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ORIGINAL ARTICLE

Deepbite correction with incisor intrusion in adults: A long-term cephalometric study
€ u  r ı Tu € zc € l Onur Alpakan,b and C € rko Selin Kale Varlık,a Od ¸ ag Ankara, Turkey

Introduction: The purpose of this study was to investigate the long-term stability of deep overbite correction with mandibular incisor intrusion with utility arches in adult patients. Methods: Pretreatment, posttreatment, and 5-years postretention lateral cephalograms of 31 patients (mean age, 26.8 years; range, 24.1-30.9 years) with Class II Division 1 malocclusion and deepbite, treated by maxillary first premolar extraction and mandibular incisor intrusion, were traced and measured. Results: Significant decreases in overjet and overbite (6.4 6 1.2 and 3.9 6 0.7 mm, respectively), significant retroclination (17 6 1.9 ) and retraction (3.8 6 1.1 mm) of the maxillary incisors, and significant increases in protrusion (0.8 6 1.5 mm), proclination (0.6 6 0.9 ), and intrusion (2.6 6 1.4 mm) of the mandibular incisors were observed at posttreatment. At postretention, there were statistically significant but clinically unimportant increases in overjet and overbite (0.4 6 0.2 and 0.8 6 0.4 mm, respectively) and extrusion of the mandibular incisors (0.8 6 1.1 mm). Conclusions: Correction of deepbite in nongrowing patients by mandibular incisor intrusion with a utility arch can be considered effective and stable. (Am J Orthod Dentofacial Orthop 2013;144:414-9)

orrection of deepbite is often a challenging step in orthodontic treatment. Untreated deepbite can cause increased anterior crowding, maxillary dental flaring, periodontal problems, and temporomandibular joint problems and can interfere with lateral and anterior mandibular movements.1-3 Deepbite can be treated orthodontically by intrusion or flaring of the incisors, extrusion or passive eruption of the buccal segments, or a combination of these.4-6 The choice of treatment depends on several factors. Extrusion of the posterior dentition, although an effective method of bite opening in growing patients,7,8 is not indicated in patients with normal incisor display or normal or long lower facial height; its stability is questionable in nongrowing patients with average to low mandibular plane angles.6,9-14 Intrusion of the maxillary incisors is indicated in patients with excessive incisor and gingival display and a large interlabial
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gap.13-15 Considering these facts, mandibular incisor intrusion is the most suitable deepbite treatment for adults with normal incisor and gingival display and a normal or high mandibular plane angle. Although many studies have examined the stability of deepbite treatment, most included growing subjects. In some studies, different malocclusions or different treatment methods were assessed together, and in others the follow-up durations were short.16-19 Two studies of nongrowing subjects did not include information about long-term follow-up results and treatment stability.20,21 The purpose of this study was to investigate the longterm stability of deepbite correction with mandibular incisor intrusion with utility arches in adult patients. The null hypothesis was that dental deepbite correction with mandibular incisor intrusion in adults is stable.
MATERIAL AND METHODS

Associate professor, Department of Orthodontics, Faculty of Dentistry, Gazi University, Ankara, Turkey. b Private practice, Ankara, Turkey. c Assistant professor, Department of Orthodontics, Faculty of Dentistry, Gazi University, Ankara, Turkey. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Reprint requests to: Selin Kale Varlık, Gazi University, Faculty of Dentistry, Bis ¸ kek Cd. 1. Sok. No: 4 06510 Emek, Ankara, Turkey; e-mail, kaleselin@yahoo.com. Submitted, February 2013; revised and accepted, April 2013. 0889-5406/$36.00 Copyright Ó 2013 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2013.04.014

In this retrospective longitudinal study, pretreatment (T1), posttreatment (T2), and postretention (T3) lateral cephalograms of 31 patients (24 women, 7 men) with Class II Division 1 malocclusion treated with a 1-phase maxillary first premolar extraction protocol by either of the first 2 authors were used. Their mean age at the beginning of treatment was 26.8 years (range, 24.1-30.9 years). The inclusion criteria were (1) standardized lateral cephalograms available at 3 time periods, T1, T2, and T3; (2) deepbite of at least 4.5 mm; (3) normal vertical dimension represented by

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were used for incisor intrusion.025-in betatitanium alloy archwires (Resolve. custom-made mandibular utility arches (0. ethical approval was not needed. The measurements are shown in the Figure and Table I. American Journal of Orthodontics and Dentofacial Orthopedics September 2013  Vol 144  Issue 3 .018-in slot preadjusted metal brackets with the Roth prescription. Onur Alpakan. GAC International. the canines were retracted with nickel-titanium coil springs (Sentalloy. Chicago. (4) 3 to 4 mm or less of maxillary incisor display at rest. The center of resistance (a point located at one-third of the distance Fig.05. The significance level was set at P \0.€rk€ Kale Varlık.016 3 0. and the force levels were checked every 4 weeks. During this period.05 was 0.25 (L1 to MP) to 0. Chatsworth. and Tu oz 415 lower face height of 47 6 3 . of the root length apical to the alveolar crest) was used to evaluate the vertical positions of both the mandibular and maxillary central incisors.5 years.016 3 0. and from 0. and method error was calculated with Dahlberg’s formula. and (6) 4 mm or less crowding in the maxillary and mandibular arches. The retention period lasted 1.V. Intrusion was considered complete when a 2-mm overbite was achieved. Dolphin Imaging & Management Solutions.022-in Blue Elgiloy stabilization utility arch was placed. Calif). GAC International) with mushroom loops. followed by multiple comparisons with the Bonferroni adjustment. RESULTS The method error ranged from 0. Because the Shapiro-Wilks test showed that all data were normally distributed.55 mm (L6 to MP) for the linear measurements.8-mm change in overbite in postretention period was statistically significant. Ormco. At this point. The mean active treatment time was 2. informed consent had been obtained at T1 from all patients as the routine protocol.) hand-traced the lateral cephalograms and identified all landmarks.017 3 0. Because the sample size was 31 subjects and the 0.22 Sixty randomly chosen lateral cephalograms were retraced and redigitized. Calif) was used to obtain the cephalometric measurements. The intrusive force of 40 g was checked before tying the archwire. activated to exert 40 g of force. The mandibular incisors and premolars were leveled by 0. and overall changes (T3-T1) were compared by repeated measurements analysis of variance (ANOVA). and Dolphin software (version 10. The patients were instructed to wear the retainers 24 hours a day for the first year and only at night after that.23 Statistical analysis Statistical analysis was completed using the Statistical Package for Social Sciences (version 13.45 (U1 to L1) for the angular measurements. The same author (S.016 3 0.016-in nickel-titanium segments if necessary. 0. Glendora.15 mm (U1CR to PP) to 0.016 3 0. Central Islip. and a 0. NY) exerting 150 g of force on 0. postretention (T3-T2). the power of the study at a significance level of 0. All patients had 0. maxillary and mandibular wraparound retainers were delivered. The incisors were retracted by 0.K. Immediately after debonding. after alignment.022-in stainless steel stabilizing sections extending from the first molars to the first premolars were placed.4-3 years). SPSS. GAC International). The treatment protocol included intrusion of the mandibular incisors to correct the deepbite and extraction of the maxillary first premolars to correct the overjet. 0.017 3 0. All patients had transpalatal arches on the maxillary first molars before the extractions. 2. treatment (T2-T1). Because of the retrospective nature of the study and because no additional x-rays were taken.025-in stainless steel wires were used for finishing in both arches. After leveling.022-in stainless steel archwires (Accuform. Ill). (5) overjet of at least 6 mm. All handtracings were scanned with a scanner at 200 dpi.86. the mandibular canines were tied to the stabilizing utility arch with elastic thread if their intrusion was necessary. In the maxillary arch.022-in Blue Elgiloy wires. Cephalometric landmarks.7 years (range.

1 6 1.9 6 1.1 115.6 6 1.2 ).3 U1CR to PP (mm) 12.9 ANS to Xi/Xi-PM ( ) Overbite (mm) 5.9 6 0.2 6 2.4 6 2.9 ) and retraction (3. Of the treatment changes (T2-T1). DISCUSSION The aim of this study was to evaluate the long-term stability of deepbite correction in adults with mandibular incisor intrusion using the bioprogressive sectional arch technique.4 4. significant extrusion of incisors (0.6 6 1.1 L1CR to MP (mm) 28. The SN to MP and ANS to Xi/Xi-PM angles did not change significantly.1% of the pretreatment overbite.7 28.1 2.4 U1 to PP ( ) U1 to APg (mm) 8. and overall changes and their comparisons are shown in Table III.8 6 0.1 *Mandibular plane (MP): formed by a line through menton. During the overall period (T3-T1).9 94.6 6 2.9 6 2.8 6 1.9 6 0.7 6 3. postretention. yXi: the geometric center of the ramus of the mandible.4 6 5. The mandibular molars were extruded. T2.7 6 1 mm).3 6 1.0 6 0.6 6 0.4 mm) and extrusion of the molars (0. kCenter of resistance (CR): a point located at one-third of the distance of the root length apical to the alveolar crest.4 6 2.9 6 0. which corresponded to 66.9 94.6 6 2. these changes contributed to a significant decrease in overjet (À6.2 2. respectively).7 Overjet (mm) 8. tangent to the lower border of the angle of the mandible.9 and 0. In that September 2013  Vol 144  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics . This ratio is higher than the ratio reported in the study of Weiland et al20 using adult patients.8 6 0.8 6 0.5 6 4.6 6 4.9 mm.1 6 0.4 U6 to PP (mm) 28.2 6 2. and the mandibular incisors were protruded (0.4 2. parallel to OP Perpendicular distance between the center of resistancek (CR) of maxillary central incisor and palatal plane (PP) Angle formed by the long axis of maxillary central incisor and palatal plane Perpendicular distance from maxillary incisor incisal edge to A-point–pogonion line Perpendicular distance from the mesiobuccal cusp tip of maxillary first molar to PP Perpendicular distance between the CR of mandibular central incisor and mandibular plane (MP) Angle formed by the long axis of mandibular central incisor and MP Perpendicular distance from mandibular incisor incisal edge to A-point–pogonion (APg) line Perpendicular distance from the mesiobuccal cusp tip of mandibular first molar to MP Angle formed by the long axes of maxillary and mandibular incisors ations Pretreatment Posttreatment Postretention Measurement Mean 6 SD 32.1 .8 6 0.0 6 2.416 €rk€ Kale Varlık.1 6 1.7 6 2. Onur Alpakan.8 U1 to L1 ( ) Mean 6 SD 33.6 47. overjet and overbite significantly decreased by 6.2 6 5.1 mm) significantly.5 mm) and proclination (0. The null hypothesis was that dental deepbite correction with mandibular incisor intrusion in adults is stable. and 3. Significant retroclination (17 6 1.2 6 3. the null hypothesis was not rejected.9 27. Other variables did not show any changes.4 mm. Cephalometric measurements at the 3 evalu- Overjet (mm) U1CR to PP (mm) U1 to PP ( ) U1 to APg (mm) U6 to PP (mm) L1CR to MP (mm) L1 to MP ( ) L1 to APg (mm) L6 to MP (mm) U1 to L1 ( ) Angle formed by the sella-nasion line and mandibular plane* (MP) Angle formed by the line extending from anterior nasal spine to Xiy and corpus axis (Xi-PMz) Distance between incisal edges of maxillary and mandibular central incisors. There were significant increases in the protrusion (0. The vertical positions of the maxillary incisors and molars and the proclination of the mandibular incisors had no significant changes from T1 to T3. In the mandibular arch. Among the postretention (T3-T2) changes.9 Mean 6 SD 33.3 6 1. and T3 are shown in Table II.8 6 1. zPM: protuberance menti point selected at the anterior border of the symphysis between Point B and pogonion where the curvature changes from concave to convex.9 L6 to MP (mm) 36.8 36.3 6 1.2 mm) and an increase in the interincisal angle (21.8 6 1.4 6 3.6 2. The mean values for the cephalometric measurements at T1. The interincisal angle increased by 21.1 6 0. respectively (Table I).3 6 0. and the treatment. and Tu oz Table I.4 SN to MP ( ) 47.4 6 1.7 mm.6 6 3.3 47.8 6 1.5 110.8 L1 to MP ( ) L1 to APg (mm) 2.8 132. the maxillary incisors were retroclined (16.1 mm) was observed.1 94. there were significant increases in overjet and overbite (0. § Occlusal plane (OP): formed by a line bisecting the overlapping cusps of the first molars and the incisal overbite.6 28. There were no significant changes in the vertical positions of the maxillary incisors and first molars.2 6 5.3 6 5. and the mandibular incisors were intruded significantly.4 6 2.3 6 2.2 12.8 6 0.1 mm) of the maxillary incisors were observed.9 ) of the mandibular incisors.3 12. In the mandibular arch.9 2.5 6 5.7 131. Cephalometric measurements SN to MP ( ) ANS to Xi/Xi-PM ( ) Overbite (mm)  Table II.1 4.9 26.3 6 0.2 6 2.6 mm) were observed.5 2.3 6 0. The mean overbite correction at T2 was 3.6 36.5 6 2.4 ) and retracted (À3. based on our results. perpendicular to occlusal plane§ (OP) Distance between incisal edges of maxillary and mandibular central incisors.6 131.4 6 0. significant intrusion of the incisors (À2. these changes resulted in a significant reduction in overbite.6 115.7 6 1.

as was proposed by Ng et al. flaring has been associated with an increased incidence of relapse.9 À17.1 6 0. and overall changes Treatment changes (T2-T1) Measurement SN to MP ( ) ANS to Xi/Xi-PM ( ) Overbite (mm) Overjet (mm) U1CR to PP (mm) U1 to PP ( ) U1 to APg (mm) U6 to PP (mm) L1CR to MP (mm) L1 to MP ( ) L1 to APg (mm) L6 to MP (mm) U1 to L1 ( ) Mean 6 SD 0.4 0. Descriptive statistics and statistical comparisons of the treatment.1%.21.34.6 0.9 À3.56 mm.2 À0.4 6 5.5 6 0.7 6 1.6 0.8. *P \0.8 À2.8 mm) at T3 was acceptable.9 0.4 0.5 0.32 At the end of the treatment.14.26-31 We used incisor centroid as a reference point and evaluated true intrusion. which was below the normal range at T1. cannot be ruled out. Similar mean intrusion values between 1. study.8 0.7 Sig NS NS * * NS NS NS NS * NS NS NS NS Overall changes (T3-T1) Mean 6 SD 0. An intrusive force that is labial to the center of resistance of the incisors would intrude them but also tip them labially.2427 However.1 6 3. follow-up and retention durations.8-mm relapse was observed at T3.1 6 0. and depending on the original inclination of the incisors.6 mm of mandibular incisor intrusion was achieved. a statistically significant but clinically insignificant relapse of 0. increased significantly after treatment mainly because of retraction of the maxillary incisors.6 0. and the overall intrusion value of 2. and retainer type.1 0. 2 different mechanics were used. these values were much lower than the values reported in other studies in which intrusion utility arches were used.10.40 However. resulting in somewhat higher than actual intrusion values. postretention.7 0.8 0. respectively.8 À3.2 6 0.34 An important consideration with regard to centroid while evaluating the mean incisor intrusion value is that although it was claimed to be independent of any change in the axial inclination. the posttreatment overbite value was slightly lower than that reported by Weiland et al.€rk€ Kale Varlık.6 21.8 6 0.5 6 5. According to Houston.9 6 0.2 6 0. initial overbite value.8 6 0.6 6 1.8 mm and 0.17 In this study.6 À0.39 Less American Journal of Orthodontics and Dentofacial Orthopedics September 2013  Vol 144  Issue 3 .9 6 0. Although statistically significant.1 6 0. not significant. muscle strength.2 6 1.4 À3. there are differences in terms of factors that were previously reported to have affected overbite stability. statistically significant increases in both proclination and protrusion of the mandibular incisors were observed after treatment.12 Labial tipping tends to decrease overbite because it influences the vertical incisal edge position.6 .1 À0. adaptation capacity. NS.8 6 1. growth pattern.3 6 0.8% and 58. Significance. The interincisal angle is believed to play a critical role in the stability of deepbite correction.3 6 0.1 6 1. the mean interincisal angle.0 6 1.1 to 2. it approached the norm values proposed by several authors and did not change at T3.9 À16. In previous studies.7.2 Sig NS NS * * NS * * NS * NS * * * Sig.10.6 6 0. either similar or higher relapse values ranging from 0.0 0.3 À0.2 6 3.1 À0. Although this relapse was statistically significant. it can be advantageous in deepbite correction.8.34.7 À6.35 an approximate interincisal angle of 135 inhibits incisor overeruption and thus has an impact on the stability of deepbite treatment. In our study. The difference could be because in our study.1 6 1.8.8 À6.1 6 0.6 21.7 6 1.9 0.4 6 1.33.13. Onur Alpakan.5 À0.1 mm were reported. corresponding to 58. and Tu oz 417 Table III.3 0.16. The mean increases in L1 to APg and L1 to MP were 0. an 0.2 À0.9 À0. 2.2 6 0.3 6 1.1 6 0.33.9 0.1 Sig NS NS * * NS * * NS * * * * * Postretention changes (T3-T2) Mean 6 SD À0.1 and 3 mm were reported in previous studies where deepbite correction was accomplished by only mandibular incisor intrusion with segmental or sectional arches. respectively.32 In this study. and the correction values were 3. and the mean overbite (2. when our results were compared with those of previous studies.2 6 3. the possibility that centroid can slightly move apically because of proclination of the incisors. it was not clinically important because the overbite value at T3 was well within the normal range.17 and 3.2 6 0.14.3 6 0.8 mm was observed at T3.4 6 0.8 6 1.6 6 1.5 6 1.36-38 The substantial stability of overbite correction in this study seems to support the validity of the interincisal angle values suggested for stability by Berg and Houston. Berg28 suggested that the interincisal angle should be less than 140 at the end of treatment for stability of deepbite treatment.3 À0.39.001.8 À2. In this study.8 6 1.7 À3.1 6 1.17.1 mm was quite remarkable. such as the subjects' growth potential.10.

prevention of posterior extrusion that could result in relapse and opening rotation of mandible was intended. To this end. Maggard BM. This value was lower than reported in other studies in which mandibular incisor intrusion was performed with segmental or sectional arches.5 mm. Deep overbite correction by intrusion. Although consecutively treated subjects were included without regard to treatment and postretention outcomes and 2 orthodontists with similar experience provided the orthodontic treatment. The molars retained their new vertical positions in the postretention period.69:175-86. In the study of Dake and Sinclair. With mandibular intrusion utility arches. In our study. sectional arches were used for intrusion.13 1 mm of maxillary or mandibular molar extrusion effectively reduces incisor overlap by 1. adhering strictly to treatment and retention protocols. a statistically significant but clinically unimportant relapse of 0. Am J Orthod Dentofacial Orthop 1989. Onur Alpakan. and stabilization sections were used to enhance the vertical anchorage of the mandibular molars and premolars. This study involved nongrowing patients with normal vertical dimensions. Angle Orthod 1999. Postretention assessment of deep overbite correction in Class II Division 2 malocclusion.016 3 0. Sinclair PM. Am J Orthod 1977. and the mean mandibular incisor intrusion was 2. St Louis: Mosby International. thus.6 mm of mandibular molar extrusion. 12. Long-term effectiveness of the continuous and sectional archwire techniques in leveling the curve of Spee. despite these measures. One explanation for the lower value in our study could be that these 2 studies were conducted with growing subjects who had a likelihood of continuing molar eruption.92:467-77. Dent Clin North Am 1997.10 when the mandibular incisors were intruded with utility arches. 2. 3. Deepbite treatment with mandibular incisor intrusion with utility arches was effective and appeared to be stable in nongrowing patients. Dake ML. Trevisi HJ. an intrusion force of 40 g might not have affected the posterior vertical anchorage. This study had some limitations because of its retrospective design without randomization. REFERENCES 1. September 2013  Vol 144  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics . Preston BC. Correction of deep overbite in adults. 1st ed.022in utility arches in this study.6 mm of mandibular molar extrusion. Overbite and vertical facial dimensions in terms of muscle balance. Important aspects of long-term stability.59: 237-56. Al Buraiki et al16 used lever arches and reported 1. molar extrusion might have contributed to overbite correction. Angle Orthod 1988. According to Nanda and Kuhlberg. A longitudinal study of anterior vertical overbite from eight to twenty years of age. together with the modest increases in the proclination and protrusion of the mandibular incisors. Little RM.7:26-33.7 mm. thus providing better torque control. Systemized orthodontic treatment mechanics. therefore.31 Moreover. J Clin Orthod 1997. these findings must be regarded with some caution. Lampasso J. 2. 5. Am J Orthod Dentofacial Orthop 2008.6 mm of true incisor intrusion was obtained. Semin Orthod 2001. The reason for no relapse might be that the L1 to APg and L1 to MP measurements were within normal ranges at T1.6 6 1.133:550-5. 8. extrusion of 0. the mean overbite reduction was 3. Associations between occlusal characteristics and signs and symptoms of TMJ dysfunction in children and young adults. Angle Orthod 1994.95:72-8. Five years after the end of the retention period. the intrusion force used in this study was lower than that was used by Dake and Sinclair. Brandt D. Burstone CJ. 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Relapse of proclined incisors is thought to be related to distortion of the perioral neuromuscular balance13 or the tendency of incisors that were upright at the beginning of treatment to return to their original positions. 4. 3.31:562-83.48:805-21. The rationale of the segmented arch.418 €rk€ Kale Varlık. and Tu oz incisor flaring could be due to the use of 0. they remained within the normal ranges at T2 and therefore caused no neuromuscular imbalance. Am J Orthod Dentofacial Orthop 1987. the potential for selection bias still exists.14:13-7. Similarly. 7. 0. Am J Orthod 1962. Burzin and Nanda14 also found no relationship between molar extrusion and overbite relapse.42 Still. McLaughlin RP. Chalabi O. CONCLUSIONS 1.41. they reported 2. Burstone CJ. Wylie WL. 11. the 0. That is. despite some flaring. Biomechanics of deep overbite correction.5 to 2.8 mm of molar extrusion was observed.

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