together with a
buccal stabilizing segment, Once a buccal stabilizing segment of at least 0.018 by
0.018 inch (0.457 by 0.457 mm.), with or without loops, can be placed, intrusive
mechanics can be begun. (The mechanics described are based upon a 0.022 inch
(0.559 mm.) slot edgewise bracket. Although the cross sections of wire will differ
 Deep oz~erbite correction 5

Fig. 6. Basic mechanism for intrusion; posterior anchorage unit, anterior segment in the
four incisors, and an intrusive arch. The intrusion arch is placed in the auxiliary tube on
the first molar attachment.
Fig. 7. Anterior view of intrusive arch. Arch lies gingivai to incisors. Canines and pre
molars are bypassed.
Fig. 8. Intrusive arch has been placed at the level of the incisors. A double rope tie pre-
vents arch from being displaced into the mucobuccal fold if a tie is accidentally lost.

Fig. 9. Forces acting on the teeth from an intrusive arch. The effect on the molar is ex-
trusion and a negative rotation (crown-distal-root-mesial). The moment (M) is equal to the
intrusive force (FA) times the distance (L) from the incisor to the center of resistance of the
molar.

with each segment for an 0.018 inch (0.457 mm.) slot, the same basic principlc)s
can be used. The cross section and design of the intrusive springs are identical.)
Right and left posterior segments are joined together across the arch by means
of a transpalatal lingual arch in the maxilla. and a low lingual arch in the
mandible.
When alignment is completed in the posterior segment, the buccal stabilizing
segments and lingual arches remain in place and arc not continually adjusted as
in continuous arch therapy. Conceptually, one should not think of the posterior
teeth as a group of individual teeth but, rather, as a single multirooted tooth
composed of all the teeth on the right and left sides of the arch in the posterior
region.
To increase the stability of the posterior segment, wires that are 0.018 by
0.025 inch (0.457 by 0.635 mm.) or 0.021 by 0.025 inch (0.533 by 0.635 mm.)
can be placed following initial alignment and thereafter maintained in place
throughout treatment. A special bracket-tube or triple-tube combination is placed
 Am J. Cbthod.
July 1.977

Table I. Force values for intrusion*

Total force Moment/Side t

Teeth Force/Side in midline (Gm.-mm.)

&w-r
Central incisors 25 50 750
Central and lateral incisors 50 100 1,500
Central and lateral incisors and canine 100 200 3,000$
Lower
Central and lateral incisors 20 40 600
Central and lateral incisors and canine 80 160 2.4OOf
*Averages only.
tMoment values based on 30 mm. distance from incisors to the center of resistance of posterior
segment.
tThis moment can efficiently tip back posterior teeth.

on the upper or lower first molar. The most lingual slot or tube is used for plaee-
ment of the edgewise arch; the large round tube is used for headgear. An auxil-
iary tube placed gingivally is the anchor point for intrusive springs. The
auxiliary tube on the first molar is standardized for an 0.018 by 0.025 inch (0.457
by 0.635 mm.) wire, regardless of the slot dimension of the strap-up. It is
important to reiterate that during t,he overbite correction adjustments are not
made tooth to tooth in the buccal segment, except for purposes of minor tooth
alignment, and that the only adjust,ment to be found is between the auxiliary
tube on the first molar and the anterior segment.
The intrusive arch normally consists of an 0.018 by 0.022 inch (0.457 by 0.559
mm.) or 0.018 by 0.025 inch (0.457 by 0.635 mm.) edgewise wire with a 3 mm.
helix wound 21/2 times placed mesial to the auxiliary tube. Curvature is placed
in the intrusive arch, so that. the incisal portion lies gingival to the central
incisors (Fig. 7). When the arch is tied to the level of the incisors, an intrusive
force is developed (Fig. 8). In order that the arch does not increase its length
during the activation, a gentle curvature should be 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.
The intrusive spring is not directly tied into the incisor bracket. An anterior
alignment arch or anterior segment is placed in the central incisors or the four
incisors and the intrusive arch is tied either labially, incisally, or gingivally to
that wire.
It is true that almost any intrusive bend placed on an arch of this type could
produce dramatic leveling of the arch. However, where there is genuine intru-
sion, greater control of the force system is needed. For this reason, the six major
principles of intrusion will now be discussed.

Controlling the force magnitude and constancy

It is important to use the lowest magnitude of force that is capable of intrud-

ing incisors. If the magnitudes of force are too great, the rate of intrusion will
Volume 72 Deep overbite comection 7
Number 1

not increase and the rate of root resorption will increase. This has been demon-
strated by Dellingers research on monkeys.j Even more significant is the reciPro-
Cal effect on the posterior segments of too great a force. The posterior teeth will
feel a vertical force which will tend to extrude the buccal segments and a moment
or torque which in the upper arch will steepen the plane of occlusion and in the
lower arch flatten it (Fig. 9). If only a single tooth, as a first molar, is attached
to an intrusive spring, the undesirable side effect is seen primarily as a tip-back
action, with the crown moving distally and the root mesially. Loss of anchorage
during intrusion is primarily produced by the moment rather than by the force,
since occlusal forces tend to negate the eruptive tendency. The moment is large
because the distance from the ihcisors to the posterior teeth is great.
The recommended forces for anterior intrusion are given in Table I. It
should be noted that approximately 25 Gm. of force is delivered to an upper
incisor and approximately half that amount to a lower incisor. A canine requires
about 50 Gm. of force, on the average, for intrusion. Fig. 10 gives the load-
deflection characteristics of typical 0.018 by 0.025 inch (0.0457 by 0.635 mm.)
intrusive arches. The length of the arch is measured from the mesial aspect of
the auxiliary tube on the molar to the midline of the dental arch parallel to the
midsagittal plane. If the orthodontist desires to intrude four incisors, 100 Gm.
of force midline would be required (25 Gm. per tooth). For a 30 mm. arch, 16.5
mm. of activation is required. (The intrusive arch is then bent so that its anterior
portion lies 16.5 mm. below the level of incisor brackets.)
The suggested forces are averages based upon clinical experience. They can
be modified if root circumference and length vary from the average. Care should
be taken, however, not to increase the magnitudes significantly because of the
possibility of upsetting the posterior anchorage. It is important to make sure
not only that an optimal magnitude of force is employed but that the force
operates relatively constantly.
Springs that deliver relatively constant force have low loa.d-deflection rates.
An intrusive arch with a 30 mm. arm (perpendicular distance from the incisor
to the first molar) has a load-deflection rate of 6 Gm. per millimeter. If this
intrusive arch is activated 16.5 mm., 100 Gm. of force is produced in the midline,
50 Gm. per side. As the incisors intrude 1 mm., there is a change of force magni-
tude of only 6 Gm.; hence, the delivery of force is relatively constant.
By contrast, high load-deflection mechanisms, such as some of the loops that
are tried for intrusion, are activated only just a few millimeters; accordingly,
the drop off of force is very dramatic for every millimeter of tooth movement.
With a high load-deflection mechanism, it is not possible to deliver optimum
forces since the activations required to produce the desired forces are in tenths
of a millimeter and the orthodontist does not have the ability to carry out such
minute activation.8 Furthermore, with a high load-deflection spring rate as the
tooth moves, a rapid drop in force magnitude occurs, so that the optimal force
may be only momentarily reached.
The clinician, therefore, learns that he must use greater than optimal forces
to achieve any appreciable tooth movement. In short, in order to accomplish
intrusion, it is necessary to deliver an optimal force constantly. A low load-
 Am. J. Orthod.
July 1977

INTRUSIVE BASE ARCHES

WIRE SIZE: ,018 x.025

DIAMETER OF HELIXz3mm. 21/z TURNS

320

L: 20mm

L-25mm

Lf30mm

z i__L=35mm
0 I I ! I I 1 I r I I I I 1 1
A 8 12 16 20 24 28

ACTIVAT!ON (mm)

Fig. 10 Load-deflection characteristics of the intrusive arch (1) is the perpendicular distance
from the incisor bracket to the mesial aspect of the molar auxiliary tube. The total force
is given on the vertical axis. Data are based on average arch forms. Activation can be
determined from this table, or a force gauge can be used in the mouth.

deflection rate spring makes it practical for the clinician to determine the magni-
tude of the force, since activation is not so critical and assures that as intrusion
proceeds there will not be a marked reduction in force magnitude.
Force magnitude can be measured either from a force-deflection graph (Fig.
10) based on average arch form or by directly measuring the intrusive arch in
the mouth with the use of a force gauge. The intrusive arch has certain character-
istics which assure a low deflection rate and relative freedom from accidental
permanent deformation under the forces of mastication. Although a wire of
relatively large cross section is used, either 0.018 by 0.025 inch (0.457 by 0.635
mm.) or 0.018 by 0.022 inch (0.457 by 0.559 mm.), the load deflection is reduced
by the long perpendicular length from the incisors to the auxiliary tube of the
first molar. In addition, a helix 3 mm. in diameter is placed at the critical section
immediately mesial to the auxiliary tube on the first molar in which 2.5 turns are
placed (Fig. 11). This spring is an example of how a large cross-sectional wire
can be used in proper design to deliver optimal and constant forces without being
so flimsy that permanent deformation can occur under accidental loading.
Anterior single point contack

The intrusive arch is not placed directly into the brackets of the anterior
teeth. The major reason why one avoids bracket engagement of the intrusive
 Deep overbite correction 9

Fig. 11. A helix 3 mm. in diameter with 2.5 turns is placed immediately mesial to the
auxiliary tube on the first molar. The helix lowers the force and delivers it more constantly
without reducing the archs ability to withstand permanent deformation.
Fig. 12. Intrusive arch is placed incisal to brackets. A separate 0.010 by 0.020 inch
(0.254 by 0.508 mm.] anterior segment joins the incisor.
Fig. 13. If the intrusive arch is placed in two incisors, it is necessary to round the wire
SO that no torque is produced.

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

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

An intrusive force placed through the center of resistance of the incisors will
intrude the center of resistance and not produce any labial or lingual rotation of
the teeth. The center of resistance of an anterior segment can be estimated to be
at the geometric center of the roots of the incisors to be intruded (Fig. 14).
In maxillary intrusion, the intrusive arch is normally placed slightly anterior
to the labial surface of the incisors as it is attached to the anterior segment. This
produces a moment which tends to flair the crown forward and move the root
distally (Fig. 14). It is important, therefore, to tie the intrusive arch back to
prevent the incisors from protruding. When the intrusive arch is placed anterior
to the center of resistance during intrusion, root retraction simultaneously occurs
and minimizes the need in many Class II patients for root movement to be
accomplished at a later stage.
In those patients who have markedly protruded incisors, an intrusive force
placed on the labial surface of an incisor will produce a moment that is very large
and hence more effective in producing lingual root movement of the incisor.
Since these protruded incisors do not require this type of lingual root movement,
a slightly different mechanism is used. An anterior segment is made with a pos-
terior extension (Fig. 15). Right and left sectional intrusive arches are con-
structed with a hook that catches on the posterior extension so that the force can
be directed through the center of resistance of the incisors (Figs. 15 and 16).
Sectional intrusive springs solve the problem of delivering an intrusive force to
the incisors without producing undesirable change in axial inclination, but they
are not as efficient as intrusive arches applied to teeth with normal axial inclina-
tions. It can be seen that an intrusive force on a flared tooth has a strong anterior
component which tends to translate the root of the incisors labially (Fig. 17).
Since only a portion of the component force is directed along the long axis of the
tooth, rates of tooth movement are proportionately low.
In the patient requiring extraction it is possible to have a better solution to
the problem of a protruded incisor. The incisors should be uprighted first and,
after they have normal axial inclination, intrusive mechanics is initiated.
In using the intrusion arches and sections, control of the active force system
 Deep overbite correctio7L 11

Fig. 14. As the intrusive force is applied more anteriorly to the center of resistance of the
incisors, a positive moment is created which tends to move the root lingually, provided the
incisor is restrained from flaring labially.
Fig. 15. A posterior extension has been placed on a lower 0.018 by 0.025 inch (0.457
by 0.635 mm.) anterior segment. Right and sectional intrusive springs are hooked on the
extension.
Fig. 16. Force system of appliance shown in Fig. 15. Only forces on the teeth are shown.
Note that the posterior extension allows force to be directed through the center of
resistance of the incisor. No incisor tipping will occur.
Fig. 17. A long posterior extension is used to protrusive lower incisors to prevent flaring.
The hook at the intrusive section is shown.

on the incisors is the major key to success. This control includes delivering
optimal force magnitudes, delivering these forces constantly, delivering the intru-
sive force at a single point contact, and controlling the point of force application
with respect to the center of resistance of the anterior segment.
Selective intrusion

Indiscriminate leveling with a continuous arch or with sections can produce

undesirable side effects in a patient with deep overbite. In Fig. 18 a Class II,
Division 2 maxillary arch is depicted. Commonly one would like to intrude the
incisors to the level of the canines or perhaps produce some extrusion of the
posterior teeth without altering the plane of occlusion (line A). A straight arch
 12 Burstone Am. J. Orthod.
July 1977

Fig. 18. A straight wire placed in brackets of a Class II, Division 2 case, instead of pro-
ducing intrusion (line A), tends to steepen the plane of occlusion (line 6).
Fig. 19. A straight alignment arch, instead of intruding incisors, will erupt lateral incisors
and tends to converge the incisor roots mesially.
Fig. 20. Arch widths are controlled with a lingual arch. Mandibular lingual arch inserted
from the posterior of the molar tubes is shown. Transpalatal lingual arch is used on the
maxillary arch.

wire placed through the brackets not only produces vertical forces but, un-
fortunately, moments which alter axial inclinations, and thus it is possible that
this maxillary arch could be leveled by not producing any intrusion but by extru-
sion and steepening of the maxillary plane of occlusion (line B) . Fig. 19 shows
the anterior segment from the frontal view. Although the central incisors should
be intruded to the level of the lateral incisors, a continuous arch wire produces
primarily extrusion of the lateral incisors, since extrusive movements can be
accomplished more easily than intrusion. The undesirable moments will tend to
converge the roots toward the midline.
If one looks at the anterior segment in the Class II, Division 2 case, occlusal-
gingival steps are seen in the position of the incisors as the upper central incisors
project occlusally to the lateral incisors. It is desirable to intrude just the two
central incisors to the level of the lateral incisors before joining all four incisors
Volume 72 Deep overbite correctio??, 13
Number 1

Fig. 21. Occipital headgear placed anterior to the center of resistance of the posterior
anchorage unit. Headgear will counteract moment and force of the intrusive arch.

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

Control of the reactive units

The best control over the posterior teeth, the reactive unit, is the minimiza-
tion of force magnitude used for intrusion. Since the moment arm is so large
from anterior to posterior segments, it is necessary to give thought to the control
of the posterior teeth.
As many teeth as possible are joined together to form the posterior anchorage
unit. Whenever possible, at least the first molars and second premolars should be
used and the addition of other teeth would further enhance the anchorage poten-
tial. All teeth are joined together by means of a buccal wire to form a buccal unit.
The buccal wires, buccal stabilizing segments, are at least 0.018 inch (0.457 mm.)
square in cross section for 0.022 inch (0.559 mm.) slotted brackets. In addition
to connecting posterior teeth by means of a buccal wire, right and left buccal
segments are joined with a transpalatal arch in the maxilla or a low lingual arch
in the mandible (Fig. 20). One should consider the posterior anchorage unit not
 14 Burstoae Am. J. Orthod.
July 1977

Fig. 22. The extrusive force on the molar during incisor intrusion tends to tip the crown
lingually. This can be prevented by using a lingual arch.

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

of all the individual teeth on the right and left sides of the arch. In segmented
arch mechanics, individual adjustments are not normally made in the buccal
segment of the lingual arch during treatment; adjustments are made between
the auxiliary tube of the first molar and the anterior teeth.
Two basic side effects could be anticipated from intrusive mechanics. Looking
from the lateral view (Fig. 9)) a moment is created which tends to alter the plane
of occlusion of the buccal segment; in the upper arch the plane is steepened. To
minimize these changes, a number of principles are used in the intrusive mecha-
nisms that have been described. The forces are kept as low as possible. The largest
number of teeth are present in the buccal segment; these teeth are relatively
rigidly connected by a buccal stabilizing segment and across the arch with a
lingual arch. Finally, as an added precaution, occipital headgear can be used in
the upper arch, designed so that its force is anterior to the center of resistance
(Fig. 21).
The headgear produces a moment opposite to the moment produced by the
intrusive arch and thus prevents the steepening of the maxillary plane of occlu-
sion. If cooperation is excellent with this type of occipital gear, this moment may
overwhelm the moment produced by the intrusive arch and the posterior segment
could tip forward. For this reason, it is important to watch carefully the effects
of occipital headgear on patients who have already undergone extraction in the
upper arch. Although occipital headgear can help to control the posterior seg-
ment, prevent their extrusion, and minimize the moment tending to steepen the
plane of occlusion, they should be used only as an adjunct to treatment. Headgear
should not cover up basic inadequacies in intraoral mechanics.
The second major side effect produced by an intrusive arch can be seen from
the frontal view (Fig. 22). With an intrusive force on the incisors, there is an
equal and opposite extrusive force on the molars. Since the extrusive force is
operating buccally at a tube, it can be seen that a moment is created that tends
to tip the crowns lingually and the roots buccally. One of the functions of the
lingual arch is to prevent any undesirable change in axial inclination of the
 Deep overbite correction 15

Fig. 23. Patient R. A. before treatment. Deep overbite is characterized by overeruption of

the maxillary central incisors.

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

If one is to accomplish genuine intrusion in patients, it would be disappoint-

ing to succeed and then to lose the intrusion by using eruptive mechanics on the
incisors and molars. Extrusive mechanics on the posterior teeth should therefore
be avoided. Examples of extrusive mechanics are the use of Class II and Class
III intermaxillary elastics, cervical gear with outer bows placed high applied to
the maxillary arch, and the placement of a reverse curve of Spee in the lower
arch wire to extrude premolars.
One of the classic situations for inadvertently erupting incisors which have
been intruded or are going to be intruded is placement of a continuous arch wire,
with or without loops, through a canine which has a crown distal to the root. If
the arch wire is placed into the canine bracket, it will lie occlusal and hence will
produce eruption of the incisors. Incisors make very poor anchorage for distal
root movement of a canine, since eruption occurs so much more easily than distal
 Am. J. Orthod.
July 1977

Fig. 24. Patient R. A. Intrusive arch in place intruding the central incisors.

Fig. 25. Patient R. A. Following intrusion of the incisors, all six incisors are aligned with a
0.010 by 0.020 inch (0.254 by 0.508 mm.] section.

root movement. It is preferable to bypass the canines during canine root move-
ment, or in certain situations canine root movement should be completed before
the incisors are joined to the rest of the arch.
The typical patient who requires intrusion also requires minimization of
extrusion of the posterior teeth. An exception is found in some of the patients
with flat mandibular planes who have well-developed musculature. Extrusive
mechanics on posterior teeth can be used on some of these patients, provided the
cant of the plane of occlusion is controlled. Intrusion could be the final result
since the muscles of mastication may intrude the posterior teeth back to their
original positions. In these patients, it is necessary to keep the arches in place
until this intrusion has occurred. Inhibition of the eruption of posterior teeth in
the growing patient can be accomplished using a number of procedures. Occipital
headgear can be worn to the upper arch, cervical headgear with high outer bows
to the lower arch. Chin caps can be useful in inhibiting the eruption of posterior
teeth. Although there is not good documentation, it is possible that temporo-
masseter exercises could further aid in this inhibition.
Volume 12 Deep overbite correction 17
Number 1

Fig. 26. Patient R. A. at completion of treatment.

Treahnent sequence

Unless the incisors are protruded, intrusion is started during or following the
initial alignment of the posterior segments. Patient R. A. (Fig. 23) exhibited
deep overbite with excessive extrusion of the central incisors. During the first
appointment an 0.018 by 0.018 inch (0.457 by 0.457 mm.) alignment arch was
placed in the buccal segments and an 0.018 by 0.022 inch (0.457 by 0.559 mm.)
intrusive arch was inserted to the central incisor only, bypassing the canines and
lateral incisors (Fig. 24). When the central incisors were intruded to the level of
the lateral incisors and canines, a 0.010 by 0.020 inch (0.254 by 0.508 mm.)
anterior arch segment was placed from canine to canine to align the anterior
teeth and to hold the incisor intrusion (Fig. 25). Simultaneously, in the lower
arch, tip-back segments were used to remove the lower curve of Spee and to re-
tract the lower posterior segments. Headgear to the upper arch was used to
restrain the buccal segments in order to correct the Class II occlusion produced
by retraction of the lower buccal segments. The occlusion at the time of deband-
ing is shown in Fig. 26. The molar bands have been left in place so that head-
gear worn 6 to 8 hours a day could be used as a retentive appliance.
At the beginning of treatment Patient M. M. showed 100 per cent overbite
and a lateral open-bite tendency (Fig. 27). Since the central incisors were posi-
tioned occlusal to the lateral incisors, an 0.018 by 0.018 inch (0.457 by 0.457
mm.) connector was fabricated joining the central incisors together, bypassing the
canines and lateral incisors (Fig. 28). Intensive arches were used until the
Fig. 27. Patient M. M. before treatment. Deep overbite with lateral open-bite. To avoid
increase of vertical and eruptive incisor relationship to upper lip, no leveling of mandib-
ular curve of Spee was planned.

Fig. 28. Patient M. M. Incisor connector in place before placement of the intrusive arch.
Fig. 29. Patient M. M. Following incisor intrusion and alignment of the six anterior teeth,
the anterior segment is retracted en masse with 0.010 by 0.020 inch (0.254 by 0.508 mm.)
retraction spring.

.
Fig. 30. Patient M. M. at completion of treatment. Curve of Spee remains in lower arch.
Deep overbite was corrected by upper incisor intrusion.
Volume 73 Deep overbite correction 19
Number 1

Fig. 31. Patient M. M. Cranial base superposition (Dotted line-After treatment]. No man-
dibular rotation or increase in vertical dimension has occurred during treatment.
Fig. 32. Patient M. M. Maxillary and mandibular superpositions. Upper incisors have been
intruded 7 mm., measured at their apices.

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

Canine inrtrusion

It is usually not possible to intrude all six anterior teeth at one time without
producing undesirable axial inclination change in the posterior segment. TJsing
20 Burstone Am. J. Orthod.
Jzcly 1977

Fig. 33. An 0.018 by 0.025 inch (0.457 by 0.635 mm.) canine-intrusion spring. Passive
position.
Fig. 34. Canine-intrusion spring is activated by placing its anterior end into the vertical
tube of the canine.
Fig. 35. An 0.018 by 0.018 inch (0.457 by 0.457 mm.) intrusive spring attached to the
auxiliary tube on the second premolar. This spring is used if molar auxiliary tube is not
available.
Fig. 36. Active state of spring shown in Fig. 35. Helices lower load-deflection rate and
reduce unwanted negative moments on the canine.

the suggested force values, typically 100 Gm. of force on a side is required to
intrude the incisors and the canines. Table I shows that 100 Gm. would produce
a moment of 3,000 Gm.-mm. to the posterior segment if the perpendicular distance
from the incisors to the center of resistance of the posterior segment was 30 mm.
Since moments of this magnitude are most effective, tipping of the posterior teeth
will occur more rapidly than the intrusion, and since this tipping is not required,
intrusion mechanics will not be successful. If the posterior segment were backed
up with an occipital headgear in the maxillary arch, it is possible to eliminate
this undesirable moment as well as the eruptive force on the posterior teeth.
Without excellent cooperation from the patient in the wearing of headgear,
intrusion of six anterior teeth simultaneously should not be attempted.
Two types of situation require separate canine intrusion. In the first the
canine lies bilaterally occlusal to the premolar and the canine must be intruded
separately following anterior intrusion. In the second, the canines have not
erupted symmetrically and canine intrusion is required on only one side. In
 Deep overbite correction 21

Fig. 37. Canine root spring. During canine root movement intrusion can be carried out
simultaneously.

patients with deep overbite it is usually a mistake to level and extrude infra-
erupted canines. Many of these canines should be left in their original position
and the incisors should be intruded to their level.
Figs. 33 and 34 show a canine-intrusion spring which is activated to produce
50 to 75 Gm. of force. It is fabricated from 0.018 by 0.025 inch wire inserted into
the auxiliary tube of the first molar and into the vertical tube of a canine
bracket. Since the intrusive force lies lateral to the center of resistance of the
canine, it is necessary to place a slight constrictive force in the spring to keep the
canine from flaring labially. To minimize the chance of producing an undesirable
moment in the canine tube, it is a good idea to round the wire in the portion of
the spring that is placed in the vertical tube of a canine. If the incisors have
already been intruded, it is necessary to join them to the posterior segments by
an anterior wire inserted in the auxiliary tubes of the premolars stepped either
occlusally or gingivally around the canine. This wire holds the incisors in place
and adds further anchorage for the intrusion of the canines.
If the auxiliary tube in the first molar is not available for an intrusive spring,
an 0.018 by 0.018 inch (0.457 by 0.457 mm.) spring can be constructed which
inserts into the auxiliary tube of the most anterior premolar (Figs. 35 and 36).
If no auxiliary tubes are available, a continuous segment from molar forward to
canine can be constructed of this design. The 0.018 by 0.018 inch (0.457 by 0.457
mm.) intrusive spring is a modified rectangular loop with helices placed mesial
to the brackets. This design reduces the load-deflection rate and, more important,
assures that as the spring works out a vertical force will be delivered without an
undesirable moment being produced on the canine. If a canine is flared, a moment
is produced which flares the canine more; hence, it is necessary to tie the canine
back on both the buccal and lingual aspects. A buccal tie alone could cause the
canine to rotate with its distal aspect toward the lingual.
In addition to specialized intrusive springs, separate canine intrusion can be
produced by canine-retraction assemblies or root springs, In Fig, 37 a root spring
is being used to simultaneously retract the root and intrude the canine.
 Ant. J. Olthod.
July 1977

Summary

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

REFERENCES .-I
1. Burstone, C. J. : Lip posture and its significance in treritment planning, AM. J. ORTHOD.
53: 262-284, 1967. *
2. Rurstone, C. J.: Segmented arch technique, syllabus, Indianapolis, 1958, Indiana University.
3. Burstone, C. 5.: The rationale of the segmented arch, AM. J. ORTHOD. 11: 805-822, 1962.
4. Burstone, C. J.: Mechanics of the segmented arch technique, Angle Orthod. 36: 99-120,
1966.
5. Burstone, C. J., and Koenig, H. A.: Force systems from an ideal arch, AM. J. ORTHOD. 65:
270-289, 1974.
6. Dellinger, E. L.: A histologic and cephalometric investigation of premolar intrusion in the
Mmaca speciosa monkey, Aa6. J. ORTHOD. 53: 325-355, 1967.
7. Burstone, C. J.: Application of bioengineering to clinical orthodontics. In Graber, T. M.
(editor): Current orthodontic concepts and techniques, ed. 2, Philadelphia, 1975, W. B.
Saunders Company, pp. 230-258.
8. Burstone, C. J., Baldwin, J. J., and Lawless, D. T.: The application of continuous forces
to orthodontics, Angle Orthod. 31: l-14, 1961.

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