A comparative analysis of

intrusion of incisor teeth Dr. Otto

achieved in adults and children
according to facial type
Ronald L. Otto, D.D.S., MS.,* J. Milford Anholm, D.D.S., MS.,** and
Gary A. Engel, A.B., MS.***
Roseville, Loma Linda, and Encino, Calif.

A comparison was made of incisor intrusion achieved in adults and children with deep
bite. Facial type was also examined for effect upon intrusion achieved. Fijiy-jive cases
treated with bioprogressive mechanics were studied cephalometrically; subjects
included twenty-four adults and thirty-one children. Neither age nor facial type was
found to be statistically related to the amount of incisor intrusion achieved in this
sample. A method of measuring intrusion at the root apices was devised and was
thought to give a more accurate indication of actual bodily intrusion. More external
root changes during treatment were observed for adults than for growing children.
There was a wide latitude in the amount of intrusion observed in both groups and in
all three facial t;lpes. Considerable overbite reduction was noted j& the sample, and
intrusion was found to be but one factor in this.

Key words: Intrusion, adults, children, facial type

I
n 1937 J. V. Mershon published a treatise on “Possibilities and Limitations in
the Treatment of Closed Bites. ” At the outset of the article he stated:
Of all conditions which the dentist encounters, probably the least understood and the most difficult to
treat successfully is the closed bite This is a controversial subject. (Int. J. Orthod. Oral Surg.
33: 581-589, 1937.)

The intrusion of teeth has become an accepted practice for many orthodontists. How-
ever, a number of issues concerning incisor intrusion have yet to be resolved. We will
examine two of these. (1) Can we intrude teeth as readily in adults as in growing children?
(2) What effect does facial type have upon amount of incisor intrusion achieved?
Thirty years ago experimental depression of teeth in dogs was done15 and human teeth
had been observed to be depressed with treatment. 24 In 1967 research which proved

This project was carried out under the auspices of the Foundation for Orthodontic Research.
*In the private practice of orthodontics at 125-B Ascot Dr., Roseville, Calif.
**Associate Professor of Orthodontics, Loma Linda University School of Denistry.
***Foundation for Orthodontic Research, Encino, Calif.

CNIOZ-9416/80/040437+ 10$01.00/O @ 1980 The C. V. Mosby Co 437

438 Otto. Anholm, und Engrl

intrusion of teeth, both histologically and cephalometrically, was reported, I” Later, small
samples of adults who had undergone intrusion of incisors were mentioned.‘“, “I
Some investigators have concluded that extrusion of posterior teeth and flaring of
incisors, rather than intrusion, are responsible for much overbite correction.‘, i
Correlation of facial type with symphysis morphology was described by Ricket@ in
1964. He remarked that high-angle or dolichofacial cases tended to have long, narrow
symphyses while low-angle or brachyfacial cases commonly had thick, square symph-
yses. Mulie and Ten Hoeve” noted three distinct types of mandibular symphyses but
failed to associate them with given facial types. Edwards” found no correlation between
the width of the anterior maxillary alveolus and a low or high angle established by the
mandibular plane in relation to the SN plane. Bench, Gugino, and Hilger? related sym-
physis morphology to facial type. They also stated that the brachyfacial pattern experi-
enced easier depression of the lower incisors because of incisor positioning within an
ample alveolus. Dolichofacial types were noted to possess long, narrow symphyses and
labially inclined incisors, making for less effective intrusion.
No data base examining the feasibility of incisor intrusion in a substantial number of
adult cases was found in the literature. Likewise, there was an absence of work comparing
adults to children or comparing different facial types with one another. This paucity of
information gave rise to the project described in this presentation.
Here, an analysis of the achievement of incisor intrusion in significant numbers of
adults with deep overbite compared with a group of growing children will be done. In
addition, the project will examine the correlation, or lack of it, of facial type with amount
of incisor intrusion attained. The inclusion of nongrowing adults removes the variable of
growth in assessment of whether, or how much, intrusion has occurred.*’ The study of
children permits comparison with a more clinically predictable group.

Methods and materials

Selection of cases for study followed a set of certain criteria:
1. Cases were not to be selected on the basis that they showed considerable intrusion;
rather, they were chosen randomly because of the presence of deep overbite prior to any
treatment.
2. Cases must have been treated according to the bioprogressive philosophy using
molar and incisor banding with a utility type of arch wire to intrude anterior teeth.3* “+ 23
3. Cases must have clear pretreatment (T,) and posttreatment (T,) lateral cephalo-
grams, taken in a uniform manner.
4. No cosmetic or other alteration of the incisal edges could occur during treatment.
Fifty-five cases were selected at random from three bioprogressive private practices.
Beginning T1 and posttreatment T, lateral cephalometric radiographs were traced on
acetate. Tracings were rechecked periodically against cephalograms for accuracy. Teeth
were drawn by means of a Dome template oriented to the long axis and registered on the
incisal edges. This gave a consistent orientation of the apices of the teeth to one another
from T, to T,. The tracings were done in the manner suggested by the Rocky Mountain
University Instruction Manual, 25 with appropriate planes and angles being drawn.
Classification of the cases followed. Adults were defined as those who showed no
cephalometrically visible facial growth from T1 to T2. The mean age for the adults was
23.04 years. All children exhibited active facial growth between T, and T2. The mean age
Volume II
Number 4
Comparative analysis of incisor intrusion 439

F.A. t L.F.H. + Md.A. + F. Ang.

Facial type vertical number =
5

Dolicho c -0.5 Meso. = -0.49 to +0.99 Brachy. z +l

Example:
Age 9 Years
Observed Normal
value (degrees) (degrees) S.D. Dolicho. Meso. Brachy.
Facial axis 98 90 t3 (++)
Lower face height 52 47 t4 (-)
Mandibular plane 14 26 +4 (++)
Mandibular arc 32 26 +4 (+I
Facial angle 93 86 +3 (++)

6/5 = +I.2 = Facial type

Vertical Number
Number of SD. divided by 5 and the sign is corrected so that all deviations of the dolichofacial type are
(-) and brachyfacial deviations are (+).

Fig. 1. Facial type vertical number.

for this sample was 11.43 years. In all, records for twenty-four adults and thirty-one
children were included in the study.‘, *l
A facial type was determined for each case. Measurements of facial axis, mandibular
plane, lower face height, facial angle, and mandibular arc were used. In each instance, the
number of standard deviations from the mean were added together and averaged to give a
numerical value to the vertical description of the patient’s facial pattern (Fig. 1).
Subjects were classified as being either dolichofacial (high-angle, vertical pattern),
mesofacial (average pattern), or brachyfacial (low-angle, horizontal pattem).4* ‘, 25 The
dolichofacial group consisted of one child and five adults, the mesofacial sample included
twenty-three children and twelve adults, and the brachyfacial category had seven children
and seven adults. This was a statistically adequate sample size, with the exception of the
dolichofacial group.
In order to create “average” group pictures of the growing children, composite
drawings were made. All of the tracings of the children were labeled T1 or Tz, and the
measurements were programmed into the computer at the Foundation for Orthodontic
Research in Encino, California. In this manner, growth effects upon intrusion would later
be calculated by comparison of T, and T, composite computer drawings.
The cases were now classified and ready for measurement. The following mea-
surements were made:
1. Upper incisor intrusion or extrusion (in millimeters).
2. Lower incisor intrusion or extrusion (in millimeters).
3. Overbite T1 (in millimeters).
4. Overbite T2 (in millimeters).
5. Lower face height T, (in degrees).
6. Lower face height Tz (in degrees).
7. Angle of upper incisor to palatal plane T1 (in degrees).
8. Angle of upper incisor to palatal plane T2 (in degrees).
440 Otto, Anholm, rind Engel Jr?! .i Orrkod
.4wr/ 1980

/’

Fig. 2. Calculationof growth effects. APM - AANS = 2.5 mm.

9. Angle of lower incisor to mandibular corpus axis T, (in degrees).

10. Angle of lower incisor to mandibular corpus axis T2 (in degrees).
11. Interincisal angle T, (in degrees).
12. Interincisal angle T2 (in degrees).
Angular measurements were made to the nearest 0.5 degree with a protractor, and
linear changes were determined with a Boley gauge measuring to the nearest 0.1 mm.
The palatal plane at the incisive canal was used for superimposition of T, and Tz to
measure upper incisor behavior. Both apical movement and long axis behavior were
determined at this point. The mandibular corpus axis at suprapogonion was used for
measurement of apical movement and long axis change, with superimposition similar to
the maxillary procedure.4j 24
Data analysis followed. Initially, patients were segregated as adults or children. This
first phase involved computation of means and standard deviations for intrusion. In addi-
tion, full-mouth or panographic radiographs were examined for visible changes in the
external apical root surfaces from T, to Tz. If any of a patient’s incisors appeared to have
undergone apical root change, a notation to that effect was made. Relative differences in
intrusion between children and adults were determined and subjected to Student’s t test. A
computation was also entered to correct for the amount of holding against vertical growth
or relative intrusion in children. Composite tracings of the younger patients before and
after treatment had been made. A measure of the increase with growth of the distance from
anterior nasal spine to suprapogonion was taken (Fig. 2). This quantity represented the
extrusive effects of growth on the teeth and was used to correct for the amount of alveolar
and dental elongation which occurred during the treatment period. Average total intrusion
could now be calculated for children and adults.
The next stage of the data analysis was designed to analyze the effects of facial type
and age on amount of intrusion. Stage 2 also involved calculation of maximum and
minimum total intrusion in both arches, including growth.
Additional data analysis involved determining the effect of facial type alone upon
intrusion. Forty-six patients had been treated in both upper and lower arches according to
Volume II
Comparative analysis of incisor intrusion 441
Number 4

Table 1. Cephalometric measurementsprior to treatment

Measurement Mean Standard deviation

Adults
OverbiteT, (mm.) 7.63 2.05
OverbiteTZ(mm.) 3.06 0.88
Lower face heightT, (degrees) 44.15 5.34
Lower faceheightTZ(degrees) 45.09 5.60
Angle of upperincisorto palatalplaneT, (degrees) 103.58 9.20
Angleof upperincisorto palatalplaneTz (degrees) 106.63 8.19
Angleof lowerincisorto mandibularcorpusaxisT, (degrees) 86.13 8.07
Angleof lower incisorto mandibularcorpusaxisTZ(degrees) 95.87 5.11
InterincisalangleT1 (degrees) 139.91 14.81
InterincisalangleT2 (degrees) 127.35 9.15
Age at T, (years) 23.04 8.17
Children
OverbiteT, (mm.) 6.51 1.10
OverbiteTZ(mm.) 2.78 0.92
Lower face heightT, (degrees) 43.60 3.33
Lower faceheightT2 (degrees) 44.58 3.95
Angleof upperincisorto palatalplaneT, (degrees) 105.33 6.83
Angleof upperincisorto palatalplaneTZ(degrees) 111.37 5.21
Angleof lowerincisorto mandibularcorpusaxisT, (degrees) 85.21 6.47
Angleof lower incisorto mandibularcorpusaxisTZ(degrees) 89.86 8.40
InterincisalangleT, (degrees) 137.44 8.30
InterincisalangleT2 (degrees) 125.56 6.55
Age at T, (years) 11.43 1.76

the criteria previously listed. Facial type vertical numbers were used, as were the figures
for total intrusion in each case. A correlation coefficient (r) was computed to test the
relationship between facial type and the amount of incisor intrusion achieved.

Results
Table I lists means and standard deviations of measurements for both populations
(adults and children). It can be seen from Table I that the populations were quite compa-
rable cephalometrically prior to treatment.
Table II shows the difference between total adult and child intrusion, including the 2.5
mm. growth factor. Statistical t tests showed that adult maxillary intrusion was sig-
nificantly greater than zero at the p = 0.05 level of significance, and mandibular intrusion
was found to be significantly greater than zero at the p = 0.01 level. Individual t tests
could not be attempted for each arch in the population of children, since the growth factor
of 2.5 mm. cannot be segregated into amounts of mandibular and maxillary growth.
However, the 2.08 mm. of corrected intrusion calculated for children must certainly be
greater than zero, considering the population size. Artificially low values for intrusion are
resultant when one neglects to account for holding against vertical alveolar growth during
treatment.
Statistical t tests also showed that there is no significant difference in total amount of
intrusion (both arches) between the adults and children (with growth correction factor) at
the p = 0.05 level.
442 Otro. Anholm, cmd En&

Table II. Average total intrusion for children and for adults
Avenge totul intrusron,for children
-0.68 maxilla 14
+0.26 mandible I2
-0.42 Total without growth factor
+2.5 “growth”
+2.08 mm.
Awrage totul intrusion for udults
+0.55 maxilla 12
+2.07 mandible
i2.62 mm.

Table III. Maximum and minimum total overall intrusions by facial type

Dolichofacial Mesofacial Brachyfacial

Children
Maximum * f7.8 +5.1
Minimum * -3.2 +1.7
Adults
Maximum +6. I +5.9 f4.6
Minimum +0.4 -2.7 -0.2

*Sample size of one only in this category.

Table III shows maximum and minimum amounts of intrusion by facial type for both
adults and children. It is readily seen that facial type does not appear to be a determining
factor in the limits of incisor intrusion achieved. A simple correlation coefficient between
vertical facial type index number and amount of total intrusion was calculated on the basis
of the entire sample of adults and children. The value of this coefficient was found to be
r = -0.04. This very low value for r is a further indication that amount of intrusion is not
related to facial type. The range of facial type vertical numbers was - 1.2 to + 2.6, with a
mean of +0.43 ? 0.81.
An additional correlation coefficient was calculated in order to determine whether age
was related to amount of intrusion within the sample of children. In this case r = 0.08.
The correlation coefficient, combined with the information in Table II, indicates that total
intrusion appears to be unrelated to age.
Pre- and posttreatment full-mouth or panographic radiographs were obtained in forty-
seven cases. Eighteen (38 percent) of these demonstrated visible changes, after treatment,
in the external apical root surface. Of these, seven of twenty-six (27 percent) children and
eleven of twenty-one (52 percent) adults exhibited apical root surface modification during
treatment. This was a subjective visual observation, and no attempt was made to quantify
or categorize the changes.

Discussion
One aim of this project was to determine whether there was a relationship between
amount of incisor intrusion achieved in deep-bite cases and age of patient. The presence or
absence of facial skeletal growth from T, to TZ was used to determine whether the patient
Volume 17
Number 4
Comparative analysis of incisor intrusion 443

was a growing child or a nongrowing adult. The study also examined the relationship of
facial type to amount of attained incisor intrusion.
Distinct mandibular symphysis morphology has been linked to specific facial type.”
Other workers have observed that three morphologic patterns of symphysis exist.17 An-
terior palate shape has been found to be unrelated to a patient’s having a “high” or a
“low” angle. l1 The configuration of the symphysis and the anterior palatal area has
previously been directly associated with limitations in tooth movement and stability of
treatment.“, I’* 27*‘*
The results of this investigation must be kept in proper perspective. No measurement
of attempted incisor intrusion was made. This was a study of achieved incisor intrusion in
deep-bite cases. Mean pretreatment overbite was 6.51 mm. + 1.10 for children and 7.63
mm. + 2.05 for nongrowing adult patients. Prior to selection of cases from their prac-
tices, the clinicians were asked whether they attempted to level the bite in their patients by
intrusion of incisors. The answer was affirmative in all cases, particularly for deep-
overbite treatment which is what the project investigated.
Significant intrusion as measured at the apex was found in both children and adults.
Some flaring of incisors was noted with treatment, and the figures for lower incisor
depression compared well with previous research. 8, l3 A method of measuring intrusion
which focused on the root apices rather than the incisal edges of the teeth was preferred
(Fig. 3). This technique was believed to give a more accurate measurement of actual
bodily depression of teeth within the bone. If anything, it gives a somewhat conservative
measure of tooth intrusion. A significant outward tipping of a tooth about its center of
resistance within the root16 would tend to raise the apex and reduce slightly the measured
intrusion. If one must err, it is perhaps better to err on the side of understatement rather
than exaggeration. Genuine intrusion has been described as the apical movement of the
root with respect to the long axis of the tooth.‘j
A number of authors have noted a flaring outward combined with intrusion.6-8* l7 This
combined flaring with intrusion or flaring alone has been observed to give an exaggerated
“pseudo-intrusion. “6 It is inaccurate to measure intrusion at the incisal edges of labially
tipped teeth, without accounting for changes in axial inclination (Fig. 3).
More adults than children (2 : 1) exhibited changes in the external apical root surface of
one or more of the incisors during treatment. The work of some investigators in adult
orthodontics would tend to agree with that observation.‘, *l One must bear in mind that
only a subjective determination of root changes was made in this study. T1 and T2 dental
radiographs were not all taken in a standardized manner and dimensional distortion could
not be accounted for.
No correlation was discovered between the age or skeletal maturation of the patient
and the amount of intrusion seen. Achieved intrusion of incisors in nongrowing or adult
patients was at least as much, if not more than, that demonstrated in growing children.
The greatest amount of incisor innusion measured (5.5 mm.) was on the lower arch of a
32-year-old female patient. Adult teeth have been shown to move very well after a slower
initial start.1s+21Facial type was seen to have no significant effect upon the amount of
incisor intrusion achieved.
Overbite was reduced an average of 4 mm, in children and adults. When growth
effects were included, the sample demonstrated a mean total intrusion of more than 2.0
mm. per case in growing subjects and in excess of 2.5 mm. in nongrowing persons. More
444 Otto, Anholm, und En@ 4 n, .I Orrhod
A/m/ 1980

/,/
/ // ‘3-9f-----
/
/I/’////’//’
0
Fig. 3. Methods of measuring intrusion. Above: Apical change method. Below: “Pseudo-intrusion”
incisal change method.

than simple intrusion accounted for the 4 mm. of overbite reduction. Lower face height
increased from T, to Tf. This may have reflected bite opening due to treatment mechanics.
Orthodontic treatment has been observed to “open the bite, ” which diminishes overbite
as one of its sequelae. 4SI43 18*26 The angle of the upper incisor to the palatal plane and
the lower incisor angle to the corpus axis of the mandible increased with treatment. The
interincisal angle decreased numerically at the same time. All of these measurements
show that a flaring outward of incisors occurred during orthodontic treatment and overbite
was reduced as a consequence.
One may conclude from the above discussion that overbite was corrected by a number
of factors, one of which is incisor intrusion.
The wide latitude demonstrated in maximum and minimum intrusion along with
substantial standard deviation values for the means could be explained by a multitude of
factors. Did one arch appear to need intrusion more than the other? Was it thought to be
easier to depress incisors in one arch or facial type more than in the other? Did some
operators decide, during the course of treatment, that it was unwise or impossible to
depress teeth farther? Did extrusion of posterior teeth make it appear to the clinician that
he had intruded the incisors? As is nearly always the case, it is far easier to ask a tough
question than it is to answer one.
Volume 71 Comparative analysis of incisor intrusion 445
Number 4

Conclusions
Significant intrusion of the upper and lower incisors occurred in the adult sample.
Furthermore, significant intrusion was demonstrated in children, although it was initially
masked by the extrusive effects of growth. Upon including the amount of relative intru-
sion, or holding against normal growth, it was shown that the figures for adults and
children were comparable. The amount of intrusion could not be correlated with the age of
the patient.
From observation of pre- and posttreatment periapical or panographic radiographs,
considerably more apical root changes were noted for adults than for children subsequent
to treatment.
The patient’s facial type appeared to have no significant influence upon the amount of
intrusion seen. The mean amount of intrusion, measured at the root apices, was more than
2.5 mm. over-all in adults and in excess of 2.0 mm. in children. Upper incisors showed an
average of near 0.5 mm. of intrusion, and lower incisors demonstrated about 2.0 mm. of
depression measured at the apex. The bioprogressive technique usually employs the
intrusion of incisors for correction of deep overbite.
Overbite reduction was due to more than intrusion alone. Increase in lower face
height, along with a labial flaring of incisors during treatment, played a correlative role
with intrusion for overbite correction.
While great latitude existed regarding amounts of intrusion seen, strong evidence was
offered for the achievement of considerable intrusion in all ages and in all facial types.
The astute clinician will keep in mind the warnings in the literature regarding root resorp-
tion and position within the supporting bone when planning intrusive treatment.
Finally, one may conclude from this study that an orthodontic patient’s age or facial
type need not preclude intrusion of incisors.
The authors wish to thank Drs. John Pearsonand Roland Walters and Mr. Ellis Jonesof Loma
Linda University School of Dentistry for their assistance.

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