ORIGINAL ARTICLE

Evaluation of marginal alveolar bone

in the anterior mandible with pretreatment
and posttreatment computed tomography
in nonextraction patients
David T. Garlock,a Peter H. Buschang,b Eustaquio A. Araujo,c Rolf G. Behrents,c and Ki Beom Kimd
Denver, Colo, Dallas, Tex, and St Louis, Mo

Introduction: Our objectives were to evaluate marginal alveolar bone height in the anterior mandible after or-
thodontic treatment and to assess any correlations between morphologic and treatment changes. Methods:
We used 57 pretreatment and posttreatment cone-beam computed tomography images (17 male and 40
female subjects; 22 Class I, 35 Class II; average age, 18.7 6 10.8 years; average treatment time,
22.7 6 7.3 months) to measure cortical bone thickness, ridge thickness, distance from the apex to the labial
cortical bone, and the distance from the cementoenamel junction to the marginal bone crest. Changes in the
cementoenamel junction to the marginal bone crest distance were correlated with pretreatment
measurements and treatment changes. Results: Although there were great variations, the average facial and
lingual vertical bone losses were 1.16 6 2.26 and 1.33 6 2.50 mm, respectively. The incisor-mandibular
plane angle changes were also highly variable, averaging 2.4
. Conclusions: Orthodontic treatment causes
changes in alveolar bone height and cortical bone thickness around the mandibular incisors. Although pretreat-
ment cortical bone thickness, ridge width thickness, and specific tooth movements all play roles in what happens
to the bone during treatment, incisor inclination was not correlated with alveolar bone height changes. (Am J
Orthod Dentofacial Orthop 2016;149:192-201)

T
he tissue response to orthodontic forces can
lead to gingival inflammation, alveolar bone loss,
damage to the tooth enamel surfaces, pulpal reac-
tions, root resorption, and marginal bone loss.1 Many
studies have evaluated the effects of orthodontic treat-
ment on alveolar bone height.
Most studies evaluating alveolar bone height have
used bitewing or periapical radiography and have
focused on the posterior dentition.2-8 The advent of
cone-beam computed tomography (CBCT) has allowed
for more extensive studies evaluating alveolar bone
a
Private practice, Denver, Colo.
b
Professor, Department of Orthodontics, Baylor College of Dentistry, Texas A&M
University, Dallas, Tex.
c
Professor, Department of Orthodontics, Saint Louis University, St Louis, Mo.
d
Associate professor, Department of Orthodontics, Saint Louis University, St
Louis, Mo.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Ki Beom Kim, Department of Orthodontics, Saint
Louis University, 3320 Rutger St, St Louis, MO 63104; e-mail, kkim8@slu.edu.
Submitted, September 2014; revised and accepted, July 2015.
0889-5406/$36.00
Copyright Ó 2016 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.07.034
192
height in the anterior region. Sarikaya et al,9 who evalu-
ated patients requiring retraction of the maxillary inci-
sors to close extraction spaces, found that the lingual
alveolar bone thickness decreased significantly; in 11
of 19 patients, at least 1 incisor was outside the alveolar
bone at the crest level. Lund et al,10 who also evaluated
premolar extraction patients, found that 84% of the
lingual surfaces of the mandibular central incisors
demonstrated bone height decreases of more than
2 mm, with average decreases of 5.7 mm on the lingual
aspect and increases of 0.8 mm on the buccal aspect of
the same tooth.
Experimental evidence suggests that vertical bone
loss can also occur when mandibular incisors are pro-
clined. Steiner et al11 found that in monkeys, moving
the mandibular incisors labially by 3.05 mm caused
5.48 mm of marginal bone loss. Also using monkeys, Ba-
tenhorst et al12 reported 7 mm of bone loss associated
with 6 mm of incisor proclination. Similar studies with
human subjects have yet to be performed.
Because of the lack of human studies, the purpose of
this study was to evaluate how changes of incisor posi-
tion affect marginal alveolar bone height using CBCT. A
Garlock et al
Fig 1. Cephalometric landmarks.
secondary purpose was to evaluate any associations be-
tween initial bone characteristics and changes in bone
characteristics with the amount of vertical alveolar
bone height changes.
MATERIAL AND METHODS
The study was based on pretreatment and post-
treatment CBCT images of 57 patients who had none-
xtraction treatment by 1 practitioner. The CBCT
images were taken with an i-CAT CBCT machine (Imag-
ining Sciences International, Hatfield, Pa). The scans
were taken in a single 360
rotation at a scan time of
4.8 seconds, 120 kVp, 0.3-mm voxel size, and
536 3 536 mm field of view.
A total of 114 CBCT images (57 pretreatment, 57 post-
treatment) pertaining to 17 male and 40 female subjects,
ages 18.7 6 10.8 years, were used. Of the 57 subjects, 22
had Class I and 35 had Class II malocclusions. Patients
were excluded if they had (1) missing or unerupted
mandibular permanent incisors, (2) periapical or perira-
dicular pathologies or radiolucencies of either periodontal
or endodontic origin, (3) a significant medical or dental
history (eg, use of bisphosphonates or bone altering med-
ications, or diseases), and (4) poor image quality.
All patients were treated with self-ligating Damon Q
brackets (Ormco, Orange, Calif) with a 0.022-in slot.
Initial leveling and aligning were performed using round
(0.014 and 0.018 in) and rectangular (0.014 3 0.025 in,
and 0.018 3 0.025 in) heat-activated nickel-titanium
archwires. Finishing archwires consisted of rectangular
(0.019 3 0.025 in) stainless steel wires. The mean treat-
ment duration was 22.7 6 7.3 months.
Each CBCT scan was imported into the software
(version 11.0; Dolphin Imagining & Management
American Journal of Orthodontics and Dentofacial Orthopedics
193
Solutions, Chatsworth, Calif) for analysis. With the 3-
dimensional image oriented along the Frankfort hori-
zontal plane, lateral cephalograms were constructed
with the midline bisecting the mandibular right central
incisor, thus creating an image representing the left
half of the craniofacial complex.
From the constructed lateral cephalograms, the
following structures and landmarks were identified
and traced: mandibular right incisor tip, mandibular
right incisor apex, labial gingival border, lingual gingival
border, inferior alveolar canal (4 points), internal
border of the symphysis (superior and inferior), B-point,
pogonion, gonion, gnathion, and menton (Fig 1). The
incisor-mandibular plane angle (IMPA), the angle
formed by the intersection of the long axis of the
mandibular incisor and the gonion-menton line, was
measured. The pretreatment and posttreatment mandi-
bles were then superimposed using stable structures as
described by Bjork and Skieller.13 From the superimposi-
tions, the x and y coordinates of each point were ob-
tained, with pogonion as the origin and orienting
along the Frankfort horizontal plane. The coordinates
were used to calculate the angular differences between
the pretreatment and posttreatment incisor positions.
The coordinate system was also used to calculate the an-
teroposterior distances that the apex and the incisor tip
moved.
To examine the morphologic features of the alve-
olar bone, each CBCT image was oriented along the
long axis of the mandibular right central incisor (bi-
secting the pulp and the canal) in the sagittal and cor-
onal planes, and bisecting the canal in a labiolingual
direction in the axial plane at the same time (Fig 2).
Only the right side was measured because there are
February 2016  Vol 149  Issue 2
194 Garlock et al

Fig 2. All 3 planes of space on the CBCT were oriented simultaneously. A sagittal section x-ray was
built from the CBCT oriented along these planes.

Fig 3. Measurements from CBCT: A, distance from the CEJ to marginal bone crest (L-CEJ-MBC,
F-CEJ-MBC), and ridge thickness (MRR, AR); B, cortical bone thickness at midroot level (MLCB,
MFCB) and apex level (ALCB, AFCB). Distance from apex to internal border of the facial cortical
bone (ACB).

no side differences in cortical bone thickness.14,15 and lingual (L-CEJ-MBC) aspects were made from
Once oriented, a sagittal cross section of the the most apical portion of the cementoenamel
mandibular right incisor was produced. From this junction (CEJ) to the most coronal aspect of the
image, measurements from the labial (F-CEJ-MBC) marginal bone crest (Fig 3, A).

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Garlock et al 195

Table I. Definitions of variables, their abbreviations, and method errors

Measurement Abbreviation Method error
Distance from facial cementoenamel junction to facial marginal bone crest F-CEJ-MBC 0.21
Distance from lingual cementoenamel junction to lingual marginal bone crest L-CEJ-MBC 0.22
Incisor-mandibular plane angle IMPA 0.86
Degree of change in incisor angulation calculated from x and y coordinates with trigonometry SUP 0.96
Distance that the apex of the mandibular right incisor moved between pretreatment and posttreatment APEX 0.44
from x and y coordinates
Distance that the tip of the mandibular right incisor moved between pretreatment and posttreatment TIP 0.32
from x and y coordinates
Distance from apex to internal border of facial cortical bone ACB 0.24
Midroot-level facial cortical bone thickness MFCB 0.13
Midroot-level lingual cortical bone thickness MLCB 0.14
Apex-level facial cortical bone thickness AFCB 0.21
Apex-level lingual cortical bone thickness ALCB 0.20
Midroot-level ridge thickness MRR 0.24
Apex-level ridge thickness AR 0.24

Table II. Descriptive statistics for tooth position changes and tooth landmark changes for pretreatment (T1), post-
treatment (T2), and differences between the variables, 1-sample t test P values for the means of T2 – T1, and method
error
T1 T2 T2 – T1 (D) t test

Variable Mean SD Mean SD Mean SD P value

IMPA (
) 95.3 6.68 97.7 1.13 2.40* 6.90 0.01
SUP (
) - - - - 2.52* 7.20 0.01
APEX (mm) - - - - -0.45* 1.47 0.03
TIP (mm) - - - - 0.07 0.25 0.79
ACB (mm) 3.44 1.33 3.77 1.88 0.32 1.39 0.08

T1 and T2 values are absent for SUP, APEX, and TIP because these variables were calculated from the rectangular “(x and y)” coordinates.
*Significant (P #0.05).

Table III. Statistics for bony changes

T1 T2 T2 – T1 (D) t test

Variable (mm) Mean SD Mean SD Mean SD P value

F-CEJ-MBC 1.90 1.89 3.06 2.46 1.12* 2.26 \0.01
L-CEJ-MBC 2.18 2.12 3.51 3.00 1.33* 2.50 \0.01
MFCB 0.75 0.38 0.65 0.40 0.10* 0.38 0.05
MLCB 1.04 0.58 0.76 0.59 0.29* 0.53 \0.01
AFCB 1.93 0.36 1.87 0.50 0.06 0.41 0.24
ALCB 2.32 0.55 2.07 0.68 0.25* 0.65 0.01
MRR 7.38 1.11 7.17 0.99 0.21* 0.70 0.02
AR 10.2 2.31 10.20 2.46 0.04 1.00 0.75
Positive numbers for CEJ-MBC values represents an increase in distance from the CEJ-MBC (bone loss), and negative numbers for CEJ-MBC values
represent a decrease in distance from the CEJ-MBC (bone gain); for all other variables, a negative number represents thinning of bone, and a positive
number represents bone thickening.
*Significant (P #0.05).

From the height of the labial CEJ point, a horizontal
line was made. From this line, a vertical distance from
the labiolingual midpoint of the pulp canal to the apex
of the root was measured. This distance was halved,
and a horizontal was drawn demarking the height at
which the midroot-level ridge thickness (MRR) (Fig 3,
A) and midroot-level cortical bone thickness (MLCB
and MFCB) were measured (Fig 3, B). Another horizontal
line was drawn at the height of the apex. This height was
used to measure apex-level ridge thickness (AR) (Fig 3,

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196 Garlock et al

Table IV. Distance changes between the pretreatment and posttreatment cementoenamel junction and the marginal
bone crest on the facial and lingual surfaces
n \ 4 mm 4 $ 2 mm  .0 mm 0 # 2 mm 2 \ 4 mm 4 # 6 mm 6 \ 8 mm
F-CEJ-MBC D 57 1 (1.8) 1 (1.8) 10 (17.5) 31 (54.3) 5 (8.8) 5 (8.8) 4 (7)
L-CEJ-MBC D 57 1 (1.8) 1 (1.8) 11 (19.3) 33 (57.8) 3 (5.3) 6 (10.5) 2 (3.5)
A negative number means that the CEJ-MBC posttreatment distance was shorter than the pretreatment distance, representing bone gain, and a
positive number mean that the CEJ-MBC posttreatment distance was greater than the pretreatment distance, representing bone loss.
Values are shown as n (%).

Fig 4. Averages and standard deviations for IMPA, SUP, APEX (a negative value is backward move-
ment, positive is forward movement), TIP, and ACB (a positive value represents a greater distance to
facial cortical bone after treatment; negative values represent a shorter distance from the apex to the
facial cortical bone after treatment). Note that 68% of the sample had IMPA changes ranging from
nearly 5
to 9
, indicating a large range of changes in the sample. Statistically significant areas are
starred (P #0.05).

A), cortical bone thickness (ALCB and AFCB), and dis-
tance (ACB) from the apex to the internal border of the
labial cortical bone (Fig 3, B).
Cortical bone thickness was measured as the line
from the point where the horizontal line intersected
the internal border of the cortical plate, perpendicular
to the external border of the cortical plate.
Technical reliability of the measurements was based
on 2 replicate measurements of 40 pretreatment or post-
treatment records, which were randomly selected from
the larger sample. Random error was quantified using
the method-error statistic, calculated with the following
formula:
rffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
X
ðReplicate1  Replicate2 Þ2 80
Statistical analysis
Skewness and kurtosis indicated that the measure-
ments were normally distributed. A 1-sample t test was
used to evaluate the changes between the pretreatment
and posttreatment measurements. The associations be-
tween variables were analyzed using the Pearson corre-
lation coefficient. All analyses were performed with SPSS
software (version 20; IBM, Armonk, NY).
RESULTS
The random method error ranged from 0.13 to 0.96
for all variables (Table I).
Tooth position changes that were statistically signif-
icant (P \0.05) included changes in IMPA, SUP, and
APEX (Table II). All bony changes were statistically sig-
nificant except for the facial apex-level cortical bone
.  thickness changes (AFCB D) and the apex-level ridge
thickness changes (AR D) (Table III).
Most of the variables showed large variations among
subjects. For example, there was an average of 1.12 mm
of facial bone loss (F-CEJ-MBC D), but the individual
changes ranged from a 4-mm gain to an 8.8-mm loss.
Similarly, there was an average of 1.33 mm of lingual
bone loss (L-CEJ-MBC D), with a range of 5.6 mm

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Garlock et al 197

Table V. Correlations with age, treatment time, and Angle classification

F-CEJ-MBC D L-CEJ-MBC D

R P R P
Age 0.01 0.94 0.11 0.43
Treatment time 0.03 0.83 0.12 0.40
Angle class 0.19 0.17 0.09 0.53

Table VI. Correlations of pretreatment variables with facial and lingual cementoenamel junction to marginal bone
crest distance changes
F-CEJ-MBC D L-CEJ-MBC D

R P R P
ACB T1 0.18 0.17 0.10 0.48
AFCB T1 0.33y 0.01 0.18 0.17
ALCB T1 0.27* 0.04 0.01 0.96
MFCB T1 0.10 0.44 0.34y 0.01
AR T1 0.31* 0.02 0.05 0.72
MRR T1 0.13 0.36 0.25 0.06

*Correlation is significant at the 0.05 level (2-tailed); ycorrelation is significant at the 0.01 level (2-tailed).

Fig 5. Scatter plot illustrating a negative correlation. This signifies that when the pretreatment cortical
bone thickness at the apex is thinner, there is an association with an increase in F-CEJ-MBC distance
change, or in other words, an increase in facial marginal bone loss.

of bone gain to 8.8 mm of bone loss. Table IV gives the
range of CEJ-MBC distance changes, organized in 2-mm
increments and shown as percentages of the sample.
There were large ranges of incisor movements and
angulation changes (Fig 4). However, on average, the
mandibular incisor angulation changed little. The
average change in IMPA was 2.4
, whereas the average
change in incisor inclination calculated using trigonom-
etry (SUP) was 2.5
. The average pretreatment IMPA was
95.4
. The changes in incisor angulation were due pri-
marily to the 0.45-mm posterior movement of the
mandibular incisor apex. The 0.07-mm anterior move-
ment of the mandibular incisor tip was not statistically
significant. The apex to internal border of the labial
cortical bone (ACB) showed a slight increase that was
not statistically significant.
Age, treatment time, and Angle classification were
not significantly correlated with changes in CEJ-MBC
distances (Table V).
There were only weak correlations between CEJ-MBC
distance changes and the other variables. A correlation
of 0.33 (P 5 0.012) existed between the facial

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198 Garlock et al

Fig 6. Scatter plot illustrating that a thinner pretreatment symphysis showed a greater CEJ to MBC dis-
tance change, or in other words, a greater amount of facial marginal bone loss.

SUP, TIP, APEX, ACB) (Table VII) after treatment. Facial

Table VII. Correlations of treatment change variables
and lingual CEJ-MBC distance changes were not statis-
to facial and lingual cementoenamel junction to mar-
tically correlated with changes in IMPA. However, there
ginal bone crest distance changes
was a weak positive correlation between changes in
F-CEJ-MBC D L-CEJ-MBC D facial CEJ-MBC distances to the changes in apex posi-
R P R P
tion (APEX D), indicating that as the apex moved for-
IMPA D 0.01 0.94 0.21 0.11 ward, there was an increase in change of the CEJ-MBC
SUP D 0.02 0.87 0.19 0.16 distance on the facial aspect (Fig 7).
TIP D 0.14 0.29 0.08 0.54 There also was a weak negative correlation between
APEX D 0.30* 0.02 0.18 0.18 changes in facial CEJ-MBC distance and the change in
ACB D 0.39y \0.001 0.23 0.09
the distance of the apex to cortical bone (ACB), indi-
ALCB D 0.31* 0.02 0.45y \0.001
MFCB D 0.59y \0.001 0.43y \0.001 cating that as the distance from the apex to the facial
MLCB D 0.39y \0.001 0.49y \0.001 cortical bone decreased, there was an increase in change
of the CEJ-MBC distance on the facial aspect (Fig 8).
*Correlation is significant at the 0.05 level (2-tailed); ycorrelation is
significant at the 0.01 level (2-tailed).
Changes in the facial CEJ-MBC distances were posi-
tively correlated with changes in lingual cortical bone
thickness at both the midroot (MLCB D) and the apex
CEJ-MBC distance change and the lingual CEJ-MBC (ALCB D) levels, indicating that as cortical bone on the
distance change. lingual aspect became thicker, there was an increase in
There were no correlations between lingual CEJ-MBC the facial CEJ-MBC distance. A negative correlation ex-
distance changes and any of the variables describing isted between changes in lingual CEJ-MBC distance and
pretreatment tooth positions (Table VI). Pretreatment lingual cortical bone thickness at both the midroot and
cortical bone thicknesses at the apex level on both the the apex levels. There was a moderate negative correla-
facial and lingual surfaces showed weak negative corre- tion between changes in facial CEJ-MBC distance and
lations with facial CEJ-MBC distance changes (Fig 5). changes in facial midroot-level cortical bone thickness
There also was a negative correlation between changes (Fig 9), indicating that the subjects who experienced
in lingual CEJ-MBC distance and pretreatment facial mid- the greatest increase in facial CEJ-MBC distance showed
root cortical bone thickness. The only correlation between the greatest decrease in facial midroot cortical bone
pretreatment ridge thickness (AR T1 and MMR T1) and thickness. Changes in lingual CEJ-MBC distance were
change in CEJ-MBC distance was a weak negative corre- positively correlated with that same surface change.
lation between ridge thickness at the apex (AR T1) and
change in facial CEJ-MBC distance (Fig 6). DISCUSSION
There were no correlations between lingual CEJ-MBC Although wide ranges of bone losses and gains
distance changes and changes in tooth position (IMPA, occurred, the average amounts of bone recession

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Garlock et al 199

Fig 7. Scatter plot illustrating a weak positive correlation. This signifies that as the apex moved forward
(a positive number), there was an increase in the F-CEJ-MBC distance change, or in other words, an
increase in facial marginal bone loss.

Fig 8. Scatter plot illustrating a weak negative correlation. This shows that as the distance from the
apex to the facial cortical bone gets smaller, there is an increase in the F-CEJ-MBC distance change,
or in other words, an increase in facial marginal bone loss.

observed on the facial (1.12 mm) and lingual (1.33 mm)
surfaces were greater than previously reported by some
and less than reported by others. Using bitewings to eval-
uate posterior interdental vertical bone height, 0.5 mm2,6
and 0.13 mm8 of bone loss has been reported in patients
orthodontically treated compared with an untreated
group. Lund et al,10 who used CBCT to evaluate marginal
bone crest levels of the anterior mandible in patients
treated with mandibular premolar extractions, found an
average of 5.7 mm of bone loss on the lingual surface.
Although a large range of IMPA changes was re-
ported, on average, very little tipping of the mandibular
incisors was observed. The average change in IMPA was
2.4
. Evaluating subjects with moderate to severe
crowding, Pandis et al16 found that teeth were aligned
with an average 3
increase in IMPA and expansion at
the intercanine and intermolar locations. This might be
why little proclination occurred in our study.
Pretreatment ridge thickness is associated with
vertical bone loss in patients treated orthodontically.
The results in this study showed that the thinner the
ridge at the level of the mandibular incisor apex, the
more facial bone loss can occur. It has been previously
reported that more dehiscence occurred in patients

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200 Garlock et al

Fig 9. Scatter plot illustrating a negative correlation. A negative correlation or a decrease in cortical
bone thickness change represents the cortical bone getting thinner. Therefore, a negative correlation
means that when the cortical bone got thinner, there was a greater F-CEJ-MBC distance, or in other
words, more facial marginal bone loss occurred.

with thin symphyses than those with a thick symphysis.17
It has been shown that a thin symphysis is associated
with thinner cortical bone,18,19 and when cortical bone
thickness decreases, so too does bone density.20 There-
fore, in patients with thinner ridges, and thus thinner
and less dense cortical bone, the alveolus could be
more prone to microfractures associated with tooth
movement, resulting in increased vertical bone loss.21
It also appears that pretreatment cortical bone thick-
ness is linked to facial vertical bone recession. There were
weak negative correlation of 0.33 and 0.27 between
facial vertical bone recession and both the pretreatment
facial and lingual cortical bone thicknesses (both at the
apex level). Based on 11 subjects, Fuhrmann18 reported
that small symphyses with reduced labiolingual bone
widths, frontal crowding, and thin facial or lingual
cortical bone were risk factors for bone dehiscence.
There were no correlations between changes in facial
CEJ-MBC distance and changes of the IMPA. Batenhorst
et al12 found that 6 mm of incisor proclination yielded
an average of 5 mm greater bone loss compared with
teeth that were not proclined. Steiner et al,11 using an
experimental model, showed that 3.05 mm of labial
incisor movement caused an average of 5.48 mm of ver-
tical bone loss. IMPA is a measurement of incisor inclina-
tion relative to the mandibular plane. It does not
measure a change in translation or vertical movement,
both of which could have an effect on vertical bone
loss. In this study, we also did not measure the transla-
tion and vertical movements of the incisors. Compared
with the aforementioned studies, our study showed little
anteroposterior incisor tip movement.
It also appears that when vertical bone recession
does occur, the thickness of the cortical bone changes.
It was observed that on the surface where vertical
bone recession happened, thinning of the cortical
bone on the same side also occurred, whereas the
opposite side showed less cortical bone thinning.
This observation makes sense if it is assumed that it
was translation of the tooth, not tipping of the tooth,
that caused bone loss. For example, if a tooth begins
in a more lingual position in the ridge, it will poten-
tially occupy space in the lingual cortical bone. If it
is then moved labially to occupy space in the facial
cortical bone, the lingual cortical bone will effectively
get thicker, and the facial thickness will be thinner.
This would be especially true if the ridge width is
thin. Sarikaya et al9 found that the lingual alveolar
bone of the mandible decreased significantly over
the central incisors (at the crest, midroot, and apex
levels) in patients who had 4 first premolars extracted,
even though the labial bone maintained its thickness.
This suggests that the bone thins as a tooth or root
approaches cortical bone. However, as a tooth or
root distances itself from the cortical bone, bone
thickness does not change.
It appears that the closer the root apex is moved to-
ward the facial cortical bone during treatment, the more
facial bone recession occurs. A weak negative correlation
(0.39) was found between facial bone recession and
the change in mandibular incisor apex position during
treatment. Yu et al22 concluded that when teeth are
facially proclined, the root apex approximates the
lingual cortical plate, indicating that proclination alone

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Garlock et al
will not move the apex forward. Therefore, the apex can
move closer to the facial cortical bone only through un-
controlled lingual crown tipping, translation in the labial
direction, a combination of these, or proclination
accompanied with labial bodily movement. Studies
have reported bone loss with incisor advancement, but
they did not quantify or specify whether the tip advance-
ment was accompanied by incisor apex advance-
ment.11,12 No studies were found that compared the
amount of vertical bone loss to the position of the
root apex. Further studies are needed to better
understand this relationship.
The CBCT images in this study had a voxel size of
0.3 mm. Therefore, bone could be measured to an accu-
racy of only 0.3 mm of thickness.23 It is possible that
subjects who appeared to have no bone in fact had
bone thinner that 0.3 mm. If this was the case, it would
be possible for bone regeneration to occur.
Because the effect sizes of some changes were so
small, our 57 subjects were insufficient to rule out the
possibility of type II errors. For example, the effect size
for the change of the ACB measurement (Table II) was
0.32, requiring 119 subjects to ensure a power of 80%.
This would have established a statistically, but not clin-
ically, significant change.
CONCLUSIONS
1. A thinner mandibular symphysis at the tooth apex
was associated with an increase in facial vertical
bone loss.
2. Thinner pretreatment cortical bone at the apex level
was correlated with greater facial vertical bone loss.
3. Changes in IMPA in this sample were not correlated
with facial vertical bone loss.
4. Thinning of cortical bone occurs on the surface un-
dergoing vertical bone loss.
5. Movements of the mandibular incisor apex moving
toward cortical bone produce greater amounts of
vertical bone loss.
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February 2016  Vol 149  Issue 2