Evaluation of continuous arch and segmented arch

leveling techniques in adult patients ,a clinical study

Frank J. Weiland, DDS," Hans-Peter Bantleon, MD, DDS, PhD, b and Helmut Droschl, MD, DDS, PhD ~
Graz and Vienna, Austria

The purpose of this study was to compare the efficacy of overbite correction achieved by a
conventional continuous arch wire technique and the segmented arch technique as recommended
by Burstone. The sample comprised 50 adult patients (age 18 to 40 years) with deep bites.
Twenty-five patients were treated with a continuous arch wire technique (CAW); in the second half
of the sample, the segmented arch technique (Burstone) was used for correction of the vertical
malocclusion. Lateral cephalograms and plaster cast models taken before and immediately after
treatment were evaluated. Statistical analysis was performed on the collected data. The results
showed that both techniques produced a highly significant overbite reduction (CAW: -3.17 mm,
p < 0.001; Burstone: -3.56 mm, p < 0.001). The CAW group showed an extrusion in the molar area
with subsequent posterior rotation of the mandible (6occI-ML: +1.30 mm; 6occI-NSL: +1.63 ram;
ML/NSL: +1.94 ~ all p < 0.001). The Burstone group, however, showed overbite reduction by incisor
intrusion without any substantial extrusion of posterior teeth (upper 1-NSL: -1.50 mm; lower 1-ML:
-1.72 ram; both p < 0.001). As a consequence, no significant posterior rotation of the mandible
took place (ML/NSL: +0.52 ~ n.s.). It is concluded that in adult patients the segmented arch
technique (Burstone) can be considered as being superior to a conventional continuous arch wire
technique if arch leveling by incisor intrusion is indicated. (Am J Orthod Dentofac Orthop
1996;110:647-52.)

Deep
overbite is a common condition in
adults. ' Because of potentially detrimental effects on
mandibular and temporomandibular joint function, 2-4
and periodontal health, 5 as well as for esthetic reasons, 6
deep overbite correction is often a major component of
orthodontic treatment. It has been shown that orthodontic correction of deep bite can be achieved in
patients with no growth left. 7I~ This correction can be
performed by extrusion of molars, intrusion of incisors,
or by a combination of both.
In certain cases, intrusion of incisors is absolutely
indicated to reduce deep overbite. One example is
overerupted incisors, frequently seen in Class II, Division 2 malocclusions. 12''3 Moreover, if elongation of
front teeth after loss of periodontal support has occurred, intrusion of these teeth is indicated. 9''4
It has been stated that arch leveling with continuous arch wires in both growing and nongrowing paSupported by the Fonds zur Frrderung der Wissenschaftlichen Forschung,
Vienna, Austria; grant P7477.
aAssistant professor, Orthodontic Department, University Dental School, Graz,
Austria.
bProfessor and chairman, Orthodontic Department, University Dental School,
Graz, Austria.
"Professor and chairman, Orthodontic Department, University Dental School,
Vienna, Austria.
Reprint requests to: Dr. Frank ]. Weiland, Orthodontic Department, University
Dental School, A-8036 Graz, Austria.
Copyright 9 1996 by the American Association of Orthodontists.
0889-5406/96/$5.00 + 0 8/1/64369

tients will produce extrusion in the molar area, 8

whereas a segmented approach with bioprogressive
mechanics predominantly produces incisor intrusion
with molar extrusion to a lesser degreeff No data
regarding a direct comparison between the effects of
different types of bite-opening mechanics in adult
patients were found in the literature. This study was
performed to analyze the skeletodental changes occurring during deep bite correction with a conventional
continuous arch wire technique and the segmented arch
technique as recommended by Burstone. '5-'8

MATERIALS AND METHODS

The sample of this study consisted of 50 adult patients
treated in the Department of Orthodontics at the University
Dental School in Graz, Austria. All patients showed lowangle, deep bite (overbite greater than 4 mm) malocclusions
and were at least 18 years old. Twenty-five patients were
treated with a continuous arch wire (CAW) technique with a
pretorqued and preangulated bracket system. Second-order
bends were used when indicated. Mean age of this group was
23.3 years (range 18 to 35.3 years) at the beginning of
treatment. There were 8 men and 17 women in this group.
The other half of the sample (5 men and 20 women) was
treated with the segmented arch technique as recommended
by Burstone. '5-t8The same preadjusted appliance was used in
the second group. Intrusive mechanics were used in both
arches in all 25 patients. The point of intrusive force application was individualized, depending on the desired tooth
647

648

Weiland, Bantleon, and Droschl

American Journal of Orthodontics and Dentofacial Orthopedics

December 1 9 9 6

34

35
..............

ir

.2
t

36

16

!!

,5

tt
r

movement, according to data in the literature. 19An intrusive

force of 10 to 15 gm per tooth was used. After correction of
the vertical malocclusion with intrusive mechanics, treatment
was continued with continuous arch wire mechanics similar
to those in the first group. Mean pretreatment age of this
sample was 25.6 years (range 18.7 to 40.3 years). The
treatment period of the Burstone group was 4 months longer
than that of the continuous arch wire group (Table I). A
transpalatal arch wire was applied in all patients to enhance
posterior stabilization. No headgear was used in either group.
In 12 patients (eight from the CAW group, four from the
Burstone group) teeth were congenitally missing, already
extracted before, or were extracted during treatment.
Lateral cephalograms and plaster cast models were made
before and immediately after treatment. Each cephalogram
was traced by two investigators independently on acetate
paper with a 0.3 mm lead pencil. Forty-two reference points
were marked on each radiograph (Fig. 1). All bilateral
structures were located midway between the two images. The
points were digitized, and the mean coordinates of the two
tracings stored in a computer for analysis. The midpoint
between the incisal edge and the apex of the upper and lower
incisors was calculated and used for analysis of vertical
incisor position. Seven angular and nine linear measurements
were selected for cephalometric analysis (Fig. 2). No correction for linear enlargement was made. Dental changes were
assessed by superimposing pretreatment and posttreatment
cephalograms on the nasion-sella line (upper dental changes)
and the mandibular plane (lower dental changes). Overbite
reduction was analyzed by the change inthe vertical overlap
of the upper and lower incisors, measured on the pretreatmerit and posttreatment plaster cast models, perpendicular to
the occlusal plane.
Statistical analysis involved comparison of the pretreatment values of the two groups by means of Student's t test
to assure comparable samples. Means and standard deviations for each variable were calculated. The changes that
occurred during treatment were compared within each group,

. . . . . .

Fig. 1. Cephalometric landmarks used in study.

;i

J. _.t

Fig. 2. Linear and angular cephalometric measurements. Var.

3 (Bj6rk polygon) = a + b + var. 2

as well as between the groups. The p < 0.05 confidence level

was considered significant.

RESULTS
Analysis of the pretreatment data revealed no statistically significant difference between the two groups.
Comparison of pretreatment and posttreatment values
of each group, as well as treatment changes between
the groups are shown in Tables II to IV. Composite
tracings showing the mean treatment effects in both
groups are shown in the Figs. 3 and 4.
Cast analysis
Treatment-induced reduction in overbite was similar and highly significant in both groups (CAW
group = - 3 . 1 7 mm, Burstone group = - 3 : 5 6 mm; both
p < 0.001). Resulting posttreatment overbite was 2.2
and 2.5 ram, respectively; this intergroup difference
was not significant.
Maxillary dental changes
The CAW group showed some upper incisor uprighting (upper 1 / N S L = - 2 . 3 5 ~ n.s.) and retraction
(upper 1-NPg = -1.61 mm, p < 0.01), whereas the Burstone group showed minor bodily retraction of the
upper incisors. This change, however, was not significant. Intrusion of the upper incisors in the Burstone
group (p < 0.001) was significantly different (p < 0.05)
from the stable vertical position these teeth displayed
in the CAW group. Upper molar extrusion occurred in
the CAW group (6occl-NSL = +1.63 mm, p < 0.001).
This was in contrast to the stable position in the
Burstone group (intergroup difference: p < 0.01).

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 110, No. 6

Weiland, Bantleon, a n d D r o s c h l

64g

Table I. Description of the sample

Se)c

Malocclusion

Treatment time (yrs., mos.)

"[.....

Age O'rs.I

Groups

Class l

Class 11,
Division 1

Class 11,
Division 2

Mean

Minimum

CAW
Burstone

8
5

17
20

25
25

9
3

10
13

6
9

25
25

23.3
25.6

18.0
18.7

Maximum

Mean

Minimum

Maximum

35.3
40.3

2,2
2,5

0.8
0,9

5,2
4,3

Table II. Comparison of pretreatment and posttreatment values of continuous arch wires
7"1
Variables
1,
2.
3.
4,
5,
6.
7.
8,

9,
10.
11.
12.
13,
14.
15.
16,
17.

Overbite (cast)
S-At-Go
Bj6rk polygon
Y-axis
ML-NSL
Anterior face height
Lower anterior face height
Upper I - N S L
Lower I - M L
Upper 1-NPg
Lower l-NPg
Upper 1-NSL
Lower I-ML
Lower l-Occlusal plane
6occl-ML
6occl-NSL
Occlusal plane-XiPm

Unit

Mean

mm
degrees
degrees
degrees
degrees
mm
mm
degrees
degrees
mm
mm
mm
mm
mm
mm
mm
degrees

5.39
142.16
388.03
65.79
28.04
119.80
66.07
101.69
91.60
6.34
0.98
70.18
29.96
3.83
31.06
70.72
18.04

T2- T1

T2
SD

Mean

1.37
7.15
7.43
3.59
7.41
6.66
5.56
9.30
7.90
5.24
4.39
4.57
5.19
2.33
2.80
4.11
6.09

2.22
143.51
389.90
67.20
29.98
122.30
68.42
99.34
97.31
4.73
2.07
69.92
28.93
1.13
32.36
72.35
16.57

SD

Mean

1.01
7.36
7.39
3.62
7.45
6.55
5.69
805
7.12
396
3.90
4.12
4.91
1.31
2.88
4.95
5.21

-3.17
+1.35
+1.87
+1.41
+ 1.94
+2.50
+2.35
-2.35
+5.71
-1.61
+ 1.09
0.26
- 1.03
-2.70
+1.30
+1.63
- 1.47

SD

Significance

1.67
2.52
1.17
0.94
1.28
2.71
2.22
9.58
8.90
3.17
2.18
1.55
1.55
2.52
1.43
1.90
5.64

***
**
***
***
***
**
**
ns
**
**
**
ns
**
***
***
***
ns

T1, Pretreatment; T2, posttreatment; *significance at p < 0.05 level; **significance at p < 0.01 level: ***significance at p < 0.001 level.

Table IlL Comparison of pretreatment and posttreatment values of segmented arch wires (Burstone)
TI
Variables
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.

Overbite (cast)
S-Ar-Go
Bj6rk polygon
Y-axis
ML-NSL
Anterior face height
Lower anterior face height
Upper 1-NSL
Lower 1-ML
Upper I-NPg
Lower I-NPg
Upper I-NSL
Lower I-ML
Lower l-Occlusal plane
6occl-ML
6occt-NSL
Occlusal plane-XiPm

T2

Unit

Mean

SD

Mean

mm
degrees
degrees
degrees
degrees
mm
nun
degrees
degrees
mm
mm
mm
mm
mm
mm
mm
degrees

6.10
143.99
389.11
66.92
29.12
121.47
66.52
99.82
92.38
5,82
0.16
71.64
30.19
3.08
32.32
73.19
17.05

1.76
6.85
5.35
3.41
5.38
9.25
6.90
8.86
9.72
6.17
4.19
5.58
4.13
1.63
2.69
529
5.49

2.54
144.60
389.62
67.01
29.64
122.25
66.90
99.72
96.32
4.30
0.44
70.14
28.47
1.21
32.88
73.05
15.72

T2-TI
SD

Mean

SD

Significance

1.14
7.04
5.74
3.44
5.74
9.95
7.35
4.24
7.90
3.49
3.01
5.80
4.58
1.46
2.59
5.54
4.74

-3.56
+0.61
+0.51
+0.09
+0.52
+0.78
+0.38
-0.10
+3.94
- 1.52
+0.28
- 1.50
-1.72
-1.87
+0.56
-0.14
-1.33

1.76
1.94
1.62
2.04
1.62
2.13
1.94
7.20
7.70
5.08
3.54
1.28
1.90
2.08
1.06
1.50
4.76

***
ns
ns
ns
ns
*
ns
ns
**
ns
ns
***
***
***
**
ns
ns

T1, Pretreatment; T2, posttreatment; *significance a! p < 0.05 level; **significance at p < 0.01 level; ***significance at p < 0.001 level.

Mandibular dental changes

Significant proclination of the lower incisors occurred in both groups (CAW: +5.71 ~, p < 0 . 0 1 ;
Burstone: +3.94 ~ p < 0.01). The difference between
the groups was not significant. Whereas the lower

incisor edge was in an approximately stable sagittal

position in the Burstone group, the CAW group
showed some protrusion (lower 1-NPg =+1.09 mm,
p < 0.01). The lower incisors were intruded 1.03 mm
(p < 0.01) in the CAW group and 1.71 mm (p < 0.001)

650

Weiland, Bantleon, and Droschl

American Journal of Orthodontics and Dentofacial Orthopedics

December 1996

CONTINUOUSARCHWIRES
T1

T2 .

. . . .

Fig. 3. Composite tracing of treatment changes in CAW group.

Table IV. Comparison of treatment changes between the two groups continuou arch versus segmented arch (Burstone)

Variables
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.

Overbite (cast)
S-At-Go
Bjtirk polygon

Y-axis
ML-NSL

Mean

SD

Significance

mm
degrees

-3.17
+1.35
+1.87
+1.41
+t.94
+2,50
+2.35
-2.35
+5.71
-1.61
+1.09
-0.26
-1.03
-2.70
+1.30
+1.63
-1.47

1.67
2.52
1.17
0.94
1.28
2.71
2.22
9.58
8.90
3.17
2.18
1.55
1.55
2.52
1.43
2.11
5.64

-3.56
+0.61
+0.51
+0.09
+0.52
+0.78
+0,38
-0.10
+3.94
-1.52
+0.28
-1.50
-1.72
-1.87
+0.56
-0.14
-1.33

1.76
1.94
0.93
2.04
1.63
2.13
1.94
7.20
7.71
5.08
3.54
1.28
1.91
2.08
1.07
1.49
4.76

ns
ns

degrees
degrees

degrees

Lower 1-Occlusal plane

T2-T1
SD

Occlusal plane-XiPm

1-NSL
1-ML
1-NPg
1-NPg
1-NSL
1-ML

T2-T1
Mean

6occl-ML
6occl-NSL

Upper
Lower
Upper
Lower
Upper
Lower

Segmented arch

Unit

degrees
mm
mm
degrees
degrees
mm
mm
mm
mm
mm
mm
mm

Anterior face height

Lower anterior face height

Continuous arch

**
**
**
*
**

ns
ns
ns
ns
**

ns
ns
*
**

ns

T1, Pretreatment; T2, posttreatment; *significance at p < 0.05 level; **significance at p < 0.01 level.

in the Burstone group. The group difference was not

significant. The mandibular molars were extruded significantly in the CAW group (+1.30 mm, p < 0.001),
and to a much lesser extent in the Burstone group
(+0.56 mm, p < 0.01). Group comparison showed significance at p < 0.05 level.
More treatment effects

The molar extrusion in the CAW group produced

some posterior rotation of the mandible. This is shown
by the increase of the Bj/3rk polygon (+1,87~ y-axis
(+1.41~ and ML/NSL (+1.94 ~ all p < 0.001). As a

consequence, total and lower anterior face height were

increased by 2 to 2.5 mm. In contrast, the vertical
dimension of the face in the Burstone group did not
change substantially. The intergroup differences were
significant at p < 0.01 level, with exception of total
anterior face height (p < 0.05).
The inclination of the occlusal plane did not
change significantly in both groups.
DISCUSSION

It is possible to correct deep overbite with two

differing orthodontic mechanics in adult patients. The

Weiland, Bantleon, and Droschl 651

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 110, No. 6

Iltlll~rom ~

Fig. 4. Composite tracing of treatment changes in segmented arch wire (Burstone) group.

only difference between the groups regarding the treatment regimen was in the first phase of treatment,
during which the vertical malocclusion was corrected.
Whereas, in the first group of patients, the arches were
leveled with continuous arch wires, in the second
group, intrusive segmented arch mechanics, as recommended by Burstone, were used. Mean overbite reduction did not differ significantly between the two groups
of our sample. Absolute values (3 to 3.5 mm) correspond with previous r e p o r t s . 7"8'm'11 Apart from some
intrusion (1 ram) and flaring of the lower anterior
teeth, the continuous arch wire treatment predominantly caused correction of the deep bite by extrusive
tooth movement in the molar area, concomitant with
posterior (bite opening) rotation of the mandible. Other
authors report similar results by using a straight wire
appliance in adults. 7,s Possibly, the high initial vertical
force levels that are generated when using continuous
arch wires" in deep bite cases result in an overloading
of the vertical anchorage.
It has been suggested that low, continuous forces
should be applied to achieve intrusion. 2~ Proffit 2~ states
that to correct a deep overbite "in the absence of
growth absolute intrusion (of the incisors) is required
and segmented arch mechanics must be used to
achieve this." Indeed, it could be shown that segmented bite opening mechanics, as recommended by
Burstone, result in a substantial intrusion of the upper
and lower incisors. Although the vertical position of
the upper molars stays approximately stable and the
lower molars show an extrusive movement that is less
than 40% of that seen in the CAW group, the intrusive
movement of the incisor teeth accounts for the overbite
correction almost completely. The low force levels

used (totaling 40 to 50 gm for four incisors) appear to

have little (lower arch) or no substantial (upper arch)
effect on vertical posterior anchorage, although no
anchorage enhancement with a high-pull headgear, as
advocated in the literature, ~7 was performed. We hypothesize that occlusal forces are able to prepare
sufficient vertical anchorage in cases with very low
extrusive force. The extent of incisor intrusion found in
our sample (maxilla: 1.50 rnm, mandible: 1.71 mm) is
somewhat lower than those found in patients in whom
utility arches are used in the lower jaw. Several
authors "'2~ state that with utility arches, it is reasonable to expect about 2 mm of incisor intrusion. The
difference in our results might be explained by the fact
that in all our "Burstone" patients, intrusive mechanics
were applied in both the upper and the lower jaws.
Therefore we hypothesize that maximum intrusion was
not needed to correct the deep overbite. Great latitude
exists regarding the amount of intrusion seen, which is
shown by the standard deviations. This is in accordance with data from the literature. '~ In addition to
individual biologic reactions, this may be due partly to
the differing amounts of intrusive tooth movement
needed in individual patients. Maximum intrusion seen
was 6.6 mm in the mandible of a female patient.
These individual variations are even stronger regarding changes in incisor inclination. This is due to
the compilation of the pretreatment malocclusions,
including Class I; Class II, Division 1; and Class II,
Division 2 cases. Depending on the original inclination, flaring of incisors can be desirable (Class II,
Division 2), undesirable, or even contraindicated, as is
the case in most Class II, Division 1 malocclusions. A
change of incisor inclination, however, has a distinct

652

Weiland, Bantleon, and Droschl

effect on overbite. 24 As genuine intrusion of a tooth is

defined as apical m o v e m e n t of the center of resistance
in relation to a reference plane 17 an approximation of
the center of resistance, defined as the midpoint between the incisal edge and the apex of the upper and
lower incisor, respectively, was used for analysis of the
vertical position of the incisors, rather than the incisal
edge.
Factors that are said to be responsible for relapse of
deep bite in adult patients include, among others,
molar extrusion during treatment ~4'25-27 and intrusion
of incisors. 2s As the two groups of patients described in
this study reacted very characteristically in one of
these two ways to the differing bite opening mechanics, it would be very interesting to reevaluate the
long-term results. A report is planned in due time.
CONCLUSIONS AND CLINICAL IMPLICATIONS
Deep overbite malocclusion can be corrected in nongrowing patients by orthodontic treatment. With a conventional continuous arch wire technique, overbite reduction will
be due mainly to extrusion of molars and some intrusion and
flaring of the lower incisors. Posterior rotation of the mandible may result. Incisor intrusion with little extrusive movement in the molar area, however, is found with the segmented
arch technique as recommended by Burstone. In certain
cases, intrusion of incisors is absolutely indicated. This holds
true particularly in patients showing elongation of incisor
teeth, e.g., in Class II, Division 2 cases 12'13or after periodontal bone 10ss. 9'14'23'25However, intrusion of teeth may aggravate the periodontal breakdown in the presence of plaque and
inflammation. 293' Experiments on dogs clearly showed that
orthodontic movement can shift supragingival plaque into a
subgingival position, producing infrabony pockets. 32 On the
other hand, though, it has been shown that orthodontic
treatment, including intrusion of teeth, does not result in
decrease of the marginal bone level, provided the gingival
inflammation is kept to a minimum.23'3t'32 Therefore, in
periodontally involved patients, as in all adults, gingival
inflammation should be brought to a minimum before starting orthodontic treatment and the periodontal condition supervised meticulously during the orthodontic procedure.
From this study, it may be concluded that the arch
leveling technique, according to Burstone, can produce genuine intrusion of the incisors with little vertical effect in the
molar area in adult patients. The application of this technique, rather than using continuous arch wires therefore is
indicated if correction of deep overbite by intrusion is
desired.

American Journal of Orthodontics and Dentofacial Orthopedics

December 1996

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