\

Atlas of

Principles and
ical Applications
Preface

Atlas of Orthodontics: Principles and Cl inical Applications was written with the
intention to introduce to the world of clinical orthodontics its first illustrated text.
This colorful . methodological presentation of the most up-t<rdate infonnation and
direct clinical application aims to aid the students of orthodontics in understanding
the logical sequence from diagnosis to a successful treatment. In additi on. as the
innovations and revolutionary improvements in clinical orthodontics over recent
years have widened the scope of diagnosis and broadened the horizons of treatment.
this work aims to serve as the most updated illustrated reference of all these new
advances. Thus, the atlas can very easily serve as a guide to students, dentists. and
orthodontists alike.
AlIas of Orthodontics is an array of original photographs and drawings that high-
light the state.of-the-art modern practice of orthodontics with fresh, new ideas on
diagnosis, treatment planning, and, above all, therapy and its clini cal application. It
provides the reader with a step-by-step decision-making approach to the practi ce of
orthodontics. The comprehensive yet easil y readable text and the legends that accom-
pany the illustrations span the breadth of the references. The clinician learns various
techniques from photographic material (in color) directl y from the patient's mouth.
This atlas offers a system that gives the best results while disclosing invaluable tips on
preventing clinical blunders that would lead to complications. It methodicall y explains
the reasons for all the clinical techniques used based on fundamental biological and
biomechanical principles, so that the reader will easily understand the orthodontic
thinking process. Furthermore, it will give the practitioner the satisfacti on of being
able to appl y clinically all that he reads. While reflecting the most current accepted
treatment methods, its structured outline and continuity provide all the information
in an easy, commonsense formal. No other book in the field of orthodontics focuses
on the clinical side of day-to-day practice with such an abundance of illustrations that
educate the reader on critical judgment and clinical modalities that give the best
treatment results. It is an invaluable educational source of the art and science of
clinical orthodontics for the graduate and undergraduate student , for the ge neral
dentist, and even for the most experienced orthodontist.
My sincere appreciation is addressed to the following individuals for their signifi -
cant contributions to my education and academic endeavors in orthodontics: from
Baylor College of Dentistry, Drs. Ri chard Cecn, Robert Gaylord, Tom Matthews, and
Peter Buschang, Rohit Sachdeva, Doug Crosby, Monte Collins, Joe Jacobs, Ri chard
Aubrey, Moody Alexander, Wick Alexander, Ed Genecov, Larry Wolford, Mr. Stan
Ri chardson, and Mr. Chris Semos; from the Universit y of Minnesota, Drs. William
Liljemark, Ri chard Bevis, Gerald Cavanaugh, T. Michael Speidel, Kevin Denis, Mark
Holmberg, James Swift, Robert Feigal, Robert Gorlin, William Douglas, and the
former President of the American Board of Orthodontics, Lloyd Pearson; from the
Uni versity of Maryland, Dr. Dianne Rekow; from Tufts Uni versit y, Drs. Nicholas
Darzenta and Anthi Tsamtsouris; from the University of North Carolina, Dr. William
vii
viii l'rti aw
Proffit ; from the University of Southern California. Dr. Peter Sinclair; from the
Universit y of Iowa. Drs. John Casko and Samir Bishara; from the Uni versit y of
Athens, Drs. Meropi Spyropoulos, Paul Apostolopoulos, and George Vouyouklakis;
from the Medical College of Virginia, Dr. Robert Isaacson; and from Louisiana State
University, Dr. Jack Sheridan; and from the Uni versity of Toronto, Dr. Angelo
Metaxas.
A special acknowledgment is addressed to one man who is an inspiration to many
in the field of orthodontics: Dr. T.M. Graber, Editor-in-Chief of the American Journal
of Orthodontics 011(1 Denlofadal Orthopedics. I am deeply grateful to him for his
advice, recommendations, endless energy and enthusiasm, and the wonderful support
that all my academic endeavors have enjoyed from him.
I am also grateful to all the students with whom I have had the distinct pleasure of
working, from the undergraduate junior dental class at the University of Minnesota
that presentcd me with the greatest honor of my academic life, the "Teacher of the
Year Award" after my very first year in teaching, to the graduate students at the same
school and at Baylor College of Dentistry for their excellent work on all the cases that
we treated together. Their critical thinking and quest for knowledge have certainly
influenced me and the way I teach.
ANTttONY D. VIAZIS, DDS, MS

Contents
Part A Preliminary Examination of the Patient
Chapter I Chief Complaint 3
Chapter 2 Dental Development 5
Chapter 3 Articulated Casts 7
Chapter 4 Radiographi c Evaluati on 13
Chapter 5 The Temporomandibular Joint 21
Chapter 6 Nasorespiralary Function 27
Chapter 7 Oral Hygiene Considcrdti ons 29
Chapter 8 Periodontal Plasti c Surgery 35
Part B Facial and Cephalometric Evaluation
Chapter I Natural Head Position 41
Chapter 2 Bolton and Michigan Standards 45
Chapter 3 Cephalometri c Landmarks 47
Chapter 4 Soft-Tissue Evaluation 49
Chapter 5 Anteroposterior Skeletal Assessment 59
Chapter 6 Vertical Skeletal Assessment 67
Chapter 7 Cephalometric Dental Evaluation 73
Chapter 8 Posteroanterior Cephalometries 75
Part C Growth
Chapter I Growth Considerations 79
ix
x Conl('lI/.f
Chapter 2 Growth Superimposition/ Evaluation 89
Chapter J Hand-Wrist Radiograph Evaluation 97
Chapter 4 Nasal Growth 99
Part D Orthodontic Mechanotherapy
Chapter J Biomechani cs of Tooth Movement 105
Chapter 1 Orthodontic Metal Fixed Appliances 117
Chapter 3 Esthetic Brackets 121
Chapter 4 Direct Bonding of Bmckets/ Adhesive 129
Systems
Chapter 5 Basic Orthodontic Instruments: Wire 141
Bending
Chapter 6 Orthodontic Wi res 153
Chapter 7 Archfonns 163
Chapter 8 Coil Springs 167
Chapter 9 Elastometric Chain Modules 179
Chapter 10 Orthodontic Elastics 189
Chapter II Class I Cuspid Relationship 199
Part E Adjunctive Appliances
Chapter J Rapid Maxillary Expansion (RME) 205
Appliances
Chapter 1 Lip Bumper 215
Chapter 3 Headgear 219
Chapter 4 Removable Appliances 223
Chapter 5 Functional Appliances 227
Chapter 6 Chin-Cup Therapy 233
Chapter 7 Thumb-Sucking and Habit Cont rol 235
Chapter 8 Protraction Faccmask 239
Chapter 9 Active Vertical Corrector 243
COn/enls xi
Pari F Orthodontic Treatment Modalities
Chapter J Early Treatmcnt 249
Chapter 2 Tooth Gui da nce (Serial Extracti on) 261
Chapter J Tooth Reconto uring 265
,
,
Chapter $ Treatment Planning in thc Permancnt 271
Dentition
Chapter 5 Incisor EXlnlction/ Missing Incisor/ 307
Second Molar Extracti on ThcnlPY
Chapter 6 Intrusion Mecha nics/ Compromised 323
Periodontium Thcmpy
Chapter 7 Retent ion 33 1
Indu 343
C" e r
Chief Complaint
The examination or the patient in the offi ce should always stan with the medical history, as is
done in any dental offiCC.
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3
The dental clinical evaluation should follow, where
general notes, as well as an evaluation of the intraoral soft tissue, teeth, and oral
function, and panoramic radiograph are made.
2

1
Any operati ve, periodontaL and
endodontic work (if needed) should be completed before initiation of onhodontic
treatment, whereas any tcmporomandi bular joint (TMJ ) pain or dysfuncti on should
be addressed before the onset of onhodontic treatment (Table A 1.1). Permanent
prosthetic work should be done afterward.
Inquiring about the patient's chief complaint, i.e .. the reason he or she seeks
orthodontic treatment, is of utmost importance. The chief complaint must have been
met by the end of treatment, otherwise the patient will not be happy, even if the
orthodontic therapy is of the highest standards. If the patient or guardian has unrealis-
tic expectations that may not be met with treatment, the clini cian ought to educate
him or her so that he or she understands the limitations of the vari ous therapeuti c
modalities in modern orthodontics. A good example is the change of the soft tissue
(li ps) as a result of extraction therapy. A patient will not be satisficd if. after 2 years of
orthodontics, he or she has a beautiful occlusion accompanied by late nasal growt h
that makes the lips appear more retrusive. In addition, the low degree of predictability
associated with the upper lip in rcsponse to orthodontic tooth movemcnt, possibly
caused by the complex anatomy or dynamics of the upper lip, I might cause undesir-
able changes in the soft-tissue profi le in crowded cases that involvc extractions of
permanent teeth. Nononhodontic measures (i.e .. rhinoplasty or genioplasty) should be
discussed with the patient before the stan of the orthodontic treatment. I
4 Pan A Preliminary EXaminOlian of/he Parieni
Table 1.1 Cl ini cul Information Form (DenIal )
General Information
Parent name Guardian name
Address
P'Jtient name Goad< Hobbies
Do"
Telephone
Chief complaint
Patient height Father's height Mother's height

Pat ient motivation
Prepubenal Cireumpubenal Postpubenal Habits
Famil y hi story of malocclusion
Intraoral Soft Tissue Evaluation -
Pathology Oral hygiene Attached gingiva Gingi val recession
Attachment Pocket depth > 3mm Frenum
Intraoral DenIal Evaluation and Panoramic Radiograph
"".,
Extracted Root length
Uypoc;alcilication Fractured CW" i11 Crownjbridgc
Missing Fractured root Supernumerary
Impacted Stained Wisdom teet h
Ankylosed Endodontically treated Bone pathology
Unerupted Condylar outline: Al veolar bone
F ne"
IOna I Eval ation

Speech pathology Muscle tenderness Internal dernngement
Breathing Clenching Stage I (early or late clicking)
Swall owing Bruxism Stage II (morning lock)
Tongue size Deviation upon opening Stage III (acute lock)
lip tonicity Deviation upon closing Stage IV (funct ion off disk)
Tonsi l size Range of motion (ROM) Stage V (pain, grating sound)
CO/CR discrepancy TMJ pain TMJ dysfuOCIion
References
I. Talass MF, Tallas L, and Baker RC: Soft tissue profile changes result ing from retraction of maxil lary
incisors. Am J Onhod Dc:qtofacial Onhop 9 1 :385-394, t987.
2. Proffit WR, and White RP, Jr. : SurgicalOrthodontic Treatment. St. Louis. MO: Mosby Year Book. 199 1.
3. Proffit WR: Contem{IQraryOrrhodolUicJ. SI. Louis, MO: C. V. Mosby Co .. 1986.
4. Buschang PH, Viazis AD, DelaCruz R, and Oakes C: Horizontal growth of the softti ss ue nose relat ive
to maxillary growt h. Jain Orthod 26:111 - 11 8, 1992.
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Dental Development
The development of teeth begins in utero, but it is not until 2 to 3 years of age that all
deciduous teeth appear in the toddler's mouth,I.2 The most common sequence of
eruption starts with the lower central incisors, followed by the upper centrals in the
first 6 months of life; the upper lateral and lower incisors crupt by the end of the first
year of age; the upper and lower first deciduous molars, followed by the cuspids,
appear by 18 months, and the lower and upper second deciduous molars erupt by the
cnd of the second year or as late as the third year of life 1): (see Fig. FI.l S). Past this
point, very little increase in dental arch width occurs. Spacing is desirable in the
primary dentition; lack of spacing means large teeth or small arches and is strongl y
suggestive of crowding in the permanent dent ition.
The eruption of the permanent dentition starts around the age of 5 or 6 years wi th
the first permanent molars distal to the second deciduous molar tceth.l .2 The periods 5
to 8 years of age and 9 to 12 years of age are called earl y and late mixed dentition
stages, respectively. Around 6.5 years of age, the lower central incisors erupl , followed
by the upper centrals by 7 years of age. 1,2 The lower laterals erupt by age 7.5 years,
followed by their maxillary counterparts at age 8 years or as late as 9 years of age
l
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l
(see Fig. F1.I6). At approximately 10 years of age, the lower permanent cuspids make
their appearance in the child's mouth, followed by the upper first bicuspids at age 10.5
years and the lower first bicuspids at age II years.1,2 The upper and lower second
bicuspids erupt very close to each other at age 11 .5 years, followed by maxillary
cuspids and the second permanent molars by the age of 12 years or as late as age 13
years.
l
,2 One must keep in mind that there is one significant variation of tooth
eruption in the population: teeth may erupt as early or as late as 2 years in relation to
the average ages mentioned above and still be considered normaL
Teeth usually erupt when the roots arc one half to three quarters formed.
2
After the
end of the early mixed dentition stage, the upper incisors may have substantial spacing
as their crowns are inclined toward the distal. This is called the " ugl y ducking stage"
and is considered a nonnal condition that will sclf-correct later on; it happens due to
the eruption path of the permanent cuspids as they come into position for eruption
along the roots of the lateral incisors (Fig. A2. 1).
The sum of the mesiodistal width of the deciduous cuspid and molar teeth is 1.3
and 3.1 mm greater than the permanent cuspid and bicuspid tccth in the maxilla and
the mandible, respectivel y (leeway space).2 This space is generally used in the p e r m a ~
nent dentition to permit improvement of possible crowding of anterior teeth and also
to allow a slight mesial migration of the first permanent mandibular molar into a solid
class I occlusion.
2
.) The leeway space may be quickly lost from premature exfoliation
of teeth and quick mesial movement of the permanent molar to an extent that the
lower second bicuspid may be blocked out toward the linguaJ2 (see Fig. 06.7). It
should be noted that the last increase in dental arch width occurs as the permanent
cuspid teeth erupt into their position in the arch. Expansion of the arches in this area
is questionable past this stage.
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Articulated Casts
The most supero-anlcrior position of the condyle is musculoskclctally the most stable position
of the joint (centric relation),I - l In this position, the condyles arc resting against the
posterior slopes of the articular eminences with the articular disks properly interposed
and all of the muscles that coordinate joint movement at rest.
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1
During rest and
function, this position is both anatomicall y and physiologicall y sound. A posterior
force 10 the mandible can displace the condyle 10 an unstable posterior (or retruded)
position. Because the rctrodiscal tissues arc highl y vasculari zed, well supplied with
sensory nerve fibers, and not structured to accept forces, there is great potential for
eliciting pain or causing breakdown,l.3
The position of the mandible where the relation of opposing teeth provides for
maximum occlusal intercuspation is called centric ocdusion.
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4
This, ideall y, should
coincide with centric relation
4
; this is what the clinician should stri ve for during
orthodontic treatment. In most cases, a slight discrepancy of about I mm also can be
acceptable, where the position of the mandible in centri c relation is slightl y behind its
position in centric occlusion.
In contrast to craniometric variables, which have hi gh heritabilities, almost all of
the occlusal variability is acquired rather than inherited.
5
Thus, a careful exami nation
of the patient's malocclusion is essential. This is best done from a set of articulated
casts in centri c relation (CR) (Fig. A3. I).
The following wax bite registration technique is suggested for proper recording of
the patient's bitc': the right thumb is placed on top of the patient's chin with the right
index finger under the patient's left gonial angle and the right second fmger under the
patient's right gonial angle (Fig. A3.2). The mandible is allowed to close (Fig. A3.3) in
such a manner that the lower incisors contact the anterior wax. until a 2-mm posterior
opening in the molar area is obtained (Fig. A3.4). When the patjent squeezes. the
muscle contractions scat thc condyles in a superior and slightl y anterior position
against the eminence.' The objecti ve is to gain an index of both maxillary and
mandibular incisal edges without making any tooth contacts. The anterior wax is
cooled down and removed whi le a soft posterior wax is placed against the maxillary
posterior teeth (first molar and second premolar area) (Fig. A3.5). The hard anterior
wax is secured in the anterior region (Fig. A3.6) and the mandi ble is gentl y manipu-
lated into centric relation as described atxlVc (Fig. A3.7). After the mandibular closurc
has been stopped by the limit of the indexes in the anterior section (Fig. A3.8), both
picces of wax are removed aftcr they are cooled down with air-spray (Fig. A3.9). A
centric occlusion wax bite is also taken as the patient opens widely and bites all the
way through the wax until the teeth touch full y.
A3.5
Flgur. A3.5 A soft posteri or piece of wax is pressed lightly
against the posterior teeth.
rtgure Al.7 The mandible is again very gently manipulated
into CR. Note that the anterior wax is held against the
upper anterior teeth during the closing motion of the man-
dible.
Cbapler 3 Aniclll(l/MCaslJ . 9
A3.6
Flgur. A3.6 While gently holding the posterior wax in place.
the hard anterior wax is secured in its positi on. Note the
indentations of the lower incisors recorded previously.
Figure A3.8 The mandibular closing motion is stopped as
soon as the lower anterior teeth come in contact with the
hard anterior wax. The posterior teeth made their cusp
indentations in the posterior wax, without even coming in
contact with their counterparts. This way, the muscles have
guided and seated the condyles in the most supero-anteri or
posit ion against the eminence.
10 Pllrt A Preliminary Examination o/llw Patient
A3.9
Figure A3.9 The wax pieces are cooled down with air-spray
before they are removed from the mouth.
Once mountcd on the articulator, the dental casts are used to evaluate the following
7
:
Angle Classification
A class I molar relation exists when the mesiobuccal cusp tip of the upper fust molar
occludes in the buccal groove of the lower first molar (sec Fig. E3.7). Similarly, a class
I cuspid relation exists when the upper cuspid occludes in the embrasure between the
lower first bicuspid and the lower cuspid (see Fig. F4.72). A full cusp width ahead of
the class I position is defi ned as a full-step class II (see Figs. F4.84, F4.92, F4.96). A
full cusp width back of the class I position is a full class III (see Fig. CI.I5). An
end-to-end relation is termed as a 50% class II (see Fig. 0 11.1) or 50% class III (see
Fig. 09.33), depending on the direction of discrepancy.
Overbite
The vertical overlap of teeth is the overbite (08). The 08 in the incisor area should
be approximately 2 mm (see Fig. CI.I8).
Overjet
The horizontal overlap of teeth is the overjet (OJ). The OJ in the incisor area should
be 1 to 2 mm (see Fig. CI.I8).
Crowding
The best and most accurate way to evaluate the existing arch length discrepancy is by
measuring the width of all the teeth in the arch with a campus, as well as measuring
the actual arch length.' A clinical way to assess crowding is by "eyeballing" it, taking
into consideration the average width of various major teeth (bicuspids- 7 mm;
cuspids-8 mm; lower incisors-6 mm; upper cent rals - IO mm). By subtracting
how much tooth material is blocked out of the arch or is in a crowded position, one
may very quickly evaluale the space that is needed to obtain good tooth alignment.
This is undoubtedly a very crude method, but one that clinical experience has shown
to approximate (+ 1 mm) to the exact discrepancy (sec Figs. 06.6, D6.7, D9.18,
09. 19, F4.62. F4.63, F5.3, F5.4. F5. 11, F5.12, F5.24, F5.25). The cause of crowding
FI
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i
C'Iulpltr J Af//CII /OIN Costs 11
may differ from one subject to another. or there may be morc than one factor
contributing to the development of crowding in any onc individual. B
Crossbite
Crossbilc occurs when one or morc teeth arc in an abnonnal buccolingual relation-
ship.? Single-tooth crossbitcs arc usuall y dental in nature (see Figs. E4. 1, E4.2).
Multiple-tooth crossbitcs are anterior (sec Fig. C1.I3) or posteri or (sec Figs. e 1.1 3.
C1.26, C1.30) and usually skeletal in nature.? Anterior looth crossbites may be
"pseudo class III " (due to a shift) (see Figs. F1.I6, F1.I 7) or " true class III " (true
skeletal) (see Fig. C1.13),7 Posterior crossbitcs arc unilateral or bilateraL Unilateral,
multi ple-tooth crossbites arc usuall y the result of a side shift to one side from a
bilateral skeletal crossbite. The vast majorit y of multiple-tooth crossbites are bilateral
and are due to a constricted maxilla (see Fig. F4. I05). Multiple-tooth crossbiles
should be corrected as soon as possible (t he youngest known pati ent is 3 years old) to
avoid the possible development of a skeletal malocclusion or abnormal eruption of
teeth, as well as to improve the patient' s esthetics
9
(sec Figs. F1.l2 through FI.1 5).
Dental Midlines
The facial midline (see Fig. B l.l ) (middle of eyebrows, tip of the nose, cupid' s bow)
should coincide with the upper dental midline (between the upper centrals) and the
lower dental midline (between the lower centrals) (sec Fig. 09.27). If a compromise
must be made due to the patient's malocclusion, it may be best to leave the lower
midline off by I to 2 mm (a lot of patients do not show their lower tccth upon
smiling). The upper denial midline should coincide with the facial midline for an
estheticall y pleasing smi le (see Fig. A8.3).
Tooth-Size Discrepancy
A3.10
A tooth-size discrepancy (TSO) exists when the size of the lower or the upper tccth is
not in proportion with that of their counterpans.
IO
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12
An anomaly in the size of the
upper lateral incisors is the most common cause, but variations in bicuspids or other
tccth may be prescnt
7
(see Figs. A3.1O, F3.7, F5.22). In such a case, it would be
impossible to obtain an ideal OB/ OJ relation of 2 mm when the cuspids are in a class
FIgUre A,3.10 Small upper left lateral. Spaces were left next
\0 i\ for prosthetic work.
12 ' >art A Preliminary Examination of till! Patient
I occlusion. If there is excess maxillary tooth material, we will end up with an
excessive OJ (sec Fig. FS.8); if the excess is in the mandibular arch, then minimal
OB/ OJ will exist and the cuspids will occlude in a slight class III relation.
A large percentage of patients have mesial-distal tooth-size discrepancies, approxi-
mately 13.8% and 9.2% for the mandibular and maxillary dentitions, respectively. I I
Such discrepancies, if left unt reated, could lead to future posttreatment relapse, espe-
ciall y in the mandibular incisor area. Interproximal reduction wi ll , in most cases,
alleviate such discrepancies.
A method used to assess TSD is Bollon's anal ysis.
1
,ll If alterations of tooth size are
to be done in the upper arch, the sum of the width of the lower anterior teeth is
multiplied by 1.3 to give the di mensions of the ideal upper arch for these particul ar
lower anteriors.
IO
If alterat ions of tooth size are to be done in the lower arch, then the
width of the upper anterior teeth is multiplied by .775 to gi ve the ideal lower arch.1O
If the TSD is in t he posterior teeth, then they may be selectively reduced in width,
enough to obtai n a class I cuspid relation (see Figs. F3.7, F3.8). Interproxi mal reduc-
tion should be done in the upper or lower arch in order to make these teeth fit in
relation to their counterparts.
References
I. Okeson IP: Management of Temporomandibular Disorders and Occ/usion, 2nd ed. St. Louis. MO: C. V.
Mosby Co .. 1989.
2. Molal NO, urb GA, Carlsson GE, and Rugh SO: A Texlbook of Occ/usiOll. Chicago: Quintessence
Publishing, 1988.
3. American Academy of Craniomandibular Disorders: Craniomandibufar {Jisordcrs: Guidelines for ~ a f
uotion, Diagnosis and Management. McNeill C, ed. Chicago: Quintessence Publishing, 1990.
4. Parker WS: Centric relation and centri c occlusion - An orthodontic responsibility. Am J Orthod
Dentofacial Orthop 74:481-500, 1978.
5. Harris EF, and Johnson MG: Heritabili ty of craniometric and occlusal variables: A longitudi nal sib
anal ysis. Am J Orthod Dentofacial Orthop 99:258-26g, 1991.
6. Carlson G: Advances in Orthodontics: Seminar Series (Course Syllabus). Minneapolis. MN. 1988.
7. Proffit WR: Contemporary Orlhodonlics. St. Louis, MO: C. V. Mosby Co., 1986.
8. Richardson ME: The role of the third molar in the cause of late lower arch crowding: A review. Am J
Orthod Dcntofacial Orthop 95:79- 83. 1989.
9. Vadiakas G, and Viazis AD: Anterior crossbite connecti on in the primary dentition. Am J Orthod
Dentofacial Orthop 102: 160 - 162, 1992.
10. Wolford LM: Surgical- onhodontic oom:ct ion of dentofacial and craniofacial deformities-Syllabus.
Baylor Col lege of Dentistry, Dallas. TX, 1990.
II. Crosby DR. and Alexander RG: The occurrence of tooth size discrepancies among different malocclu-
sion groups. Am J Orthod Dentofacial Orthop 95:457 - 461, 1989.
12. Bolton WA: The clinical application of tooth si ze anal ysis. Am J Orthod Dcntofacial Orthop 48:504 -
529,1962.
Ii
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J Radiographic Evaluation
A careful dental and rndiographic (panoramic or peri apical) evaluation may reveal a number of
situations that need to be addressed before the initiation of orthodontic mechano-
therapy.
Ankylosis
Ankylosis, ' a localized fusion of alveolar bone and cementum, is the result of a
defective or discontinuous periodontal membrane and is apparentl y caused by me-
chanical, thermal, or metabolic trauma to the periodontal membrane during or after
toot h eruption. It occurs most often in the primary dentition (see Fig. 010.8) in the
mandibular teeth, and in molars. It can sometimes be detected from radiographic
evidence of periodontal membrane obliteration or by a sharp or ringing sound upon
percussion and by lack of tooth mobility or soreness, even wi th heavy, continuous
orthodontic forces.
'
In the pri mary dentition, ankylosis is usually treated by simple neglect, restoration,
or extraction.
l
Ankylosis of a permanent tooth, however, is more complicated if
orthodontic treatment is planned. Intervention can include luxation, corticotomy, or
ostectomy. I
Most infra-occluded and ankyloscd primary molars with a permanent successor
exfoliate normall y.2 The decreased height of the alveolar bone level at the si te of the
infra-occluded primary molar has been reponed to normali ze after the eruption of the
permanent successor. Infra-occlusion and ankylosis of primary molars docs not con-
stitute a general risk of future alveolar bone loss mesial to the fi rst permanent molars.
Primary Failure of Eruption
Primary failure of eruption describes a condition in which nonankylosed, usuall y
posterior teeth fail to erupt, either full y or partially, because of fai lure of the eruption
mechanism.
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The teeth most commonl y involved are the deciduous and permanent
molars, although premolars and cuspids may also be affected.$ There appears to be no
mechanical impediment to eruption in these cases. ' Unilateral situations occur more
frequently than bilateral ones. A posterior open bite, caused by a primary failure of
eruption, will not respond to orthodontic treatment ; a segmental alveolar osteotomy
offers the only possible treatment modality.
Diastemas
Midline diastemas arc quite common among individuals (see Fig. F4.11). Closing
them poses no problem orthodontically, but in many patients they lend to re-open,
especially if caused by an abnormal labial frcnum.
6
14 Part A I'fI'fimi nary Examination oj lhe Path'nl

It is important to close the space orthodonti call y as soon as possible and then
perform the surgical procedure of abnonnal labial frenum, thus allowing healing of
the tissues to occur with the teeth in their newly established positions.
6
It is suggested
that when the frenum is wide and attached below the mucogi ngival j uncti on in
ker'J.tinj zed tissue, it often will regenerate after frenectomy. ' To prevent this from
occurring, epi thelial graft from the palate is placed over the area on removal of the
frenum, preventing its ingrowth.
'
Root Resorption
Root resorption occurs in every patient who undergoes orthodontic treatment. In the
majority of cases, it is a mere blunting of the root apices. In some pati ents, it is more
severe for reasons that seem to be idiopathic. wit h the exception of previousl y trau-
mat ized teeth, which are more susceptible to resorpti on and loss of vital it y (Fig.
A4. 1 ).' Around 16.5% of patients have approximately I mm of resorpti on of the
maxillary incisor teeth.' Maxillary incisors have been reported to be the most suscep-
tible to this severe resorpti on, with other teeth less affected. A recent study showed
that 3% of patients have severe resorption (greater tha n one q uarter of the root
length) of both maxillary central incisors (Fig. A4.2).
Less resorpti on is observed in patients treated before age II years, perhaps due to a
preventive effect of the thick layer of predentin on young, undevel oped rool s.
9
Con-
tact of maxi ll ary incisors wit h the lingual cort ical plate may predispose to resorption.'
Class III patients are overrepresented in the group with severe resorption.'
Figure A4.1 Trauma to these central incisors from a bicycle
accident led to their severe root resorption and loss of
vitality.
F I ~
of
roo
,
A4,2
Figure A4.2 Resorpt ion of central incisor teeth after 2 years
of orthodontic treatment. One quarter to one third of these
roolS have been lost.
Chapter 4 Radiographic EI'afliation 15

The longer the active treatment time, the greater the chance of severe resorption.
Obviously, a patient wit h small, rounded roots is not a good candi date for excessive
tooth movement. Iatrogenic root resorpti on is caused by j iggling teeth over long
periods of time, indecisive treatment that causes cha nges in the direction of tooth
movement, and proximating of the cortical plate.
1O
No relation has been found
between the amount of root shortening and degree of intrusion achieved,!1 In general,
treatment time is the most significant factor for occurrence of root shortening. In a
recent long-tenn evaluation of root resorpti on occurring during orthodontic treat-
ment, it was shown that there are no apparent changes after appliance removal except
remodeling of rough and sharp edges.!2
Impacted Cuspids
Impacti on of the cuspid tccth
ll
-
20
is caused primarily by the rale of root resorpti on of
the deciduous tccth, disturbances in tooth eruption. tooth size/ arch length discrepan-
cies, rotation or trauma of tooth buds, premature rOOI closure, ankylosis, cystic or
neoplasti c formation, clefts, and idiopathic causes. Most of the impacti ons arc uni lat-
eral and on the palatal side. 16 The evidence of maxillary impaction ranges from 0.92%
to 2.2%; maxill ary impaction is twi ce as common in females than in males, I6 The
incidence of mandibular impaction is much less, 0.35%,16 Impacted cuspids may
cause resorpti on of the adjacent incisor teeth; thus, their extraction or uncovering and
movement into thc dental arch is necessary (Fig. A4.3). Potential incisor resorption
cases from impacted cuspids are those in which the cuspid cusp in periapical and
panoramic films is positioned mediall y to the midline of the lateral incisor (0.71 %).!6
The ri sk of resorption also increases with a more mesial hori zontal path of eruption.
2
!
16 J'art " Prriimmar}' Examinalioll of/hI' I'miml
M.3
Figure A4.3 An impacted cuspid has caused almost complete
resorption of the lateral incisor tooth and significant de-
structi on of the central incisor tooth.
Surgical uncovering of these teeth is the standard treatment procedure, followed by
direct bonding of an orthodonti c bracket onto the tooth and mechanical traction wit h
elasti cs or springs to bring the teeth into the arch (see Fig. F4.58). An apicall y
reposit ioned nap for labially situated cuspids is recommended. I. Adequate attached
gingiva need be present (or surgically placed) to avoid mucogingival problems. Wire
ligation ("lasso" type) instead of direct bracket placement onto the uncovered tooth is
prohibited because it leads to loss of attachment and to external root resorption and
ankylosisY In addition, any surgical exposure beyond the cement - enamel junction
leads to bone loss.
Treatment of cases with impacted cuspids is quite lengthy, depending on the
position and orientation of the impacted tooth in the bone.
'6

'7
It may take between
12 and 30 months. Also, at the end of treatment, these teeth will show the presence of
a 5- to 7-mm pocket, usuall y on the distal side. They display significantl y more loss
of periodontal support on the buccal and palatal surfaces than do normal teeth.11
Excellent oral hygiene wi ll preserve these teeth throughout life without further sequelae.
An alternative to surgical uncovering and lengthy orthodontic treatment of im-
pacted teeth is the autotransplantation of these teeth. Autotransplantation should be
performed at a stage when optimal root development of the transplant may be
expected; namely, one half to three quarters of the full root length. I' When transplan-
tation is performed at an earli er stage of root development, the final root length may
be shorter than desirable. If autotransplantation is performed at a later stage of root
development. the ri sk of root resorpti on increases. The surgical procedure should be
as atraumatic as possible and requires a surgeon well acquainted with the method.
Teeth transplanted with incomplete and complete root formation show 96% and
15% pulp healing, respcctively.'9 The size of the apical foramen and possibl y the
avoidance of bacterial contamination during the surgical procedure are explanatory
factors for pulpal healing. Trauma to the periodontal ligament (PDL) of the trans-
plant is the explanatory factor for the development of root rcsorption. '9
.'"
in&!
cu.
Cliapll'r 4 Radiographic f :l'ulliulion 17
A rairly new technique, transalveolar transplantation, is used to remove large
amounts or bone with a bur except ror a thin layer close to the root surface.20 This
bone is then very gent ly removed with an elevator to avoid damage to the cement um.
The tooth is stored in the socket throughout the operative procedure. Finally. the
cuspid is moved through the alveolar process into its determined position. A secti onal
arch wire is used to stabilize but not immobil ize the transplanted cuspid. Sometimes,
grinding or the antagonist tooth is required to avoid traumatic occlusion. A postoper-
ati ve orthodontic appliance check is perrormed I week later, when the sutures are
removed. Further orthodonti c controls are performed every 2 weeks ror 6 to 8 weeks.
Tooth Transpositions
A4.4
Transposition has been described as an interchange in the position or two permanent
teeth within the same quadrant or the dental arch.22-n The maxillary permanent
cuspid is the tooth most rrequentl y involved in transposition with the first bicus-
p i d . 2 2 , 2 ~ less orten with the lateral incisor (Fig. A4.4).1224 The retained deciduous
cuspid may be the primary cause for deviation of the permanent cuspi d from its
normal path of erupti on.
If the mandibular cuspid and lateral incisor have already erupted in their trans-
posed position, correcti on to their nonnal position should usuall y not be attempted.
22
Al ignment in their transposed position wi th reshaping of their incisal surraces will n01
damage the tcct h or supporting structures and will present an acceptable esthetic
result . If one or the transposed or adjacent teeth is severely affected by caries or
trauma or if there is a severe lack or space, extraction of that tooth should be
considered.2
2

23
Ir tooth movement is undertaken to correct the transpositi on, in order
to avoid root interference or resorption during treatment and to prevent bony loss at
the cortical plate of the labially positioned cuspid, the transposed tooth (premolar or
lateral incisor) should first be moved palatally, enough to allow ror a frce movement
of the cuspid to its normal place.
22
.23 This last met hod is the least desirable treatment
of choice.
Figure AU Transposed maxillary right cuspid. as it is erupt-
ing distal to the first bicuspid. Note the retained primary
cuspKl .
18 Part A Prelimi/Jaf}' Examinalion oj/he Paliem
Supernumerary Teeth
Supernumerary (extra teeth) or congenitall y missing teeth occur Quite frequentl y
among patients.
u
The most common situation of a supernumerary tooth is a meso-
dens between the central incisors, which may prevent their nonnal eruption. The
most frequent missing teeth are the upper laterals (see Fig. F5.30), followed by the
lower second bicuspids, the upper second bicuspids, and lower incisors. Of course, the
third molars (wisdom teeth) arc missing in a large percentage of the population.
Third Molars
The role of mandibular third molars in the relapse of lower anterior crowding after
the cessation of retention in orthodonticall y treated cases has provoked much specu
lation in the dental literature over many years.21 Most practitioners are of the opinion
that third molars sometimes produce crowding of the mandibular anlerior teeth.
2
A
number of studies over recent years have substantiated very clearly that the presence
of third molars does not appear to produce a greater degree of lower anterior crowd
ing than that which occurs in patients with no third molars. 21 . 29 Therefore, the
recommendation for mandibular third molar removal with the objective of relieving
interdental pressure and thus alleviating or preventing mandibular incisor crowding is
not justified. 28,29
References
I. Phelan MK, Moss RB Jr .. Powell RS, and Womble BA: Orthodontic management of ankylose<! teeth. J
Clin Orthod 24:375- 378, [990.
2. Kurol J , and Olson L: Anky[osis of primary molars-A future periodontal threat to the tirst penna
nent molars? EurJ Orthod 13:404- 409, 1991.
3. Proffit WR, and Vig KWI: Primary failure of eruption: A possible cause of posterior open bite. Am J
Orthod80:173- 190, 1981 .
4. Ireland AJ: Familial posterior open bite: A primary failure of eruption. Br J Onhod 18:233-237. 199 1.
5. Nashed RR. and Holmes A: Case report - A posterior open bite. Br J Orthod 17: 47 - 53, 1990.
6. Bishara SE: Management of diastemas in orthodont ics. Am J Onhod 6 1 :55- 63, 1972.
7. Takei H: Periodontal problem-solving for ort hodontics. Summarized by Turley PK. Pacific Coast
Societ y of Orthodontists Bulletin. Spring, 34 - 36, 1991.
8. unge L, and Linge 80: Patient characteristics and tre-oltment variables associated with apical root
resorption during orthodontic treatment. Am J Onhod Dcntofacial Onhop 99:35-43. 199 1.
9. Kaley J, and Phillips C; Factors related to root resorption in edgewise practice. Angle Onhod 61:125-
131. 1991.
10. Hickham Jt!: Oire<:tional forces revisited. J Clin Orthod 20:626- 637,1986.
II. McFadden WM, Engstrom C, Engstrom H. and Anholm JM: A study of the relationship between
incision intrusion and root shorteni ng. Am J Orthod Dentofacial Onhop 96:390-396, 1989.
12. Remington ON. Joondeph DR, Artun J, Riedel RA, and Chapko MK: Long-term evaluati on of root
resorption occuning during orthodontic treatment. Am J Orthod Dcntofacial Orthop 96:43- 46, 1989.
13. Bishara SE, Kommer DO. McNeil MH, Mantagana LN. Oestler U , and Youngquist HW: Manage-
ment of impacted cuspids. Am J Orthod 69:37 1- 387, 1976.
14. Vanarsdall RL, and Com H: Soft-tissue management of labially positioned unerupted teeth. Am J
Onhod 72:5]-64, 1977.
15. Boyd Rl: Clinical assessment of injuries in orthodontic movement of impacted teet h. Am J Onhod
82:478- 486. 1982.
16. Bishara SE: Impacted maxillary canines: A review. Am J Onhod Dentofacial Orthop 101:159- 17[ ,
1992.
17. Wisth PJ, Norderal K, and Boe OE: Periodontal status of orthodontically treated impacted
cuspids. Angle Orthod 46:69-76. 1976.
18. Lagerstom L. and Kristcrson L: Influence of orthodonti c treatment on root development of autotrans-
planted premolars. Am 1 Orthod 89: [46- 1 50, 1986.
19. Andreasen JO. Paulsen HV, Vu Z. Ahlqui st R, Bayer T. and Schwartz 0: A long-tenn study of 370
autotransplantcd premolars. Eur J Onhod \2:3- 50, 1990.
20. Sagne S, and Thilandcr B: Transalveolar transpla.ntation of maxillary cuspids. A follow-up study. Br 1
Orthod 12: 14{I - 147, 1990.
21. Ericson S. and Kurol J: Resorption of maxillary lateral incisors caused by ectopic eruption of the
cuspids. Am J Orthod Dentofacial Orthop 94:503-5 13, 1988.
22. Shapira Y, and Kuninek MM: Tooth transpositions- A review of the literature and treatment consid-
erations. Angle Orthod 59:271-276, 1989.
Chapler 4 Radiographic El'uillufion 19
23. Laptook T. and Silling G: Cuspid transposition - Approaches to treatment. J Am Dent Assoc
107:746 - 748, [9&3.
24. Gholston LR, and Williams PR: Bilateral transposition of maxi llary cuspids and lateral incisors: A rare
condit ion. Journal of Dentistry for Children 5 I :58 - 63. [984.
25. Joshi M R, and Bhatt NA: Cuspid transposi tion. Oral Surg Oral Med Oral Pathol 3 I :49-54. 1971.
26. Undergraduate Syllabus. University of Minnesota. Ort hodontic Department, Minneapolis. MN. 1989,
27, Kaplan RG: Mandi bular third molars and postretention crowding. Am J Orthod 66:411 - 430. 1974.
28. Ades AG, Joondeph DR. lillIe RM. and OJapko MK: A long-tenn Study of the relationship of third
molars to changes in the mandibular dental arch. Am J Orthod [)entofacial Orthop 97:323- 335, 1990.
29. Southard TE. Sout hard KA, and Weeda LW: Mesial force from unerupted third molars. Am J Orthod
Dcntofacial Orthop 99:220- 225.1991. .
C lla
The Temporomandibular Joint
The key to understanding temporomandibular disorders (TMOs) is in the differential diagnosis
of joint (internal derangement) versus muscle pathology (myofacial pain) or a combi-
nation of the two,l - 6 Internal derangement of the temporomandibular joint (TMJ )
refers to any abnormal anatomic relation between the three parts of the TMJ , namel y,
the condyle, the disk, and the articular fossa.1.4,6 The most common internal derange-
ment is that of anterior disk displacement, which results in the clinical sign of "click-
ing" or " poppi ng" as the condyle snaps over the posterior band of the disk and on to
it during mandibular movements' (stage I). The click may again be audible in a
closing movement as the condyle slips off the back of the disk, and this is termed a
reciprocal c1ick.
I

6
This clicking on and off the disk is called anterior disk displace-
ment with reduction. I
Anterior disk displacement also may occur without reducti on (the condyle functions
off the di sk- stage II ), Extracapsular muscle pain (myofacial pain) with no internal
derangement usually presents with bilateral or unilateral soreness in the muscles of
mastication and restricted mandibular motion due to muscle spasm!.6 (but not due to
internal derangement-no joint sounds should be prescnt and radiographs should
reveal nonnal osseous contours).
One should keep in mind that as much as 50%, if not more, of the population has
one sign of joint dysfunction (noise, tenderness, etc.); the female to male ratio ranges
from 3: 1 to 9: 1, and only 5% of the patients with signs and symptoms are in need of
TMJ therapy.6 During the TMJ examinat ion of the patient, the cl inician should look
for possible sore muscles (in the neck and mouth area) and any " cli cking" noises (with
the usc of a stethoscope or digital palpation), as well as any deviation on opening and
c1osing
7
-
9
(t he mandible wi ll deviate toward the side of a n anteriorl y dislocated disk),
any signs of bruxism and clenching (it is nighttime clenching that in many cases
results in morning headaches), and the overall strain-level status of the patient.
The mouth should be able to open anywhere between 35 to 45 mm. Onen, the
patient may have a "closed lock" where he or she cannot open the mouth because the
displaced disk is hindering mouth opening (stage III ). At other times, the patient
cannot close the mouth, "open lock," because a posteriorly displaced disk may not
allow the condyle to return to its position in the fossa.
7
-
9
This may occur in the
orthodonti c office during bracket placement. where the patient's mouth remai ns open
for a long period of time. If the joints demonstrate a high level of mobility (" loose
joint" ), it should be noted in order to avoid overstretching the already compromised
ligaments. Any crepitus joint sound (a cracking sound indicating a rough condyle,
disk, or eminence surface) may be the result of direct. long-term bone contacts
between the fossa and the condyle" (stage IV). Unless the condition stabilizes at this
point, pain a nd degeneration of tissues may develop, resulting in severe dysfunction
(stage V).
The management of TMJ disorders ranges from behavior modification, pharmaco-
therapy, and palliative home care to physical therapy, orthopedic appliance therapy,
and surgical treatment.
6
The description of these is beyond the scope of this text.

22 J'arl A PrelimifJar,' E ..xam;fJ(1/;QfI oj/he Pa/iem
AS .. 1
Figure AS .. 1 An interocclusal :lppli:lncc (splint) ..
Excell ent sources are available in the literature on such treat ment modalities .. ' - 6,10
Sclf-<:are, including a soft diet (no gum or caffei ne), limited function, heat, and
self-massage, should be instit uted ..
2
Disk di splacement may be an adaptat ion to stabil-
ity a nd should not necessaril y be viewed as pat hologic.
2
It is most probably d uc to a
slow alterati on a nd not to trauma ..
2
No orthodontic treatment should be initiated before possible TMJ pain or dysfunc-
tion is under control. Sometimes this can be addressed wit h si multaneous orthodont ic
therapy, but in no case should it be postponed until after ort hodonti c tooth move-
ment. In most cases, an interocclusal appli ance (splint ) generall y improves the TMJ
status of the pati ent.
1I
An interocclusal appl iance is generall y considered to be a
removable device made of hard acrylic resi n that fit s between the maxi ll ary and
mandibul ar tcct h (Fig. AS, I ) .. It stabili zes and improves the funct ion of the TMJ and
the masticatory system and protects the teeth from att rition and the TMJ from
traumatic loading. In some instances, however, TMJ surgery is the treatment modalit y
of choice, which is sometimes combined with orthognat hi c surgery.12
The clinician must make every possible attempt to ensure that ort hodont ic me-
chanotherapy does not aggravate a patient 's compromised TMJ status.
13
-
l j
In the
treatment of class II pati ents with deep bites and hi gh cusps, a fl at plate of acryli c that
is placed over the occl usal surfaces of the lower posteri or teet h in conjunction with
fixed appliance therapy may prevent any unnecessary distal pressures on the con-
dyles.
7
One must be careful, however, not to create posterior open bi tes .. In the
treatment of class III patients, chin-cap and class 111 elasti cs that exert di stal pressure
should not be used duri ng sleeping hours, when the muscles are relaxed and therefore
when there is more distal pressure on the condyles.
7
In the retent ion phase of a deep
bite. one may consider the use of a Hawley bite plate to prevent the bite from gett ing
deeper and thus exerting di stal pressure on the condyle.?
TMJ dysfuncti on symptoms after orthodont ic therapy may occur in an individual
case, but in ge neral there seems to be no connecti on between functional disturbances
and well-planned orthodont ic therapy.16 Scveml good, scientific, cont roll ed, long-term
studi es indicate that orthodonti cs is not a cause of TMJ dysfuncti on,17- 19 No data
exi st to support the notion that orthodonti c treatment of children or adults prevents
or lowers the risk of subsequently developing TMD.20 Postonhodonti c patients who
were treated in various tmdi ti onal ways of orthodont ic treatment have no more TMD
symptoms than do people with untreat ed malocclusion or people wi th normal occlu-
sions.. 20 If TMD symptoms arise during ort hodonti c treatment, observation and com-
mon sense are the best approaches.
20
If the symptoms arc painful, it may be necessary
AS .. :
AS.2
Cbapler 5 Tlrl' T''nr[IQTomo"dibulur Joint 23
to modify active therapy: reduce forces, stop headgear, eliminate direct mandibular
distalizing forces, minimize interareh elastic use, and eli mi nate gross occlusal interfer-
ences, preferabl y by bite plates that open the bite by I or 2 mm, and occlusal
coverage splints. These measures will allow sore muscles and joints to recover so
treatment may proceed.
20
Orthodontic treatment does not appear to pose an increased risk for development
of TMJ sounds or symptoms, irrespecti ve of whether extraction or nonextraction
treatment strategies are Used.
21
The original growt h pattern that caused the teeth to be
selected for extraction -rather than the extracti on itself-is the most likely factor
responsible for the frequency of TMD reported years later.
22
Bicuspid extract ions and
subsequent orthodontic treatment do not lead to irreparable damage of TMJ mus-
cles.
23
Condylar position is unrelated to extraction treatment and to bite depth.2<I It
has been shown that the claim that bicuspid extraction and incisor retraction must, of
necessit y, lead to unsightl y profil es and distal mandibular displacement cannot be
supported.
2S
Persons who have undergone orthodontic treatment have a significantl y
lower clinical dysfunction index than those who have nol.
26
Orthodontically treated
patients arc not more likely to develop TMD signs while undergoi ng treatment Y A
relation between either the onset of TMJ pain and dysfuncti on and the course of
orthodontic treatment or the change in TMJ pain and dysfunction and the course of
orthodontic treatment has not been cstablished.
2S
At the end of the orthodontic treatment, the patient should be left with a healthy,
functional occlusion in centric, excursive, and protrusive movements.
29

30
Centric
occlusion (maximum intcrcuspation) should coincide with the centric relation posi-
tion (rest position) (Fig. AS.2). In excursi ve movements on the working side (the side
to which the mandible is moved when food is chewed), the max.illary cuspid should
cOntact the mandibular cuspid, whereas no posterior teeth should contact at any point
(mutually protected occlusion) ( Fig. AS.3). In the event that cuspid guidance cannot
be achieved (due to severe wear, absence of maxillary cuspids. or cuspids in place of
laterals). the maxillary buccal cusp inclines of the posterior teeth should be in even
contact with the mandibular buccal cusp inclines of the lowers (unilaterall y balanced
occl usion or group function). In both cuspid guidance and group functi on, there
should be no tooth contacts on the side opposite the working side (nonworking or
balancing side). In protrusive movement, there should be no posterior tooth contact
A5.3
Figure AS.2 Patient in centric occl usion that coincides with
centric relation.
Figure A5.3 Cuspid guidance in excursive movement (work-
ing side). Note the clearance or post eri or tooth contacts.
There is also posterior di sclusion of teeth on the other
(balanci ng) side.
24 PIIr' A Preliminary ExamilJa/ion of /he Pa/ienl
when the maxillary six anterior teeth contact the eight most anterior mandibular tccth
in an edge-to-edge position (in both cuspid guidance and group functi on scenarios)
(F;g. A5A).
References
Figure A5 . Protrusive movement. Again, note the absence
of posteri or tooth contacts.
I. Collins MR: Temporomandibular joint: Diagnosis. Current Concepts in Qnhodontics and Dentofacial
Orthopedies 1: 1- 2, 1991.
2. Solberg WK: Update on TMD. Summarized by Turley PK. Pacific Coast Sock ty of Orthodont ists
Bulletin, Spring, 52- 55,199 1.
3. Williamson EH: Occlusion and TMJ dysfunction. J a in Orthod 15:393 - 4 10, 198 1.
4. Okeson JP: Management oj Temporomandibular Disorders and Occ/llsion. 2nd ed. SI. Louis: C.V.
Mosby Co., 1989.
5. Mohl NO. Zarb GA, Carlsson GE. and Rugh JD: A Textbook of Occiruion. Chicago: Quintessence
Publishing, 1988.
6. American Academy of Craniomandibular Disorders: Craniomandibular JJisorders: Guidelines for E'a/
liD/ion, Diagnosis and Management. McNeill C, cd. Chicago: Quintessence Publishing, 1988.
7. Williamson Eli: Occlusion and TMJ dysfunction. Jain Qnhod 15:333- 350, 1981.
8. Williamson EH: Occlusion: Understanding or misunderstanding. Angle Onhod 46:86 - 93. 1976.
9. Wyatt WE: Preventing a d v e ~ effects on the TMJ through onhodonti c treatment. Am J Onhod
Denlofacial Orthop 91:493 - 499, 1987.
10. Neff PA: Occlusion and function. Georgetown Unh'ersity School of Dentistry, Washington, DC, 1975.
11. Bocro RP: The physiology of splint therapy: A literature review. Angle Orthod 59: 16S -180. 1989.
12. Bell WH: Modern Prac/ ice in Orthognathic and It(>con.\truc/il'/, Surgery. vols. 1- 3. Philadelphia: W.B.
Saunders Co . 1992.
13. Roth RH: Temporomandibular pain- Dysfunction and occl usal relationships. Angle Onhod 43: 136-
IS3, 1973.
14. Roth RH: Funetional occlusion for the onhodontisl. Jain Orthod.. Pan 1,25:32- 51; Part 2, 25:100-
123: Pan 3, 25: 174- 198; Pan 4, 25:246 - 265, 1981 .
15. Rot h RH, and Ware WH: Orthognathic treatment in patients with temporomandibular joint pain-
dysfunction. J a in Orthod 14: JOiI - 120, 1980.
16. Kcb K, Bakopulos K, and Witt E: TMJ funct ion with and without orthodontic treatment. Eur J
Orthod 13:192- 196, 1991.
17. Baker RW, Catania lA, and Baker RW, Jr.: Occl usion as it relates to TMJ : A study of the literature.
NY State Dent J January. 57:36 - 39, 199 1.
18. Sadowsky C, and Polson AM: TMD and functional occlusion after onhodontie treatment: Results of
two longterm studies. Am J Onhod 86:386- 390, 1984.
19. Sadowsky C, and SeGol e E: Long-term status ofTMl functi on and funct ional occlusion after onho-
dont ic treatment. Am J Onhod 78:201 - 212, 1980.
20. Greene CS: Onhodontics, orthodontists and TMD. Summarized by Croueh DL Pacifi c Coast Society
of On hod on tis IS Bulletin, Winter, 33- 35, 1990.
Chaptt'r 5 The TemporOllla/ldibular Join{ 25
21. Sadowsky C. Theisen TA. and &tkols EI: Onhodontic treat ment and TMJ sounds-A longit udinal
Sl udy. Am 1 Orthod Dentofacial Ort hoJl 99:44 I - 447, 199 1.
22. Dihbets JMH, and van der Weele LT: Extrxtion. onhodontie treatmen\. and craniomandibular dys.
function. Am J Orthod Dentofacial Orthop 99:210-219. 1991.
23. Kundinger KK. Austin SP, Christensen LV. Donegan SJ, and Ferguson 01: An evaluation ofTMJ and
jaw muscles after orthodontic treatment involving premolar extractions. Am J Orthod Dentofacia!
Orthop 100:110- 11 5. 1991.
24. GiancHy AA. Hughes HM, Wohlgemuth P. and Gildea G: Condylar position and extraction treatment .
Am 1 Orthod Dc:ntofacial Ort hoJl 93:210-205. 1988.
25. Luecke PE III. and Johnston LE, Jr.: The effect of maxillary fiJ"!it premolar extraction and incisor
retraction on mandibular position: Testing the central dogma of "functional orthodontics." Am J
Orthod Dentofacial Orthop 101: 4- 12. 1992.
26. Egennark I. and ThiJandcr B: Craniomandibular disordeB with pCCial reference to orthodontic treat-
ment: An evaluation from childhood to adulthood. Am J Ort hod Dentofacial Orthop 101 :28- 34, 1992.
27. Hirata RH. Heft NW. li emandez R. and King GJ: Longitudinal study of signs of temporomandibular
disorders (TMD) in onhodont icall y lrealed and nonlTCatOO groups. Am J Orthod Dentofacial Ort hop
101 :35- 40,1992.
28. Rendell lK. Norton LA. and Gay T; Orthodontic treatment and temporomandibular joint disorders.
Am J Orthod Dentofacial Orthop 101:84- 87. 1992.
29. Parker WS: Centric relation and centric occlusion - An orthodonti c responsibi lity. Am J Orthod
74:481 - 500. 1978.
30. Andrews LF: The six keys to normal occlusion. Am 1 Orthod 62:296- 309. 1972.
ell f e r
Nasorespiratory Function
A thorough functional evaluat ion is an essential part of the development of the patient's
stomatognathie problem li st. Habits should be evaluated carefull y, keeping in mind
that approximately 50% of children without malocclusions have what is considered to
be bad habits. I The duration and intensity may be more important than the actual
presence of an abnormal condition.'
Nasal obstructi on, causing mouth-breathing and a loweri ng of the mandible and
tongue, may produce remarkable changes in the dental and facial relationships! (Figs.
A6.1 and A6.2). If, after the age of 5 years, especiall y in the earl y mixed dentition
stage of 6 to 8 years of age, the child has difficult y breathing through the nose, a
referral to the otolaryngologist would be most appropriate. Alt hough the liter.Hure is
replete with statements that airway impairment alters facial and dental growth, there is
substanti al evidence to the contrary.)
In a recent study of mandi bular and maxi llary growth in boys after a changed
breathing mode 5 years after adenoidectomy, it was found that there was almost a
4 mm greater mandibular growth (statisticall y significant) but no change in maxillary
growt h direction. Conversel y, there was also no change in the breathing mode in 20%
of the sample. A concurrent studyS on the relation between vertical dentofaeial mor-
phology and respiration in adolescents concluded that different breathing modes may
be behaviorally bascd, rather than airway dependent, and that intervention to alter the
nasal airway and thus to influcnce dentofacial growth is unj ustified. What may be an
excell ent therapeutic modality for one patient docs nOI indicate that it wi ll have the
same effect in the majori ty of patients. Although there seems to be a weak tendency
among mouth breathers toward a class II skeletal pattern, increased anterior facial
height, high mandibular plane angles, and retroclincd incisors-all characteri sti cs of a
long face-a more thorough anaJysis of respiratory pattern is required to support the
dedsion for clinical intervention.
6
Ciia
Oral Hygiene Considerations
Enamel demineralization (Fig. A7.1) is associated with fixed orthooontic therapy in an ex
tremely rapid process that is caused by a high and continuous cariogenic challenge in
the plaque developed around brackets and underneath ill fitting bands! (Fig. A7.2).
Because orthodontic appliances tend to increase the accumulation of plaque on the
teeth, it is not surprising that gingival inflammation tends to increase in orthodontic
pat ients as wel l.
l
-
Ii
Careful inspection at every visi t. preventi ve flu oride programs, and oral hygiene are
very important throughout the duration of orthodontic treatment.
l
-
4
Proper brushing
and flossing three times daily is recommended, followed by fluoride mouth rinses once
a day.5 The combination of daily brushing wi th a fluoridated dentifrice, coupled wit h
daily rinsing with a fluoride wash provides complete protcction for the orthooontic
patient by inhibiting demi nerali zation or by promoting remineral ization of the surfaces
at ri sk.
7
Toothbrushing with a relatively new electric, counterrotational power tooth-
brush is highl y advisable. A rotary electric toothbrush is more effective than conven-
ti onal toothbrushes for removing plaque and cont rolling gi ngivitis in adolescents dur-
ing orthodontic treatment wit h fixed applianccs.
B
A recent study that compared
electric and manual toothbrushing found that the use of the electric system resulted in
overall lower plaque scores.
2
Another study of the effectiveness of the new appl iance
concl uded that plaque and gi ngival scores were significantly lower after brushing for 2
months with the electric counterrotational toothbrush than foll owing brushing with the
manual one.) The orthodontic treatment itself has an impact on oral hygiene in the
long term as well ; a study showed that children who received onhodontic treatment
had a greater reduction of plaque and gingivitis than children who did not.' This was
related more to behavior factors than 10 improved tooth alignment.'
Orthodontic treatment during adolescence has no discernible effcct on late perio-
dontal health.' In the absence of compromising conditions (e.g .. high decayed -
missi ng-fill ed (teeth) [DMF] scores, periodont itis), adult patients are not inherently
more likely than adolescents to lose dental support (e.g.. crestal bone height) during
treatment, !O In patients with passive-controlled periodontal disease, no increased pro-
gression of marginal periodontitis will occur due to orthooontic tooth movement
provided that excellent oral hygiene is maintained throughout the orthodontic therapy
and that the patient visits the periodontist every 3 to 4 months for check_ups.11 - 11 Oral
irrigators generall y enjoy a hi gh mle of compliance with adults.
l
! Oral rinses. such as
Listerine, can be effective adj uncts if compliance is good.!! Cases with unmanageable
gingival inflammation can be put on a 6-week regimen of rinsing with Pcridex (Proc-
tor & Gamble) twice dai ly 11 (Figs. A7.3 and A7.4). Dental cleaning wi ll be needed at
the end of the 6 weeks 10 remove stai n. II Surgical treatment is generally employed for
defi nitive pocket reduction postorthodontical1y. In addition, although graft ing before
ort hodontics to prevent recession of prominent lower anteriors is highly recom-
mended, there may be no need for grafti ng to prevent further recession in the post-
treatment patient because most recession occurs quickl y and then stabi lizes.
1i
Bony
30 Pllrl A Preliminary Xaminatioll of/h., Patient
Figure A7.1 Severe enamcl demineralizati on and white spot
formation due to lack of proper oral hygiene after 2 years
of orthodontic therapy.
Figure A7.3 Severe gingival inflammation, despite thorough
brushing. This patient was placed on Peridex (Proctor and
Gamble, Cincinnati, OH).
Figure A7.2 Severe tooth decay underneath an ill-fitting
band that was placed for space maintenance until the erup-
tion of the bicuspid teeth.
A7.4
Figure A7.4 Occlusal view of the same patient as in Figure
A7. 3. Note that the central incisors are almost buried un-
derneath the soft-tissue overgrowth.
dehiscenccs can be created during the treatment phase, especiall y with a thin alveolar
process, by inflammation or overzealous brushing
6
(Figs. A 7.5 and A 7 .6).
During orthodontic treatment, forces should always be kepI wi thin physiological
limits, 12 wit h the appliances and the mechanics used as simple as possible.
6
In general,
the forces used in adults should be kept at a lower level than those used in children.
Light, continuous, int rusive forces should be maintained during tooth displace-
ment.
14
,15 When dealing with teeth with bony defects, especially in the anterior regions
(i.e., fl ared upper incisors with palatal bony defects), it is advisable to consider me-
chanics that will intrude those tceth.14,u Even if no intrusion takes place, this int rusive
force may negate the effects of the extrusive component. 14 If the onhodontist is
contemplating bodily movement of teeth into areas of intrabony pockets, it is often
prudent for the periodontist to do an open debri dement procedure to prepare the root
surface adjacent to the pocket.
16
Bodily movement of teeth can enhance bone growth
and reattachment if the periodontjum is properly prepared,"
Figure
ease,
ment.
Figure A7.5 This patient, who has extensive periodontal dis-
ease, would not be a good candi date for orthodontic treat-
ment.
C h a p [ ~ r 7 Orallly!-:il'lll' Considerations . 31
Figure A7.6 Ovenealous brushing in combination with a
prominent occlusion and thin tissues has led to gingival
recession. gingiva l clefts. and tooth abrasions.
Edentulous areas of the mouth need special attention during the treatment-planning
phase, especially if attempting to move teeth through these spaces,11.I1 When attempt-
ing to close the edentulous space of a lost first molar by mesial and distal movements
of the second molar and premolar, respectively, one should expect a definite loss of
bone averaging more than I mm around the second molar and 0.5 mm around the
premolar tooth,7 As much as 4 to 5 mm of reduction in vcnical bone height can
OCCUr.17 Closed spaces are difficult to maintain in these patients as well ," In addition.
the longer the treatment tenure. the greater the amount of root resorption of the
second molar,7 . 1 Although younger patients respond more favorably. older patients
seem to resist the opposition of new alveolar bone.'
7
In cases of overerupted maxillary molars, where the use of conventional fixed
appliances would lead to undesired extrusion of the adjacent teeth (extrusion happens
much faster than intrusion), a single-stage osteotomy is used to reposition the in-
volved tooth with its surrounding bone at the proper level.
19
Onhodontic tooth
movement with sectional archwires will stabilize Ihe result before the bone heals
completely,,9 In cases where teeth need to be extruded, ample time needs to be given
for "bone fill-in" around the new position of these teeth (1 mm/month),20
In patients with mild incisor irregularity or anterior tooth size discrepancies, inter-
proximal enamel is removed during orthodontic treatment , and the roots are brought
into closer proximity, In other patients with unusual crown/root morphology, root
proximity is inevitable in order to produce alignmenl of the crown, The clinician
need not be overly concerned, because these situations do nOI seem to result in a
higher predilection for periodontal brcakdown.
2
'
32 l'Brt A Preliminary Examiltalion oflhe Pmicnl
A7.7
Finall y, one should be very careful in cases wit h a prominent denti t ion relative to
t he alveolar cortical plate with thin, overlying sort tissue and inadequate oral hygiene.
Recession can occur quite rapidly. The donor site shoul d be carefull y evaluated for
the existence of fenestration or dehiscence
22
(Figs. A 7.7 and A 7 .8).
A7.B
Figure A7.7 Severe gingival recession of all the lower ante-
rior teeth that was created wi thin a few mont hs of onho-
dont ic treatment. Thi s was a result of tooth movement in
an environmcnt with poor oral hygiene, promi nent roots,
a nd parafuncti onal habits.
Figure A7.8 A fenestration in the lower bicuspid area that
was revealed.
References
L Ogaar<! B, Rolla G. and Arends J: Orthodontic appliances and enamel demineralization. Am J Orthod
Dcntofacial Orthop 94:68-73. 1988.
2. Jackson CL: Comparison between electric toothbrushing and manual toothbrushing with and without
oral inigation. for oral hygiene of ort hodontic patients. Am J Ort hod Dentofacial Orthop 99: 15-20.
1991.
3. Wilcoxon DB, Ackennan RJ. Killoy WJ, Love JW. Sakamura J. and Tira DE: The effectiveness of a
counterrotationaJ-action JX)wer toothbrush on plaque control in orthodontic patients. Am J Orthod
Dcntofacial Ort hop 99:7 - 14, 1991 .
4. Davies TM, Shaw WC, Worthington HV. Addy M. Dummer P, and Kingdon A: The effect of
ort hodontic treatment on plaque and gi ngivitis. Am J Ort hod Dentofacial Orthop 99: 155 -162. 1991.
5. Shannon IL: Prevention of deQ.lcification in ort hodont ic patients. J ain Orthod 15:695- 705, 1981.
6. Artun J: Long-tcnn periodontal response to ort hodontic treatment -Summary by Hawlcy B. Pacific
Coast Society of Orthodontists Bulletin, Spring. 42- 43, 1991 .
7. O'Reilly MM, and Featherstone JOB: Demineralization and remineralil.ation around orthodontic ap-
pliances: An in vitro study. Am J Orthod Dentofacial Orthop 92:33- 40, 1987.
8. Boyd RL, MUTnlY p. and Robertson PB: Effect of rOlary electric toothbrush venus manual toot hbrush
on periodonlal status duri ng orthodontic treatment. Am J Orthod Ocntofacial Ort hop 96:342-347,
1989.
9. Polson AM, Subtenly JD. Heit ner SW. Polson AP, Sommers EW, Iker HP, and Reed BE: Long-term
periodontal status ancr orthodontic treatment. Am J Orthod Dcntofacial Orthop 93:5 t -58, 1988.
10. fl anis EF. and Baker WC: Loss of root length and creslal bone height before and during treatmenl in
adolescent and adult orthodontic patients. Am J On hod Ocntofacial Orthop 98:463-469, 1990.
I I. Boyd RL: Can adults wi th periodontitis be lreated onhodontica1J y? Summary by Quinn RS. Pacific
Coast Society of Ort hodontists Bulletin, Spring. 48- 49, 1991.
12. Eliassen LA, fl ugoson A. Kurol J, and Siwe H: The effects of orthodontic Ire'dtment on periodontal
tissues in patients with reduced periodontal support, Eur J Orthod 4: 1-9 1982.
13. Page R: Frontiers in periodontics.. Summary by Nichols O. Pacifie Coast Society of Orthodontists
Bulletin. Spring. 39-41, 1991.
14. Kessler M: Interrelationshi ps between orthodontics and periodontics. Am J Ort hod 70: 154- 172. 1976.
I S. Melsen B: Adult ort hodontics, J a in Orthod 22:630-641, 1988.
16. !-I OSI E. Zachrisson BY. and Baldauf A: Orthodontics and Pl'riodonlics. Chicago: Quintessence Publ ish-
ing, 1985.
,
o.aptcr 7 OraillY81('ne CQlIsi(/,'r(Jf itms 33
17. Goldberg D, and Turley PK: Onhodonlic space closure of the edentulous maxillary first molar area in
adu lts. International Journal of Adult Ort hodontic and Orthogn.l1hic Surgery 4:255 -266. 1989.
18. Stepovich ML: A clinical st udy on closing edentulous spaces in the mandible. Angle Orthod 49:227-
233.1979.
19. Mostafa YA, Tawfik KM, and EI-Mangoury NH: Surgical orthodontic treatment for overcruptoo
maxillary molars.} Q in Or1hod 19:350-35 1. 1985.
20. SJx'rTY TP: The role of tooth ext rusion in treat ment planning for onhognathic surgery. International
Journal of Adult Orthodontic and Onhognathie Surgery 4: 197 -2 11, 1988.
21 . Artun }, Kokich VG, and Osterberg SK: Long-term effect of root proximity on periodontal health after
orthodontic treatment. Am J Onhod Oentofacial Orthop 91: 125- 130, 1987.
22. Viazis AD. Cori naldesi G, and Abrolmson MM: Gingival recession and feneStrJtion in orthodontic
treatment.} Clin Orthod 25:633- 636, 1990.
ell
Periodontal Plastic Surgery
For years. covering exposed roots with soft-tissue grafting has been the ultimate goal in
periodontal mucogingivai surgery. Today that goal has been largely met with the usc
of various techniques. I _ of The larger arena of esthetic enhancement now dominates our
thought processes in dentistry. Periodontal plastic surgery is the term used to describe
surgical procedures performed to correct or elimi nate anatomic, developmental , or
traumatic deformities of the gingiva and alveolar mucosa, I These procedures would
also include treatment of marginal tissue recession, excessive gingival margins. and
localized alveolar ridge deficiency, and exposure of unerupted teeth for orthodontic
treatment.)
Excessive gingival display is a condition resulting from exccssive exposure of maxil -
lary gingiva during smiling, commonly called gummy smile or hi gh lip line.) This
condition may be caused by a skeletal defonnit y, a soft-tissue deformity, or a combi-
nation of the two. Another cause is short clinical crowns due to incomplete cxposure
of the anatomic crowns. If short clinical crowns result in a gummy smile. gingival
contouring may be accomplished to achieve the desired cstheti c result.
Periodontal plasti c surgery may be used not only to enhance esthetics but also to
aid in orthodontic treatment by a variety of means. The gummy smile can be man-
aged to create proper clinical crown length and achi eve pleasing gingival contours.
Diagnosis of this problem can be made by the orthodontist early in treatment. Evalu-
ation of the smile line, lip line, and tooth length can help differentiate between
excessive gi ngival display due to vertical maxillary excess (Fig. AS.I) or insumcient
crown length (Figs. AS.2 through AS.S). Furthermore, the establishment of the mar-
ginal ti ssue at the level of the ccmcnto-enamel juncti on (eEJ) enhances estheti cs and
creates a sit uati on in which the orthodontist can have a larger comfort zone when
treating periodontally involved cases.
In addition, successful root covcrage techniques can aid in the treatment of inade-
quate attached gi ngiva as well as root sensitivi ty and unesthetic appearancc. Root
coverage techniques for treatment of cuspid marginal tissue recession in the past have
been relatively unpredictable procedures. Soft-tissue grafting was done primaril y to
increase the band on attached gingiva. In 19S2, a predictable technique was described
for covering Toots using the free gingival graft foll owing citri c acid root conditioning.
l
In 1985, the subepithelial connecti ve tissue graft for improved esthetics in root cover-
age grafting was introduced. Since then, it has proved especiall y useful in the treat-
ment of gingival recession (Figs. A8.6 through AS.9).
36 Part A i7('hminurJ' mmi nal i OIl ojl hI.' PUlil'fll
AB,2
Figure AB.2 Excessive gingival display due to insuffi cient
crown length.
AB.l
Figure AII .l Excessive gingival di splay due 10 venical maxil-
lary excess.
AB.3
Figure AII .3 The same patient as in Figure AS.2 after perio-
dontal plasti c surgery.
Flgc
quw
"""'.
InClS
figure AS.4 Anterior view: lower incisor spacing and inade-
quate clinical crown length or the upper anterior teeth.
figure AS.e Soft-tissue recession in the maxillary central
incisor area that resulted in root exposure.
Chapter 8 P{'riodonwl !,las/ic Surgery . 37
Figure AS.S The same pat ient as in Figure A8.4 after peri o-
dontal plastic surgery.
Figure A8.7 The same patient as in Figure A8.6 I month
after a CT graft was placed over the exposed root surfaces
in the CEJ area or the cent ral incisors.
38 Part A Preliminary Examination ofl he Palicm
Figure A8.8 Gingival recession of the mandibular right cus-
pid. Peri odontal grafti ng is highly recommended to prevent
further recession during tooth movement.
References
Figure A8.9 The same patient as in Figure A8.8 3 months
after a CT graft covered the exposed root. Orthodontic
treatment ca n now be attempted.
t. Miller PO, Jr.: Root coverage using a free soft tissue autograft rollowing citric acid appliallion: I.
Technique. International Journal of Periodontics and Restorative Dentistry 2:65, t982.
2. Langer B, and Langer L: Subepithelial connective tissue graft technique for root ooverage. 1 Periodontol
56:715, 1985.
3. Allen EP: Use of mucogingi val surgical procedures to enhance esthet ics. Dent Oin North Am 32:307-
330, 1988.
4. Jacoby 8. Viazis AD, Abelson M, and Allen EP: Periodontal plastic surgery in orthodontics. Jain
Orthod (in prtSS)
Facial and Cephalometric
Evaluation

Par J
Cit ler
Natural Head Position
Facial examination is the key to diagnosis.' Onhodontic compli cations nearly always stem
from errors in diagnosis, not from failures in execution of treatment After the prelim-
inary dental clinical information is obtained, the evaluation continues with the exami-
nati on of the face from the frontal and profile views. The patient is instructed to sit
upright and look straight ahead into the horizon or directly into a mirror on the wall.
This position, called the natural head position (NHP), is the position in which the
patient carries himself or herself in everyday life
1
-
s
(Figs. BLl and BI.2). Therefore,
this is the reference position we should use in our examination. In this position the
pupils of the cyes are centered in the middle of the eyes, defining the line of vision or
true horiZOlllal (TH).6-1 The TH line should be parallel to the floor.'
Natural head position has been established over the past 30 years as the most
appropriate reference position for cephalometric radiography.2-8 It has been shown
that it is related to the correct natural body posture and al ignment with the cervical
column, is based on the line of vision, and is determined by the overall head and body
balance when the individual looks straight ahead.l.49-,5 The reproducibility of NHP
has been shown to be within the clinically acceptable spectrum of variance of 4
degrees, which is certainl y much better than the 26-degree variabi lit y of the Frankfun
horizontal and SN plane among different individuals.
4
-
6
An NHP radiograph is takcn with the patient in the cephalometer looking straight
ahead into a mirror. The patient is observed from the side to ensure that the pupil is
in the middle of the eye. In the event that the patient states that he or she is in NHP
but the pupils are not centered in the middle of the eyes, the clinician should correct
the head position.' -8 Any habitual tendency for an individual to keep the head in an
" unnatural" flexed or extended position must be observed, and it may be necessary to
"correct" the registered head position.1
6
Rccently, using tracings of facial profiles,
observers made independent, subjecti ve estimations of NHP in 28 adults.' 1 The results
of these estimations were compared with recordings of NHP obtained through photo-
graphic registration of the same subjects. Only minor average differences (between 0
and 1.4 degrees) wcre found betwecn the two methods. Estimation of NHP may,
therefore, be performed with acceptable accumcy in most cases. Thus, it is the clini-
cian, and not the patient, who determines the final position.
6
-
8
The ear rods should be placed directly in front of the tragus so that they lightly
contact the skin, establishing bilateral head support in the transverse plane. Lateral
cephalostats with ear rods alter the position or the head and neck during postuml
recordings." Subjects extend thei r hcads and necks higher with car rods in place than
they do without ear rods. ' s The patient should be comfonable and relaxed, and the
head should not be tilted or tipped. The correct position is confirmed by checki ng the
patient from the front. The nose piece is then placed so that it lightly contacts the
skin, to establish suppon in the vertical plane. The three light contact points secure
the patient in NHP. After a final check, the x-ray is taken. The enti re procedure
42 Part 8 Facial and Cepha/oll1efric Eva/uation
should take onl y I to 3 mi nutes. The determination of an aesthetic true horizontal by
visual inspection of the patient's face has been shown to be highly reproducible and to
have more relevance to the soft tissue than does the Frankfon horizontal.
19
-
H
" ' .,
,
,
"
"
"
' I "
,
..
I
,,,
,
B1.2
Figure Bl .2 The IntI' horizon/af coi ncides with the line of
vision. The pupils of t he eyes are centered in the middle of
the eyes. The major cephalometric landmarks are also indi-
cated.
Bl .1
Figure Bl .1 Natural head position. The patient is looking
straight ahead. The Irue is perpendicular to the
floor. The true horizontal is parallel to the floor and is
defined from the pupi l oflhe eycs.
References
I. Arnett GW: Excellent treatment results using ideal or1hodontic/or1hognathie treatment planning. Sum-
marized by Nichols LO. PCSO Bulletin. 31- 39. 1991.
2. Moontts CFA, and Kean MR: Natural head posi tion. a basic consideration in the interpn.:tation of
cephalometric radiographs. Am J Phys Anthropol 16:213- 234. 1956.
3. Solow B. and Tallgren A: Head posture and craniofacial morphology. Am J Phys Ant hropol 44:411 -
436. 1916.
4. Sotow B, Siersbaek-Nielsen 5, and Greeve E: Airway adequacy, head posture. and craniofacial mor-
phology. Am J Orthod 86:495-500. 1983.
5. Cooke MS, and Wei SHY: A summary five- factor cephalometric analysis based on natural head
posture and the true horizontal. Am J Orthod 93:2 13- 223. 1988.
6. Viazis AD: A cephalometric anal ysis based on natural head position. Jain Or1hod 25: 172- 182. 1991.
7. Viazis AD: A new measurement of profile est hetics. J a in Orthod 25: 15- 20. 199 1.
8. Viazis AD: The cranial base t riangle. Jain Orthod 25:565 - 510, 1991.
9. Luyk NP, Wllitfietd PH. Ward-Booth RP. aod Williams ED: The reproducibility of the natural head
position in lateral cephalometric rudiog.rn.phs. Br J Oral Maxillofacial Surg 24:357 - 366, 1986.
10. Cannon J: Head posture-An historical review of the literature. Aust Orthod 9:234 - 237, 1985.
II. Solow B, SieBback-Nic1sen S. and Greeve E: Airway adequacy, head posture, and craniofacial mor-
phology. Am J Orthod 86:214-223.1984.
12. Vig PS. Showfety KJ. and Phillips CP: Experimental manipulation of head posture. Am J Orthod
77:258 - 268, 1980.
Chapler J Nalr/fal Head Position . 4 3
13. Luyk NP, Whitfield PH, Ward-Booth RP, and Williams ED: The reproducibility of the naturJ.1 head
posi tion in lateral cephalometric radiographs. Dr J Oral Maxillofacial Surs 24:357 - 366, 1986.
14. Cole SC: Natural head position. posture. prognathism. Br J Onhod 15:227 - 239. 1988.
IS. Michiels LYF, and Tourne LPM: Nasion true vertical : A proposed method for testing the cli nical
validit y of cephalometric measurements applied to a new cephalometric reference line. Int J Adult
Onhod Onhog Surg 5:43 - 52, 1990.
16. Lundstrom A: Guest editorial: IntercraniaJ reference lines v e ~ u s the true hori:wntal as a basis for
cephalomet ric analysis. Eur J Onhod 13:161 -168, 1991.
17. Lundstrom A. Fosberg CM, Wcsterwcn H, and Lundstrom F: A comparison bctlO.'een estimated and
rqiSlered NHP. Eur J Onhod 13:59- 64. 1991.
18. Greenfield B, Kraus S. Lawrence E, and Wolf SL: The influence of cephalostatic ear rods on the
positions of the head and neck during postural recordings. Am J On hod Dentofacial Onhop 95:312-
318,1989.
19. Bass NM: The aesthetic anal ysis of the face. Eur J Onhod 13:343- 350. 199 1.
20. Siersbaek-Nieistn S, and Solow B: Intm- and intcrexaminer variability in head posture recorded by
dental auxiliaries. Am 1 Onhod 82:50- 51, 1982.
2 I. Chang HP: Assessment of anteroposterior jaw relationship. Am J Onhod 92:117 - 122. 1987.
22. Showfety KJ, Vig ps, and Matteson SA: A simple method for laking natuml-hcad-posi tion cephalo-
grams. Am J Onhod 83:495 -500.1983.
23. Lundstrom F. and Lundstrom A: a inieal evaluation of maxillary and mandibular prognathism. Eur J
Onhod 11 :408 - 41 3, 1989.
Clla
Bolton and Michigan Standards
A major disadvantage of nlost existing cephalometric analyses is that their differences in
normative sample selection make direct comparisons among them scientifIcall y unreli -
able, even though, in practice, many clinicians use measurements from various analy-
ses to support their diagnoses.
In addition, most analyses offer onl y one mean for adolescents, regardless of the age
or gender of the growi ng patient. Although patients shoul d not be treated "by the
numbers," a cli nician usi ng measurements from a particular analysis should be reo
ferred to a table appropriate to the patient's age. Such tables arc avai lable in the
Bolton and Michi gan standards.1.2
Many of the Bolton and Michigan standards are based on the Frankfort hori zontal.
Downs) has said that this plane could be considered level (that is, the same as the true
horizontal) when the subject is standing and looking straight ahead. In the cases where
he found a discrepancy between cephalometric measurements and his clinical impres-
sion, he noticed that the Frankfort hori zontal deviated from the true horizontal plane
(Fig. B2. 1). When he incl uded the degrees of deviation in his calculations (i n other
words, when he leveled the Frankfort horizontal), he found that his measurements
agreed with his cli ni cal findings.
In essence, Downs used a true horizontal plane in conj uncti on with the norms
based on the Frankfort horizontaL We can foll ow this concept by taking radiographs
in nat ural head posit ion (NHP), basing the measurements on the true horizontal , and
comparing them to the means and standard deviations of the Bolton and Michigan
standards.
46 Part B Facial and Cephalometric Evaluntion
References
82.1
Figure 82. 1 Note the marked incl inat ion of Frankfo n hori
zontal (FH ) relati ve to the true ho rizontal (TH). Allhough
the maxilla is prognathic relative to the TH, it appean
rctrognathic relat ive to the FH. (See Anteroposterior Skele-
101 Assessment.)
l. Broadbent BH Sr, Broadbent BH Jr, and Golden WH: Bollon Standards of Den/ofacial Development
Growth. St. Loui5: C. V. Mosby Co., 1975.
2. Ri olo ML, Moyer.; RE, McNamara lA, and Hunter WS: An Alias ofCran/ofacial Growth: Cephalometric
Standards. Ann Arbor, MI: University School Growth St udy, the University of Michigan. Monograph
Number 2, Cr,miofacial Growth Series, Center for Human Growt h and Development. 1972.
3. Downs WF: Analysis of the dento-facial profile. Angle Orthod 26: t 9 t - 212, t 956.
(
Clr a
Cephalometric Landmarks
The following are some cephalometric landmarks most commonl y used in cephalometric
analyses 1- 3 (Fig. B 1.2):
A-point (A,: An arbit rary point at the innermost curvature from the anterior nasal spine at
the crest of the maxillary alveolar process.
Anterior nasal spine (ANS,: The process of the maxilla that forms the most anterior
projection of the floor of the nasal cavi ty.
Articulare: A constructed point at the int ersect ion of the posterior cranial base and the ramus
of the mandible.
B-point (B,: An arbit rary point on the anterior profil e curvat ure from the mandibular land-
mark, pogonion, to t he crest of the alveolar process.
Columella (Cm,: The most anterior and inferi or point of the nose.
ClabelialOI,: The most anterior soft-ti ssue point of the frontal bone.
Cnathlon (Cn,: The most downward and forward point on the profile curvature of the
symphysis of the mandible.
Oonlon (00,: The most posterior and inferior point on the angle of the mandible that is
fonned by the junction of the ramus and the body of the mandible.
Hairline (Hr,: The midpoint of the fore head where the hairline begi ns.
Inferior labial sulcus (ILS,: A poi nt at the innermost curvature of the lower lip.
Labialls Inferiorls (LI,: An arbit rary point at t he vermi llion of t he lower lip.
Lablalis superloris (LS): An arbitrary point at the vermi lli on of the upper lip.
Menton (Me,: The most inferior point on the symphysis of the mandible.
Middle of the nose (No,: The midpoint betwccn Sn and Pr on the true horizontal , p ~
jected on the inferior outline of the nose.
Nasion (N or Na,: The most anterior point of lhe front al su ture.
Pogonion (P or Pg,: The most anterior point on the symphysis of the mandible.
Posterior nasal .pine (PNS): The process formed by the most posterior projection of the
juncture of the palat ine bones in the midline.
Pronasale (Pr,: The tip of the nose.
Sella (S,: A constructed point in the middle of the sella turcica.
Soft-tissue menton (Me',: The point on the lower cont our of the chin opposite to the
hard-t issue menton.
Soft-ti ue pogonion (P',: The most anterior son-tissue poi nt ofthe chin.
StamiDn (St',: A point al the interlabial junction of the mouth where the upper and lower
lips connect.
48 Pan 8 Facial and Ct'phalomt'tric Evaluation
Subna.al_ ,Sn): The point at whi ch the base or the nose meets the upper lip.
Th-polnt: The point at the junction or thc neck and the submandibular sort tissue.
V-point: Thc midpoint orthe distance between A-poi nt and Sn.
Zygoma (Zy): The outennost point or the zygomatic processes o n the son tissuc.
References
I. Proffit WR: Contemporary Orthodontics. 51. Louis, MO: C. v . Mosby Co., 1986.
2. Viruds AD: Cephalometric analysis based on naltlral head position. J Oin Orthod 25: 172- 182. 1981.
3. Bass NM: The esthetic analysis of the face. Eur J Orthod 13:343-350, 1991 .


1
I
ella
Soft-Tissue Evaluation
The significance or sort-tissue e\'aluation lies in the importance of the role that dentofacial
attr.dctiveness plays in our society.l-" As clinicians, we need to make sure that we do
not compromise the soft ti ssue for a good occl usion and vice versa. A sort-ti ssue
evaluation from the facial and profile view is essential in order 10 have a comprehen-
sive understanding of the patient's esthetic characteristics.' See the previous chapler for
a glossary of cephaJomelric landmarks used in abbreviations here.
Rules of Thirds""
The midline true vertical. as it passes through the middle of the forehead (GI), tip of
the nose ( Pr), and the lips, divides the face into two halves and crosses perpendicular
to the line of vision (true horizontal; TH) (see Fig. 81.1). A very slight asymmetry is
nonnal and should be present in all indi viduals' (Fig. 84.1).
Along the true venkal , one may define the three equal veni cal facial thirds
1
(Fig.
B4.2) as the upper facial third. middle facial third. and loll.w facial third. The main
face (eye to eye) may be divided into three equal thirds along the true horizontal (Fig.
84.3); right eye width, nasal width. and left eye width. According to this dimension,
the eyes, intercantbaf d,stance, and afar base should all be of approxImately equal
width. The whole face (ear to ear) may also be di vided into equal thirds along the
true horizontal (Fig. 84.3): right facial width. mouth width. and left f acial width. The
aforementioned thirds provide the clinician with a fairly good idea of the overall
facial appearance and proportionality of the patient.
Facial Ralios:J ...
We can define f acial height as the distance between the glabella (GI) and the sort-
tissue menton ( Me' ) and facial width as the distance between the two most outer
points of the malar promi nences. Their rati o should be about 90%. The pUIJiI width
and gOllial width should be around 50% and 75% of the facial width, respectively. The
nasal width should be about 70% of nasal height (GIPr). Agai n, these ratios give a
good impression of the patient's specific facial characteri sti cs and proport ions (Fig.
84.4),
Facial Taper
The facial taper may easily be determined from the facial taper angle that is formed
by extending the right and left lines connecting the most lateral points of the orbits
and the junction of the upper and lower lips at the corners of the mouth (Fig. 84.5).
Their intersection fonns an angle that, with a mean plus or minus one standard
deviation (+ SD), is 45 degrees + 5 degrees. Larger values of this angle would indicate
a wider, more square face, whereas lower oncs indicate a longer, narrower face.
50 Part B Facial and Cephalometric Eralzwlion
64.2
FIgure 84.2 The face divided into three equal vertical thirds.
84.1
Figure 84.1 A very slight asymmetry IS normal in every
indi vidual .
64.3
Figure 84.3 The face divided into equal thirds along the true
hori zontal; the eye width should equal the nasal width; the
mouth width should eq ual the di stance from the ears to the
comers of the eyes on each side.
64.4
Figu'
9: Ie
heigl
I
84.'
F"'!Iure 84.4 The facial ratios. Facial height : facial width =
9: 10; pupil width : facial width - 1: 2; nasal width : nasal
height - 7: 10; gonial width ; facial width - 7.5: 10.
Evaluation of the Nos.
a.pl er4 SQ/I-TissuI'Emlual ion . 5 1
64.5
FtgUre 84.5 The facial taper angle indicates a square, nOT-
mal. or narrow face.
The rati o of the nasal width to the nasal height (GI-Sn) should be 70%. It gives us an
overall estimate of nasal proportion.} A wider alar base appears to flatten the midfacc,
a nd a narrow one lengthens the upper lip.
Two perpendicul ar lines to the TH from So and Pr define the nasal length as the
distance of these two points on TH ( Fig. 84.6). The mean SO is 18 2 mm. If we
locate t he midpoi nt of Sn- Pr on TH and draw a vertical linc to the lower contour of
the nose, we may define the middle of the nose (No). Female profil es with small er
noses are considered more estheticall y It is considered ideal for females to
have less prominent noses and for males to have more prominent ones in relation to
their
Convexity of the Profile
A parall el to the true vertical from No and the li ne NoPg' defi ne the V-angle (Fig.
84.6). This angle denotes the convexity of the face. The mean SO is - 13
degrees 4 degrees. The NoPg' ti ne (Steiner's S-Iine)' - the line connecting the mid-
dle of the nose (No) and the chin (Pg)-should barely touch the upper and lower
lips. Steiner's S-line' has been used for more than 2S years as a quick reference of the
anteroposteri or position of the li ps relati ve to the nose a nd chin.
The V-angle is similar to the facial contour angle (FCA) (GISn-SnPg')'o." but
provides a better indi cati on of profil e convexi ty because it concentrates on the lower
half of the face and takes into account the size of the nose. It does not allow the size
of the nose to affcct the evaluation of lip posi ti on as much as the E-line (the line
connecting the ti p of the nose to the chin, PrPg') does,12-I. because it uses only half
of the nose length.
54 Pan 8 Facial and Cephalometric Evaluation
.11
Figure 84.11 Thin lips (anterior view).
Figure 84.13 Thick li ps (anterior view).
Figure 84.12 Thin lips (side view). Extracti on of teeth
should be avoided in such patients.
Figure 84.14 Thick lips (side view). Extract ions may not
induce any significant lip changes.
84.15
Figure 84.15
thi ckness. A
height and UA
AguN 84.1'
2 mm of gil
SUS
f"'!Iure 84.15 A I : I : I ratio of upper lip: lower lip:chin
thickness. A 2 : I ratio exists between lower anterior dental
height and upper lip length.
84.17
Figure 84.17 Upon smiling. the lips should reveal 0 to
2 mm of gingiva above the incisors.
Chapter 4 55
84.16
Figure 84.16 The lip r.nios (SnLi : LIMe'''' I : I and
SnSI : StMe' - I : 2).
F"tgure 84.18 Tooth exposure al rest should be in the range
of2 to 3 mm.
56 Pan 8 Pacial and Cephalometric /;.'valuution
3 mmY- IB These are the most important observations from the facial view. The
desire to have a beaut iful smile is the primary reason patients seek orthodontic
treatment, and we must ensure that we set our esthetic goals from the onset of therapy.
Evaluation of the Throat
84.19
We can define the throat line by Th and Me' (see Fig. 84. 15). As this line intersects
the V li ne (No perp), the throat angle is formed. The mean SO shoul d be 105
degrees + 5 degrees. The throat length (Th Me' ) should be approximately 40 mm +
5 mm (Fig. 84. 19). These measurements are important in planning mandibular or-
thognathic procedures; i.e .. a mandi bul ar setback may not be possible when there is
a short throat lengt h.
A thorough evaluati on of the soft tissue enables the cl inician to develop a better
understanding of the skeletal and dental problems of the individual pati ent (Figs.
B4.20 and B4.2 1).
J.
,
,

84.20
Figura 84.19 The throat length and angle. These are very
important measurements in cases of orthognathic surgery of
the mandible.
Figure 84.20 This IOyear-old boy presents wi t h a seVert
class II , division I malocclusion. It is obvious from the
soft-tissue evaluation that this individual has significant dis-
crepancies in the anteroposterior dimension. The increased
convexity (V angle - 18 ). the significant tooth exposure at
rest (6 mm), the di stances of t he soft-tissue points LS, LI ,
and P from t he Sn perpendicular, as well as the S-mm
posterior relationshi p of the chin in relation to the V per-
pendicular (normal - 0 mm) and the short t hroat length,
are in accordance with the overall assessment of this pa-
tient as dentoalveolar maxillary protrusive a nd mandibular
rctrognathic.
84.21
.......
in a 5t
Chapter 4 Soft-Tissue EI'u/ual i QII 57
- ----- ---
84.21
F"I\IUri 84.21 The project ion of the maxilla ry incisors results
in a sirong alterati o n of the soft tissue .
References
I. Tedesco LA. ('I at. : A dental facial attractiveness scale. Am J On hod 83:38- 43, 1983.
2. Guyuron B: Precision rhi noplasty I; The role of life-size photographs and soft-tissue cephal omet ric
analysis. Pl ast Reconstr Surg 81 :489. 1988.
3. Stella JP, and Epker BN: Systematic aesthetic evaluation of the nose for cosmetic surgery. Oml
Maxill ofacial Surg a in North Am 2:273. 1990.
4. Kerr WJS. and O' Donnell 1M: Panel perception of facial attract iveness. Br J Orthod 17: 299-304. 1990.
5. Lines PA. Li nes RR, and Lines C: Profi le metrics and facial esthetics. Am J Orthod 73:648, 1978.
6. Proffit WR: Conlemporury Orlhodonlics. 51. Louis, MO: C. V. Mosby Co., 1986,
7. Proffit WR, and White RP, Jr: Surgicaf Onhodonlic Trrolmenl. SI. Louis, MO: Mosby Year Book. 199 1.
8. Vi:u:is AD: A new measurement of profile estheti cs. J ain Orthod 25: 15- 20, 1991 .
9. Steiner CC: Cephalometries for you and me. Am J Orthod Dentofacial Orthop 39:729 - 755, 195).
to. Burstone CJ: The integumental prolile. Am J Orthod 44: 1- 25, 1958.
II. Burstone CJ: IntegumentaJ contour and extension patterns. Angle Onhod 29:93 -104, 1959.
12. Ricketts RM: Perspectives in clinical appli cation of cephalometrics. Angle Onhod 51 : 11 5- 150, 1981 .
13. Ricketts RM: Planni ng treatment on the basis of the facial pattern and an estimate of its gro""h. Angle
Orthod43:105- 119, 1957.
14. Ricketts RM: The influence of onhodontic treatment on facial growth and development. Angle Orthod
30:103- 133, 1960.
15. Burstone CJ: Lip posture and its signifi cance to treatment planning. Am J Onhod 53:262 -284. 1967.
16. Wolford LM: Surgical-orthodontic correction of dentofacial and CT1I niofacial defonnities. Syllabus.
Baylor Coll ege of Dentistry, Dallas. TX, 1990.
17. Bell WHo and Jacobs JD: Tridimensional planning for surPcal/ onhodontic treat ment of mandibular
excess. Am J Onbod 80:263 - 288, 1981.
18. Epker BN, and Fish l C Evaluati on and treatment planned. [n DI'ntojacia/ Deformi l ies. edited by BN
Epker and LC Fish. St. Louis: C. V. Mosby Co. ; 1986, p. 18.
19. Bass NM: The aesthetic anal YSIS of the face. Eur 1 Ort hod 13:343- 3.50. 199 1.
Anteroposterior Skeletal
Assessment
Clta fer
The ant eroposterior position of the jaws is assessed based on measurements that use the true
horizontal (TH) as the reference line
l
(Fig. 85.1). See Chapter 3 in thi s part for a
glossary of abbreviations used here.
Size of the Mandible (GoGn, Relative to the Anterior Cranial Base (SNa)
A ratio of GoGn :SN = J indicates a wcllbalanced mandibular body relative to the
cranial base (Fig. B5.2). A differential of 0 to 5 mm (SNa > GoGn) would be ex
pected for the prepubertal period and the opposite (SNa > GoGn) for the postpuber
tal period. The size of the anterior cranial base, unl ess severely deformed due to a
geneti c disorder/malfonnation, may be considered constant or of normal size in all
cases. Therefore, the maxilla and mandible have to be in good anteroposterior rela
tion to the " nonnal" anterior cranial base length.
The importance of thi s measurement lies in the fact that a very retrognathic profile
may be due to a short mandibular body (t hat affects the anteroposterior plane), which
may require surgical intervention. depending on the defonnity and the age of the
patient.
Maxillomandibular Ratio I PNS - ANS: ArGn)
According to the Michigan growth atias,2 the length of the mandible, defined from
articulare (Ar) to gnat hion (Gn), is almost exactly double of the maxillary length,
defined from the posterior and ant erior nasal spine (PNS-ANS), for all age groups
and for both males a nd females. The actual length is not as important as is the
maxillomandibular ratio, PNS - ANS:ArGn (similar to the maxillomandibular differ
entiaP), that provides the relati onship of the two jaws relative to each other (Fig.
85.2). A ratio of I : 2 indicates that the actual lengths of the maxi lla and mandible are
in good balance with each other. This information, along with the relationship of the
body of the mandible to the cranial base, relate the cranial base, maxi ll a, and mandi
ble with each other.
A'''lament of tlte P\alitic:wl of dbe.Jaws Us '9l..inep sret AngI.p Meal,peilb8Cbb
Proffit and White
4
have proposed using a perpendicular from the nasion with the TH
in assessing the maxi ll ary and mandibular anteroposterior relationship with linear
measurements. Three suggested linear measurements from points A, B, and pogonion
( Pg) to nasion perpendicular to TH relate the position of the maxilla, mandible, and
chin, respectively. A-point should be I mm in front of the Naperpendicular, whereas
B-point and Pg should be 3 mm and I mm behind the line, respectively (Fig. BS.3).
60 P.rt B Facial and Cephalometric Evaluation
,
85.2
""'" ... 1='" ~ ~ :
,
,
" ,
,
,
,
,
Figure 85.2 The cranial base mandibular differential (solid
lines) and the maxillomandibular ratio (dotted lines) of the

Jaws.
Measurement Patient
SN:GoGn I : I
PNS ANS: AriJn 1 : 2
A:NperpTH + Imm
B:NperpTH -3 mm
P:NperpTH - 1mm
" True Wits" (ab) 4 2mm
Chin Length (bp) 2mm2mm
NaA-TH 90' 3'
NaB-TH 87' 3'
NaP-TH 89' 3'
ANa 3' 2'
aNPg -2' 2'
85.1
Figure 85.1 The 12 cephalometric measurements used in the
anteroposterior assessment of the jaws.
85.'
Figure 85.3 Nasion perpendicular to the true horizontal.
Note the relationships of points A, B, and P to this line.
As
M.
85.4
Flgu ...
posterill!
Values .1
values I,
deviatiol
Chapter 5 Antl'foposII'riQr Siw{rw{ AsU'ssmrlll 61
Due to the imp0l1ance of accurate assessment of the anteroposterior position of
both the maxi lla and the mandible relative to each other and the cranial base, angular
measurements are also calculated between the TH and NaA. NaB, and NaP. These
are 90 degrees + 3 degrees, 87 degrees and 89 degrees 3 degrees, (Fig.
85.4).
Assessment of the Relative Anteroposterior Position of the Maxilla and the
Mandible-the True Horizontal Wits and the ANB Angle
65.4
If points A and B are projected on the TH through perpendicular lines, points A and
B are defined, respectivel y. I The AB distance is defined as the true horizontal Wits
(Fig. BS.S) versus the ori gi nal Wits 011 (he occlusal plane. The TH Wits provides a
better and more clear relationship of the anteroposterior position of the jaws relative
to each other than does the origi nal Wits, which can sometimes be affected by the
incli nation of the occlusal plane or by the inclinations of the Frankfort horizontal
6
-
11
(Fig. BS.6). The Wits appraisal does not necessari ly focus attention on changes actu-
all y occurring in the sagittal relation between the mandible and the maxilla.
6
,7 Rather,
because of changes in the angulation of the occlusal plane, the true sagittal changes
are likely to be disguiscd.
II

12
A correlation between angle AN8 and Wits would not
be expected because they each involve an excl usive point or plane, which is not
necessari ly biologicall y related. The mean + SD for this measurement is 4 2 mm.
,
85.5
I
True I
horizontal I
F'tgure 85.4 Angul ar measurements Ihal the antero-
posterior position of the jaws from poi nts A. B, and P.
Values above the mean indicate prognathism, whereas
l'lllues less than the mean (especially more than I standard
deviati on) indicate fCtrognathia.
Figure 85.5 The " true hori zontal Wi ts" and the chin length
measurements.
62 Put B Facial and Cepha/oml'fric
Occlusal plane
True hOrizontal b. a
"
Occlusal
85.6
Figure 85.6 The value of the Wi ts can be affected by the
incli nation of the occl usal plane.
In addition to the TH Wits linear measurement, an angular measure ment, Ihe
ANB angle, is also used 10 assess the anteroposterior position of the jaws. The ANB
angle is a very popular measurement; its usc has been well documented in the
literature.
I
-
12
The mean SD is 3 degrees 2 degrees (see Fig. B5.4).
Anteroposterior Assessliient of the Chin-the Chin Length and the BNP Angle
A line paralfcJ to the TH is drawn tangent to the mandible at ment on ( Me). Projec-
t ions of B-point and Pg define the chin leI/gIlt ( BP). The mean + SD for this mea-
surement is 2 2 mm
l
(see Fig. B5.5). An angular measurement, the BNP angle,
assesses the prominence of the chin relative to the body of the mandible (see Fig.
B5.4). The mean SD for the BNP angle is - 2 degrees + 2 degrees.
By applying the aforementioned measurements, the clinician will develop an ap-
preciation of the position of the jaws in the anteroposterior plane (Fig. 85.7 through
8 5. 12) and will then be ready for the evaluation of the skeletal substrate in the
verti cal plane.
85.7
Figure B
cephalOi
sessmenl
fercntial
mandibl
There h
Wits ani
the man
iary sub
the clini l
85.9

clearl y s
the same
" .7
FIgure 85_7 Ten-year-old pati ent who, according to the 12
cephalometric measurements of anteroposterior skeletal as-
~ m e n t , demonstrates a slightly small mandible (the dif-
ferential with the cranial base is 7 mm and the maxilla-
mandibular ratio grealer than I : 2_ approximalely 1.1 : 2).
There is a significant discrepancy of the true horizontal
Wils and the ANB measurements, due partly to Ihe size of
the mandible but mostly to the procumbcncy of the maxil-
lary substrate. These observations are in accordance with
the clinical impression of a retrognathic profile.

'"


Figure 85.9 A follow-up of this same patient aficr 5 years
clearly shows that the true horizontal Wits has remained
the same.
Cbapler 5 AnteropoSll'f"ior Skeletal ASJt'ssmenJ 63
Measurement Patient
SNaGoGn I : I 7 mm diifcn:nlial
(SN > GoGn)
PNS ANS: ArGn I : 2 5 mm shorter Ixxiy
A:NaperpTH +Imm + II mm
8:Napc:rpTH :""3 mm - 5mm
P:NapcrpTH -Imm - 4mm
"True Wils" (ab) 42mm II mm
Chin Length (bp) 2mm 2 mm Imm
NaA-TH 90' 3' 97'
NaB-TH 87' 3' 87 '
NaP-TH 89' 3' 88'
ANB 3' 2' 10"
BNPg -2' 2' - I '
85.8
Figure 85.8 The 12 cephalometric measurements of the pa-
lient in Figure 8 5.7.
6 4 Pari 8 Facial and Ci!plla/olll'fric El'u/umion
85.10
Figure 85.10 This 11 year-old patient has a cranial base
differential and maxill omandibular ratio within normal
limits. The cephalometric measurements rcveal a slight
procumbency of both maxillary and mandibular skeletal
bases relative to the cranial base. The true horizontal Wits
reveals that the I WO jaws are in good antcroposterior rela.
tionship to each other. even though the ANB angle is
sl ighll y increased.
Measurement Patient
~ I
SNa:GoGn 1 : I Differential is 4
mm (within
nonnallimits)
PNS ANS: ArGn I : 2 Approximately
I : 2
A:NapcrpTH

+l mm +7mm
B:NaptrpTH - J mm +lmm
P:NapcrpTH - lmm + 2 mm
"True Wits"' (ab) 4 2 mm 6mm
Chin Length (bp) 2 mm 2 mm Imm
NaA TH 90 ' 3' 97'
NaB-TIt 87' 3" 9Q
NaP-TH 89' ) '
,, '
ANS ) ' 2' 7'
--1
BNPg - 2' 2' -I '
85. t 1
rtgUre 85.11 The 12 cephalometri c measurements of the
patient in Figure 8 S. IO.
85.12
Figure 85.12 Fi ve years later. at the age of 16, the samt
skeletal relationships are still evident.
Chaptn 5 AmeroposteriOT Skeletal Assenmem 65
References
I. Vi;uis AD: Anteroposterior assessment of the and the mandible based on th( true horizontal. J
Oin Orthod 26:673-680, 1992.
2. Riolo ML. RE. McNamara JA, and Hunter WS: An Atlas 0/ Cranio/acial GroM'/h: Cepha/om('/.
rie Standards. Ann Arbor, MI: Universily &;hool Growt h Study, the Unh'ersity of Michigan. Mono-
graph Number 2, Craniofacial Growt h Series. Center for Human Gro ... 1h and Development, 1972.
3. McNama11l LA. Jr.: A method of cephalometric evaluation. Am J Orthod 86:449-469, 1984.
4. Proffit WR, and White R: Surgical Orthodontic Treatment. SI. LQui s: C. V. Mosby Co.: 1990. pp.
]()9- 111,11 7- 124.
5. Viazi s AD: A cephalometric anal ysis based on natural head position. J Clin Ort hod 25: 172- 182. 1991 .
6. Oktay 1-1: A comparison of AND. WITS. AF- BF. and APDI measurements. Am J Onhod Dentofacial
Orthop99: 122- 128, 1991.
7. Sherman SL. Woods M, and Nanda RS: The longitudinal effects of growt h on the Wi ts appraisal. Am J
Orthod Denlofacial Onhop 93:429- 436. 1988.
8. Wallen T, and Bloomquist D: The clinical eKamination: Is il more importanl Ihan cephalometric
analysis in surgical orthodontics? International Journal of Adult Orthodontics and Orthognathic Sur-
gery 1:179, 1986.
9. Ellis E. 111 . and McNamara JA, Jr.: Cephalometric reference planes- Sella nasion vs. Frankfort
horizontal. International Journal of Adult Orthodontics and Orthognathi e Surgery 3:3 1, 1988.
10. McNamara lA. Jr. . and Ellis E. Ill: Cephalomet ric analysis of untreated adults with ideal facial and
occlusal relationships. International Journal of Adult Ort hodontics and Orthognathic Surgery 3:221.
1988.
I I. Jarvinen $: The relation of the Wits appraisal 10 the AND angle: Statistical appraisal. Am J Orthod
Denlofacial Orthop94:432- 435, 1988.
12. Rushton R, Cohen AM, and Linney AD: The relationship and reproducibi lity of angle ANB and the
Wi ts appraisal. Dr J Onhod 18:225-231. 1991.
C II Ie r
Vertical Skeletal Assessment
The influence of mandibular growth rotalion in the development of deep or open bites before,
during, or after orthodontic intervention has been the center of extensive investiga-
tions over the past 40 years.
I
-
11
A number of diagnostic modalities have been intro-
duced to provide the clinician with the ability 10 "predict" abnormal rotational pat-
terns thai may appear as part of the growth and development of the patient's facial
skeleton, especially of Ihe mandible:' -6,l- lo.14- 11 It has been shown that there is no
measurement or set of measurements that can be used successfull y to predict growth
rOlation, even by experienced c1inicians.lO Conversely, the orthodontist may use some
cephalometric parameters to assess the individual patient. The following 10 cephalo-
metric measurements may aid the clinician in appreciating a patient's facial vertical
growth. II A fair number of these measurements indicate a rotational pattern tendency
that will increase the relative prediction ability of the clinician when evaluating the
unique features of each individual case (Figs. 86.1 and 86.2). See Chapter 3 in Ihis
part for a glossary of abbreviations used here.
Width of the Symphysis Parallel to the True Horizontal from Pogonion (P TH)
The greater this measurement is, the more of a forward growth rotation (a deep bite
tendency in most cases) is to be expected (see Part C, Chapter I, Growth Considera-
tions). A narrow symphysis corresponds to a backward growth rotation (an open-bite
tendency). 14- 16 The mean SO is 16.5 mm 3 mm.
Angle of the Symphysis CBP-MeTH)
This is defined by the line connecting B-point and pogonion (P) as it crosses a line
parallel to the true horizontal (TH) at menton (Me). The mean SO is 75
degrees 5 degrees. If the symphysis is inclined backward, that is, if the angle of the
symphysis is acute, this is an indication of a forward growth rotational pattem.9.14- 16
Ifit is inclined forward (angle is obtuse), there will be backward rOlalion.9.14- 16
Mandibular Plane Angle (GoMe-TH)
One of the most widely used cephalometric measurements, this angle may sometimes
mask the true growth tendencies of the mandible due to extensive remodeling changes
occurring at the angle of the mandible and the symphysis. High values indicate a
backward growth rotator, and low ones indicate a horizontal growth pattern. The
mean SO is 27 degrees + 5 degrees. The angle will decrease approximately 2
degrees + 2 degrees from childhood to adulthood.
68 PII.r1 8 facial and Cephalometric Evaluation
Mean + SDI
Measurement Ratios Patient
I . Symphysis Width 16.S mm 3 mm
(PgTH)
2. Symphysis Angle 1S S
(8Pg-MeTH)
3. Mandibular Plane Angle 21 S
(GoMe-TH)
4. Sum of Poslerior Angles 396 4"
(SNa - SAr - ArGo - GoMe)
S. Gonial Angle 130
o
1
(ArGo-GoMe)
6. Gonial Angle Ralio 75%
(ArGoNa:NaGoMe)
1. Pos1.Cranial Base to Ramus 75%
Height Ralio
(SAr:ArGo)
8. Posterior/Anterior Facial
, , ~
Height Ral io
(SGo:NaMe)
9. Posterior/ Anlerior Maxillary
"'" l'leight Ratio
(EPNS:NaANS)
10. lower 10 Total Facial Heighl
"'"
Ral io
(ANSMe:NaMe)
86.1
FIgure 86.1 The 10 cephalometric measurements used to
assess the vertical relati onship of the jaws.
Sum of Posterior Angles
66,2
Figure 88.2 The 10 measurements of vertical assessment
drawn on a single t racing.
The mean value of the sum of the cranial flexure angle SNa- SAr (saddle angle),
articular angle (SAr-ArGo), and gonial angle (ArGo-GoMe) is 396 degrees + 4
degrees.
J

n
High values indicate a vertical growt h pattern (clockwise, opening, or
backward rotation), whereas low ones show a hori zontal growth pattern (counter-
clockwi se, closing, or forward growth rotation). The mean SO of the indi vidual
angles is: SNa- SAr, 123 degrees + 5 degrees; SAr - ArGo, 143 degrees 6 degrees;
ArGo - GoMe; 130 degrees 7 degrees. The saddle and the articular angle increase
approxi mately 1 degree each from ages 12 to 20 years, but the sum remains the same
because the gonial angle wi ll decrease by 2 degrees during this period.
J

17
Gonial Angle (ArGoMe)
As described by Bjork 17 and Jarabak and FizzclJ,3 with a mean of 130 degrees + 7
degrees, an increased gonial angle indicates a backward growth rotator, and a de-
creased one indicates a forward growth rotator.
G
p
P'
P
Chapter 6 Vertical Skeielai AHessmenl 69
Gonial Angle Ratio
A line from gonion to nasion divides the gonial angle into upper (ArGoNa) and lower
(NaGoMe). If the ratio of the upper to the lower angle is more than 75% (high upper
angle), we have an increased hori zontal growth rotation.) The oppositc (high lower
angle) indicates a vert ical growth pattern.
Posterior Cranial Base to Ramus Height Ratio (SAr: ArGo)
The length of the posterior cranial base needs to be measured and compared to thc
mean for the individual sex and age group. Providing that the length of Ar is withi n
nonnal limits, a ratio value of more than 75% would indicatc a short ramus height,
thus contributing to a clockwise rotation skeletal pattern. A short posteri or cranial
base is also indicative of a backward grov.rth rotator.
Posterior/Anterior Faee Height Ratio (SGo: NaMe)
Values higher than 65% favor a forward growth pattern, whereas a ratio of less than
65% indicates a backward grov.rt h rotator.
Posterior/Anterior Maxillary Height Ratio (EPHS:Na AHS)
Values higher than 90% indicate an upward rotation of the anterior maxilla and a
downward movement of its posterior componcnt, thus contri buting to an open bite.
Values lower than 90% may indicate a rotational pattern that contributes to a deep
bite.
Lower to Total Anterior Facial Height Ratio (ANSMe: HaMe)
Values higher than 60% or a long lower face height are indicative of a backward
grov.rth rotator. Low ratio values suggest a forward growth rotator.
The distinction between open- and deep-bite tendencies, especially in borderline
cases, is very important, not only for the initial diagnosis, but also for the planning of
the treatment mechanics of choice. A deep mandibular antegonial notch is indicative
of a diminished mandibular growth potential and a verti call y directed mandi bular
grov.rth pattern.
19
High-angle cases generall y may be more prone 10 mechanical extru-
sion of posterior teeth during orthodontic treatment, pri mari ly because the high
mandibular plane angle is associatcd with less muscle strength.
The vertical assessment of the jaws aids the clinician in recognizi ng open-bite
tendency patterns that may be detrimental to a successfull y trcated case ( Figs. 86.3
through 86.8).
70 I'art B Facial and Cl'phlilomt'tric Evaluation
86.3
Figure 86.3 A l2-year.old boy who presented elinicall y with
a I-mm open-bite relati onship. It is apparent that a suc-
cessful treatment outcome for this individual would depend
greatly on the openbi te tendency that he may exhibit, es-
pecially during his pubenal growth spun.
Mean+SD/
Measurement Ratios Patient
I. Symphysis Width 16.S mm 3 mm 7 mm"
(PgTH)
2. Symphysis Angle 75 So
""
(BPg-MeTH)
.
3. Mandibular Plane AngiC' 27" 5'
,,'
(GoMe-TH)
4. Sum of Posterior Angles 396" 4" 399
(SNa - SAT - ArGo - GoMe)
5. Gonial Angle 130" 7" 141"
(ArGo-GoMe)
6. Gonial Angle Rati o ,,%
''''' (ArGoNa:NaGoMe)
7. Posl.Cranial Base to Ramus ,,% 81%
Height Rat io
(5Ar:ArGo)
8. Poslerior/Anterior Facial 65%
,""
Height Ratio
(SGo:NaMe)
9. Posterior/ Anterior Maxillary 90%
,-,
lleight Ratio
(EPNS:NaANS)
10. u,wer to Total Facial Height
"'"
, ..
Ratio
(AN5Me:NaMe)
86.4
Figure 88.4 Same patient as in Figure 86.3. Six of the III
measurement s (+) are beyond I standard deviation from tilt
mean, indicating a backward growth pattern, i.e., a stroOt
open-bite tendency. Not all of the measurements show U!
thi s tendency. The cli ni cian may use his or her judgment
and cli nical expenise to balance the infonnation prcscntal
by the indi vidual case.
86.5
Figure BI
expressa
open bill
of choice
I.
2.
3.
4.
(5Na
,.
6.
7 .


10.
-
....;:". --
86.5
,
,
,
,
1 mm
oe
3 mm
AOB
Figure 86.5 Three years later, thc patient in Figure 86.3 had
expressed a significant vertical growth, whi ch increased his
open bite by 4 mm. A surgical approach was the treatment
of dlOire.
Measurement
1 Symphysi s Width
(PzTH)
1 Mandibular Plane Angle
(G<l Mc-TH)
4. Sum
SAr AIGo-
S, Gonia] Angle
(ArGo-GoMe)
l Posterior/Anterior F"acial
Height Ratio
(SGo:NlMe)
, PosIerior/Anterior Maxillary
Height Ratio
(EPNS:NaANS)
, Lower to Tolal Facial Height
...,

Mean + SDI
Ratios
16.5 mm 3 mm IS mm
75 ' S' 85"
27' S' 21. 5' "
396' 4'
3"-
130' 7" 132
75% 76%
75% 87.SiJio
--
,,%
Chapter 6 Vert ical Skeletal Asse.UII!i'nI 71
86.6
Figure 86.6 This l().. year..old boy presents with Imm open-
bite relationship.
86.7
Figure 86.7 The same patient as in Figure B6.6. The cepha-
lometric evaluat ion shows that three (+) of Ihe measure-
ment s indicate backward growth (open-bite tendency),
whereas two ( ) indi cate forward growth (deep-bite tend-
ency). The rest of the measurements are right on or around
the mean values. It was decided that this patient would
continue to grow in the same manner (the open bite would
not get worse) and orthodonti c mechanotherapy would try
to limit any extrusive si de effects as much as possibl e.

72 l'art 8 Facial and Cl'pha/O/llrlric E,'u/unlioll
References
86.8
,
,
", , ,

,
,
Figure 86.8 Five years later, the palien! has a similar rela-
tionship, with an overbite of 0 mm. Clinical judgment and
realistic evaluation of the numbers from the cephalometric
evaluation allowed for a thorough understanding of Ih(
indi vidual patient's growth tendencies in the venical plane.
I. Schudy FF: The rotation of the mandible resulting from growt h: Its impl ications in onhodonlic
treat ment. Angle Orthod 35:36- 50. 1965.
2. Odegaard J: Growth of the mandible: studied with the aid of metal implant. Am J Orthod 57: 145- 157.
1970.
3. Jarnbak JR, Ilnd Fizzell JA: Technique and Treatment wi/h Light Wjrl' Edgt'V>'iJe Appliances. 2nd ed.
St. Louis: C. V. Mosby Co .. 1972.
4. L a ~ e r g n e J, and Gasson N: A metal implant st udy of mandibular rotation. Angle Orthod 46; 144-150,
1976.
5. Isaacson R. Zapfel R, Worms T. and Erdman A; Effects of rotational jaw growth on the occlusion and
profile. Am J Orthod 72:276-286, 1977.
6. Isaacson R, Zapfel R. Worms F. Bevi s R. and Speidel T; Some effects of mandibular growth on the
dental occlusion and profile. Angle Orthod 47:97- [06, 1977.
7. Lavergne J, and Gasson N: Analysis and classification of the rotational growth pattern without im-
planU. Br J Ort hod 9:51 - 56. 1982.
8. Lavergne J: Morphogenetic classification of malocclusion as a basis for growt h prediction and treat-
ment planning. Sr J Orthod 9: [32- [45,1982.
9. Ski eller V, BjOrk A, and Linde-Hansen T: Prediction of mandibular growth rotation evaluated from a
longitudinal implant sample. Am J Orthod 86:359- 370.1984.
10. Baumrind S, Korn EL and West EE: Prediction of mandibular rotation: An empirical test of clinician
performance. Am J Orthod 86:371 -385, 1984.
I I. BjOrk A: The face in profile: An anthropological x-ray investigation on S .... "edish children and con-
scripts. Svensk Tandlakare Tidskri fi 40 (Suppl) (58), 1947.
12. Ricketts RM: Planning treatment on the basis of the facial pallcrn and an estimate of ilS growth. Angle
Orthod 27:14- 31, 1951.
13. Ricketts RM: The inDucnte of onhodontic treatment on facial gro .... 1h and development. Angle Onhod
30: 103-133. 1960.
14. BjOrk A: Variations in the growth patterns of the human mandible; Longitudinal radiographic study by
the implant method. J Dent 42:400- 41 1, 1963.
15. BjOrk A: Prediction of mandibular grov.1h rotation. Am J Onhod 55:585-599. 1%9.
16. BjOrk A, and Skieller V: Facial development and tooth erupt ion; An implant study at the age of
pUberty. Am J Onhod 62:339-383, 1912.
17. BjOrk A: The face in profile: An anthropological x-ray investigation on Swedish children and con-
script!. Svensk Tand1akare Tidskrift. 40 (Suppl l. 1941.
18. Viazis AD: ASSMSment of open and deep bite tendencies using the true horizontal. 1 ain Onhod
26;338-343. 1992.
19. Singer CP, Mamandras AH. and Hunter WS: The depth of the mandibular antegonial notch as an
indicat or of mandibular growth potential. Am J Orthod Dentofacial Orthop 91: 11 1- 124, 1981.
The ii
Inclll
IncU.
Incllr.
Clta
Cephalometric Dental Evaluation
The inclination of the denlition relati ve to the skeletal substrate is provided with the foll owing
measurements
1
(Fig. 8 7.1). See Chapter 3 in this part for a glossary of 3bbreviations
used here.
Inclination of the Functional Occlusal Plane (Occlusal Plane Angle)
The angle between TH 3nd the functional occlusal plane (OP) is deri ved from the
lower molar and bicuspid cusp tips and locates the teeth in occlusion relati ve to the
rest of the face. As with the mandibular plane, high values indicate a backward and
low values a forward growth rotation. The mean + SO is 8 degrees + 2 degrees.
Inclination of the Upper Incisor to the Maxillary Plane (Upper Incisor Angle'
This is the angle formed from the long axis of the upper incisor (UI) and the
ANS/ PNS line. The mean + SO is 110 degrees 5 degrees.
Inclination of the Lower Incisor to Hse Mandibular Plane (Lower Incisor Angle'
The long axis of the lower incisor (U) and the GoGn plane form this angle. The
mean SO is 92 degrees 5 degrees (GoMe can be used as well).
74 Part B Fuciul and Ct'phalollll'lrk f:raluation
Reference
87.1
Figure 87. 1 The inclination of the dentition is detennined
from the occlusal plane angle and the relation of the inci-
sors to their skeletal substrate.
t . Viazis AD: A cephatomelric anal ysis based on naluraJ head posi lion. J Clin Orthod 25: 172 _ t81 , 1991.
Po:
As er
Clla
Posteroanterior Cephalometries

As emphasized by Proffit and White,' the primary indication for obtaining a posteroanterior
cephalometric film is the presence of facial asymmetry. A tracing is made and vertical
planes arc used to illustrate transverse asymmetries, I Lines are drawn through the
angles of the mandible and the ouler borders of the maxillary tuberosit y (Figs. 88. 1
and 88.2). Vert ical asymmetry can be observed readi ly by drawing transverse occlusal
planes (molar to molar) at various vertical levels and observing their vertical orienta-
tion,l If a significant skeletal asymmetry is detected, orthognathic surgery may be
incorporated in the treatment plan. A more thorough evaluation would then be
needed.
2
.}
,
76 hr1 8 Facial and Cephalomelric
88.1
Figure 88.1 A posteroanterior cephal omctri c radiograph.
References
88.2
Figure 68.2 Venical and horizontal lines are a good first
impression of the existence offacial asymmetry.
I. Proffit WR, and While RP, Jr.: Surgical Oflhodomic Trl'almem. SI. Louis. MO: Mosby Year Book;
1991. p, 121.
2. EI-Mangoury NH, Shaheen SI, and Mostafa YA: Landmark ident ificat ion in computeriloo posteroante-
rior cephalometries. Am J Orthod Dcntofacial Orthop 91 :51- 61 . 1987,
3. Grummons IX, and Kappeyne de Cappello MA: A frontal asymmetry analysi s. J Clin Ort hod
21:448- 465.1987.
GI

Par
Growth
ella ler
Growth Considerations
Cranioracial growth is a complex phenomenon and its understanding requires an in-depth study
or the changes that occur from inrancy to adulthoo(Ll-12 The clinician should be
aware of a few basic principles of maxillary and mandibular growth.
1
-
12
The maxilla and the mandible grow in both a downward and forward direction
relative to the cranial base (Fig. CI.I). At the peak of the juvenile growth spurt (7 to 9
years of age), the maxill a grows I mm/yr and the mandible 3 mm/yr, whereas during
the prepubertal period (10 to 12 years of age) there will be a reduced rate of growth
(maxilla, 0.25 mm/yr; mandible, 1.5 mm/yr), only to reach maximum growth levels
during puberty (12 to 14 years of age) (maxilla, 1.5 mm/yr; mandible, 4.5 mm/yr).8- 11
The lower facial height (ANS-Me) increases approximately 1 mm/ yr, and the pogon-
ion (Pg) comes forward about 1 mm/yr.
In general , from 4 to 20 years or a g ~ . there will be on average 10 mm of pure
alveolar growth (Fig. C1.2).8-12 Overall, mandibular growth is approximately twi ce
that of overall maxillary growth.? The average direction of maxillary sutural &r0wth
has been found to be 45 degrees to 51 degrees in relation to the nasion-sella line from
8.5 to 14.5 years of age.
l
-
ll
Mechanisms responsible for the maxillary growth dis-
placement may be different in the earlier and later periods of maxillary growth. as the
direction of sutural growth changes to almost horizontal at the age of 14.5 years. This
corresponds to the fi nding that the mean vertical maxillary displacement has termi-
nated by the age of 15 years, whereas the horizontal displacement continues until 18
years of age in boys and until 16 years of age in girls. The angle of maxillary
prognathism (NA- TH) remains almost constant during growth because the forward
displacement of the maxilla is accompanied by a forward displacement of the nasion
point due to periosteal apposition. If the maxillary growth in boys is assumed to have
terminated by age 18 years and in girls by age 16 years, this corresponds to an average
annual lowering of 0.7 mm. Furthennore, increase in facial height (vertieal growth)
continues at a much reduced rate throughout early adulthood both in men and
women. The mean increase for total face height (nasion to menton) during adulthood
is almost 3 mm, but in individual cases it may be in the order of 10 mm (I cm)! 12 All
of the aforementioned guidelines should be taken into consideration when evaluating
the cephalometric measurements of the individual patient relative to the presented
average values.
The position of the condylar surfaces relative to the articular fossae probably does
not change appreciably with growth. The lowering of the maxillary complex displaces
the anterior, toothbearing part of the mandible. whereas condylar growt h and lower-
ing of the articular fossae displace its posterior part.
2
,12 If the amounts of lowering of
the anterior and posterior parts are not equal, the mandibular displacement will
contain a component of rotation.
2
When the direction of condylar growth is upward and forward in relation to the
mandibular base, the lowering of the posterior part of the mandible usually exceeds
that of the anterior part. The result ing type of mandibular rotation is termed forward
growth rotation
1
,2,8- 11 (counterclockwise rotation). If, during the forward growth rota
80 l'IIrt C GrOll'I h
CLl
Figure C1.1 Growth of the jaws in a downward and forward
direction.
,
,

' .
C1 .2




-
,
,
Figure C1.2 Alveolar growth from childhood to adulthood.
tion, there is occl usal contact in the incisal region, the eruption of the posterior tccth
normall y serves to maintain occlusal contact in the posterior part of the dental arches.
If there is no occlusal contact in the incisal part of the dental arches, the forward
growth rotation o c c u ~ as a rolling movement around a point in the bicuspid region of
the dental arches. The incisal segment of the lower dental arch is thereby carried inside
the incisal segment of the upper dental arch, leading to the development of skeletal
deer) bitel.2I- 11 (Figs. CJ.3 and CIA). Depending on the severity of these cases,
adjunctive orthodontic/surgical treatment may be needed.
Il
.
I

If the lowering of the anterior and posterior parts of the mandible is identical, there
wi ll be no component of rotation and the mandibular displacement with growt h will
be a pure translation.
In subjects with a predominantly backward direction of the condylar growt h or with
onl y a small amount of condylar growth, the loweri ng of the posterior part of the
mandible can be smallcr than that of its anterior part. Mandibular displacement in
such instances will contain a component of backward rotation and the mandi ble will
seem to roll backward around a point in the molar region. This is termed backward
growlII rO/at;on2. -
11
(clockwise rotation). In such cases, occlusal contact in the anterior
segment of the dental arches can be maintained by increased eruption of the front
tccth. If the teeth are not able to compensate by supra-erupti on, a skeletal open bite
develops (see Figs. C1.20 to CI. 22). Again, an orthognathic surgical approach should
be considered for the severe cases.
Il

I

It should be emphasized that facial changes also occur in adulthood. Males tend to
have a countercl ockwise rotation of the mandible, whereas the mandibles of females
seem to rotate clockwise. This may have a bearing on the long-tenn stabili ty of
treated cases; a treated class II female might be more prone to relapse toward a class
II sit uation, and a treated class HI male might be more prone to relapse to class III. In
addi ti on, as some individuals age, the mandible might appear less protrusive owing to
a number of factors: the maxillary incisors are continuall y uprighting during adult-
hood, and with the continued growth of the nose a nd chin, the reposi tioning of the
lips, and the vertical increase, one could easily envision that the adult face would
Chapter I GrQlwl! CQl1sid('T(JliollS 8 1
appear less protrusive over time.' This might make us more conservative in our
diagnosis of bimaxillary protrusion.'
Every clinician who practices contemJXlrary orthodontics should be able to recog-
nize and diagnose cases wi th skeletal problems that shoul d not be treated by ort ho-
dontic means alone, but wi th an adj unctive orthognathic procedure. These problems
may involve the anteroposteri or dimension, mandibular retrognathia (Figs. CI.3
through CUI ), mandibul ar prognathism (Figs. C1.12 through CU 8), or the vert ical
di mension (Figs. C 1. 19 through C1.24) wi th the cl inical appearance of a skeletal open
bite. Someti mes, they may involve skeletal discrepancies in both (Ji mensions (Figs.
C1.25 through CI. 29). Problems in the transverse di mension should be detected as
well (Fig. C1.30). The abilit y to evaluate and fC(:ognize these cases should be in the
realm of every practitioner.
The description of the treatment of these cases is beyond the scope of this text. The
clinician who becomes involved in the treatment of such cases must first spend a
considerable amount of time studying the state-of-the-art literature on the subject of
comprehensive surgical/orthodontic treatment.
Il
A t h o r o u ~ h understanding of the
numerous orthognathic procedures available (and thei r advantages and drawbacks) is
an absolute must for the successful management of these cases; failure, sometimes
beyond repair, is otherwise guaranteed.
Figure C1,3 Ad ult patient with t he clinical impression of a
rttrognathie mandible. Note the deep labiomental fold.
C1.4
Figure C1.4 Same pati ent as in Figure CU. The anterior
view of his occlusion reveals a vcry deep bite (the lower
incisors cannot even be secn! ). His overjet was 12 mm, and
he had a futl class II molar relationship.
82 l>art C GrQw/1!
Cl .S
Figure Cl.5 A mandibular advancement orthognathic proce-
dure is the surgery performed on patients with mandibular
rctrognathia.
Cl .6
Figure Cl .6 The same patient as in Figure CU after ortho-
donti c treatment and surgery. Note the improvement in tM
patient'S profile.
Figure Cl.7 The dentition after surgery in the palient seen
in Figure CU.
Ct.8
Figure CU Sue
rognathia. N o t ~
is a fun (100\
150% OS!).
Figure CUI
onhodontio
(mandibula
molar relat
CI .8
Figure C1.8 Buccal view of a patient with mandibular rel-
rognathia. Note the IS mm overjet. The molar relationship
is a full (I()()C\() class II. The bite is very deep (more than
150% OB!).
CUD
Figure CUD Buccal view of the patient in Figure CL8 after
CI1hodontic treatment followed by onhognathic surgery
(mandibular advancement). Note the class I cuspid and
molar relationship.
Chaptt'l I Gro ....th COIlsidl'rat ions 83
C1.9
Figure C1 .9 Anterior vicw of the same patient as in Figure
C I.8.
C1.11
Figure Cl .11 Anterior view of the patient in Figure CLIO.
Note the dramati c improvement in the overbite relationship.
84 Part C Grow/h
Figure C1.12 A IO-year-old girl with evident mandibular
prognathism.
Figure Cl .14 Same patient as in Figure C1.l2 after puberty
and cessation of mandibular growth. Note the prognathic
profile.
Figure C1.13 Same pati ent as in Figure C1.12. Right buccal
view of the occlusion. Note the ret roclined lower inci sors
and the cnd-to-end multiple crossbites.
Cl .15
Figure C1.15 Same patient as in Figure C1.I 4. Fued onho-
donlic appli ances in prepamtion for surgery.
CU6
FIgure C1.
ular selba
a positi ve
Agure C1.
view of tI
in the 00
relatio nsll
..
C1.16
Figure C1.1B Same patienl as in Figure CJ.l4. In a mandib-
ular setback procedure, the mandible is brought back until
a positive overjet is achieved.
Figure C1.1B Same patient as in Figure C1.I 7. Right buccal
,iew of the occl usion after surgery. Note the improvement
in the occlusion. The cuspid teet h are in a solid class I
rdationship.
Ch. pler I GrQwth Considerations 85
F"l{Iure C1 . 17 Patient shown in Figure CI.I 4 after surgery.
C1.19
Figure C1.19 Cephalometric radiograph of a patient wit h a
signifi cant vertical problem.
86 Part C Growth
-
n
_ OP E> BITE
Cl .20
Figure Cl .20 Same patient as in Figure C 1.I 9. The cephalo-
metric tracing reveals a 6.5-mm open bite, high mandibular
plane angle (32"), and a very long lower face.
Figure Cl .21 Right buccal view of the same patient as in
Figure CI. 19. Note the extent of the open bite all the way
to the posterior teeth.
Figure Cl.22 Anterior view of the same patient as in Figurt
C1.I9. Note the "rainbow" appearance of the skeletal opec
bite.
Figure Cl.23 In cases with such a significant vertical prob-
lem, a leFort I osteotomy is pcrfonned above the maxilla .
Figure Cl.24 A segment of bone is removed and the whol
maxilla is repositioned superiorly. In most instances, tb:
mandible autorotates and aids in the closing of the Ope!
bite.
Fig...,. Cl
posterior
problem):
.......
C1.25.
FIgure Cl .25 Patient with mandibular prognathism (antero-
posterior probl em) and a very long lower face (vert ical
problem).
C1.27
f9Jl1l Cl .27 Anterior view of the same patient as in Figure
e1.25. This case requires a double-jaw ort hognathic ap-
proach (three-pi ece maxi ll ary leFort I osteotomy and a
mandibular procedure).
napier 1 Growth COfuidcralions 87
Cl .26
FIgure C1.26 Same patient as in Figure CL2S. Right buccal
view of the occlusion. Note that the open bi te extends
posteriorly to the molar area.
Cl .26
Ftgure Cl .28 Cephalometric radiograph of the patient in
Figure CI.2S.
88 Plrt C GrQI'I1h
n '

Cl.29
, ,1. "
Figure C1.30 Skeletal asymmetry or the jaws as a result of
mandibular prognathism. A mandibular orthognathic pro-
cedure is the treatment of choice.
Figure C1.29 The cephal ometric tracing and analysis reveals
a very hi gh mandibular plane (37 ). a large mandible rela-
ti ve to the size or the maxilla (ratio, 1: 2. 15), and a 1-mm
open bite. Such a case is almost impossible to treat with
orthodontic means alone at any age.
References
I. SkieUer V. BjOrk A. and Linde-Hausen T: Prediction or maodibular growth rotat ion evaluated from a
longilUdinal implant sample. Am J Orthod 86:359- ) 10, 1984.
2. Solow B: The dentoalveolar compensatory mechanism: Background and clinical implication. Br J
Orthod 1: 145- 16 1, 1980.
3. Nielsen IL: Ven ical malocclusions: Etiology, development, diagnosis and some aspects of treatment.
Angle Onhod 61 :241-260, 1991.
4. Kom EL, and Baumrind S: Transverse development of the human jaws between the ages 8.5 and 15.5
years. studied longitudinally with use of implants. J Dent Res 69:1298- 1306, 1990.
5. lseri H, and Solow B: Growth displacement of the maxilla in gi rls studied by the implant method. Eur
J Onhod 12:389-398, 1990.
6. Behrents R: Adult craniofacial growth. J Clin Orthod 20:842-847, 1986.
7. Love RJ, Murray TM, and Mamandras AH: Facial growt h in males 16 to 20 years of age. Am J
Orthod Dentofacial Onhop 97:200- 206, 1990.
8. Bp k A: Variations in the growth patterns of the human mandible: Longitudinal radiOKl1lphic study by
the: implant method. J Dent 42:400- 411. 1963.
9. Bpk A: Prediction of mandibular growth rotat ion. Am J Onhod 55:585- 599, 1969.
10. Bp k A, and Skieller V: Facial development and tooth eruption: An implant study al the age of
pubert y. Am J Onhod 62:339-383, 1972.
II. BjOrk A: The race in profile: An anthropological JIO -tay investigation on Swedish children and con-
scripts. Svensk Tandlakare Tidskrift. 4{) (Suppl ) (5B). 1947.
12. Enlow DH: Facial Growth. Philadelphia: W.B. Solllnden Co .. 1990.
13. Proffit WR, and While RP, Jr. : Surgical-Orthodontic Treatment. SI. Louis, MO: C. V. Mosby Co., 1991.
14. Bell WH: Modern Practice in Orthognathic and Rt"-VlIstrllctivl' Surgery, vols. 1-3. Philadelphi a: W.B.
Saunders Co .. 1992.
Ith
Growth Superimposition/
Evaluation
ell
II has been well documented that the anterior wall of the sella turcica and the cribriform plate
remai n unchanged after the fifth year of life. L_. This means that no growth or remod
eling changes affect these areas of the cranial base by the time the first permanent
tooth erupts in the oral cavity, which is most likely the earliest time an orthodontic
consultation or intervention may be needed. Growth changes of the facial skel eton can
be carefull y evaluated by superimposing cephalometric radiographs on these stable
structures. Yet the various existing superi mposition techniques do not concent rate on
using this portion of the cranial substratc.
5
-
16
All of the other arcas presently used arc
subject to growth changesY Evcn the most popular superi mposition techniquc-
superimposition on the SN line by registering on S (sella)-expresses growth more
anteriorly than it actuall y occurs.
9
-
11
A reason for avoiding the use of the aforemen-
tioned stable areas has been the difficulty in accurate location of the cribriform plate
and the small dimension of the anterior wall of the sella turcica.
The following superimposition approach offers a sound and practical way of incor-
porating these structures in the evaluation of facial growth.
17
Three points are used to
define the triangle (Fig. C2.I):
I. T-poilll : The most superior point of the anterior wall of the sella turcica at the
junction with tuberculum sella. It can be quickly located on the radiograph and
does not change wi th growth, as does the sella (S).
2. C-poilll: The most anteri or point of the cribriform plate at the junction wit h the
nasal bone. Even though the cribriform plate is not easily detectable, the C-point is
always very clear on the cephalomet ric radiograph at the most posterior tip of the
nasal bone.
3. L-poilll: The most inferior (lower) poi nt of the sella turcica. This point also defines
the most posterior point of the anterior wall of the sella turcica.
The triangle incorporates in its area the whole anterior wall of the selJa turcica and
extends over a large area that includes all of the anterior and part of the middle
cranial base. The three points selected are at the greatest distance from each other
wi thin stable structures. This provides the clinician with a large marking area. By
registering on the T-point and superimposing on the anterior wall of the sella turcica
and the stable TC line (cranial base li ne), a solid formati on is provided through the
shape of the triangle in both the anteroposterior and the vertical planes for a practical
and dependable evaluati on of facial growth. The purpose of the triangle is to provide
the clinician with a quick, solid, visual ori entation of the most stable areas of the
cranial base.
It is preferable to obtain a cephalometric radiograph of all growing patients at the
age of 9 or 10 years or at the initial visit at the office. Just before orthodontic
treatment is to begi n and at least 6 months after the initial radiograph, a second
cephalometric radiograph will give the clinician the ability to compare the two and
evaluate facial growth. When superimposing the two triangles as described above, the
two lower sides of the triangles may not necessarily fit right on top of each other,
,
90 PIlr1 C GrOluh
C2.1
,
,
" ':.--------
FIgure C2.1 The cranial base triangle (TLC), the G (growt h)
line, and 0 (directi onal) angle.
especially because of the L-point (due to slight remodeling changes in the area) (see
Fig. C2. J). Focus should be placed, in the order of registering. on ( I) the T-point and
superimposing on (2) the inner structure of the triangle (anterior wall of the sella
turcica) and (3) the TC line. This recommended methodology si mplifies the proce-
dure of the "best-fit" approach while recognizing the limits of reali stic ex.pectations of
a superimposition technique.
A line connecting the T-point with gnathion (Gn) is defined as the G-Iine, which
may be used as a growth line (see Fig. C2.I). The advantage of the G-line over the
other ones that use sella is attributed to the stable position of the T-point versus the
unstable S (sella point) due to growth and remodeling. In addition, the T-point is an
anatomic landmark, whereas the sella is a constructed one (as the middle of sella
turcica).
The mean SD of the angle formed between the G-line and the true horizontal
(D-angle) is 58 degrees 4 degreesl7 (see Fig. C2. 1). Growth is downward and for-
ward along this line (D-angle stable with growth). Backward rotation of the G-line (by
registering at the T-point) with growth indicates vertical growth (D-angle increases)
(Fig. C2.2). Anterior rotation of the G-line with growth indicates a forward hori zontal
growt h pattern (D-angle decreases) (Fig. C2.3).
The angle between the TC line (stable cranial base line) and the (me vertical (TV)
may be established on the first traci ng of a patient (Fig. C2.4). Any additionaJ
radiographs of this patient taken to evaJuate either growth changes or treatment
effects may be oriented so that the TC- Til angle remains constant. In this way, the
patient is treated to his or her initiaJ natural head position (NHP), establi shed in the
beginning of treatment, illespective of postural, behavioral, or surgical effects. In
other words, the patient is treated to a constant NHP based solely on the line of
vision, which is established when the pupil is in the middle of the eye and the
individual is looking straight ahead.
In understanding the importance of craniofacial growth and its role in the develop-
ment of an individual's malocclusion, one needs onl y to comprehend the role of
dental compensation to the skeletal growth pattern.
C2.'
""'"
opn
C2.
""'.
,
on,
pati
'.
"
"'
-
'il ,-
C2.2
Fill"'. C2.2 Backward or clockwise rotat ion and the devel-
opment of an open bite.
- ....
C2.'
r ... C2.4 The angle between TC and TV can be used to
OIlent any future cephalometric radiographs of the same
pati(nt.
C2.3
Chapter 2 Growth SIIJX'rimposilion/E"ulllatioll 91
'\
\)'
-
--
-- -
-
Figur. C2.3 Forward or counlerclockwise rolation and the
development of a deep bi te.
92 Part C GrO .... 1h
C2.5
--,
C2.6
Figure C2.6 Dental compensation in deep-bite cases. The
lower incisors have flared (110") in an effon to reduce the
overbite (normal, 92 5").
FIgure C2.5 Dental compensation in open bites: the anterior
teeth tip lingually and supererupt. Here, the lower incisor
to the mandibular plane angle is 75 " (normal, 92" + 5").
Malocclusions stem from the inability of teeth to compensate for an abnormal
skeletal pattern. II If we were to look at severe skeletal open-bite cases, we would
notice that the anteri or dentition (i ncisors) is retroclined (ti pped linguall y) and has
supererupted in the majority of these cases" (Fig. C2.5). This is nature's attempt to
compensate for the abnormal skeletal growth pattern that has created the open bite
(backward rotation) with dental movement that decreases the extent of the open bite
over the years. The opposite would take place in a deep-bite patient. The teeth would
flare labiall y in an effort to decrease the deep overbite relationshi p18 (Fig. C2.6). Of
course, this is not clearly visible in all cases, because other factors playa role in the
overall appearance of the dentition (muscles, soft tissue, tongue- lip equili bri um,
tongue function, parafunctional habits, etc.).
The aforementioned differences in nature's dental compensations involve the verti-
cal plane. If we were to look at skeletal development problems in the anteroposterior
dimension, we would notice a similar compensatory pattern. In a class III mandibular
prognathism patient, as the negative overjct (underjet) develops, the upper incisors tip
labially and the lower incisors tip linguall y in an effort to keep as normal an overjet
relationship as possible. It is as if the teeth are trying to "hold on" while the mandible
grows excessively anteriorly (Fig. C2.7).
The diagnosis of such problems may become more complicated when we have
abnormal skeletal development in both dimensions, verti call y and anteroposteriorly,
such as the class III, open-bite patient presented previously (see Figs. Cl.2S through
CI. 29). A thorough cephalometric evaluation along wi th proper superimposition of
serial radiographs will help in locating the extent of the problem in both dimensions.
-. ,
C2.7
FIgure C2.71
the mandil
maxillary 11
of tipping).
the teeth (
compensati
Cbaptcr 2 Groll1h SU{Jerimpositionj Elolualion 93

I
e2.7
Figure C2.7 As the mandible continues to grow anteri orly,
!be mandibular teeth gradually lip lingually, whereas the
maxillary teeth tip labially (the arrows show the direction
of tipping). Note the angles fonned from the lo ng axes of
the teeth (these axes would remai n parallel if no dental
compensation occurred).
An example of dental compensation is given in the situation of two patients who
may have the same skeletal open-bite tendency, but one has a normal open bite/ over-
jet of 2 mm and the other an open bite. The teeth of the first patient compensated by
supereruption of the anteriors, whereas they did not for the second patient. In the
past, when orthognathic surgery had not yet developed to its current level, cli nicians
would correct such malocclusions by completing nature' s work; i.e., extrude the teeth
(in the case of an open bite) to close the bite.
Another example of the role of dental compensations involves the decision of
extracti on versus nonextraction on two individuals who have the exact same crowdi ng
and dental appearance, but one has an open-bite tendency (backward rotation) and
the other a deep bite (forward rotation). Nat ure tends to compensate in open-bite
cases by supererupting the anteri or teeth and tipping them lingually. Nat ure compen-
sates a deep bite by flaring the anteriors labiall y. We would rather extract teeth to
resolve the crowding in an open-bite case, because this treatment modalit y would
allow us to tip the rest of the teeth lingually (working along wi th nature' s attempt to
compensate) to close the bite. Extractions in a deep-bite case should be avoided if
possible, bci:ause the remaining teeth would move linguall y and make the bite deeper.
Therefore, nonextraction approaches should be investigated for deep-bite cases.
Finally, if we were to consider two patients wi th identical malocclusion but totally
different growth patterns, we would attempt to treat them in two different ways
because it is not the malalignment of teeth that directs our treatment planning, but
the individual growth patterns (Figs. C2.8 through C2. IO).
94 Part C Growlh
FIgure C2.B This 100year-old girl demonstrates severe dental
projecti on of the upper anterior teeth. Note her long lower
face height (Sn to Me').
Figure C2.9 This 100year-old boy demonstrates a dental
problem similar to that of the gi rl shown in Figure C2.g,
Note his shon lower face height (Sn to Me'). Also note the
deep labiomental fold, indicative of a deep-bite, class 11
malocclusion.
,
-"'-
- co
-, ..
C2.10
Figure C2.10 Arbitrary superimpositi on of the cephalometri
radiographs of the two patients presented in Figures OJ
and C2.9. Although a very crude method of eval uating *
growth of different individuals of the same age, one CD
notice the difference in their growth patterns. The girt lIlm
the long lower face has 0 mm overbite and is a bachmd
growth rotator (venical grower). The boy is a forwzn!
growth rotator and has a deep bite of 6 mm. Altboup
these patients have the same dentaJ problem (severe projct.
tion of the upper incisors and a Qass II tit
treatment approach will be different according to their it
dividual growth pattems.
Chapl 2 Growlh SuperimposiliOllj EvaluOIioll 95
References
I. Melsen 8 : The cranial base. The postnatal development of the cranial base studied histologically on
human autopsy material. Acta Odontol Sc:and 32(Suppl):62, 1974.
2. Roche AF, and Lewis AB: Late growth changes in the cranial base. In Developmem of the Basimmiuln.
edited by JF Bosma. Bethesda: DHEW 1976, pp 22 1-239.
3. BjOrk A, and Skielk:r V: Normal and abnormal growth of the mandible. A synthesis of longitudinal
cephalometric implant studies over a period of 25 yeaB. Eur J Onhod 5: I - 46. 1983.
4. Buschans PH, LaPalme L, Tanguay R, and Demirjian A: The technical reliabi lity of superimposition
on cranial base and mandibular structures. Eur J Onhod 8: I 52 - 156, 1986.
S. de Coster L: The familial line, studies by a new line of reference. Trans Eur Onhod Soc 28:50- 55. 1952.
6. Brodie G: Late growth changes in the human face. Angle Orthod 23: 147 - I 57, 1953.
7. BjOrk A: Cranial base development. Am J Onhod 41 : 198- 255, 19S5.
8. Coben SE: The integration of facial skelctal variants. Am J Onhod 41 :407 _434, 1955.
9. IUcketls RM: A foundation of cephalometric communication. Am J Orthod 46:330- 357, 1960.
10. Ricketts RM: Cephalometric analysis and synthesis. Am J Onhod 3 1; 141 - 156, 1961 .
II. IUcketts RM: The value of and oomputeri.u:d technology. Angle Onhod 42: 179-199,
1972.
12. Ricketts RM: Perspecti ves in clinical application of Angle Onhod 5 I: II 5-150, 1981 .
13. Bj Ork A: Variations in the growth pattern of the human mandible: Longitudinal radiographic study by
the implant method. J Dent Res 42: 400- 411. 196J.
14. Solow B, and Tallgren A: Natural head position in standing subjects. Acta Odontol Scand 29:59 1- 607,
1971.
15. Coben SE: Basion horizontal coordinate tracing film. Jain Onhod 13:598 - 605, 1979.
16. Frankel R: The applicabili ty of the occipital reference base in cephalometries. Am J Onhod 77:379-
]95, 1980.
11. Viazis AD: The cranial base t riangle. J ain Orthod 25:S65 -570, 1991.
1&. BjOrk A, and Skiller V: Facial development and tooth eruption. An implant study at the age of
puberty. Am J Orthod 62:]] 1- 383, 1912.

Hand-Wrist Radiograph
Evaluation

ell
The course of ort hodontic treatment often depends on the intensity of facial growth; thus, the
knowl edge of the growth velocity variations of the jaws is of importance in clinical
orthodontics.
1
.2 The clinician would like to know t he onsct of the growing patient's
pubertal growth spurt so that he or she may intervene with maximum results in the
minimum time framc. The physical maturit y shown in a hand - wrist radiograph of the
individual child can be visually compared with that of normal children of the same
age and gender using Greulich and Pyle's Atlas.) where a number of hand-wrist
radiographs arc presented.l,l Consequently, the practitioner may evaluate the stage of
development of the patient by matching the individual radiograph to one in the At/as.
Conversely, one may assess a hand-wrist radiograph without the Atlas. based on the
following guidelines:
l
.2
I. When the width of the epiphysis of the second proximal phalanx ( PP2) is equal to
that of its diaphysis ( PP2= ), we are close to, but certainly before the onset of
puberty.
2. When the width of the epiphysis of the third middle phalanx (MP3) is equal to
that of its diaphysis (MP3=) and the sesamoid (s) bone has begun to ossify and can
be secn on the radiograph, we are right at the onset of puberty or slightl y past its
onset (Fig. C3. 1). One must remember that in one fifth of patients, the sesamoid is
visi ble 2 years before maximum growth is reached.
I

2
This is why the information
obtained from MP3 is very critical.
3. Capping of MP3 (where the epiphysis covers completely the diaphysis) occurs
almost invariably simul taneously with the maximum of I year after the peak
growth.
1

2
4. The most intense period of growth may be expected between ossification of the
sesamoid and onset of the capping stage.
Menarche in girls occurs well after the pubertal growth peak.' Dental development
is of lillie value as a criteri on of puberty.' The mean sesamoid bone appearance
precedes mean peak mandibular velocity (puberty) by 0.72 year in males and 1.09
years in One should note that in one quarter of males and one fifth of
females. the adductor sesamoid appears after pUberty.'
One may start his or her observation of the patient' s hand - wrist radiograph by
looking at the adductor sesamoid of the thumb.
6
If it is not ossified, we then look at
the width of the epiphysis of tbe middle phalanx of the third finger (MP3). If this is
equal to or less than the width of the diaphysis of MP3, then we know the patient has
not yet reached puberty. If the sesamoid is ossified and we can sec capping of MP3
(i.e .. the epiphysis is wider than the diaphysis and starts to cap it), then we know the
patient has pretty much just reached pubeny. Within 2 years after this, fusion of MP3
will occur, and this is an indicator that there is very little growth left. Finally, if we
see fusion of the radius, we can be sure that growth for this patient has been completed.
98 Pin C Growth
References
Figure Cl.1 This radiograph of the third fi nger shows that
capping of MP) is j ust begi nni ng.
I. Helm S, Siersbael Nelson S, Slcidler Y, and BjOrk A: Skeletal maturation of the hand in rdation to
maximum pubertal growth in body height. Tandlaegebladet 6: 1223- 12]4, 1911.
2. BjOrk A, and Helm S: Prediction of the age of maxi mum pubenal growth in body height. Angle Onhod
]1:1]4- 143, 1961.
]. Greulich WW, and Pyle SI: Radiographic Atlll$ of Skeletal Developmem of the "and and Wrist, 2nd ed.
Stanford, CA: Stanford University Press, 1959.
4. Enlow DH: Facial Growth. Philadelphia: W.B. Saunders Co., 1990.
5. Pile:ski RCA, Woodside 00, and James GA: Relationship of the ulnar sesamoid bone and max.imum
mandibular growth velocity. Angle Onhod 4]: 162- 110, 1973.
6. Fishman LS: Radiographi c evaluation of skeletal maturation: A clinically oriented method based on
hand - wrist films. Angle Onhod 52:88- [ II , 1982.
[
1
Nasal Growth
The growth of the nose has been the focus of many invcstigations over the past 30 years, due
to the important role that nasal development plays in orthodontic treatment
planni ng.
l
-
Il
Class I subjccts tend to have straighter noses, class III subjects reveal a
concave confi guration of the nose along the dorsum, and class II individuals exhi bit a
morc pronounced elevation of the nasal bridge (greater dorsal hump), leading to the
increased convexity observed in the class II patient. Most investigators state that nasal
growth for girls continues until the age of 16 years.
1

9
In addition, very small incre-
ments of nasa) growth have been reported between the ages of 18 to 22 years, and as
lale as 26 to 29 years of age. 10, 11
The tip of the nose progressively attains a more forward and downward position
with age (due to forward growth of the nasal, septal cartilages) and the forward growt h
of the nose is greater in proportion than that of other son ti ssues of the face.2,) Nasal
growth increases at a rate of about 25% greater than of the maxilla.
4
This cont ributes
significantl y to the increased convexity of the soft -tissue profile with age. In a recent
study, it was concluded that patients with marked horizontal max.illary growth have
more horizontal growth of the nose than those patients wi th verti cal growth of the
maxilla (who have more verti cal nasal development). 12
Developmentally, the greatest change occurs in the anteroposteri or prominence of
the nasal tip in both sexes, and because the forward positioning of the nose is greater
than that of the soft-tissue chin, it appears that the li ps are receding within the facial
profile.
2

s
Havi ng failed to explain the possibility of excessive nasal growt h potential,
the cli nician finds it difficult to convince the parents or the patient that the unesthetic
profi le is due to the excessive nose and not to orthodontic mechanotherapy that
resulted in retrusive lip position 12 (Figs. C4. ! through C4.3).
100 Plrt C Gro .... th
Figure C4.1 Profile of a patient at age 12 years, before orth
odonti c treatment.
Figure C4.2 Same patient as in Figure C4. 1, at age 14 years,
after orthodontic treatment. The nasal length appears to
have remai ned the same.
C4.3
F"tgur. C4.3 Same patient as in Figure C4. 2. 6 years later, at
age 20 years. Note the excessive late nasal growth that
resulted in the "' false" appearance of retruded lips (attrib-
uted by the patient to the orthodontic treatment).
Chapter 4 Nasa/Gro .... th . 10 1
References
L Posen TM: A longitudinal study of the growth of the nose. Am J Orthod 53:746- 756, 1967.
2. Sublenly 10 : A longitudinal swdy of soft tissue facial structures and their profile characterist ics defined
in relation to underl ying skelet.al structures. Am 1 Orthod 45: 481- 507, 1959.
3. Subtenly JD: The soft tissue profile, growth and treatment changes. Angle Orthod 31: 10S- 122, 196 1.
4. Proffit WR: Contemporary Orthodontics. SI. Louis. MO: C. V. Mosby Co., ]986.
S. Rudee DA: Proportional profik changes concurrent with orthodontic therapy. Am J Orthod 50:421.
]964.
6. Charonas SJ: A statistical evaluation of nasa] growth. Am J Orthod 56:4{I 3- 4 14, 1969.
7. Oements BS; Nasal imbalance and the onhodontic patient. Am J Orthod 55:244 - 264, 329- 352,
477 - 497,1969.
8. Burstone CJ: The integumental profile. Am J Orthod 44: ] - 25. 1958.
9. Meng HP, Goorhuls J, Kapi la S, and Narida RS: Growth changes in the nasal profile from 7 to 18
yeaB of age. Am J Orthod 94:911-926, 1988.
10. Samas KY, and Solow B: Early adult changes in the skeletal and soft tissue profile. Eur J Onhod
2:1-12. 1980.
II. Fosberg CM: Facial morphology and aging: Or longi tudi nal tq)halometric investigation of young
adullS. Eur 1 Onhod 7:15-23, 1979.
12. Busehang PH, Yiazis AD, DelaCruz R, and Oakes C: Horizontal growth of the soft-tissue nose relative
to maxillary growth. J Cl in Orthod 26: 111 - 118. 1992.
Par t
Orthodontic Mechanotherapy
ell ler
Biomechanics of Tooth Movement
Tooth Movement Simplified
If "'e take a pencil, and place it flat on a desk, and try to move it with a finger by contacting it
in its middle, we will notice that the pencil rolls and moves parallel to itself (Figs.
01.1 and 01.2). If we try to move it from its sharpened edge, we will see that it
moves, but it also rotates slightly (Figs. 01 .3 and 01.4).
Now if we imagine the tooth as the pencil, the orlhodomic forces as our fmger, the
middle of the pencil as the center of resistance of the tooth, and the sharpened edge of
the pencil as the crown of the tooth, and if we define as bodily movement the parallel
motion of an object to itself and tipping as the movement of the object as it rotates
and spins around itself, then we may appreciate the following when it comes to tooth
movement in orthodontics
l
-
1
:
Because the center of resistance of the tooth is four tenths away from its apex, i.e.,
within the alveolar bone, it would be impossible for us to apply a direct force on the
tooth in order to make it move parallel to itself (Figs. 01.5 and 01.6). Thus, our only
option is to attempt to move teeth by applying a force on the crown, which, according
to the aforementioned correlation with the pencil, will cause the tooth to tip. This
happens because there is a Moment "" Force X Distance that rotates the tooth (Figs.
DJ.7 and 01.8). In order to move a tooth bodily, we need to apply a countennoment
equal to and in the opposite direction of the one that is created by the orthodontic
force. This can be done only with rectangular wires.
I
-
1
Let us imagine the upper incisors as we try to retract into the available space that
we have obtained from the extraction of the first bicuspids (Fig. 01.9). The bracket
that is bonded onto the crown of the tooth has an opening in it, called the slot, where
the archwire is placed. An elastic chain can be used to pull the brackets together and
thus apply the necessary force to move the tooth. As soon as the force is applied, the
tooth tends to tip, as explained previously. When that happens, the edges of the
rectangular wire grab hold of the bracket slot and thus apply a couple (equal and
opposite forces), which tends to spin the tooth in the opposite direction than the
moment from the force is attempting to tip it (Fig. 01.10). In other words, the
rectangular wire has created a countennoment. If the moment and countermoment
are equal , they will cancel each other out. I,) This means that the tooth will move
bodily (translation, parallel movement) from the action of the force from the elastic
chain and solely from it.
The same principles apply if we were to look at a tooth from its occlusal surface,
with an orthodontic bracket bonded on to its buccal surface
l
-
3
(Fig. 01.11). Thi s
time, the tooth will tend to spin around its long axis if the main archwire is not
securely wire tied with a ligature in the bracket slot. In this dimension we do not have
much control. whether we use a round or rectangular wire, unless we usc a deltoid
bracket.
106 Part D OrrhodOlllic MlXhflrwtherupy
FigUffl 01.1 A force (from our finger) is applied in the mid-
dle of the pencil at point A.
Figure 01.3 Try to move the pencil from one of its ends.
Figure 01.2 Notice thaI the pencil moves parallel to itself ro
point B.
01 .4
Figure 01.4 II rotates as it moves from poi nt A to B.
flo'"
a\ tl
bod;
F " " ~
appl y
t he I(
appl ic
looth.
01 .5
fI\lUf" 01.5 and 01.6 It is impossible to appl y a direct force
at the center of resistance of a tooth (and thus move it
bodily), because it is in the alveolar bone.
Apt. 01.1 and 01.8 As we attempt to move the tooth by
appl)ing a force ( F) on its crown, a moment ( M) rotates
the tooth as it moves; (d) is the distance of the point of
iIIlPIication of the force from the center of resistance of the
,.,th.
Chapter I Biomt"Chanics Qj TOOth Movement 107

01.8
108 Part D Orthodontic Mer:hanQlherapy
0 1.9
Figures 01.9 and 01.10 As we try to move t he upper incisor
posteriorl y by applyi ng a force on it from point A to point
8, the tooth moves bodil y if the countermoment applied
from the rectangular arch wire is equal to the moment that
tends to tip the tooth.
01.1 0
F
01 .11
Figure 01.11 As this bi cuspid tooth is pulled from an ortho-
dontic elastic ' wire chain to close the extracti on space me
sial to it, the tooth tends to rotate from t he moment ( M)
that is created. CR is the center of resistance of the tooth.
B
(:
01 .12
Figure ~
standarc
in-and-c
ence In
preadju!
ets com;
may usc:
ness has
Chapler I Biomechanics O/TOOlh Mow!"Jent 1 09
Bracket Prescriptions
(I )
01.12
Conlemporary orthodontic mcchanotherapy4- 9 leads to treatment results that are
based on the six keys to normal occlusion
6
: (I) a class I molar relationship (as
described previ ously); (2) crown angulation (Iip)- the gingi val portion of the crown
of teeth is distal to the incisal portion in most individuals; (3) crown inclination
(Iorque) - anterior crowns have an anterior inclination, whereas posterior crowns
have a lingual inclination; (4) absence or rotations; (5) absence or spaces; and (6) the
plane or occlusion shoul d vary rrom generall y fl at to a slight Cijrve or $pee. In order
to achieve these results, we need to understand the relationships and posilions of teeth
in the arches.
If one were to closely observe an ideal dental arch, it would immediately become
apparent that the position or each tooth in tbe alveolus is defined by three
parameters
4
-
6
: ( I) the "in - out" position (Fig. DI.I2), (2) the crown angulation to
"tip" (Fig. DI.I 3), and (3) the crown inclination or " torque" ( Fig. DI.I4). These
three parameters define Ihe three-di mensional position of each tooth in ils space. In
the past, all orthodontic brackets were the same for all teeth, with the same slot. The
clinicians had to incorporate into the main arch wire three bends ror each tooth, in
order to maneuver each tooth in its ideal position: (I) the " in-out" or first-order
bend, (2) the " tip" or second-order bend, and (3) the " torque" or third-order bend.
Modem fixed appliances have all these bends built into their slots, thus maki ng each
bracket specifi c for each toot h. Providing that the bracket is positioned ideall y on the
tooth surface (in the middle or the crown, along the long axis, and parallel to the
incisal edge), these preadj usted prescription appbances theoreticall y have the capability
to finish the treatment with no bends in the archwires whatsoever! Obviously. this is like
saying that everyone's feet should fit in the same size shoe. No mailer how perfect
bracket placement is with preadjusted appliances. compensating bends will always be
needed at the end of treatment for final detailing and finishing of the ocdusion.
A suggested prescription is given
4
-
8
(Fig. D 1. 1 5):
t
+
(Jr)
f91re D1 .12 In the original onhodontic brackets of onc
ltandard size and prescription (/), the clinician had to place
inand-out bends in the wire to compensate for the differ-
met in the buccolingual thi ckness of teeth. In the modem,
prtadj usted appliances (II), different thickness in the brack-
dS compensates for that of the teeth so that the clinician
may use a straight wire without bends (the bracket thick-
a has been exaggerated for purposes ofillustrat ion).
110 Pan 0 Of/hot/I)nlic M('ChwJolherapy
-
~ a _
(I)
01 .13
FIgure 01.13 The difference in the angulation of the teeth
(tip) in the past forced the clinician to compensate with an
up-and-down bend (I ). In contemporary, preadjusted appli-
ances, thi s is not necessary because the tip is built into the
bracket. If A is perpendicular to P (P forms 90" with inci-
sal edge) and 8 is perpendicular to the base of the bracket
slot, then the angle fonned between the two represents the
compensating bend that needs 10 be placed with the stan-
dard appliances (I ). A and 8 coincide in II.
I I
1 I
1
I
I
1
I
I
1
-
- I
I
I

1
I
>
I
I I
I
I
I
- -
L
...
I
(I)
Ill)
01 .14
Figure 01.14 The torque or incl ination of teeth in the bone
is again compensated for by the preadjusted appliance (II).
Note that the angl e formed between the perpendicular (B)
to the base of the slot and the perpendicular to line P, (A),
coi ncide (A - 8) for the preadjusted appliances (II).
whereas the two perpendiculars B and A fonn an angle in
the standard brackets (/).
BRACKET PRESCRIPTIOSS

1 .. ~ " , ~ . , . .... , ~
- .
, ~
--
'-

-
,-

,

"
,
"
" "
,


,
"
.,
"
,
"
,
.,

., ,


.,
,

., , ,

,
"

,
"
."
".+

. ~
,
"

"

. , , , , ,
,

, ,
,
, ,

,
."
,
"
,

."
"
,
"
,
"

n
,
n
,
n

,

,

,

~
,
n
,

,
."
DLlS
Figure 01.15 Bracket prescriptions. V - Viazis; A-
Andrews; first R- Roth; S- Swain; W-"Wick" Alex-
ander; 11- Hilgers: second R - Ricketts.

"

.-.
'-
-..
'-
-.
'-
..........
-
- - -
,
"
,
"
,
"
.,

,

"

"
...
"

"
,
"
,
,

.,

.,


,

,

."
."

,
."

, ., , ,

,

,


, ,

, ,
,
.,
,
." ."
."
."
."

, n

n
. ,
..
,
.,
n

n
.,

,
Figu..,
the bn
bracke
Upper central Incisor
First-order bend (in -out ): Standard
Second-order bend (tip): 5 degrees
Third-order bend (torque): 20 degrees
OuIpler I Biom('Chanics ofTOQlh Mon'ment 111
A specific thickness is given to the upper incisor bracket of a regular size. The
5-degree angulation is similar to the one proposed by Andrews' classic work.
6
It is
also widely used in other prescriptions. The 20-degree torque is definitely greater than
the torque proposed by Roth,' and Alexander,1 and close to the 22 degrees
suggested by Hilgers.' Because sliding mechanics are used, it would be quite easy to
"dump" the anterior teeth lingually during retraction and space closure (Figs. DI.16
through 01.18). Accentuated torque would reduce this and, it is hoped, by the end of
treatment the teeth would be in the area of 10 degrees of torque, similar to that
proposed by Andrews for the ideal occlusion (7 degrccs). In addition, it is easier to
alleviate the torque effect by undersized rectangular wires than to add torque in the
wire. Because O.c)QI inch of play (tolerance) relates to approximately 4 degrees of
torque lost, space closure with a .016- X .022-inch2 stainless steel wire would theoreti-
call y have 8 degrees of torque effect lost, if desired. Accentuated lingual root torque of
the upper central incisors is needed in the majority of cases during sliding mechano-
therapy, and this prescription offers this advantage.
figules D1 .16 and D1 .17 The effect of additional torque in
the bracket (note the twi sted rectangular archwire in the
blacket slot) rotates the tooth from A to B.
112 Part J) Orthodontic MechanOJhl>rapy
Upper Lateral Incisor
First-order bend (i n-out): More thi ckness
Second-order bend (tip): 10 degrees
Third-order bend (torque): 10 degrees
/,
I \
I
\
#
I





I
,
I



"

I




,

,





,
01.18
Figure DU8 If A is the OOITttI incl inat ion of the upper
incisor teeth in the bone and B is the position they would
assume if they tipped linguall y during space closure if the
countermoment provided by the wire is not enough, then C
should be increased torque that is incorporated inio the
preadjusled appliance so that the tooth may end up in
position A after space closure.
More bracket thickness is needed to compensate for the buccal- lingual relationship
of the lateral incisor compared to the central incisor. The IO-degrcc angulation is
slight ly greater than that suggested by Andrews6 and R o t h ~ (9 degrees) or Alexander1
and Hilgers' (8 degrees), but simi lar to that recommended by Ricketts
8
(10 degrees).
This additional angulation is needed to prcvcnt close proximity of the central and
lateral incisor roots, especially during space closure. The 10-dcgrce torque is again
greater than that in othe_ prescriptions for the same reasons addressed for the central
incisor bracket.
Upper Cuspid
First-order bend (in -out): Thinner than central incisor
Second-order bend (tip): 15 degrees
Third-order bend (torque): 5 degrees
The bracket thickness on the cuspid has to be thinner than the regular size of the
upper central incisor due to the bulkiness of the cuspid. The 15 degrees of tip are
similar to that proposed by Roth
5
( 13 degrees). It positions the root of the tooth more
di stall y, thus enhanci ng bodily movement and reducing the tipping effect of sliding
mechani cs. A 5-degree torque is necessary because, as support ed by Hilgers,B there is a
Chapter I Biomechanics o/ TOOIh MQI'emem 11 3
mechanical tendency to detorque the upper cuspids as they are retracted in extraction
cases, and there is always the possibility of impacting the root on the dense cortical
labial plate on space closure. In nonextracti on cases, where a slight expa nsion occurs
in all cases and the toot h is tipped outward anyway, the effect of the torque can be
mini mized by placing an undersized fi nishing wire (i.e .. a 0.01 6- X 0.022-inchl wire
in the 0.0 18 slot system).
High li ngual torque on the upper cuspid is also advocated in the prescriptions by
Hilgers! and Ricketts' in order to maintain the integri ty of the labial surface cont ours
between the cuspid a nd the lateral by keeping their torque differential to a minimum.
In addition, a more vertical inclinati on of the upper cuspids alleviates the det rimental
effects of the " narrow cuspid" look, which is also detrimental to fu ncti onal jaw
movements and the periodontal healt h of the tissues overlying prominent roots. Thus,
a ni ce, broad " Holl ywood" type smile is created with a gentle rise in excursions and
stabilit y through reduction of excessive lateral forces.
Upper Bicus pids
First-order bend (in - out ): Simi lar to the cuspid
Second-order bend (tip): 0 degrees
Thi rd-order bend (torque): - 5 degrees
The fi rst-order compensati on is the same as the cuspid one because of their simi lar
prominence. The O-degree tip agrees wi th the overcorrected position suggested in most
prescri pti ons. The - 5-degree torque placed on the bicuspids, alt hough it encourages
"dropping down" of the lingual cusps, does so j ust enough to ensure good intercuspa-
tion of the bicuspid teeth with their counterparts of the opposing arch. This comes as
the rcsult of numerous observati ons of fi nished cases that appeared fine from the
buccal side but from the lingual side lacked the ni ce, solid occl usion of an ideally
finished case. Undersized wires can be used in open-bite tendency cases.
Upper Molars
Fi rst-order bend (in -out ): Very thin mesiall y/ very thi ck distall y (20 degrees)
Second-order bend (tip): 0 degrees
Third-order bend (torque): - 10 degrees
As suggested by Hilgers,! a IS-dcgrce distal rotat ion of this tooth ensures the
shortest arch length occupi ed by the molar tooth, which is S degrees more than
Andrews" recommendat ion. Thus., the bracket shoul d be very thin around the me-
siobuccal cusp and very thi ck on the distobuccal cusp. A 20-degrec distal overrotati on
is especiall y helpful in the overcorrection of class 11 , division I cases, and it counter-
acts the movements placed on the molar teeth from the side effects of slidi ng me-
chanolherapy with elasti c chains. The O-degree angulation is similar to other prescri p-
tions. The - IO-degree torque all ows a good intercuspal occlusion, especiall y of the
li ngual cusps. Incorporat ion of the second molar teeth is advisable onl y if absolutely
necessary.
Lower Incisors
First-order bend (in - out ): Thick
Second-order bend (tip): 0 degrees
Third-order bend (torque): - S degrees
Thi ck brackets on the lower compensate for their lingual relationship
relati ve to the upper anteri ors. The O-degrec ti p positions these tccth in a n upright
position while the - 5-degrcc torque, similar to that suggested by Alexander,1 has been
shown to hold the mandi bular incisors in their ori gi nal position, thus ensuring maxi-
mum retention stability.
114 PIIrl D Orthodontic Ml'ChanOlherapy
Lower Cuspid
First-order bend (in-out ): Thinner than regul ar
Second-order bend (tip): 5 degrees
Third-order bend (torque): - 5 degrees
A thin bracket is necessary to compensate for the prominence or this tooth. The
5-degree tip is similar to that proposed by Andrews,' Alexander,' a nd Hilgers.' The
- 5-degree torque gives the lower cuspid a more labial version than in other prescrip-
tions in order to articulate with the upper cuspid, as defined by this prescripti on, and
offer the proper cani ne gui dance duri ng excursive movements. In addi ti on, by havi ng
si milar torque to the incisors, the cuspid tooth is positioned slightl y lingual to the
incisors (being at the corner of the arch). This supports the lower anterior dentition
and enhances post-retention stabilit y.
Lower First Bicuspid
First-order bend (i n-out): As thin as the lower cuspid
Second-order bend (tip): 0 degrees
Third-order bend (torque): - 15 degrees
A thin bracket is required due to the similarity of this tooth to the cuspid. The
O-degrcc tip is again similar to that suggested by the prescriptions of Alexander,1
Hilgers,' and Ricketts.
s
The - 15-degree torque provides a sli ghtly greater elevation of
the lingual cusp than that suggested by Andrews' ( 17 degrees) in order to provide a
sol id occlusion with the opposing dentition.
Lower Second Bicuspid
First-order bend (in - out): Same as the lower first bicuspid
Second-order bend (tip): 0 degrees
Third-order bend (torque): -20 degrees
All compensations for this tooth are made for the same reasons as for the lower
first bicuspid.
Lower Molars
First-order bend (in - out): Mesially very thin/ distall y very thick
Second-order bend (tip): - 5 degrees
Third-order bend (torque): - 30 degrees
For the same reasons described for the maxillary molars, an overcorrection of the
first-order compensation of 10 degrees is needed to counteract the mesial rotation
imposed on the molars by the clastic chains of sliding mechanotherapy. The
- 5-degree tip maximizes the lower molar resistance to mesial tipping from the sliding
mechanics and offers ' tip-back" effect by placi ng the roots mesially, thus contri buting
to anchorage control during space closure. The - JO-degrce torque allows for good
intercuspation of the lingual cusps without allowing unnecessary extrusion.
Ch.pl er I BiomechanicHI/TOOlh }.{/J\'i'rllI'nt 115
References
I, Smi th RJ, and Bumone CJ: Mechanics of tooth movement. Am J Orthod 85:294- 307. 1984.
2. Staggers JA. and Gennane N: ainieal considerations in the use of retraction mechanics. J ain Orthod
25:364-369,1991.
3. Proffit WR: COnli'mporary Onhadon/ics. S1. Louis, MO: C. v. Mosby Co" 1986.
4. Swain BF: Straight wire design strattg.i es: Five-year evaluation of the Roth modification of the Andrews
straight wire appliance, Chapttr 18, pp. 279-298. in Graber lW: Onhadonlics-SJaJe 0/ the An,
Essence of the Scien((', St , Louis. MO: C. V. Mosby Co . 1986.
5. Roth RH: Treatment mechanics for the st raight wire appl iance. Chapter II , pp. 665 _ 716, in Graber
TM. and Swain BF: O"hodomicr-CIirr/>fII Principles and Techniques. St. louis, MO: C. V. Mosby Co.,
1985,
6. Andrews IF: Straight Wire -Concept and Appliances. San Diego: L.A. Wells Co., 1989,
7. Alexander RG: The Alexander Discipline. Glendora, CA: Onnco Co., 1986.
8, Hilgers JJ: Begin with t ~ end in mind: Bioprogrcssive simplified. Jain Onhod 9:618-627. 10:716-
734. 11 :794-804.12:857-870, 1987.
9, Mclaughlin RP. and Bennet TC: The transition rrom standard edgewise to preadjusted appliance
systems. Jain Orthod 23:1 42- 153. 1989,
Orthodontic Metal
Fixed Appliances
Cha
Orthodontic fixed appliances are used to apply correcti ve forces to malaligned teeth.
I
-
4
These
appl iances generally include brackets, which are bonded onto the facial surface of the
crown of the teeth, and a main archwire, which is inserted in the brackct (slot
portion). The wire is all owed to slide through the brackets during tooth movement and
guides tooth movement while appl yi ng a certain force to the bracket (a nd thus the
tooth) if it is acti ve (Fig. 02.1). Additional forces may be applied to the teeth by
elasti cs (rubber bands) and/or elastomeric chain modul es, especiall y during the closing
of spaces (Fig. 0 2.2).
Conventional brackets have (1) a base, which has a mesh configuration that all ows
for adequate bond strength to the tooth surface; (2) a slot, which receives the wire; and
(3) wings or hooks, on which clasti cs, elastomeric modules., ligatures, and coil springs,
etc., can be attached (Fig. 02.3).
The twi n-type brackets are basically made of two verticall y oriented parallel bars
that are spaced apart with a slot cut in each bar to receive the main archwire (Fig.
02.3). The single-type brackets are made of one vertical bar, with a smaller size slot
than the twin brackets., and " wings" that arc acti vated to contact the main arch wire
for rotational control, as needed (Fig. 02.4). The major disadvantage of the twi n
brackets is the narrow interbrackct distance (between adjacent teeth), thus resulting in
a small span of wire between t he brackets. which reduces the Oexibility of the arch-
wire. Conversely, the rotati onal wings of the single brackets are too big; rotations are
not easily corrccted and teeth may tip into the extraction side more easil y during space
closure.
The deltoid bracket provides a narrow slot of the same dimensions of a single-wing
bracket and delivers the same interbracket distance (see Figs. 02.3 and 02.4). It offers
excell ent rotational control due to the horizontal segment of the bracket and the
triangular manner with which the 0 rings or the ligature wires encompass the bracket.
It is small er than the twin brackets and superior to the si ngle bracket's rotational
wings, which cause problems with the pati ent's oral hygiene. It is easy to orient onto
the tooth surface (the vertical bar is along the long axis of the tooth and the horizontal
parall el to its incisal edge). Sliding mechanics are greatl y facilitated through the rota-
tional and ti p control that the horizontal bar offers duri ng space closure. It greatl y
reduces friction during space closure due to the elevated slot.
The size of any bracket slot can be either O.OI8-i nch or O.022-inch. Because we
stri ve for as Iowa force as possible in orthodonti c mechanotherapy, it is preferable to
use the O.OI8-inch slot system, because it takes a smaller size wire to fill its slot and
thus lighter forces are exerted on the teeth. Brackets are bonded on all teeth except the
first molars (Figs. D2.5 and 02.6). Metal bands arc cemented onto these teeth. Bands
provide better bond strength on these teeth. especially if a headgear appliance is used.
118 Part D Orthodontic Ml'ChanotherapJ'
02.2C
Figure 02.2. A-D. An elastomeric chain is applying a force
on the teeth as it pulls all the brackets together. Note the
rotational control of the deltoid bracket. Within one
month, the anterior spaces were closed.
Figure 02.1 Various contemporary orthodontic brackets
(from len to right): single wi ng bracket (Ormco, CA), del
toid brackets (GAC. NY), and twin brackct (Unit ck!3M,
MN).
02.20
D2.3A
Figure
cuspid
on th(
ti cs, V
( b o d i l ~
the ho
02.4
Figure
dehoi(l
bracke
deltoi ll
11 B Part D Orthodontic Mechanotherapy
02.2A
02.2C
Figure 02.2. A- O. An elastomeri c chain is applying a force
on t he tccth as it pulls all the bmckets toget her. Note the
rotational cont rol of the deltoid bracket. Within onc
month, the anteri or spaces were closed.
Figure 02.1 Various contemporary orthodont ic brackets
(from left to right ): single wi ng brdcket (Ormco, CAl, del-
toid brackcts (GAC, NY), and twi n bracket ( Unitekj3M,
MN).
02.20
02.3;
Figul
cusp
00 (
ti cs.
(bod
thet
02.41
F I g ~
delta
brno
delta
02.3A
Figure 02.3. A, B. Close-up view of the dellOid (on the upper
cuspid) and twin brackets (on the incisors). Note the hook
on the deltoid bracket for the placement of auxiliary elas-
tics. Within two m o n t h ~ cuspid retraction was completed
(bodily movement and complete rotational control due to
the horizontal bar of the deltoid bracket).
02.'
Figul'e 02.4 Close-up view of the single wing (left ) and the
ddloid (right) brackets. Note t he much bulkier single wing
bracket. Also note the "stretch" of the "0" ring on the
deltoid bracket, which aids in rotational control.
Chapin 2 Orlhodomic Metal Fixed Appliances 119
D2.3B
Figure 02.5 The slot of the single wing bracket is too narrow
and offers no rotati onal conlrol. Note the rotated left lal-
eral incisor despite correct bracket placement. Also note
that brackets (instead of bands) can be bonded on the
molar teeth when no headgear is to be used.
I
120 Part D Orthodofllic /If('('hanOlilcrapy
References
02.6
Figure 02.6 An orthodonti c band. Note the triple tubes. The
upper one is for insertion of auxiliary wires (used in some
techniques); the middle one receives the main archwire; the
lower and bigger one receives the inner bow of a headgear.
On the lingual side, the sheath receives the TPA or TeA
appliances (see further),
J. Graber LW: Orthodonlics- Slale of Ihe Art. Eswnce of Ihe Science. 51. Louis. MO: C.V. Mosby Co ..
1986.
2. Graber TM. and Swain BF: Orthodonlics-Currefll Principles and Tedniqlles. 51. Louis, MO: c.v.
Mosby Co . 1985.
3. Andrews LF: Siraight Wire-Concept and Appliances. San Diego: L.A. Wells Co., 1989.
4. Mclaughlin RP, and Bennet TC: The transition from siandard edgewise 10 preadjusled appliance
systems. J Oin Ortbod 23: 142 - I 53. 1989.
Es
R",<
ell
Esthetic Brackets
Recent advances in the field of esthetic fixed appliances have resulted in the development of
fixed appliances made of polycrystalline or si ngle-crystal aluminum oxide (99.5%),
call ed ceramic brackets
l
-
24
(Figs. 0 3. 1 and 0 3.2). The most apparent difference
between polycrystalline and singJe-crystal brackets is iOl. their opti cal clarity, ' Polycrys-
talline brackets tcnd to be more translucent, I whereas both si ngle-crystal and polycrys-
talline appliances resist staining and discoloration,' Almost all of the currentl y avail-
able ceramic brackets arc made of polycrystalline mat'!rial.' - 11 The physical properties
of aluminum oxide that interest the practicing clinician arc tensile strengt h, fracture
toughness, material hardness, and friction.1,4-8,20
The tensile strength of ceramics is not a si mple bulk material property, as it is for
stainless steel;2,I, it is very dependent on the condition of the surface of the ceramic. A
shallow scratch on the surface of a will drasti cally reduce the load required for
fracture, whereas the same scratch on a metal surface will have little, if any, effect on
fracture under load.
2
,u In addition, the elongation for stainless steel is approximately
20% when it finally fail s, 2 The elongation for the ceramic at failure is less than 1%,
making these appliances more brittle
2
(Fig. D3.3).
The fracture toughness of material is the total energy loading required to cause its
failure.
2
The fracture toughness values for ceramics are 20 to 40 times lower than
those of stainless steel. It is, therefore, much easier to fracture a ceramic bracket than a
metal one.
Thus, it is important for the orthodontist to inspect ceramic brackets for cracks at
each patient visit.
2
Care should be taken during treatment not to scratch bracket
surfaces with the instruments or overstress when ligating or activating a wire.
2
,1 The
patient should be cautioned against chewing on hard substances.' Pieces of bracket
could be ingested or inhaled inadvertentl y if the fracture occurs in the mouth during
function.' The problem of bracket fracture may also occur when placing or removing
rectangular archwires, which almost completely fill the slot.' Placement of additional
torque in the archwires may cause either ti e-wing or slot microfractures on insertion.
'
The fracture resistance of the ceramic brackets appears to be adequate for clinical use
in the range of 8 to 10 degrees of
In ge neral, ceramic brackets produce more friction than metal brackets. In reference
to the presence of fricti on between the ceramic bracket and the archwires, one study
emphasized that it decreases wit h increased archwire sizes
lO
because light wires are
pressed not onl y against the edges of the bracket but along the anterior slot as well. A
more recent studyl l showed that there is a decreased rate of tooth movement with
ceramic brackets that ranges from 30% to 50% when compared to metal brackets, and
that the amount of tooth movement decreased with an increase in wire size. In
general, slot surfaces and edges of the ceramic brackets were more porous and rougher
than those of the metal brackct,21 and wire surfaces are obviously scratched by the
ceramic bmckets, whereas only sli ght scratches are observed on the wires uscd with
metal brackets.
122 J>lIIrt D Or/hodonric Mt>chanOlht7apy
Figures 03.1 and 03.2 Cernmi c brackets offer patients an
esthetic smile while undergoing onhodonti c treatment.
03.2
Figure 03.3 A fractured, si ngle-crystal ceramic bracket (Star.
fire, "A" Company, CA), caused by the brittle nature of the
material. (Reproduced from Viazis AD, Cavanaugh G, and
Bevis RR: Bond strengt h of cerami c brackets under shear
stress: An in vitro report. Am J Onhod Dentofacial Orthop
98:2 14- 221, 1990. With permission of Mosby-Year Book,
Inc.)
FlgU"
Ing 3 1
with
like s
"'".
duceo
surfa!
cial c
518,
Chapter 3 Esthetic Brackets 123
As a result of this, effi ciency of tooth movement is significantly reduced by ceramic
brackets when compared to metal brackets. Refinement of ceramic brackets, slot
edges, and surfaces in particular should one day produce more efficient and desi red
tooth movement. Stai nless steel is the smoothest wire, followed by Sentall oy (GAC).24
At present, these wires are the most suitable for use with ceramic brackets in sliding
mechanics.
A very important physical property of ceramic brackets is the extremely hi gh
hardness values of aluminum oxide.' The hardness of ceramic brackets is almost nine
times that of stainless steel brackets or enamel.
M
Serious consideration should be
given to the possibility of enamel contact with an opposing ceramic bracket and the
detrimental effects it may have on the integrity ofthe enamep6
Ceramic brackets cause significantly greater enamel abrasion than stai nless steel
brackets
6
(Figs. D3.4 and D3.5). We should realize that the constrai nts faced by
prosthodontists in not opposing natural enamel with porcelain appl y equall y to the
field of orthodontics.' It would be rat her simple to state that as long as the brackets
are kept out of occl usion, this undesirable side effect is not to be expected.' Unfortu-
nately, during the course of orthodontic treatment one cannot be sure of avoiding this
problem, especiall y in extraction cases in which tooth retraction is initiated.'
03.4
FIgures 03.4 and D3.5 Scanning electron micrographs show-
iog abrasion of a bicuspid cusp tip before and after contact
.'im an opposing ceramic brackct. Notc the cat scratch-
lite surface. Half of the abraded area has been delaminated,
revealing the intact enamel prisms underneath. ( Repro-
duced from Viazis AD, Delong R, Bevis RR, ct al: Enamel
surface abrasion from ceramic onhodontic brackets: A spe-
rial case rcpon. Am J Onhod Dentofacial Onhop 96:5 14-
518,1989. With permission of Mosby-Ycar Book, Inc.)
03.5
124 Part D Or,hodomic MechanOlherapy
Avoid placing ceramic brackets in deep-bite cases.
5
Ceramic brackets used on the
mandibular tccth should be kept out of occlusion at all times during treatment.5.6
Routine check of this matter is advised at every visit.5.6 Crossbites should first be
correeted before the application of ceramic brackets.) Use of ceramic brackets on the
anterior maxillary teeth is possibly the best way to benefit from the esthetics of
porcelain while avoiding potentially deleterious enamel wear of occluding teeth.j It is
not an exaggeration to correlate this type of abrasion to a saw blade applied against a
hard surface area.
j
Severe enamel abrasion from ceramic brackets might occur during
a si ngl e meal, sometimes within a few seconds.'' Qinicall y, damage occurs immedi.
ately on tooth contact with these appliances.!!" (Figs. 03.6 and 03.7). Enamel wear
may occur from metal appliances as well, but this would be gradual (weeks or
months) and not as aggressive.' The use of elastomeric rings with covers for the
occl usal pan of the ceramic brackets may be a way to avoid this problem.
According to the literature, the incidence of enamel damage on debonding of
ceramic brackets ranges from 0% to 40% for clinically sound teeth and is as high as
50% for compromised teeth (enamel cracks, endodontic therapy, large restorations).7.8
The incidence of bracket failure on debonding is in the range of 6% to 80%.1.8 The
design of the bracket, more specifically of the tie wing itself, affects the performance
of the bracket during debonding.7 The j uncti on between the bracket body and the tie
wing is relatively narrow and reduces the bulk of ceramic material supponing the tic
Figure D3.6 Contact or a lower ccmmic appl iance with an
opposing tooth. (Reproduced rrom Viazis AD, Delong R.
Bevis RR. et al: Enamel abrasion rrom ceramic orthodontic
brackets under an artificial oral environment. Am J Orthod
Dcntoracial Ort hop 98: 1 0] - 109. 1990. With pcnnission or
Mosby Year Book. Inc.)
03.7
Figure D3.7 Dramatic damage done to the opposing toot h in
Figure D3.6 within seconds after contact with the ceramic
appli ance. ( Reproduced rrom Viazis AD, Delong R, Bevis,
RR, et al: Enamel abrasion from ceramic orthodontic
brackets under an artificial oral environment. Am J Orthod
Dcntofacial Orthop 98:10]-109,1990. With pcnnission of
MosbyYear Book, Inc.)
Figure
upon I
the re:
Allure:
bracke.
Ch.pler 3 ESlheric Brackets 125
wing extension.
1
Absence of adequate bulk, in addition to crack propagation, is
contributory to bracket failure at the site of application of the debonding force.
1
The mean shear bond strength of the silane chemical bond provided by some
ceramic brackets is significantl y higher than the mean shear bond strength of the
grooved mechanical bond of vari ous other ccramic appliances and the foil mesh base
of the stainless steel brackets.'
Mechanical bonds, that is, metal foil mesh and grooved-base ceramic bracket bases,
under shear stress fai l primarily within the adhesive itsclf8 (Fig .. 03.8). This is called
brittle failure of the adhesive from locali zed stress areas due to the bracket base
design.' Chemical bonds, provided by silane-treated ceramic bracket bases, fail mostl y
at the adhesive- bracket interface.' This is defined as pure adhesive failure caused by
wider stress distribution over the whole interface.'
The maximum value of shear bond strength reported in the literature exceeded
100 lb of force.' This occurred with the first-generation Transcend (Unitek/ 3M)
bracket, which is no longer available and has been withdrawn from circulation
B

I
" .
17
(Figs. 0 3.9 and 03. 10). The high bond attributed to this bracket was due to a
combinati on of micromechanical and chemical adhesion that was provided by the
coupling effect of the silane layer of the bracket baSt!. giving it a shiny, smooth surface
area that increased the stress distribution during debonding.11
It must be noted that the new bracket base of the Transcend 2000 (Unitek/3M)
appears to be much "safer" when compared to the original Transcend. L1 No tooth
failures were noted in a study wi th the Transcend 2000Y Both Fascination (Denta-
raum, Germany) and the origi nal Transcend caused enamel failure in the same study,
which is in accordance with the findings of previ ous investigati ons.
B
,I ... 17 The new
Agure D3.11 Mechanical bonds fail safely within t he adhesive
upon debonding. This is a scanning electron mi crograph or
the residual adhesive on the tooth after dcbonding or an
Allure (GAC) ceramic bracket. Note the imprints or Ihe
bracket base.
126 Part D Orthodontic Mechanotherapy
Figure D3.9 First-generation Transcend (Unitek/3M) ce-
ramic bracket bonded onto a bicuspid toot h. (Reproduced
from Viazis AD, Cavanaugh G, and Bevis RR: Bond
strength of ceramic brackets under shear st ress: an in vitro
report . Am J Orthod Dentofacial Orthop 98:214-221,
1990. With permission of Mosby-Year Book, Inc.)
Figure D3.10 Tooth failure upon debonding of the bracket
shown in Figure D3.9. Debonding force levels of these
brackets exceeded 100 lb. These appliances have been with
drawn from the market. (Reproduced from Viazis AD, Ca
vanaugh G, and Bevis RR: Bond strength of ceramic
brackets under shear stress: an in vitro report. Am J
Orthod Dentofacial Orthop 98: 21 4- 221, 1990. With per
mission of Mosby-Year Book, Inc.)
generation of the Starfire brackets also appeared to have been improved.17 There were
less cohesive bracket failures than previously reported.I.
I
...
11
The Allure (GAC) brackets demonstrate safe debonding.11 Their bond strength
appears to be strong enough to bond to the enamel throughout the length of treat-
ment without compromising the integrity of the tooth on debonding
8
(Fig. 03.8). As
supported by various studies,8.9 the Allure bracket is the ceramic bracket system of
choice for both predictability and bond strength. For those cl inicians still usi ng the
original Transcend or the Fascination brackets, a more fl exible, lower, fil led adhesive
may be the answer to lower bond strength and prevention of enamel fractuTCS.
17
In the event that part of a bracket remains on the tooth on debonding, a high-
speed diamond handpiece with ample water spray may be used to take the residual
ceramic material Off.
7
.
1
' Sensi tivity of the tooth may develop if the pulp is irritated by
this procedure.
7
The need for relatively strong forces to obtain bond failure may result in various
degrees of patient discomfort.' In the clinical setting, such a force would be transmit-
ted 10 teeth that are often mobile and sometimes sensitive to pressure at the end of
the active phase of orthodontic treatment.' To minimize such an episode, the teeth
should be well supported during bracket removaL7 It has been suggested that the
orthodonti st have the patients bite firml y into a cotton roll to help stabilize these
sensitive and relatively mobile teeth.7
It needs to be pointed out to the clinician that the likelihood of bracket failure can
be minimized if the debonding instrument is full y seated to the base of the bracket
and to the tooth surface
'
(Fig. 0 3.11). This firm scating allows the forces used for
bracket removal to be transmitted through the strongest and bulkiest part of the
bracket; namely, the bracket base. Failure to adhere to this requirement as a result of
hastiness by the clinician or the presence of large amount of composite flash on the
surface of the tooth and around the bracket periphery could result in a greater
incidence of bracket failure.' Because bracket failure is usuall y quick and sudden, it
could result in inj ury to the pericoronal soft ti ssue, the oral mucosa., the tooth, or the
clinician if debracketing is performed carelessly.
7
en.pler 3 ESlhel;c IJrackels 127
Figure 03.11 Special instruments are recommended by
various manufacturers to debond ceramic appliances. This
instf1lment, by Unit ek/3M, should be fully and finnly
scated before the debonding force is applied.
Whole or fractured bracket particles can become dislodged into the field of opera-
tion and ingested or aspirated by the patient, creating a signi ficant medical emer-
gency.' Furthermore, the fl ying bracket panicles subject both the patient and the
clinician to possible eye injury if protecti ve eyewear is not avai lable or not worn by
both individuals.
7
If the pliers designed for removal of brackets have a protective
sheath that covers the working end of the instrument, the probability that bracket
fragments will become dislodged in the patient's mouth or in the field of operation is
decreased. The plier blades progressively lose their sharpness because of the interac-
tion between the stainless stccl blade and the much harder and more abrasive ceramic
materi al. As the plier blades become dull, debonding effi ciency is reduced.
It has been advocated that techniques used during debonding of conventional
stainless steel brackets may be inappropriate for removal of ceramic brackets. Alter-
nati ve debonding, such as ultrasonic and electrothermal debracketing, techniques that
minimize the potential for bracket failure as well as the trauma to the enamel surface
during debonding, have been investigated. These may be more time consuming, and
the likelihood of pulpal damage needs to be thoroughl y investi gated. Prototype de-
bracketing instruments are, at present, undergoing clinical trials.
A lot of the aforementioned problems will be avoided if the orthodontist performs
a very careful cl inical examination of the patient, with particular attenti on to com-
promised teeth, goes over a thorough informed consent and treatment agreement with
the patient, emphasizes to the patient the advantages and disadvantages of ceramic
brackets, adheres to the manufacturer's instructions, and is kept up to date with the
information that becomes available in the literature.
References
I. Swanz ML: Ceramic brackets. J Oin Orthod 22:82-88, \988.
2. Scott GE: Fracture toughness and surface cracks- The key to understanding ceramic brackets.. A n g l ~
Orthod l:3- g, 1988.
3. Odegaard T, and Segnes D: Shear bond strength of metal brackets compared with a ncw ceramic
bracket. Am J Orthod Dcntofacial Orthop 94:201-206, 1988.
4. Gwinnelt AJ: It. comparison of shear bond strengths of metal and ceramic brackets. Am J Orthod
Dentofacial Or1hop 93:346-348, 1988.
128 Part D Orthodon/ic /I!('chuIIQln.erapy
5. Viazis AD. Delong R. Beri! RR. Douglas WHo and Speidel TM: Enamel surface abrasi on from
ceramic onhodonti e brackets: A special case repon. Am 1 Onhod Denlofaeial Onhop
1989.
6. Viazis AD. Delong R. Scris RR, Rudney TD. and Pintado MR: Enamel abrasion from ceramic
onhodontic brackets under an artificial oral environment. Am J Onhod Dentofacial Orthop
109. 1990.
7. Bisl\ara SE. and Trulove TS: Comparison of different debonding techniques for ctramic brackets: An in
vitro study. Am 1 Orthod Dentofacial Orthop 1990.
8. Vinis AD. Ca\l3naugh G. and Beris RR: Bond strength of ceramic brackets under shear stress: An in
vi tro repon. Am J Orthod Dentofacial Orthop 1990.
9. Britton JC, Mcinnes p. Wei nberg R, Ledoux WR. and Relief DH: Sh.ear bond strength of ceramic
orthodontic brackets to eDamel. Am 1 Orthod Dentofacial Ortbop 353, 1990.
10. Angol kar PV, KapiJa S. Duncanson MG, aDd Nanda RS: Evaluat ion of friction between ceramic
brackets and orthodontic wires offour alloys. Am J Onhod Dentofacial Onhop 1990.
[I. Kusy RP. and Whitley 1Q: Coeffi cients of friction for arch wires in stainless steel and polycrystalline
alumina bracket slots. Pan I: The dry state. Am J Onhod Denlofacial Onhop 312, 1990.
12. Pratten DH. Popli K. Gennane N. and Gunsollcy JC: Frictional resistance of ceramic and stainless
steel onhodontic brackets. Am J Onhod Dentofaeial Onhop 1990.
13. Harris AMP. Joseph VP, and Rossoun E: Comparison of shear bond strength of onhodonti c resins 10
cerami c and metal brackets. J ain Onhod 24:725 728. [990.
14. Eliades T. Viazis AD, and Eliades G: Bonding of ceramic brackets 10 enamel : Morphological and
struct ural considerations. Am J Orthod Dentofacial Orthop 1991.
[5. Viazi s AD: Direct bonding in orthodontics. Journal of Pedodont ics J: I [986.
16. Gwinnelt A1: A comparison of shear bond of metal and cerami c bnlckets. Am J Onhod
Dentofacial Orthop 1988.
17. Eliades T. Viazis AD, and Lekka M: Fail ure mode analysis of cerami c brackets bonded to enameL Am
J Onhod Dentofacial Onhop (in press)
18. Vukovich ME. Wood DP, and Daley TO: Heat generated by grinding duri ng removal of cerami c
brackets. Am J Orthod Dentofacial Orthop 199 I.
19. Holt MH. Nanda RS, and Duncanson MG. Jr.: Fracture resistance of ceramic brackets during arch
wiTt torsion. Am J Onhod Dentofacial Onhop 99:287 1991.
20. Bednar JR, Gruendemau GW, and Sandrik JL: A comparati ve study of frictional forces between
orthodontic braekets and :uchwires. Am J Orthod Dentofaeial Onhop [(1):5 1991.
21. Tanne K. Matsubara S. Shibaguehi T. and Sakuda M: Wire rriction from ceramic braekets during
simulated canine retraction. Angle Orthod 1991.
22. American Association of Orthodontists: Ceramic braeket survey, memorandum to members. Apri l 7.
1989.
23. American Associat ion of Orthodontists: Ceramic bracket survey results update, memorandum to memo
bers. December 1989.
24. Prososki RR. Bagby MD, and Erickson LC: Static frictional rorce and surface roughne:ss of nickel
ti tanium arch wires. Am J Onhod Dentofacial Onhop 100;34 1991.
Dil
Ad
Sine:
Direct Bonding of Brackets/
Adhesive Systems
ella
Since the introduction of the acid-etching technique by Buonocore, l.2 whi ch enhanced the
adhesion of resi ns to enamel, rapid developments have led to the concept of direct
bonding in orthodontics, where attachments are directl y bonded to the enamel
surface}- II Naturall y, the effectiveness of the bonded appliances in transferring the
desired forces to the tccth is dependent on the bond strength to the tooth. This can be
accomplished by an adhesive system that will bond the brackets directly to the tooth
surface and maintain them throughout the duration of treatment (Figs. 04. 1 through
04.20).
Orthodontic resins must ideally have adequate strength, be able to rond to both
ceramic and metal brackets, remain stain-free and thus be estheticall y pleasing, have
variable setting times for multiple uses, and possess adequate hardness to facilitate
debonding.) They are divided into two systems: the ultraviolet (UV)- and seJf-cured
systems.)
The UV curing systems rely on externally supplied, long-wavelength, UV radiation
to produce a free-radical-liberating compound, such as benzoin methylether, in the
resin.)'" They are one-component systems and therefore are easier to usc; the most
important advantage is that of unlimited working time. In general, there is no statistic-
ally significant difference between the mean shear bond strength of light-cured and
chemicall y cured adhesives (two pastes or no mix).! The fact that visible, light-cured
resins are being used successfull y would seem to indicate that, although their in vitro
shear bond strength is clinicall y less than that of the chemicall y cured resi n, visible,
light-cured resins can be used clinicall y with good results.'
Both li ghtl y filled a nd heavily filled resins predispose to plaque formation without
significant Qualitative differences betwccn them.) There is a trend toward an increased
bond strength with increased fill er concentration.
6
The removal of hi ghly filled com-
posite cements on average causes more loss of enamel than removal of an unfilled
adhesive.1O A lower filler content decreases the abrasive resistance and simplifies pol-
ishing and finishing of the enamel surface after debonding.
Recently, glass ionomer cements were introduced in clinical orthodontics (Figs.
04.21 through 04.26). A great advantage of glass ionomer cements is their ability to
act as reservoirs of fluoride ions, thus reducing the possibility of decalcification.II- 2"
Auoride ions are released in the immediate vici nit y of the cement soon after place-
ment, and this ion release continues at signifi cant levels for at least 12 months.
Glass ionomer cements were found to adhere without etching; simple prophylaxis
and drying of the enamel produced the strongest bond. Etching actually reduced bond
strength, because glass ionomers form a direct chemical bond with the enamel, unlike
the mechanical bond of composi te resins. They also bond relatively better to the
bracket than to the enamel; fractures tended to be cohesive fai lures, within the cement
itself. The clinical implication is that little cement will be left on the toot h after
debonding.
130 Pari D Orthodontic MechanOlh"Tapy
... I'
~ "
,
Figure 04.1 After isolalion with cheek retractors (for both
arches) or cotton roll s (for single-tooth procedures), the
teeth are pumiced and adequately rinsed, followed by acid
etching with a disposable brush for 15 seconds.
04.3
Figure 04.3 Most adhesives come with two parts: a liquid
form and a paste form.
04.2
Figure 04.2 Thorough rinsing and drying are absolutely nec-
essary in order to obtain the chalky-white etched tooth
surface that allows for a good bond. At this point, the tooth
is ready to receive the bracket.
Figure 04.4 The liquid part is applied onto the tooth surfact
with a brush by the clinician.
Figur,
chair
04.7
Figure
long E
edge.
"'.5
Figure 04.5 The paste is pl aced onto the bracket base by the
chairside assistant.
Rgur. 04.7 The cl inician then ali gns tbe bracket along the
long axis of the tooth at a specific distance from the incisal
""'.
Chapl,,4 Direcl Bonding 0/ BracketsjAdht's;I'e Systems 131
Figure 04.8 The bracket is then placed on the center of the
tool h with a special holding plier or even a pair of cotton
pliers.
Figure D4.8 This is more easily done for the twi n and del-
toid brackets wit h the perio probe. due \0 the convenient
shape of these appl iances.
132 1" r1 1) Orthodontic Ml'ChunOlhaapy
Figure 04.9 At t he end. as a fi nal check, the bracket is
checked wit h a mouth mirror to ensure that it is aligned
properly.
Figures 04.11 through 04.15 The placement of the ciastO-
meric modules ("0" rings) over the bracket is done wi th a
hemostat. The module is hooked around one wing and
then. with the "baseball home-run" twisting motion. all
four rings of the twin bracket arc engaged.
Figure 04.10 Wire placement is done intraoratly with the
Howe pliers which allow a finn grip of the wire and easy
placement in the molar tubes and the bracket slots.
Cbapltr 4 DirI'C1 Bonding of BrackelSj Adhesire S}'SlemS 133
04.13 04.14
134 Part D Orthodomic MrxhulI()/herapJ'
Figures 04.16 and 04.17 For the hook-up of the elastic
chai ns, the procedure is quite similar: on insertion of one
of the loops.. the chain is stretched and the rest is tied in a
simi lar manner.
Figure 04,18 To secure the archwire in the bracket slot
tightly, a ligature wire-tie is used. It is placed beneath ftrst
the mesial wi ngs of the bracket and then the di stal ones
whi le sliding along the main archwire. At this point, the
two legs are crossed over, twisted by hand a few times, and
then securely tightened with a hemostat. The excess ligature
is cut off and the remaining J- mm twi sted pan is placed
beneath the main arch wire.
Figure D4.19 When removal of a ligature wire-tie is desired,
a ligature-cutter pli er may be used to cut the wire and,
without letting go of it, the ligature ti e is removed with the
same plicr.
Figurel
placen
moveo
Figurel
9O-<l"
01.20
F'l9IIre 04.20 Colored jigs aid the practitioner in the correct
plactment of the ceramic appliances. These jigs are re-
mo\"t(j after the adhesive has scI.
Flgurt 04.22 The separator IS held by two hemostats at a
~ a n g l e .
Chapler 4 Dim:l lJonding of Brackf'{sjAd}lI'si l'e SYS/ l'n!S 135
Figure 04.21 One week before band fitting and cementing,
separators are placed around the teeth thai are 10 be banded.
Figure 04.23 The separator is stretched and then inserted
between the teeth. Its thin. stretched secti on (the lower.
panly white area) can easily slide through the tooth contacts.
136 Part D Orthodofllic lIfocholWlheropy
04.24
Figure 04.24 The band's triple tubt.'S are waxed so that ad-
hesive will not enter the tubes.
04.25
Figure 04.25 A glass ionomer cement is used to bond leeth
because the bond is stronger than that of zinc phosphate
cements, especially if headgear is used al some point during
treatment.
Figure 04.26 Regardless of the bmcket type used, brackets
should all be placed in the middle of each tooth, at the
same distances (x) from the incisal edge, with the exceptioo
of the cuspids. which should be I mm more gingivally
(x + I mm), and molar teeth, which should be I mm mOlt
occlusally (x - I rnm). This bracket placement ensures cus-
pid guidance at the end of treatment and minimizes 1M
extrusion of the molar teeth, whi ch may otherwise lead to
int erferences.

Chapter of Direct 80ndirlg of 8rack('lsj ArihNII't System! 137
In a recent study. it was found that a glass ionomer cement, Ketae-Cem (Espe.
Fabrik Pharmazulischer Preparate GMBH & Co., Germany), had a 12.4% failure rate
when it was used to bond brackets on teeth or 40 consecut ive patients. II More recent
investigations showed that convent ional composite adhesives leave a considerably
higher bond strength than glass ionomer cements.
IH
' It is recommended that if glass
ionomer cements arc used for bonding of orthodontic brackets, the archwires not be
placed until the next day, in order to have sufficient cli nical strength. I I In a recent
study,2' it was concluded that the mean shear bond strength of fluoride
releasing glass ionomer is higher tha n that of the chemicall y cured ionomer.
A problem that may arise during treatment with directtxmded appliances is corro-
sion. Corrosion appears as black and green stains around the corner or the brackets,
some of which permanently mark the enamel, cspecially on anterior teeth. I' It is
primarily caused by the percolation of the salivary fluids, which are rich in electro-
lytes, at the junction of the resin-enamel or resin- mesh interface for a long period.
16
Contributory factors may be corrosion susceptibility of the alloy, the effcct of welding
or brazing on the structure, and galvanic action arising from contact wi th other alloys
in the mouth.
16
It is advisable that the clinician re move the affected bracket and
rcbond.
I
'
Visible. light-activated, fluoridereleasing orthodontic bondi ng systems are capable
of adequatel y retaining brackets while aiding in the prevention of decalcifi cati on
around bonded appliances. I' Such bonding systems were found to provide bracket
retention ratcs similar to those of conventional ort hodontic bondi ng systems. II Acid
etching the enamel before fluoride application increases fluoride uptake.
19
This type of
post-etch fluoride treatment docs not alter bond strength.
20
Use of fluoride-exchanging
adhesive resulted in a reduction of early demineralization.
21
Findings indicate that the
application of either 2% or 4% sodium fluoride (NaF) in a diluted orthophosphoric
acid ( H)PO,,) soluti on docs not significantly influence the tensile bond strength of the
adhesive material to the enamel surface.
ll
Equal susceptibility to white spot formation
has been reported whether teeth are banded or bondcd.
H
Auoride-releasi ng base liners
are not acceptable as orthodontic adhesives, but they may be placed around already-
bonded brackets.
25
It should be noted that an allergic reaction to the ni ckel clement of the metal
brackets has been reported.17 It seems that there is a high initial release of metals but
that the effect diminishes with time. There are fewer symptoms associated wi th oral
exposure to nickel. Inter-individual differences must be considered.
In reference to bonding to gold teeth, roughing the surface before bonding is
necessary to provide a successful bond. Acid etching should then be used to provide a
clean gold surface and should be followed by bonding with highly filled resi ns.26
The tcchnique used to bond orthodontic brackets to porcelain relies on a hydro-
lyzed silane coupling agent. If a non hydrolyzed silane agent is used (Ormco porcelain
primer, Onnco, CAl, it needs to be appli(.'(j onto the tooth without removal of the
acid etchant. The phosphoric acid etchant acti vates the silane and hydrolyzes it. The
process of hydrolyzi ng activates the silane and prepares il for chemical interaction
with the porcelain surface. A second layer or nonhydrolyzed silane should follow.
After a thorough rinse and air dry, the adhesive resi n may be applied. When a
hydrolyzed si lane is used (Scotch prime, Unitek/3M), it should be applied onl y once
for 2 minutes without acid etching and dried with warm air. To remove the brackets
during debonding, a tensile pull with a " pinching and peeling" force should be
applied.
26
The porcelain should not be touched with the fmishing bur (No. FG 7909.
Teledyne Denseo Co.) that removes the residual composite from the tooth.26 Insta-
Glaze (Taub Products and Fusion Co.) can be used to polish the porcelain surface at
the end of the procedure.
16
Various adhesive systems currentl y exist in the market that allow for clinicall y
successful bonds to porcelain teeth: System I (Ormco) with porcelain bonding primer,
Enamelite 500 enamel cooti ng/porcelain repair (lee Phannaceutical), lsopast with
Si lanit contact-resi n (Vivadent). and Concise with Scotchprime (Unitek/ 3M). Gener
138 hrt I) Orthodontic MfYhaIlOlht>rap,'
ally speaking. t!cbonding and clean up with scalers and pliers create surface defects
such as craters. pits. and porcelain fracture as the resin is removed. Diamond polish-
ing paste is better in restoring the surface than are polishing stones. Irreversible
damage to porcelain may also occur. Because the bond strengths to glazed and
deglazed porcelain are not significantly different, it may be desirable to bond to glazed
porcelain to minimize surface damage.
ll
Roughening of porcelain with silane treat-
ment allows for clinically acceptable bond strengths of orthodonti c brackets to porce-
lain.2I Roughened surfaces and surfaces with microfracturcs can be satisfactorily fin-
ished and polished with either a series of gr.lded ceramist's 'points (Shofu Dental Co.)
or a diamond-impregnated polishing wheel ( Meissi nger, Jan Dental Co.), followed by
a diamond poli shing paste (Vident).29
References
I. BuonOCOf'e MG: A si mple: method of ilM;reasing the :tdhesion of acrylic filling matcrials to cnamel
surfaCC$. J Dent Res 34:849- 853, 1955.
2. Viazis AD: Direct bonding of onhodontic brackcts. J Pedodontics II:], 1986.
3. Maijer R: Ihmdinx S),$/('m$ in Biocfm!ptJlibifil), oJ DenIal Materials. Vol . II. Boca Raton.
FL: CRe Press. 1982, pp. 3:51- 76.
4. Lee: HI.. Orlowski JA, and Rocm; BJ : A comparison of ultr.aviokt-curing and sclf-<,uring poIymmi in
preventive, restorative and orthodontic dentistry. Int Dent J 26: 134-1 S 1. 1976.
5. Gwinnrt AJ, and Ccen RF: Plaque distribution on bonded brackeu. A scanning microsoope study. Am
J Onhod 75:667 - 678, 1979.
6. Ostenag AJ. Ohuru VB, Ferguson OJ, and Mcyer RA: Shear, torsional, and tensile bond strengths of
ceramic brockelS using three adhcsive filler concentrations. Am J Onhod Dcntofa.cial Onhop 100:25 ] -
258,1991.
7. Dtlpon A, and Grobler SR: A laboratory cval uation of the tensile bond strength of some orthodontic
bonding resins to enamel. Am J Onhod Dentofocial Onhop 93:137, 1988.
8. Viazis AD. Cava.naugh G, and Beris R: Bond strength of ceramic brackelS under shear stress: An
in-vitro repon. Am J Onhod Dtntofacial Orthop 98:214, 1990.
9. Greenlaw R, Way DC. and Galil KA: An in vitro evaluation of a visi ble light-<,urtd min as an alter-
native to conventional resin bonding resins. Am J Onhod Dcntofacial Onhop 96:214 - 220. 1989.
10. Brown CR. and Way DC; Enamel loss during orthodontic bonding and subsequent loss duri", removal
of lilled and unfilled adhesives. Am J Onhod 74:663 - 671 . 1978.
II. Cook PA: Direct bonding .... ith glass ionomer cement. JOin Orthod 24:509-5 II. 1990.
12. Rtzk-lq,a F, Opard B, and Arends J : An in-vivo study on the: merits of two glass ionomeB (or the
cementation of onhodootic bands. Am J Onhod Dentofacial Onhop 99: 162-167. 1991 .
13. Rtzk-Lega F, and ()pard B: Tensile bond force of glass ionomcr cements in dirtCt bonding of
onhodontic braekelS: An in vitro comparative study. Am J Onhod Dcntofacial prthop 100:357 - 361,
1991.
14. Bishara SE, Swift FJ. and Chan DCN: Evaluation of Ouoridc rclca5C from an onhodontic bonding
systcm. Am J Onhod Dtntofaci:al Onhop ]00: 106 - 109, 1991.
15. Gwinnet AJ: Corrosion of resin-bonded onhodontic brackets. Am J Onhod 82:441 - 446, 1982.
16. Maijer R. and Smith OC; Corrosion of onhodontic bracket bases. Am J Onhod 80:43 - 48. 1982.
17. Gjerdrt NR, Erichsen ES, Remlo HE, and Evjen G: Nickel and iron in saliva of patients with lixed
appliaDCts. Acta Odontol Stand 49:73- 78, 1991.
18. Sonis AL, and Snell W: An eval uation of a Ouoride releasi ng visible lightactivated bonding system for
orthodontic bracket placement. Am J Onhod Dcntofocial Onhop 95:306, 1989.
19. Kajandtr KC. Uhland R. Ophang RH. and Sather AH: Topical Ouoridt in onhodont)c bonding. Angle
Onhod57:70-76, 1987.
20. Klocl;:owski R, Davis EL. Joynt RB. WieczkowsJci G. and McDonald A: Bond strength and durability
of glass ionolTlC' r cements used as bondi", agents in the placement of onhodontic brackets. Am J
Onhod Dentofacial Onhop 96:60 - 64, 1989.
21. Underwood ML, Rawls HR, and Zimmerman BF: Oinical evaluation ora Ouoride-e1.changing resin as
an onhodontic ad hesive. Am J Onhod Dentofacial Onhop 96:93-99, 1989.
22. Bishara SE, Chan D, and Abadir EA: The cffect on the bonding strength of onhcxlontic brdckcts of
fluoridc application afier etching. Am J Onhod Dcntofacial Onhop 95:259-260. 1989.
23. Geiger AM, Gorelick L, Gwinnrt1 AJ. and Griswold PG: The effect of a Ouoride Pl'OVolm on white
5pO( formation duri", onhodontic treat ment. Am J Onhod Dcntofaci.al Orthop 93:29 - 37, 1988.
24. Compton AM, Mcym CE, Jr., Hondrum SO, and Lorton L; Comparison of the shear bood slrengih of
a light-curtd gla ionomer and a chemically glass ionomer for use as an on hodontic bondi",
agent. Am J Onhod DenlOfacial On hop 101: 138-144. 1992.
25. McCoun JW, Cooley RL. and Barnwell S: Bond strengt h of light wire fluoride-releasing basc-liners as
orthodontic bracket adhesives. Am J Onhod Dcntofacial Onhop 100:47 -52, 1991.
26. Andreasen GF, and Stieg MA: Bonding and debooding brackets to porcelain and gold. Am J Orthod
Dcntoracial Onhop 93:34 1-345, 1988.
Chapler 4 Direct IJom/ing oj IJrackl'lSj Adh/!sil'l' Syslmu 139
27. Eustl1quio R. Garner LD. and Moore BK: Comparative tensile strengths of brackels bonded to porce-
lain with ort hodontic adhesive and porcelain repair systems. Am J Onhod J)enlofacial Onhop 94:421-
425. 1988.
28. Smit h GA, McInnes-ledoux P. Ledoux WR. and WeinbrrJ R: Onhodonlic bondmg to porcelain -
Bond strength and refinishing. Am J Onhod l)entofacial Onhop 94:245 -252. 191111.
29. Kao EC, Boltz KC, and 10hnston WM: Direct bonding of onhodonlic brackcts to porcelain v e n ~ r
laminates.. Am J Onhod I)cntofacial Ort hop 94:458-468, 1988.
ella er
Basic Orthodontic Instruments:

Wire Bending
A re'" pliers arc needed in the modem practice of orthodontics ( Fig. 0 5. 1). Here are some
basic oncs
l
.2:
The IIlrd IN ... pHer: (the most popular onhodontic plier) used to bend round wires.
Th. squ.re plier: used to bend rectangular wires.
The Howe pli ... : the clinician's " hand" in the mouth; most ly used to place the archwire in
the bracket slots.
Th. 'hr .. P"Or1I' pll.r: used to bend larger size wires; i.e., O.03D-inch round retainer wi re
and clasps.
Th. hemosf.f: used to place elastomeric modules, clasti c chains, and ligature wi res over the
bracket wings.
The wire cutter pilar: used to cut wi res outside or the mout h.
The dis'.' end' cutt., pll.r: used to cut the archwire distal to the molar tube in the mouth.
The .. aCId-sitter: faci litates the smooth fit or the molar bands around these teeth.
1M brae"" remover: is the same ror all metal appliances, but vari es depending on the
manufact urer ror the ceramic brackets.
1M band r .... o".,: has a soft end, which contacts the tooth surface, and a metal end, which
dislodges the band from its position.
Cotton p11.,s/br.c".f.lto'dlng pliers: used to place brackets onto the tooth surface.
It. 3" .... periodontal ".0111: aids in the accurate placement or the brackets onto the teeth,
Despite the e ~ i s t e n c e of modem, prcadjusted appliances, compensating bends arc
almost always needed to fini sh a case. 1.2
" In- out" or FirstOrder Bends
These are done in the horizontal plane. One should remember that we always start
with an archwire that li es flat on the rabie, and that it shoul d still li e flat after the
bend has been placed in it (Figs. 0 5.2 through 05.15). This is why "ori entation" of
the archwire is of vital importance: we should always hold the pliers ( bird beak for
round or squ.uc for rectangular wi res) perpendicular (0 and the a:rchwire parallel (0
the fl oor. This way, we arc not introducing any unnecessary bends in the wire that we
may not be able to take out later on.
" Up and Down" or " Tip" or SecondOrder Bends
These are done just like the first.o rder bends, only in the verti cal plane ( Figs. 0 5. 16
through 0 5. 19).
142 h'l D OrthodonllC MrchurlOlherapy
FIgure OS.1 Various instruments and pliers used in the
modem practice of ort hodont ics: (A) bird beak plicrs. ( /J)
square pliers. (e) three-prong pliers. (D) Howe pliers. (E)
torquing key. (,.-) torquing pliers. (G) hemostat. (1/) band
siuer. (/ ) band remover. (J) bond remover. (K) distal-end
cutter pliers. (L) win: cutter plier.
Figure OS.3 First-order bends. (A) A molar offset is placed to
move the mesiobuccal cusp of the molar slightl y more buc-
call y while at the same time smoothl y curving its distal
cusps linguall y. The latter is accomplished because the end
of the arehwire points linguall y ("toe-in"). This bend also
helps to counteract the mesiolingual rotational movement
exerted on the molar from the c1astomeric chain modules
during space closure. (B) A Cllspid offset is placed to accen-
tuat e the posi ti on of the cuspid buccally, especiall y in a
brood, full " Holl ywood" smile. (C) An inset is the opposi te
of an offset. Its purpose is to move a toot h lingually.
Figure OS.2 Archwire prefonncd to the shape of Ihe dental
arch as it is available in Ihe market.
05.4
Figure OS.4 Proper orientation during wire bending is , 'CI)'
important. Always hold the pliers perpendicular to and tilt
wire parallel to the noor. In a clinical si tuation, mark with
an indelible pencil in the patient's mouth the point whrn
to bend the wire. That is where the pliers should hold the
wire. This is usuall y toward the mesial side of a tooth. For
purposes of orientation while looking at the photogrnph, .... t
will call A the segment of the win: on the left side of th(
pliers and B the segment on the right side.
l
A
OS.5
Flgurl 05.5 To place an offset on JJ, stan by bending A out
'IIith the thumb of the other hand. (It is the fingers that do
!be win:: bending. not the pliers. The instruments are simply
used 10 hold the wire.)
A
OS.7
Figure 05.7 The molar offset bent has been created.
ellapl" 5 Basic Orthodontic I nslrumenfJ. Wlft' Bending 143
05.6
Figure 05.6 Side 8 of the wire is bent inward.
OS.8
Figure OS . To create an offset for an incisor or bicuspid (in
the middle of the arch). all one needs to do is repeat the
same procedure on the distal side of that specific tooth.
144 Ptln D OrthodlJf1tic Mrciml10fherapy
05.9
Figure 05.9 A bicuspid offset.
05.11
Flgute 05.11 The A segmenl is bent OUI. similar 10 Ihe
molar offset.
05.10
FIgure 05.10 The placement of a cuspid offset is done a
little differently. due to the smooth curve that must be
given to the archwirc. Start by holding the wire at a point
that corresponds mesial to the cuspid bracket.
05.12
FIgure 05.12 Because square pliers have been used up to
now (for bending m:1angular wires). one needs to switch to
bird beak pliers. Posilion the wire in the middle of the
prongs of the pliers. di stal 10 the point initiall y marked on
the B segment.
A
05.13
FIgure D5.13 Taking ad vant age of the roundness of the beak
of the pliers, bend t he B segment inward.
05.15
FigurtI 05.15 The cuspid offset that was crealed. The offset
should curve as smoothly as possible past the initial point
rJ contact with the plicB.
Chaptt r 5 Basic O"hodtmllC llUlrunrerllJ: Wlft Bending . 145
05. 14
Figure 05.14 The bird beak pli ers are then repositioned
slightly more distall y on the B segment: again. exert light
pressure 10 curve the wi re around the beak of the pl icn.
146 hrt 0 OrrhodOfllir
05.16
Figure 05.16 The placement of a second-order bend is done
just like the bicuspid offsets, but in the yertical plane.
Shown is the first bend. which has already been placed on
the mesial side. The square pliers are holdi ng the archwire
on the distal side of Ihe bracket (as it would appear in tile
mouth).
B
05.18
FIgure 05.18 The A segment is then bent downward.
05.17
Figure 05.17 In order to complete the sccond-order bend,
the 11 segment is bent upward.
05.19
Flgur. 05.18 The completed second-ordcr bend. Usually,
when placing such a bend, the tooth, as it is brought down,
tends to roll in (lingually) as well. Therefore, il is a good
idea \0 place a first-order bend (offset) as well to count eract
this side effect.
ChaPIH 5 Bafic Onhod<mllc '"s/rllnJNlI5 Wm' Bending 147
" Torque" or Third-Order Bends
These are a little different from the other two. In order to apply "torque," we need to
"twist" the wire so that the roots of the teeth may move either buccally or lingually
(buccal root torque and lingual root torque. respectively). There are generally three
types of "torque'" bends (Figs. 05.20 through 05.32): (a) single-tooth torque, (b)
anterior torque, and (c) posterior lorque.
The following needs to be emphasized: even if a bend is necessary to compensate
for bad bracket placement, it is much easier to reposition the brackets than to place
unnecessary bends. Without anterior archwire bends, the wire slides through the
brocket slots far more efficientl y. allowing effective use of sliding mechanics for space
closure. Although it is true that very little bending is needed during the first five
stages of treatment , finishing requires some wire bending in almost cvery casco Be-
cause the appliance prescriptions arc based on avcrages, they cannot possibly account
for all the variations of tooth size and shape. This means that detailing bends will be
needed in the fini shing wires of some patients.
FIgure 05.20 The placement of torque or third-order bends
is achieved with the help of the torquing (holding) pliers
and torquing key. The pliers hold the wire as shown.
Agur. 05.21 In order to torque (twist) the wire distal to the
holding pliers, the key is positioned next 10 the pliers, par-
allel to the pliers and the wire.
148 Part D Orthodontic
Figure 05.22 A closer view shows the relationship of these
auxi li ary instruments. If torquing one tooth only. the
torquing key would have to be placed between the two legs
of the torquing pliers.
Figure 05.24 If the archwire is of the upper arch and we
wish to place lingual root torque on the upper right poste-
rior teeth, then the key is moved inferiorly.
FIgure 05.23 Side view. Note that the pliers arc pardllel to
the fl oor.
Figure 05.25 If we now hold the posterior segment of the
archwire with the square pliers. we notice that the pliers
ha\'c moved upward posteriorly and are no longer paralkl
to the floor. When we place this archwire in the mouth and
into the bracket slots, the roots of the upper right posterior
teeth will move toward the same direction as the pl iers did,
i.e .. palatally (lingual root torque).
Fip'1 05.26 The rest of the archwire has not been affected
by the torque applied in the posterior segment. The pliers
are still parall el to the fl oor.
F9n 05.28 Placement of anterior torque, usually from lat-
eral incisor to lateral incisor but onen from cuspid to cus.-
pid. starts by gent ly bending the anterior part of the arch-

"ne.
Chapter S BasiC Orthooofll ic !rU/rume1lls: lI';r,. Bending 149
05.27
Figure 05.27 Movement of the rOOIS of the upper right p0s-
terior tt'Cth toward the buccal conical plat e (buccal rool
torque) would require the opposite twi sting activation of
the wire. Similar logi c can be applied for a mandibular wire.
Flgurl D5.2t The pliers are moved toward the midline as
the fingers of the other hand continue to gentl y bend the
wire. The same sequence is followed from the other side
toward the mi dline.
150 Part D Onnodonlir Ml'CnanOlnt.7ap),
05.30
Figure 05.30 With the help of the torquing key, any residual
torque in the posterior segments of the archwire is taken out.
Agure 05.31 As the orientation of the pliers rclati\'e to the
torqued ant eri or part of the archwire shows, upon pl ace
ment of this wire in the upper arch the roots of the anterior
teeth will move toward the palatal cort ical plate (lingual
root torque).
Figure 05.32 The posterior archwire is flat .
The wires need to be handled wit h care in the patient' s mouth (Fig. 0 5.33). In
addition, apart from the main arch wire. other auxil iary wires may be used when
needed (Fig. 0 5.34). If we need to secure the wires tightl y in the bmckel 51015, a
ligature tie is preferred to the elastomeric modules (especially for the expression of
torque) ( Fig. 0 5.35).
Figure 05.33 It is very important that the main archwire is
CUI close to the most posterior molar b..1nd with the distal
end cutler pliers. Wires that "stick" the patient's soft tissue
Cln create quite an ulceration between 3 to 4-wcek ap-
pointment periods.
Flgur. 05.35 The elastomeric modules and ligature wires
mtd to lie the wires in the bracket slots.
References
Outpt('r 5 8(Jsic OT/nodulI/l{' InS/nllllt'II/S' Win' Bt71ding 151
05.34
F'!Iur. 05.34 The transpalatal arch (TPA) is available in
different sizes and is easil y inscned in the sheaths of the
first molar bands with Howe pliers when headgear is used
(to control the position of the molar teeth in the
dimension). For crossbi te correction. an RME appliance is
preferred for more stable results.
I. Vanarsdall PL. Jr.: UprigiJring Int' ble/ined Mandihular Molar in I'rt'IJaratiOlJ jor ReslOralil'l' Tr(!QIIIJenl
Chicago: Quintessence Publishing Co., 1980.
2. Proffit WR: Contemporary Orthooot!lics. St. louis. MO: C. V. Mosby Co" 1986.
ella ler
Orthodontic Wires
There are generally 1"'0 types of orthodonti c wires: round and rectangulac
l
-
10
Even though in
the past most of these wires were made of stainless steel, the development of the
nickel-titanium (NiTi) wires has led to tbe wide range of "elastic" wires that are
available today. 1- 10
After the procedure of bonding the bracket onto the teeth has taken place, the steps
in treatment that are followed during the 12- to 24-month treatment period are
l
-
1o
:
Alignment
This is where the initial arch wire will, over a period of a few months, bring the teeth
into their correct "ali gned" position in the dental arch. This is when rotations and
crossbites are corrected.
LeVeling
This is where the curve of Spee is leveled (in most instances) and all the teeth are
brought into their normal vertical positions within the alveolus and in compari son to
the adjacent teeth.
Space Closure
This is the third step of orthodontic treatment Any remaining extraction spaces arc
closed during this phase with rectangular wires for the reasons that were discussed in
the biomechanics section of this book. The rectangular wires provide the thrce-
dimensional control of the teeth in the bone (tip/torque control), whereas elastomeric
chain modules, rubber bands, and coil springs are used to pull the teeth together and
close the spaces in the arch. One millimeter per month is, on average, the rate of
space closure.
Finishing
This is the final phase of treatment, where bends are placed in the archwi rcs to
compensate for incorrect bracket position or peculiar tooth morphology. In an 0.018-
inch slot system, a wire that completely fills the bracket slot and thus provides
maximum torque control is the 0.018 X 0.02S-inch2 rectangular wire (fi nishing wire).
Often, a 0.017 X 0.02S-inch2 or even an 0.016 X 0.022-inch2 wire is used (they are
not as stiff and are easier to insert in the bracket slot). It may be better to usc the
0.016 X 0.022-inch2 wire because it reduces the friction in the bracket slot, especiall y
if fini shing clastics are used to correct the midlines.
In the past, both alignment and leveling were done si multaneously with light,
round stainless steel wires with monthl y progression to a larger diameter wire. This
sequence in the O.OIS-inch slot system is O.OI2-inch, followed by O.014-inch, and then
O.016-inch diameter round wire (Fig. 06. 1). The objective was to start with a very
light wire, such as O.OI2-inch wire, that would have the least stiffness (stiffness is a
measure of the amount of force required to bend a wire a certain distance), so that it
154 Pllr1 0 Orthodontic Mt'ChanOlhl'fapJ'
may be fully engaged in the bracket slot without deformati on and thus start tooth
movement with the least discomfort for the patient. If even lighter force levels were
needed, braided stainl ess steel archwires were also used (Fig. 06.2). Usually, within a
month or two, the teeth would have moved toward the correct arch form and the
nClt t size wire would be inserted in the bmckets. One must remember that the stiffer
the wire. the more force it takes to place it in the bracket ; thus, the more force it will
deli ver and the more pain it will elicit. Space closure in the 0.018-inch slot system
would begin with a 0.016 X 0.0 16inch
2
rectangular stainless steel wire, followed by a
0.016 X 0.022inch
2
size wire. The fmi shing archwire would 'be a 0.016 X 0.022inch
2
wire or a 0.017 X 0.022-inch2 wire.
The amount of force needed to move tecth is very low, approltimalely 0.025 g/cm
2
,
equal to the pressure in the capillaries. Higher force levels will cause " hyalinization"
or " temporary necrosis" of the surrounding ti ssues, which will take about a 7- to
14.day period to reorganize. Pain will occur as well. The forces applied with the
stainless steel wires are always heavier than needed, thus causing a delay period of 7
to 14 days of no tooth movement.
During this lime, undermining resorption occurs (from within the bone) until it
reaches the bone surface after 7 to 14 days, at which point the bone is resorbed and
the tooth is moved abruptly. Hyalinization occurs again, and so on. This happens
even with the lightest stainless steel wires (i.e .. 0.012 inch).
The recent introduction of the "elastic" wires has changed all this. Ovcr the past
few years, the use of NiTi wires has trul y brought modern clinical orthodontics to
another level. NiTi wires may deflect as much as six-fold compared to a stainlcss steel
wire of the same size.
12
Research of the unique properties of this alloy over the past
two dccadcs.
l
-
7
along with the satisfactory results from its preliminary clinical appli-
cation, has offered new horizons for research of biomechanics and challenging chap-
ters in the practice of orthodontics. The supcrelastic NiTi wires can be displaced a
considerable distance without developing eltccssive force. In addition, they can be
reactivated (i.e.. manipulated to increase the force on a tooth after it has been
partially moved into posi tion) simply by releasing the elastomeric module holding it
in the bracket slot, allowing it to spring back to its origi nal shape (by Dulling it out of
the bracket), and then retying it.'
Figura 06.1 A round stainless steet initial archwire (0.012
inch).
Agura 06.2 A braided stainless steel initial archwire. This
wire, before the introduclion of the sur;w:retastic wires. ex
encd the lightest forces on the teeth.
Chi pier 6 Orthodontic Wires 155
The work by Andr;:ascn and co-workers
1

2
led to the development or the Nit inol
wire (Unitek). Alt hough Nitinol has an excell ent spring-back property, it does not
possess shape memory or superelasticit y because it has been ma nuractured by a
work-hardening process.' Shape memory is a phenomenon occurri ng when the alloy
is soft and readily amenable to change in shape al a low temperature but can easil y be
rerormed to its original conrlguration when it is heated to a suitable tmnsition tern-
perature.
6
The superelasti c propert y is demonstrated when the stress val ue remai ns
rairl y constant up to a certai n point or wire derormation and, as the wire derormation
rebounds. the stress value again remains fairly constant. ' Miura et al.
6
claim that
Japanese NiTi wire possesses all of the aforementioned properties and can thererore
deli ver a relati vely constant force for a long period of time, whi ch is considered a
physiologically desimble force for tooth movement. Their research rmdings and clini-
cal application of this round wire, under the trade name Scntall oy (GAC), showed
that , due to the superelasticit y of the archwire, tooth movement occurred effectively
and patients did not exhibit any discomfort because the wire deli vered a constant
force ror a long period during the deactivation of the wire.
In a more recent study,' it was found that the new superelastic NiTi recta ngular
wires, NeoScntalloy (GAC), can be used with extremely li ght force in the initial phase
or treatment. Based on their three-point bendi ng test and torque test on these wires,
Miura et al. support findings that this new NiTi all oy shows extremely light continu-
ous force. regardless or deflection, and that this superclasti c force can be appl ied at
low levels, regardless of wire size.
The rectangular NiTi wires have excellent c1inic.s! application, especially in the
early phases of orthodontic treatment; i.e .. alignment and level ing. The greatest arch-
wire flexibilit y and least patient discomfort in clinical trials appear to be provided
with the NeoSentalloy (GAe) wires ( Figs. 06.3 through 06.5). The rectangular NiTi
wires can replace all or the stainless steel round wires, as well as some or the
rectangular ones, but certainl y not the fini shing stainless steel wi res that are necessary
for fine detailing, arch coordination, and fini shing bends (Figs. 06.6 through 0 6.21).
A recommended treatment sequence with the O.OIS-inch system would be a rectan-
gular NiTi wire as initial archwire and 0.0 16 X 0.022-inchl stainless stcel as finishing
archwire. By using rectangular archwire5 from the onset of treatment, torque control
Figure 06.3 The rectangular superelastie NeoSentlllloy
(GAC) arehwi re provides the greatest archwire fl exibilit y
lvailable today, as well as control of torque from the onset
of tre:ltment.
FIgUre 06.4 The same patient as in Figure 06.3 after I
month. Note that the cuspid has almost reached the occl u-
sal plane (5 mm movement!). No patient discomfon was
expressed.
156 Part 0 Orlhoti(mlic MochollOlherop}'
06.5
Figure 06.5 A O.014 inch stai nless steel wire in a box con
figuration in a patient. This configurat ion allows for more
wire to be incorporated between the adjacent brackets;
otherwise the stainless steel wire would have been defonned
had it been activated like the superelastic wire. In compari.
son, the efficacy in treatment is quite obvious with the
NiTi wires.
06.7
06."
Figure. 06.6 through 06.9 A 12 ycar-old patient with a class
I molar occl usion, orthognathic skeletal substrate, and se
vere upper and lower crowding ( 12 mm and 10 mm, reo
spectively) requiring extraction of the upper fint and lower
second bicuspids. Note the overbite of 3 mm.
fiaure 01.10 A Sentalloy (GAC) round NiTi wire is placed
as the ini tial archwire in the maxillary arch. A O.OI 2-i nch,
round. stai nless steel wire is placed in the lower arch. Thc
upper latcral incisors and bicuspids were not incorporated
in this alignment phase in order to avoid unnecessary tip-
pin&oft hese teeth.
f9n 01.12 After I month of treatment. The cuspid tooth
has come down 3 mm. A O.OI4-inch round wire is placed
in the lower arch as the next stcp of stainl ess steel mechan-
otherapy.
Chlpt""6 Orthodontic IYjr('S 157
06.11
Figure oti .ll Anterior view. Compare the venical activation
of more than 7 mm of the Sentall oy (GAC) round wire in
the maxillary arch to the 0.5 mm of activation of the 0.0 12-
inch stai nless steel wi re in the mandibular arch.
06. t 3
Figure 06.13 Anterior wire. Note that there is a slight dia-
stema that has opened between the central incisors as these
teeth moved slightly mesially from the reaction to the cus-
pid movement.
is immediatel y obtained. This may have significant importance in posttreatment
stability. In addition, cuspid retraction can be initiated rrom the onset or treatment
(Figs. 06.22 through 06.27). By the time the cuspid teeth are in a solid class I
relationship (about S mont hs into treatment), ali gnment and leveling have been
completed and the patient is ready to receive the stai nless steel fini shing coordinated
archwires (0.0 16 X 0.022 inch), which will be the final archwires of therapy.
Finall y, depending on the type or growth pattern being treated. the clinician should
use the appropriate mechanotherapy sequence (Fig. 06.28).
158 Part 0 Orrhodofllil'
Figure 06.14 After 2 months of trealment. The initial acti -
vation of the up(X:r wire has brought the cuspids 5 mm
more occlusall y.
06.16
Figure 06.16 After J months of t reat ment. the cuspid has
reached the occlusal plane. A O.OI6-inch round wire is the
next size of stai nless stccl wire that is placed in the lower
arch.
Figure 06.15 Anterior view. Note that the diastema is clos-
ing as the cuspids are coming down and the incisors return
to their original posit ion.
06.17
Figure 06.17 Anterior view. The cuspid tccth have bttn
brought into the arch without any side effects (the overbilt
is still J mm). The diastema has almost closed. Had ttlt
two central incisor teeth been wire tied together with a
ligature ti e, the diastema would not have been created.
l
F\gIn DUe Six months into treatment. 0.016 X 0.022-
inch) stainless steel finishing wires are placed in both arches.
06.20
Flglure 08.20 Eight months into treatment. a figure-S config-
uration of ligature wire (from the left first molar to the
right one) consolidates and keeps the teeth in contact after
space closure.
Chapttr 6 OrthooOtllic "'iff'S 159
06.19
F.gUl1l 06.19 Anterior view. Elastic chai ns help in closing of
any remaining spaces in the lower arch.
06.21
Figure 06.21 Toward the end of treatment (10 months).
This case will ~ finished in less than I year. A total of two
wires were used in Ihe upper arch: the init ial $uperelastic
wire and the finishing stainless steel.
160 l'art 0 Orthodonlic Mt'(h(IlIQIherap,'
Figur. 01.22 Initiation of cuspid retraction using a rectan-
gular, superclastic NeoSentalloy (GAC) wire immediately
after bracket pl:lCcmcnt.
06.24
Figure 06.24 Five months int o treatment, the tipped teeth
have uprighted into a solid class I occlusion simpl y by
holding them tied together (with a ligature fi gure-S pattern)
as the prescripti on in the preadj usted appliance bracket sys-
tem is given the time to "worlc--Qut " in relation to the wire.
Figure 06.23 Three months into treatment. The extraction
space is closed. Space closure occurred rapidly due to the
presence of osteoclastic activi ty brought about by the ex
traction of the bi cuspid; .3Cl'% of this closure was the result
of the tipping of the teeth.
062.
Figure 06.25 This case shows a retained right primary cu
spid, moderate crowding on the same side. and spacing on
the opposite side from the previous extraction of the left
first pennanent molar. It was decided to extract the right
first molar and alleviate the crowding.
1
Dl26
f9,n 06.26 A superelast;c, rectangular NeoScntalloy (GAe)
Mit was placed and space closure was initi ated immcdi-
aid), afler bracket placement, I week aflcr the extraction of
tIIr: first molar (to take advantage of thc presence of osteo-
clastic and osteoblastic activity in the extraction side).
Within 3 months. Ihe I().mm eXIr.lcli on space had been
rtduct.d to only J mm. Also note how rapidly the right
cuspid is moving into the space provided by the extraction
mine retained primary toolh.
Open Bites
I. Placement of upper
InH:rior brackets more
lingivally
2. Banding of lower second
molars Iale in treatment if
"""'"
l. Pbn: menl of molar bands
Of brackets more occlusally
' . Pl ese. vat ion of t he curve of
Spee in the archwires
,. Use of iklI.ible rectangular
archwires (NiTrs)
6. Plattment of lingual crown
torque on the upper molars
if ncedcd
1. Use of high pull headgear
as nceded
I. Use of bonded RME
appl iances for expansion
.,,""''''
C! .28
Deep Bites
Normal placement of upper
anterior br:ackc:ts
Banding of Iowcr second
molars early in treatment
Normal placement of posterior
bands and bl"3ckeu.
Placement of revcrsC' curve of
Spec in the lower arch and
accentuated in the upper
Usc of st ilf rectangular
arch wires (stainless steel)
No additional torque
ncccsS1ry
Usc of low occipital headgear
as nceded
Usc of h)1.icnic banded RME
appliances for C1lpansion as
"""'"
Allure oe.28 Open versus deep-bite onhodont ic mechano-
therapy.
Chapter 6 OnhodOll/lr IVm'j 161
06.27
rtgure 06.21 Fi ve months into treatment . The superelastic
wire allowed for quiet space closure and easy alignment of
the cuspid tooth into the arch.
162 Part 0 OrihodOOf/c MlThanothl.'f"apy
Referenceu
I. Andrcasc:n GF. aoo Hineman TB: An evaluation of SS cobalt substituted nitinol wire for use in
orthodontics. J Am Dent Assoc 82: I ]73- 1 ] 15. 1912.
2. Andreasen GF. and Morrow RO: Labol1ltory and clinical analyses of lIitinoi wire. Am J Orthod
73:142- [5 1. 1918.
3. Lopez I. Go[dbers J. and Burstone CJ : Bending characteristics of nitino[ wire. Am J Orthod 15:569-
515. 1919.
4. Watanabe: K: Studies on new supcrelastic NiTi orthodontic wire. part I. Japanese Journal of Dental
Materials 1:41- S1. 1982. .
S. Burstooe CJ. Qin B. and Morton JY: Chinese NiTi wire - a new orthodontic alloy. Am J Orthod
81:445-452. 1985.
6. Miura F, Mosi M. Otlura Y. and Hamanaka H: The SUperelaslic property of the Japanese NiTi alloy
wi re for use in orthodontics. Am J Orthod 90: 1- to. 1986.
1. Miura F, Mogi M. and Okamoto Y: New appl ication of $uperelastic NiTi rectangular wire. J ain
Orthod 24:S44 - S48. 1990.
8. Johnson E. and Lee RS: Relative stiffness of orthodontic wires. Jain Onhod 2]:]S] - ]63. 1989.
9. Proffit WR. and White RP: Surgical-Orthodonlic Tft.'Olmeni . SI. Louis. MO: C. V. Mosby Co .. 199 1.
10. (}.Ikes C. and JE: Delcnnining physiologic arehforms. Jain Orthod 25:19- 80. 199 1.
II. Creekmore TO: The importance of intcrbruckct width in ort hodontic tooth movement . J ain Orthod
10:5]0- 534, 1916.
12. KUly RP. and Greenberg AR: Comparison of the elastic properties of nickel-titanium and beta
titanium areh wires. Am J Orthod 81: 199. 1982.
13. Proffi l WR: Contemporary Orthodoruics. SI. Louis. MO: C. V. Mosby Co .. 1986.
======: C:':.,: ' (l pt e r
Archforms
Determination of the corrcct archfonn is onc of the most important aspects of ort hodontic
trcalment.
l
,2 The archform. especiall y in the mandible, cannot be permanentl y ex-
panded by appliance therapy. The mandi bular model with all permanent teeth present
provides the best basis for construction of a correct or physiologic archform. Although
preformed arches have been made using vari ous geometri c or computer-generated
data, the fll to an individual mandibular model is highl y variable.
It is recommended that the clinician place a sheet of tracing paper over the man-
dibular cast at the onsct of treatment and mark wi th dots the most Quler point of the
buccal surfaces of all the teeth, l The points should then be connected to form the
denIal arch form of treatment for the mandibular wires. The maxillary wires should
always be coordinated with the mandibular ones (Fig. 0 7. 1); otherwise various dis--
crepancies may occur (Figs. 07.2 through 0 7.5).
In the event that there is excess buccal overjet on the right posterior dentition and
an end-to-end (no overjet) on the len si de, the upper archwire is skewed to the len
side ( Fig. 0 7.6). Occasionall y, a reverse curve of Spce is added in the lower archwire
during space closure with clastomeric chai ns (Fig. 0 7.7). In the upper arch, we can
simpl y increase the curve. This prevents the teeth from tipping lingually, but it also
tends to extrude the bicuspids and flare the anteriofS.
164 Part I) Orthodontic Mechanotherapy
07.1
Figure 07.1 Coordinated archwires must be used from the
onset of treat ment so that a normal buccoli ngual relation-
ship (transverse dimension) can be achieved from the ear-
lier stages of corrective orthodont ic mechanotherapy.
FtgUre 07.2 Patient before treatment. Note the good buccal
intercuspation oftccth.

Figure 01.3 Development of posterior open bi te from incor
rect bracket placement and arch incoordination. Same pa.
ti ent as in Figure 07.2.
OH
Agute 07.4 Patient in fixed appliances during space closure.
Ap. 07.6 Archwire "skewed" to the left.
References
Ch.apttr7 Arrhjorms . 165
07.5
Figure 07.5 Incorrect bracket placement. lack of coordina-
tion in the archwires, and lingual tipping of teeth during
space closure led to the development of thi s open-bi te situ-
ation. Same patient as in Figure 0 7.4.
Figure 07.7 Re\'erse curve of Spec in the lower archwire.
This wire configurati on is available for NiTi wires. Stainl ess
steel archwires can be bent to this shape quite easil y with
the thumb.
I. Oakes C, and Hatcher JE; Determining physiologi c archronns. J Clin Orthod 25:79- 80, 1991 .
2. Proffit WR, aod White RP: Surgical - Orthodonlic TrOOlmml. SI. Louis, MO: C. V. Mosby Co., 1991.
Chapter
Coil Springs
,
The most important characteristic of the Japanese NiTi alloy coil spri ngs is the abilit y to exert
a very long range of constant, light, continuous force over months for a single
activation.' -} The new Scntalloy (GAC) coil springs have opened new hori zons in the
treatment of anteroposteri or discrepancies,2-} i.e., the correction of a full class II
malocclusion into a class I occlusion with 4 to 7 mm of sequential distal movement of
all maxi llary tccth (Figs. 08. 1 through 08.36). It is very important to note that this
posterior movement is bodily in nature. Accordi ng to the literature,l.} the superelasti c
coil s should produce distal movement of posteri or teeth at a rate of I 10 1. 5 mm!
month. Adjunctive headgear therapy, along with the juvenile and pUbertal growth
spurts, make the correction of Class II malocclusion in contemporary orthodontics an
easy task to accompli sh.
,


168 r.rt I) Onhoooll ic MochaflOlh('roPY
DB. l
Figure 08.1 Typical class II . division I with a 12-mm over-
jet. In t he past, cases such as thi s onc were treated with
headgear for at lellst 2 to 3 years (for correction of the
7-mm class 11 discrepancy into a class I occlusion) or with
extraction of the upper first bicuspids. These cases can now
be treated without extraction with the sequential use of the
5uperelastic Sentalloy (GAel coil springs.
Figure 08.3 Occlusal view. Note the signifi cant second
molar movement (2 to 3 mm) distall y.
DB.2
Figure 08.2 A 100 g light sect ion of the superelastic coil
spring is compressed between the first and second molars,
immediately after bracket and wire placement (from tM
first appointment of the patient's treatment). The initial
wire is a superelastic rectangular wire. An e1astomeric chaJD
may also be placed from t he onset of treatment from tht
first molar to t he one on the opposi te side in order 10 clost
any anterior spaces and retract t he flan.-d anteriors. This
photograph is 2 mont hs into treatment.
Figure 08.4 Ooscr view. The typical mesial rotation of
class 11 molars is simultaneously correc1ed as the me""'n ,.
moved distal1 y.
'".,
flgur. 08.5 After 4 months into treat men!. the second
molar has moved 6 mm distally in a t to 2 mm over-
corrected position. A stop is placed in the archwire in front
of the second molar 10 prevent its mesial movement during
tIw: distal movement of the first molar. The same coil
~ n l is used again, but this lime it is compressed between
the second bicuspid and first molar. The arch wire is now a
0.016 X 0.016 inch
2
stainless steel that all ows pl3cemenl of
the slOp in the archwire (the superelaSlic wires are difficult
Qa.pler 8 COil SpringS 169
\0 bend). 08.6
Flgur. 08.7 The stop in front of the molar is fabricated
l/"Olmd t he round part of the birdbeak pliers.
F'9I.If' D8.' This photograph, of another patient. shows the
extent of di stal movement of the molar that can be ob-
tained (7 to 8 mm),
08.8
Figure 08.8 The wire (segment B) IS bent at a 45-degree
angle to segment A.
170 Put 0 Or,hod()flllc Mf'danOinerGpy
08.'
Figure 08.9 Segment B is brought back down again.
FIgure 08.11 The molar stop.
DB. l0
F'tgure 08.10 The stop (in the form of a loop) is formro
around the beak ofthc plicrs.
Figure 08.12 Aft er di stal movement of thc fi rst molar teeth
on a patient after 9 months of treatment.
08.13
Flgur. 08.13 Deactivated coil spring after significant distal
molar movement.
FigIII'. 08.15 Radi ograph after the distal movement of the
ftrst molar is completed. Note that during this period, the
!On<! molar roots have uprighted (they are not in proxim-
ity'fti th the first molar roots any longer). In essence. both
roars have moved posteriorly bodily about 6 mm. This
happens because. as the second molars are held in the
O\crcorrected position (with the SlOP in the archwircs). the
roolS upright on their own and with some aid from the
momem created by the high-pull headgcar appliance (see
later). above the center of resislance of the molar teeth.
Ouipter 8 COli Springs 171
Figure 08.14 Radiogrnph showing the second molar in its
overcorrected position. Note the position of its rools in
reference to their proximit y to the first molar roots.
08.16
Figure 08.15 The coi l spring can be easil y reactivated with-
out taking out the main archwire. simply by compressing it
distally with a scaler and adding the residual springs from
the adjacent interbracket area. The clinician should try to
a\'oid cutting the springs in a way that may impinge on the
soft ti ssue. As soon as all posterior teeth and the cuspid
have been sequentially brought back with the coil springs,
the four incisor teeth can then be rctmcted with etaslomeric
chai ns.
172 Part I> Orthodontic MI,:humJlht'rapy
Figure 08.17 During the movement of the second molar
distall y. there should not be any signi fica nt reaction from
the coil spring anl eriorly ( i . t ~ .. increased oveljet). The three
roots of Ihe second molar move faster than the roots of all
the rest of the teeth anterior to the second molar (three of
the first molar, three of the bicuspids, three of the cuspid
and incisor teeth; total: nine) because the root ratio is 3: 9
or I: 3. When we ancmpt to move the fi rst molar. the ratio
increases to 3: 6 or I : 2. It is during this period that there is
an increased possibilit y for adverse elreets anteriorly. At
this point. we may elect to reinforce the distal movement
of the first molar tooth with daytime use of elastics and
nighttime use of high. pull headgear. The headgear appli
ance may al so help with the uprighting movement of the
molar roots as they move di stall y. When it is time to reo
tract the second bicuspids. the root ratio is I : 5. The elas--
ti cs or headgear may be di sconti nued at this point, because
they are no longer as necessary to reinforce the anchorage
requirements. It is the distal movement of the molar teeth
that is most critical. If one wants to ensure that no a nchor-
age loss will occur during this period (3 to 4 months for
each molar. lotal 6 to B months), especiall y in a full class II
case. then headgear is advised. The patienl is still happy
because he or she does not have to wear the headgear for
the full 2 years of therapy, unless an ort hopedic (skeletal)
elrcet is desired.
08.18
Agure 08.18 The di stal movement of the bicuspid teeth can
be reinforced wi th a Scntall oy (GAe) closed coil spring that
extends from the first molar hook to a hook on the bicus-
pid bracket. The stop in the arehwire right in front of the
first molar prevents its mmement mesially.
Figure 08.19 This is a case of uni lateral maxi llary right
KCOnd bicuspi d impaction due to premature exfoliation of
the: second pri mary molar and mesial drift and rotation of
the first permanent molar, which brought t his tooth in
rontac1 wit h the first bicuspid. The mesial rotation also
brought the first molar into a class II 50% relationship with
tile mandibular molar. Notc t he class I cuspid relati onship
and normal overjet.
figure 08.21 It was deci ded to use a nexible NiTi coil spri ng
10 mo\'e the right first molar tooth di stall y.
Chapt er 8 Coil Springs 173
Figure 08.20 Anterior view. Note the nonnal overbite.
08.22
Figure 08.22 Aft er only 5 weeks, on return of the patient for
her first adj ustment appointment. the molar had moved
distally more than 4 mm! The cuspid was st ill in a class I
occlusion and the overjet was the same as before. thus
emphasizing that the adverse effects of this system (i ncrease
in the overjet. flaring of the anterior teeth) are kept to a
minimum or that they do not have the time to cxpn.""SS
themselves before the desired distal molar movement takes
place.
174 Part 0 Or,Won/if Mochanotht".apy
Figure 08.23 Anterior view. Note that the overbite has de-
creased due to initial alignment and leveling.
FIgure 08.25 Three months into treatment and the molar
tooth has been moved distally 7 mm! The coil spring has
been substituted with plastic tube that maintains the opened
.""".
08.24
Agure 08.24 Oosc=r view of the spa<:e that has been created.
08.26
Figure 08.26 Thc anterior view shows that the o"crjet is
normal (2 mm).
Figure 08.27 The occlusal view shows that the second bicus-
pid is erupting on its own in the space that has been pro-
\ided for it.
fivure 08.29 Anterior view. Note the stable normal overbite.
Oup4er 8 Coil S",mgs 175
08.28
Figure 08.28 Five months into treatment , thc ncwly erupted
second bi cuspid can ~ secn from the buccal view. Note the
full class I cuspid relati onship.
Figure 08.30 Ooser view of the erupting second bicuspid.
176 Part 0 Orthodonlic }.fochamxht'1"apy
08.31
Figures 08.31 8nd 01.32 This palien! demonslrmes a mal oc-
clusion of minor 10 moderate (5 mm) crowding in the
maxillary arch in the cuspid region. j ust enough 10 block
Ihe cuspid teeth from erupting in their normal positions.
Figure 08.33 Use of coil springs belween the laterJI incisors
and firsl bicuspid teet h provides the extra 1 mm nct:ded on
each side to accommodate the cuspid leelh. which other-
wise would have stayed in the labial position as they crup-
ted through the soft tissue. The use of fl exible NiTi wires
brought the cuspid Iccth into their final posi ti on in tM
arch. The tolal treatment time is kept agai n to less than a
year.
" .34
figure. DI.M end 08.35 Anterior view. The overbite has
dtcreascd by I mm due 10 the patient' s slight vertical
puwth pattern.
FIQurt 01.36 Use of a NiTi coil spring in the anterior n.-gion
10 mo\'c the len cuspid distall y and provide space for the
IaItraI incisor.
References
Chapter 8 Coil Springs 177
08.35
I. Gianell y AA. Bednar I . li nd Dietz VS: Japanese NiTi coil used to move molars distally. Am J OMhod
Dentofacial Orthop 99:S64- 566, 1991.
2. Miura F, Magi M, Ohura Y, and Karibe M: The super-dD.Stic Japanese NiT; alloy wire for use in
onhodontn Am J Onhod Dentofacial Onhop 94:89- 96, 1988.
3. Gianell )' A: Oass II DOnu tract ion treatment using Sentalloy roi ls. Summarized by BalO' ley DP, Pacific
Coast Society of Orthodontists Bulleti n 50- 5 1, 199 1.
e lla l er
Elastometric Chain Modules

Ebstomeric chain modules ( p m n ~ r chains or C--chains) are used in sliding mechanotherapy
primarily to close spaces.
I
-
4
The elastic chain is hooked on the most posterior molar
tooth that is banded and is then stretched and placed on every bracket of each tooth
all the way around the arch to the most posterior molar tooth (Figs. D9. 1 through
09. 10). The " pull" of the chain has two major side effects: mesial molar rotation and
lingual "dumping" of all the teeth of the arch. These are counteracted with a distal
"toe-in" bend in a rectangular stainless steel archwirc in the molar region and an
increased curve of Spee in the upper and reverse curve in the lowcr wire.
When attcmpting to correct the rotation of various teeth, one may easily do so with
the help of clasti c chains, in addition to the full engagement of the rectangular NiTi
supcrclastic wire in the bracket slots. No wire-tie should be placed on the tooth to be
rotated, so that the moment created by the force vector of the elastic chain may
"spin" the tooth freely around its axis. The other side of the chain will be placed on a
tooth that is wire tied onto the rectangular supcrelastic wire, unless this also needs to
rotate, but in the opposite direction (Figs. 09. 11 through 09.35).
Elastomcric chains should be changed every 4 to 5 weeks. If they are replaced every
2 to 3 weeks, initial tipping occurs, but the tooth does not have time to upright
1
(root
movement) as the force of the chain dissipates. thus accentuating the tipping of teeth
during space closure and not promoting the desired bodily tooth movement.
180 Par1 0 Of/hodOtUk Mt'Chanothl'rapy
Figure 09.1 This patient presented with bimaxi llary dentoal
vl:olar prot rusion that led to the extracti on of the upper
first ::and lower second bicuspid teeth (despit e the moderate
crowding).
09.3
AglK. 09.3 Elastomcric chains wen: placed from molar to
molar. Shown here is 4 months into treat ment. The arch
wire is a finishing stainless steel 0.016 X 0.022 inch!.
09.2
Figure 09.2 Two months int o treatment. the teeth .... 'trt
aligned with a 0.016 X 0.022-inch
l
rectangular Neasent
alloy (GAC) wire.
09.'
FIgure 09.4 MOnlhl y change of the chains led to almost
completi on of space closure 8 months into treatment. Re-
verse curve of Spec added to the nat archwire. Note tilt
slight lingual rotation of the len first molar from the "pull"'
of the chain due to the absence of a " toein" bend in the
wire in front of the molar.
Flguf. Di.S This is a case of general ized spacing on both
arches, with a solid class I molar and cuspid relationship.
Fa n 09.7 Ideal bracket placement and the use of two sets
(hires, a rectangular 0.016 X O.On-inchz NiTi for initial
lfi&nment and a 0.016 X 0.022-inchl rectangular stainless
\11 \\.; th elast ic chains to close the spaces, brought this
aseto oompletion in less than a year.
Chapter 9 Elostomeric Chair! Modl.l/rs 181
Agur. 09.8 The 08/0J relati onship is normal (2 mm).
FigIJl" 01.8 No bends in the archwire were made. The only
adjustments were monthl y changes of the chains (done by
the assistant) and a sli ght increase of the curve of Spec of
the straight archwires 10 avoid lingual tipping of teeth dur-
ing space closure.
182 Put D OrlhQlll)tllic Afer:haIlQlherap, '
Agor. 09.9 Patient after 8 months of active treatment.
Figure 09.11 Placement of clastic chain from the lateral
incisor to the ipsilateral first molar ror the correction or the
rotation on the incisor teeth. Note the "stretch" or the
chain around the bracket wings.
Figure 09.10 The 08/0J relationship has remained normal
(2 mm).
09.12
Figur. 09.12 Two months into treatment (chain was
changed once). Note thai hal f of the rotation has !xeD
corrected.
09.13
Flgure 09.13 The incisor rotatio n was corrected in 4
mont hs. The anchorage of the posterior teeth did not allow
them \0 rotate during this procedure.
09.t5
FIgum 01.15 through 01.18 This adult patient has a class I
IDIIIir relationship on the right side and a class III SO% on
1be \eft with moderate malUllary and severe mandibular
tIOtI'ding, 7 and 10 mm, respectively. Due to the severe
CIO\II"ding and the blocked-out lower second bicuspids. all
IttORd bicuspids were extracted in order to be able to end
up with a class I cuspid relationship. Although the upper
w bicuspids could have been extracted in.stead of the
mnd, it was esti mated that it would be rather si mple to
OOtain a solid class I relationship on both sides wi th .sliding
Khanotherapy while keeping the extractions symmetrical.
r\ote Ihal the cuspids are in a class II SO% relation.ship due
10 1bc blocked-out second mandi bular bicu.spids that have
allowed the teetb anteri or to them to slip di.stall y.
IIIu.tr.tJon. continued on following " . ~ .
Chapler 9 luJwmer;c Chain Mod/J/eJ 183
Figure 01.14 Lingual bUllon.s on the first bicuspid teeth and
the addition of elastic chains 10 "spin" the teeth around
thei r tong axis, with the help of the TPA appliance.
09.16
184 Part 0 OrthodQIIlic !<Iechunolherapy
Figurel 09.20 through 09.22 It was decided to treat this case
wi th only two sets of wires: an initial 0.016 X 0.022-inchl
superelasti c NeosentaUoy-NiTi rectangular wire, which
would allow for torque cont rol from the onstart of treat-
ment, and a finishing 0.016 X 0.022-inchl stainless steel
rectangular wire. Shown here are the initial superelastic
wires engaged in the bracket slots without any deformation.
The superelastieity of these wires allows for a gentle rota-
tion and leveling of the teeth during the initial phases of
treatment. The elastic chains help in the derotation of the
teeth by the simple pull that they exert on the teeth as they
force them to rotate around themsel ves (their long axis).
The upper and lower right first bicuspids are being pulled
by the three-unit c-chains attached 10 the molars; the four-
unit c-chain from the left upper cuspid to the opposite
central helps dcrotate the cuspid tooth (the central is wire
tied with a ligature wire around the main archwire so that
it will not rotate itself); t he upper right lateral derotates
with the help of the fi ve-unit chain that extends all the way
to the upper right molar tooth; the lower right cuspid as
well as the opposite left first bicuspid both rotate around
thcir long axes from the equal and opposite forces exerted
by the elasti c chain.
"23
f9ns 09.23 through 09.25 The result of the effect of Ihc
riaslic chains: compl ete rotation of Inc teeth after 2 months
treat ment.
Chapltr 9 Elaslomeric Chain Modull'J 185
09.24
186 Pari D OrlhodOfllic Mt'Ch(UlOIherapy
09.26
Ftgures 09.26 through 09.28 A class I molar and cuspid
relationship has been achieved and the midlim.'s an: on; 5
months int o treatment.
09.27
09.28
09.29
09.31
......
Elasto
the go
Flgu,..
the de!
first bic
f9nt DI.2i tflrough 09.31 Ten months into treatment.
E\astomeric chains help close any remai ning spaccs. Note
die good class I intercuspation.
01.32 and 09.33 This patient has an asymmetry of
dental arches. which led to the extraction of the left
ChsplH 9 /aMOtneric Cham Modules 187
188 Part 0 Orthodontic Mt'ChallOfherapy
J tG;j l
, f
I
09.34
Agures 09.34 end 09.35 After the cuspid teeth were re-
tracted, note how the lateral incisors drifted di stall y (caus-
ing spacing in the arch) on their own without any ortho-
dontic mechanotherapy. This is "free" movement , which
one should be aware of and take advantage of during t reat-
ment.
References
I. Graber LW: OrthodOlllio -Slall' ofthl' Art. .ue"7Ia St. Louis. M(); C.V. Mosby Co. ,
1986.
2. Graber TM, and Swain BF: Ort!wdo#lli($-Current Pr;ncip/l'$ and Tethniqun. SI. Louis. MO: c.v.
Mosby Co., 1985.
3. Ale:tan<ler RG: The Alexander Diseip/inl'. Gkndora, CA: Ormco Co .. 1986.
4. Mclaughlin RI', and Bennet TC: 'The transition rrom standard edgewise to preadjusle(i appliance:
J Oi n Orthod 2): 142-15], 1989.
(]
EI
AI
Cit ler
Orthodontic Elastics
Elastics h.\'e been a va luable adj unct of a ny orthodontic treat ment for many years.
I
-
4
Their
usc, combined with good patient cooperation, provides the clinician with the ability to
correct both anteroposterior and verti cal discrepancies" -" They are used primarily
with rectangular archwires,,-
4
The introduction of the fl exible rectangular NiTi wires
allows the clinician to obtain immediate torque control from the onset of orthodontic
mechanotherapy and thus use elastics from the beginning of
The following elastics are suggested for cli ni cal usc.
Anteroposterior Elastics
CI I EI tics (Fig. 010. 1) extend wi thin each arch (intra-arch elastics) and are
primarily used to close spaces, in aid of the elastomcri c chains.
CI II Elastics (Figs. DIO.2 and 010.3) extend from the lower molar teeth to
the upper cuspids (interarch elastics). They are primaril y used to cause anteroposterior
tooth changes; i.e., aid in obtai ning a class I cuspid relationship from a class II
relationship. If the lower second molars are banded and included in the treatment
mechanotherapy, it is best to extend the elastic from the first molar to the cuspid
tooth to avoid extrusion of the second molar and the creation of an open bite
anteri orl y. If the lower second molars are not banded, it is best to extend the elasti cs
from the second bicuspids to the upper cuspids (or even to the lateral incisors for a
longer horizontal vector) if they are to be used for over 2 months of treatment. If
elastics are to be used for 2 to 6 weeks onl y, then one may extend them from the
lower first molars to the upper cuspid teeth. This treatment regimen minimizes the
side effects from the use of elastics (extrusion of the lower posterior tccth and labial
tipping of the lower anterior teeth, lowering of the anterior occlusal plane and the
creati on of a gummy smile). If any temporomandibular joint discomfort occurs,
elastics should be discontinued, at least temporaril y.
CI III EI tlc. (Figs. 010.4 and 010.5) are the exact opposite of the class lis:
they extend from the upper molars to the lower cuspids and are used in the treatment
of class III cases. They promote extrusion of the upper posterior teeth and flaring of
the upper anteriors, along with lingual tipping of the lower antcriors. The same
principles discussed above apply for class III elasti cs as well .
190 Part D OrrhodOll/ic Ml'ChuflOlhf'rapy
010.1
Figure 010.1 Class I elasti c from the upper first molar to the
cuspid tooth.
010.3
Figure 010.3 Long class II elastic (used to increase the hori-
zontal effect of the elastic).
010.2
FIgure 010.2 Class II elastic from the lower first molar 10
the upper cuspid.
Rgur. 010.4 Class III elastic from the upper first molar to
the lower cuspid.
Figure
effect).
v.
Figure Dlt
open bite.
f\gIn 010.5 long class 111 clastic (for increased horizontal
..recti
Vertical EI.stics
Ch. plff to OnhooOtlticE/astiN . 191
Triangle Elastics (Figs. 010.6 through 010. 13) aid in the improvement of class I
cuspid intereuspation and increasi ng the overbite relationship anteriorly by closing
open bites in the range of 0.5 to 1.5 mm. They extend from the upper cuspid to the
lower cuspid and fi rst bicuspid teeth.
Box Elastics (Figs. 010. 14 and 010. 15) have a box-shape configurati on and can
be used in a variety of situations to promote tooth extrusion and improve intercuspa-
tion. Most commonly. they include the upper cuspid and lateral incisor to the lower
first bicuspid and cuspid (class II vector) or to the lower cuspid and lateral incisor
(class III vector). All bicuspid teeth of one side can be extruded as well.
,... 010.5 Triangular vert ical elastics. Note the slight
"bite.
T ., conUooed on"..,. J!M.
Figure 010.7 Within 2 months, the open bite is closed. Rec-
tangular Neosentalloy (GAC) NiT! wires are the arch wires
used in both arches from the start of treatment.
192 Part D Onhodonlic Mt'Challotherapy
Figures 010.8 through 010.10 This case demonstrates a se-
vere right posteri or open bite caused by the ankylosed,
retained primory fi rst and second molars (no successors
were present ). Note the almost ideal class I occlusion of the
patient's left side. It was decided not 10 remove the decidu-
ous teeth because of the possible rugh position of the
osseous defect that may have been created. Therefore, ex-
tractions of these teeth were postponed until after the open
bi te has been significantl y reduced with venical elastics.
010.9
Flgur<
loy (I
and .

wU'.
may
lower
day.
mont
Flgu .. t
010,11
FigIn. 010.11 thtough 010.13 A O.OI6-inch l1exible Sental-
\0)' (GAC) round NiTi wire is placed on the maxill ary arch
Ind a rigi d 0. 0 16 X 0.022-inch2 rectangular stainl ess stccl
wire on t he mandibular arch. This way. the upper cuspid
may be extruded wi thout any extrusive side effects of the
1I.wo-er dent it ion. A heavy triangul ar clastic is worn 24 hI
clay. Note the signifi cant closing obtained in the first 6
mont hs of trcatment. The patient isstiIJ in therapy.
figI.n 010.14 Box elasti cs (class II vector).
Cluptn to OrthodOfllic Elastics 193
010. t 2
010.13
Figure 010.15 Box elastics (class 11\ vector).
194 Pan D OnhodOlltic Moc/uJflOlhl!rapy
Figure 010.16 Anterior clastics used toward the end of treat-
ment to close this minimal open bi te.
Figure 010.17 Aftcr 2 months of clastic wear.
Anterior EI tics ( Figs. 010. 16 through 010. 18) are used to improve the overbite
relationship of the incisor teeth. Open bites up to 2 mm may be corrected with these
elastics. They may extend from the lower lateral incisors to the upper laterals or
central incisor teeth or from the lower cuspids to the upper laterals.
Other EI.stlcs
Asymmetrical Elastics (Fig. 01 0. 19) are usually class 11 on one side and class
111 on the other. They are used to correct dental asymmetries. If a significant dental
midline deviation is present (2 mm or more). an anterior elastic from the upper
lateral to the lower contralaterallateml incisor should also be uS(."<l .
Finishing EI.stics (Figs. 010.20 and 010.21) are used at the end of treatment for
final posterior settling. tn class II cases, the elastic begins on the maxillary cuspid and
continues to the ma ndibular first bicuspid, and in the same " up-and-down" fashion it
fini shes at the ballhook of the mandibular first molar band. In an open-bite or class
III case, the elastic begins at the lower cuspid, continues to the maxillary cuspid (sec
below), and finishes at the maxillary molar.
The clastics are attached to ballhooks on the brackets or to K-hooks ( beavy ligature
wires with an extension). They should preferably be worn full time (24 h/day) for
maxi mum effect, alt hough J 2 h/ day wear may be indicated to minimize their side
effects (Figs. 010.22 through 0 10.35). They should be changed once or twi ce a day
because t he elasti cs fatigue rapidly (in contrast to the elastomeric chains, which last 3
to 5 weeks). The recommended sizes for the various elastics are (a) anteroposterior
elastics: 1-inch, 3.5 02. ( light) or i -inch, 602. ( heavy); (b) .'er(icol elastics: iinch, 3.5
02. (light) or 1\-inch, 6 01. ( heavy); and (c)jinishing elastics: i-inch, 2 oz.
Figure
upper
on tilt
D10.2O
FIgu .. ,
proved
wear ( I
FIgurt 010.18 Anterior elastic rrom lower laterals to the
upper centrals. The effect of the clastic primarily would be
00 the upper central incisors.
010,20
figures 010.20 and 010.21 Finishing elastics. Note the im
pnr.'td intercusp3tion or the bicuspids after 6 weeks or
wtar(l4 to 16 hr/day).
Cbpter 10 Orthodontic EfaSl ia 195
010. 19
FIgure 010.19 Asymmetrical clasti c 10 "shift" the midline
over to the left .
010.21
196 Put D OrrhodOlllic MedrallOfherapJ'
Agures 010.22 and 010.23 A 16-year-old gi rl presented with
a class II 50% molar malocclusion. a 4-mm posterior open
bite. a borderline anterior open bile, impacted maxillary
cuspids, aDd a bilateral edgeto-edge posterior crossbi te. The
treatment objective was to close the open bite solely by
extruding t he maxillary dent ition. without undesirable ex
trusion or tipping of the lower teeth.
Figures 010.24 end 010.25 After initial uncovering of t he
impacted cuspid. a light ( IOO g) Ncoscntalloy (GAC) rec
tangular NiTi archw;re was placed in the upper arch, and a
0.016 X 0.0 1 6-inchl stainless steel archwire in the lower.
Light triangular vertical elastics were worn full . time. h e l ~
ing 10 bring lhe exposed cuspids into the arch. A tf"dnspala
tal arch. designed to correct the posteri or crossbi te. initiall y
opened the bite further. as it is shown here 2 months after
bracket placement.
Figul
cusp
solid
"'"
mon
stilfe
010.2
Flgun
"",,,
ti cs Co
Flgurn 010.26 and 010.27 Three months into treatment, the
cuspid teeth are in alignment. Elastomeric chains help con-
IOlidate spaces in the upper arch. Elastics (rubber ~ n d s )
are still being worn to help bri ng the whole upper dentiti on
more occlusally, because they pull it against the mu('h
Slifer lower archwi re.
Figuf 010.28 and 010.21 After 5 months of treatment the
pmlmor open bi te had closed signifi cantl y. The light clas-
tics conti nued to be worn full -time.
Cbaplt r 10 Orthodomic I:."/(lstics 197
198 hrt D OnhooQlIlic Mer:hanOlherupy
010.30
Figures 010.30 end 010.31 After 8 months, a harmonious
occlusion is almost achieved. Final detailing is to be ac-
complished with upper and lower 0.016 X 0.022inch
1
stainless steel archwires. This case should be compl eted in
less than a year.
References
L Proffit WR; OnhodOnJia. St. Louis., MO: C.V. Mosby Co .. 1986.
2. Alexander RG: The Aluander Discipline: COtllernporaT)' Conapu and Philosophies. Glendora, CA:
Ormco Cn., 1986.
3. Alexander RG: Countdown to retention. Jain Orthod 21 :526- 527, 1987.
4. Steffen 1M, and Haltom Ff: The live cent toot h positioner. J ain Orthod 21:525- 529, 1987.
5. Viazis AD: ainical application of the rectangular NiTi wires. J ain Orthod 25:370- 374, 1991 .
1
Cha l e r
Class I Cuspid Relationship
The first objective or orthodontic mechanot herapy in the anteroposteri or dimension is the
attainment of a class I cuspid relationship.l.2 This wiU not only result in a stable,
functional occlusion, but it will also ensure a good overbite (08) and overjet (OJ)
relationship when no tooth size discrepancy is present. The upper cent ral and lateral
incisor roots should be slightl y convergent, and the remaining upper teet h should show
a distal incli nation, except for the second m o l a ~ which should be mesially tilted. The
lower incisors should be upright, and the other lower teeth should be increasingly
distall y inclined as onc moves posteri orl y.
In most instances, in order to obtain a class I cuspid relationship, the cuspid tooth
needs to move into the extract ion space of the first bicuspid without loss of anchor'Jge
( Figs. 011.1 through 0 11.10). All the cli nician has to consider is t he number of roots
to be placed in opposition with each other in each unit. For example, if the posteri or
unit is composed of the fi rst molar (three roots) and the second bicuspid (one root)
and the anterior unit is the cuspid (one large root) and the incisor teeth (two roots),
we have a total of four posterior roots against three anteri or roots. This will cause both
units to move into the extraction space, thus resulting in anchorage loss. When,
conversely, individual cuspid retraction is used (one anterior root) and the posteri or
unit is composed of the second and first molars and the second bicuspid (a total of
seven posterior roots), one may easily comprehend that the cuspid tooth wi ll move
posteriorl y without almost any anchorage loss (i .e .. mesial movement of the upper
posterior teeth).
0 11 .1
Figure. 011.1 and 011.2 This pat ient presents with a class II
50% (end. to-cnd) molar and cuspid relationship with a
midline deviat ion or 3 mm to the right (the right side is
class I). Due to the increased proclinat ion or the denti tion,
rullness or the profile, the prolrusive lips, and the general
bimaxillary dentoalveolar outlook or the patient, extra<::'
tions or the upper first and the lower second bicuspids were
performed (the lower fi rst bicuspids could have been ex
tmcted instead).
-
1.2
0 11 .3
Figure. 0 11.3 through 0 11.8 Rectangular Neosentalloy Nili
(0.016 X 0.022 inch
l
) ini t ial arthwires were placed on both
arches. One month into treatment, the teeth are aligned.
The next objective or t he mecha nothempy is to obtain a
class I cuspid relat ionship. This is very easil y done with a
supcrciasti c NiTi coi l spring between the lateral and cuspid
and an elast ic chain rrom the molar to the cuspid tooth.
NOIe that the lateral is wire tied to avoid unnccessa.Ty rota-
lion or that toot h. The spring (shown here after 2 months)
is left in place unti l completi on or the movement, wt.erus
the elastic chain is changed once a month.
011.
Chapltr II Cla.u 1 Cuspid Relationship 201
D1I .4 011.5
202 Pan 0 O,/JuxiQflfic Ml'rhanOlhl'Tapy
0 11 .9
Figure 011.1 Fi ve mOnlhs inlo t reat ment, the len cuspid has
been moved bodil y into a class I relati onshi p and is part of
the posterior anchor unit (it is wire tied with a ligature to
the posterior teeth). Note that there was no increase in the
overjet relationship from the react ion force of the coil
spring to the anterior dentiti on.
References
011 .10
Figure 011.10 General space closure may be initiated with
elastic chains from molar to molar, upper and lower. Oass
II elastics are also used at night.
I. Proffit WR: COIIlemporaryOrthodOlllics. St.louis. MO: C.V. Mosby Co., 1984.
2. Graber T, and Swain SF: Orthodontics: Currl'Tll Prindpln and Thniques. St. Louis. MO: c.v. Mosby
Co .. 1985.
202 I'.rt D Orrhodomic Mlumothl.'rap,'
Dl ' .9
figure 011.9 Fi ve months into treat ment, the len cuspid has
been moved bodily into a cl ass I relati onshi p and is part or
the posterior anchor unit (il is wire t ied wi th a ligature to
the posterior teeth). Note t hat there was no increase in the
overjet relationshi p rrom the reaction rOrte of the coil
spri ng 10 the anterior dentiti on.
References
Figure 011.10 General space closure may be initiated with
elastic chains rrom molar to molar, upper and lower. Class
II clastics arc also used at night.
\ . Proffit WR: Commtporary OnhodonJia. St. Louis, MO: C. V. Mosby Co., \984.
2. Graber T, and Swain BF: Orrhodotllia: CI4m!1If Principlu and Techniquf'J. St. Louis. MO: C.V. Mosby
Co" 1985.
Par t
Adjunctive Appliances
Clla ler
Rapid Expansion

fRME) Appliances
One of the first objecth'es in orthodontic treatment is the correction of any skeletal or dental
discrepancies in the transverse dimension, If there is a single-tooth crossbite, dental in
nature, full arehwire engagement will, in most cases, correct the problem, If the
crossbite is skeletal, either bilateral or unilateral in nature, rapid maxillary expansion
( RME) I - I' should be attempted at the start of treatment.
Maxillary expansion appliances may be used to correct unilateral or bilateral poste-
rior crossbites involving several teeth when the discrepancy between the maxillary and
mandibular first molar and bicuspid widths is 4 mm or more, I The applied pressure
acts as an orthopedi c force that opens the mid palatal suture. I The appliance com-
presses the periodontal ligament, bends the alveolar processes, tips the anchor teeth.
and graduall y opens the midpalatal suture. I The separati on is pyramidal in shape, with
the base of the pyramid at the oval side of the bone. I The amount of sutural opening
is reported to be equal to or less than one half the amount of dental arch expansion.
1
- '
The increase in the intermolar width can be as much as 10 mm, with a mean increase
of 6 mm.
2
- ' During the retention period there is uprighting of the buccal segments;
therefore, one can appreciate the need for overcorrection of the dental arches'6 (Figs.
El.l through EI.9).
Because the midpalatal sut ure may ossify as early as age 15 years and as late as age
27 years, the optimal period for sutural expansion is between 8 and 15 years of age.'
The appliance should never be regularly activated for a period longer than I week
against an unyielding suture in the hope of achieving maxillary scpamtion.
It is believed that, during active suture opening, the incisors separate approximately
half the distance the screw has been opened.' The incisors also upright or tip linguall y.
This is thought to be caused by the stretched circumoral musculat ure.' On completion
of the expansion, the transseptal fibers pull first the crowns and then the roolS to their
original axial inclinations. I
Parallel to the changes in the transverse dimension, the maxilla consistentl y moves
inferi orly and anteriorly to a varying degree, approximately 1 mm.9.1' The inferi or
movement of the maxilla, I' as well as the correcti on of the crossbites, account for the
consequential opening of the mandibular plane angle.
9
The anterior open-bite tend-
ency is sometimes successfull y masked by the uprighting incisors.
Advocates of rapid expansion ( I to 4 weeks) believe that it results in minimum
tooth movement (tipping) and maximum skeletal displacement (each turn of the screw
opens the appliance 0.25 mm). Advocates of slow expansion (2 to 6 months) believe
that it produces less ti ssue resistance in the circum maxillary structures and bener bone
formati on in the intermaxi llary suture, and that both factors help to minimize post-
expansion relapse. I
It has been shown that RME results in concurrent expansion of the lower arch.
Haas observed an increase of as much as 4 mm and 6 mm of lower intercuspid and
intermolar width, respectively.'" He advocated that the mandi bular arch tends to
El .l
FtgUres El .1 and El .2 A lJ.ycar--old boy with bi latcr.11 pos.-
tenor crossbite and a constricted maxilla. A typical l-I yr.1X
RME appliance is banded on the first bicuspids and first
permanent molars. The screw is activated twice a day
(every 12 hours). two turns each time (each tum causes
0.25 mm of ex pansion). A tolal of 0.5 mm per day is the
desired rat e of expansion. Within a week. a midline di as-
tema is created (as shown here). If not, the expansion
should be ab:Jndoncd .

El .3
FtgUre E1.3 Opening of the midpalatal suture (radiograph
from another patient).
,
EU
figures E1.4 and E1 .5 After 21 weeks or expansion. Note the
si&nificant midline diastema and the increase in arch width.
The same result may be achieved wi t hi n I month if the
iCteW is turned only once per day.
Et .6
figures E1.6 and E1.7 Wi thin 2 to 3 weeks of expansion, the
transeptal fibers have pulled the cenlral incisor teeth to-
~ h e r and closed the unesthet ic diastema. Acrylic has been
added to the screw to keep it in its open positi on.
Et.8
Flgurn E1 .8 and E1.9 Overcorrection or the buccal segments
mould be such that the lingual cusps of the maxi llary teeth
rtach the buccal of the mandi bul ar ones.
Chll pter I RtJpid !oiw;illary Expansion (RM ) Appliances . 207
E1.5
E1.7
E1.9
208 Adjunaire ApplIU1IUJ
Et . t O
foll ow the maxi ll ary teeth by tipping laterall y and that the mandibular intercuspid
width in the non-grower may be increased if the maxillary complex is widened.
Sandstrom et al.
10
found a statistically significant increase of the mandibular intercus-
pid (1.1 mm) and intermolar width (2.8 mm) after
RME also has been an accepted procedure to relieve deficiencies in arch perimeter.
Wit h the increasing emphasis on nonextraction therapy, the procedure has gained
popularity because of the relief it provides in cases of crowding (Figs. E I. 10 through
EI.25). RME with the Hyrax appliance produces increases in maxillary arch perimeter
at the rate of approximately 0.7 times the change in the fitst bicuspid width.
1I
Slight
palatal movement of the maxillary incisors and mild buccal tipping of the anchor
teeth, as well as slight compensatory buccal uprighting of the mandibular posterior
teeth, arc also nOled.
1I
E 1. 11
Agur E1 .10 through E1 .14 Although this patient has a nor-
mal buccolingual occlusion (no crossbite present). it was
decided to attempt to create space for the impacted central
incisor with an RME appliance. Note the shan root of the
impacted toot h in Figure EI . 14.
E1.12
, ,
E1.16
Chl pl tt I Rapid Maxillar,' Expansion. (RAtE) Applianct'l 209
El . 15
Figur 1.15 through E1.17 After 2 weeks, the expansion
was terminated; acrylic was placed over the screw to stabi-
lize it in its position. and the impacted incisor was surgi-
cally unco\'cred. Note the open midpalatal suture on the
radiogroph. The teeth wert bonded and an initial 0.0 16 X
0.022 inchl Ncosentalloy (GAC) light (100 g) rectangular
NiTi wire was plattd in all the teeth but the right lateral
incisor (to avoid unnecessary lipping of that toot h).
E1.17
210 Part E Adjuncri l't Applia"Cf'$
Figures El .18 and E1 .19 One mont h later. the right cent ral
incisor had come closer to the occl usal plane (from the
continuous ligh t force of the flexible wire). at which point
the lateral was auached to the wire.
Agures El .20 through El .22 Three months from the begin-
ning of treatment. the right central incisor has assumed its
position in the arch. The midpaJalal suture has begun to
ossify. Note the normal txme st ructure around the small,
deformed root of the right central in Figure E 1.22.
El .21
Chapltr I Rapid Maxillary Expansion (RME) AfJp/wnces 211
E1.23
Figures E1 .23 through E1 .25 The posterior buccal crossbites
that had blocn created from the expansion (for the sake of
space gai ning for the impacted tooth) were corrected by
si mply allowing t he teeth \0 return to their pretreatment
positions (the expansion was not retained posteriorly). The
RME appliance was remo\ed after the expansion. and the
same day/ lite<! applianct.'S were bonded on the patient's
teeth. Note the normal overbit e relationship. Funher treat-
ment will finish the nonexlracti on casco
212 P1lr1 E Adjunctivl' Appliances
El .26
In a study of the skeletal changes in vertical and anterior displacement of the
maxilla with bonded RME appliances,' it was found that inferior movement of the
jaw is lessened, and that there is a slight upward posterior movement at the posteri or
nasal spine (PNS) with a downward and posterior displacement at anterior nasal spine
(ANS) that carries the upper cent ral incisors in a clockwise rotation. RME, as it
expands the maxilla and tips the dentition outward, causes the li ngual cusps of the
upper posterior tceth to move downward, thus opening the bite. It is suggested that
bonded appliances instead of banded ones are indicated in .open-bite tendency cases
(long lower face, high mandibul ar plane angle), where extrusion of the maxilla or
maxillary dentition would worsen the open-bi te situation and ereate a more difficult
vertical pattern to treat. The 2 to 3 mm of bonded acrylic introduces a passive stretch
of elevator and retractor musculature that provides an apicall y directed (intrusive)
force to the maxilla and the mandible, which limi ts changes in the vertical dinx:ti on
9
(Fig. E 1.26).
RME causes extensive buccal root resorption.
12
Repair of defects occurs by deposi-
tion of cementum. The clinician has no way of estimating the full extent of the
resorption.
' 2
The expansion should be retained for about 3 months to allow for bone
regeneration in the mid palatal suture and to avoid coll apse of the maxilla to its
ori gi nal state.
Correction of the transverse maxi11ary deficiency, where a constricted upper arch
occludes wi th a normal mandibul ar arch demonstrated with a bilateral posterior
crossbite, is attempted surgicall y when the patient is generall y age 16 years or older
and the transverse discrepancy exceeds 4 mm.1 An RME appliance is acti vated at the
time of surgery to keep the upper arch in its expanded position postsurgicall y, or the
patient is instructed to activate it four turns a day for I to 2 weeks postsurgery.16 The
procedure is called surgically assisted rapid palatal (or maxillary) expansion and
involves surgical relief of the zygomati c buttresses
ll
(Figs. EI.27 through EI.29). It
can be done on an outpatient basis in the beginning of treat ment. It may also be
incorporated into the overall treatment plan of a more complicated skeletal problem
(class II or III ), when totaJ maxillary or mandibular osteotomies are needed. It should
be noted that the mandible's tendency to rotate backward in conventional RME also
applies to the surgicall y assisted procedure, especially in patients wi th open-bite ten-
dencies.
11
E1 .27
Figure E1 .26 A bonded RME appliance with acrylic cover-
age of thc posterior teeth and a screw conformed 3 mm off
the palate. Note the cold-curc acrylic placed in the screw to
hold the appliance: in its expanded position.
Figure E1.27 Adult pati cnt with bilatcr.ll postcrior crossbite.
Chapter I Rapid Maxillary /;.xpans;on (RME) Appliances 213
El .28
"29
figure El.28 After surgicall Y assisted RME. Figure E1 .21 Patient toward thc end oftrealment.
References
J. Bishara SE, and Staley RN: Maxillary upansion: Oinical implications. Am J Onhod Dentofacial
Orthop 9 1:3- 14, 1987.
2. Krebs A: Expansion of the midpalawl suture st udied by means of metallic implant!. Transactions.
European Onhodomic Society 34: 163- 171, 1958.
3. Krebs AA: Expansion of midpalatal suture studied by means of metallic implants. Acta Odontol Scand
17:491-501, t959.
4. Krebs AA: Rapid expansion of mid palatal suture by fixed appliance. An implant study ove- a 7 )'t.1r
period. Transactions. European OnhodonlK: Society 40:141 - 142, 1964.
5. Haas AJ: The Imumenl of m.axillary deficiency by opening the midpalalal suture. Angle Onhod
35:200- 2 17, 1965.
6. WCftt. RA: Skeletal and dental changes accompanying rapid midpalatal suture opening. Am J Onhod
58:4t - 66.1970.
7. Persson M, and Thilander B: PaJat.al suture closure in man from 15-35 )cars of age. Am J Onhod
72;42, 1977.
8. Haas AJ: Rapid tJlpansion of the maxillary dental arch and nasal cavi ty by opening the midpaJatal
suture. Angle Onbod 31 :73-90. 1961.
9. Sarver OM. and Johnston MW: Skeletal changes in vertical and anterior displacement of the maxilla
with bonded rapid palatal expansion appl iances. Am J Onhod Dentofaci al Onhop 95:462 - 466. 1989.
10. Sandstrom RA. KJaper L. and Papaconstantinou S: Expansion of the lower arch concurrent with rapid
maxillary expansion. Am J Onhod Dcntofacial Orthop 94:296-302. 1988.
II. Adkins MD, Nanda RS. and Cumer GF: Arch perimeter changes on rapid palatal expansion. Am J
Onhod Dcmofacial Onhop 97: 194- 199. 1990.
12. BarbcT AF, and Sims MR: Rapid maxi llary upansion and external root resorption: An SEM study.
Am J Onhod 79:630- 652. 198 1.
13. Wintner MS: Surgically assisted palatal expansion: An important consideration in adult treatment . Am
J Onhod Dcntofacial Onhop 99:85-90.1991.
14. daSilva 00, Boas MCV, and Capelozza L: RME in the primary and mixed d('ntitions: A cephalometric
evaluation. Am J Or1hod Dcntofacial Orthop 100: 171- 181. 1991.
15. Timms OJ : Rapid Maxillary F..xpansion. Chicago: Quint('$SCnce Publishing Co., 1981 .
16. Turpin DL: Case report. Angle Orthod 59: 155- 159, 1990.
17. Woods MG, Swift JQ, and Markowitz NR: ainical implications of advances in orthoen.3thic surgery. J
ain Orthod 23:420- 429, t989.
;::======C:;1t apt e r
Lip Bumper
The lip bumper is a very popular appliance for expansion of the mandibular arch a nd thus for
gaining space as a result of the transverse changes. as well as from the di stal uprighting
movement of the lower molar teeth and forward movement of the incisor teethl.l
(Figs. E2.1 through E2.6). Based on various recent studi es, the mandibular first molars
lip back arout 1.5 mm on each side and are 8 degrees more uprighl.2 The incisors lip
forward approximatel y 1.4 mm.
2
Depending on whether the lip bumper is passive or
expanded on its insen ion in the molar buccal tubes, the transverse changes range from
2 to 2.8 mm, 2.5 to 4 mm, and 2 to 5.5 mm in the cuspid, first bicuspid, and fIrst
molar regions, respcclivcly.I-4 The total arch length increase ranges from +7.45 mm
to + 18 mm,, -
4
The lip bumper can maximize space gain in the lower arch, and-in conjunction
with class III elastics-it can effectively correct tooth mal posilions in special situations
and help to determine the shape of the lower arch." It is important to scat the
bumper into the second molars if they can be banded (in deep-bil e cases). Mandibu
lar right and len second molars are rotal ed until their lingual surfaces are parallel, and
thi s positioning has an important effect on the eventual arch rorm. When this rota-
tion is completed, a lip bumper is fitted against the first molars. Later. the bicuspids
arc rotated mesiobuccall y with fi xed appliances and then moved toward the first
molars.
The lip bumper should be worn rull-time for a period of 6 to 18 months, depending
on the amount of tooth movement and correcti on required. It is an effecti ve appliance
in mixed dentition therapy.
216 Put t: Adjllndi n' ApP/IOtfCf'5
Figure E2.1 The lip bumper appliance in place in the lower
first molar auxi lial)' tubes. Note the distance from the an
terior teeth: the lip bumper should be 5 to 7 mm anteri or
to the teeth in order to avoid injury to the gingiva as the
appliance progressively moves posteriorl y with molar
movement.
Figures E2.3 through E2.6 When the lip bumper is properl y
placed, the lower lip should vel)' easil y cover the appliance
and rest (without any e!fon from the patient) against it.
Figure E2.2 The lip bumper wire embedded in the acrylic
should be at thc level of the CEJ or the lower incisors. Note
the loops on the side. which. along with the aCl)'lic anteri-
orly, keep the soft tissue (lips and cheeks) away from tbe
ah'eolus, thus allowing for natural transverse expansion.
The loops also help increase the length or the appliance.
E2.4
ChaPleT 1 u p Bum{H'T 217
E2.'
References
I. Osborn WS. Nanda RS. and Currier GF: Mandibular arch perimdcr changes wilh lip bumper ttealmt:nt.
Am J Orthod Dentofacial Onhop 99:521-5]2. 1991 .
2. Nevan! cr, Buschang PH, Alexander RO. and Steffen 1M: Lip bumper ther-IPY for gaining arch length.
Am J Ort hod Dentofacial Onhop 100:330-336. 1991.
J. Cetli n NM, and Ten Il oevc A: Nonextr.lction therapy. J aiD Onhod 17:396- 413, 1983.
4. Ten Hoeve A: Palatal bar and lip bumpers in noneA-traction treatment. J a iD Onhod 19:272 - 291, 1985.
Chapler
Headgear
Extra-oral anchorage or headgear mechanics are primarily used in cases of maxillary protru-
sion where the objectives arc to restrict forward growt h of the maxilla while the
mandible continues its growt h (skeletal effcct) and to move the maxillary molar tccth
distally (dental effcct). I- lo
The headgear has two bows: an outer bow, which conneets to the head (high pull)
or neck (cervical) strap. and an inner bow. which is inserted into the tube of the upper
first molar.l.l There are various types of headgear, the one used the most with the least
side effects is the high-pull headgear (composed of a head strap that is connected to
the facebow) 1 (Fig. E3.1). This produces a distal and upward force on the first molar
teeth that causes a sli ght intrusion of these teeth. A cervical headgear (around the
neck) tends to significantl y extrude the molar teeth, which even in some deep-bite
patients may be contraindicated. A more occipital type of a force vector (instead of a
hi gh-pull) may be used in such C:Ise5.
l
In order to obtain a skeletal effect with headgear mechanics, the extraoral appliance
should be worn around 12 to 14 hr/day (during sleeping hours) with a force of about
10 to 16 oz (400 to 450 g) per side. I Hyali nization due to the excessive forces exerted
on the first molars limits dental movement and promotes the skeletal effect (because
the force would be transmiued 10 the skeletal substrate). After 2 years of treatment. a
total of 5 to 7 mm of molar position change may be expected: 3 to 4 mOl from
retardation of maxillary growt h relative to the mandible and 2 10 3 mm from actual
distal tooth movement. I The total force to the maxilla should not exceed 2 to 3 Ib.
I
-
J
To produce bodily movement of the molar tccth, the line of force (defined by the
direction of pull by the strap 10 the outer bow) should pass through the center of
resistance of the first molars} (Figs. E3.2 through E3.4). If the length of the bow or its
position creates a line of force above or below the center of resistance. tipping will
occur because of the movement that is produced.
When a headgear appliance is worn, the patient should not engage in any activities
that might promote accidental release of the facebow and damage to the face (espe-
cially the eyes). This is the reason for the recent development of "safety" headgear
products.
Headgear therapy can most readily be achieved in the early mixed dentition. I I The
bones are less mineralized and therefore more easily deformed; sut ures and li gaments
are more cell ular, result ing in more rapid biological responses; and growing tissues arc
generally morc responsive to external forces. II The best orthopedic results are obtained
when growth is most active and the juvenile period has greater growth on the average
at its beginning.1I The headgear can be used as a retainer-appliance for the first year
after treatment for 4 to 5 hr/ day or every other day if the anteroposterior correction
was a full class II or 50% class 11 , respectively_ This retention plan will not only keep
the molar teeth in their overcorrCCled position, but also will help in Ihe final class 11
skeletal correction post retention. Nonexlraction edgewise therapy combined with ex-
traoral force (headgear) on a class II . division I malocclusion inhibits the forward
220 Part [ Adjunctive APIHiD1IUJ
growth of the maxilla and allows the downward and forward growt h of the mandible,
thus resulting in the correction of the class II malocclusion into a class I. 12 It should be
noted that the inner bow of the headgear appliance may sometimes cause the first
molars to tip buccall y (due to the heavy wire, even the slightest activation wi ll C' dUse
tooth movement ). In order to avoid this, a trnnspaJatal bar (TPA) made of O.036inch
round wire should be inserted in the lingual sheaths of the upper first molars. TPAs
are available prefabricated and in various sizes. Another way to avoid buccal tipping is
to constrict the inner bows of the headgear.
E3.1
FIgure E3.1 The highpull headgear appliance.
Figure E3.3 The o uter bow should be bent upward in a
high pull headgear appliance system.
E3.2
Agur. E3.2 The line of force. as defined by the direction of
pull by the white strap to the outer bow, should p;m
through the center of resistance of the first molars locatt<!
at the trifurcati on of the roots of these teeth. This can be
checked with a cephal ometric radi ogrdph.
Figur. E3 . The inner bow is inscr1ed in the molar band
headgear tube.
Chaptet J IINdgNf . 221
References
I . Wieslander L: The effect of force on craniofacial development. Am J Orthod 65:53 1- 538, 1914.
2. Armstrong MM: Controlling the magnitude, direction and duration of utraor.!1 force. Am J Orthod
59:211 - 243. 1911.
3. Jacobson A: A key 10 the understanding of extraoral forces. Am J Orthod 75:36 1- 386, 1979.
4. Mossey PA. Hodgki ns IFW, and Williams P: Oinica] technique. a safet y adaptation to Interlandi
headgear. Br J Orthod 18:131- 133. 1991.
5. Wieslandcr L: Denlofacial orthopedics: Headpr li erbst treatment in the mixed dentition. Jain
Orthod 18:551 -564. 1984. .
6. Teuscher U: An appraisal of 1I'O"1h and reaction 10 extra oral anchorage. Am J Onhod 89: 113- 121.
1986.
1. Teuscher U: A growthrelated concept for skeletal class II treatment. Am J Orthod 14:258 -275. 1978.
8. Teuscher U. and Stockli P: Combined orthopedics. In Orthodont ics: Cumml Princi
pIes WId SI. Louis: C. V. Mosby Co.: 1985, pp 405- 480.
9. Van Reek U: Combination headpr activalor. J Clin Orthod 18: 185- 189, 1984.
10. Olubre C: Vertical COninX wi th a headgear.activator combination. J O in Orthod 24:618 - 624. 1990.
11. King GJ, Keding SO, Hocevar RA, and Wheekr n : Timint of treatment for aass 11 malocclusions
in children - a literature review. Angle Orthod 60:81-91, 1990.
12. Cangliaklsi n . Meistrell ME. Leung MA. and Ko JY: A cephalometric appraisal of edgewise class 11
nonextraction treatment with eXlraornl force. Am J Orthod Dentofacial Onhop 93:3] 5- 324. ]988.
Clla er
Removable Appliances
A remo"able orthodontic appliance is composed of ( I) a retenli ve part, which consists or the
various clasps (circumfe rential , Adam's. or ball clasp) that hold the appliances in
place; (2) the acrylic component, which gives it its particular size and shape; and (3)
the active or passive wirc component (bow, spring, screws) that expresses the action or
the appliance on the teeth.
I
- )
The biggest advantage of removable appliances is that they can be removed by the
patient whenever the social environment indicates it. 1- 3 Conversely, this presents their
major disadvantages: patient compliance and interrupted tooth movements.
I
-) Most
removable appliances need to be worn either full-time or for a number of consecut ive
hours during the day in order to obtain the dcsired treatment outcome. Unless the
patient agrees to cooperate fully, the treatment objectives will not be mel. In addition,
removable appliances mainl y have a tipping effect on the teeth.
I
-) Comprehensive
major bodily tooth movement is almost always obtained with fixed appliances.
The most popular removable applianccs are the vari ous modifications of the Haw-
ley appliances. The Hawley-type appliance has two primary purposes: as a retainer. to
maintain a status quo; or as an active spring appliance. to achi eve tooth movement
(Figs. E4. 1 through E4.6).
As a retai ner, it must retain the teeth in their proper positions. pennit the forces of
physiologic activity to act on the teeth when desired, and be hygienic, strong, and
esthetically and physiologicall y acceptable.
As a tooth-moving appliance, the Hawley appliance can be considered a limited
correcti on device. Realistic treatment objectivcs for Hawley-type appliances are usuall y
limited 10 tipping movcments of the leeth.
Individual incisor movcment by tipping can be easily done with a flexible spring
(0.014-inch or 0.OI 6-inch stainless steel wire with loops) behind the tooth (spring
retainer) (Fig. E4.3). Arch expansion in the lowcr arch can be obtained with a screw.
embedded in the acrylic of a lower retainer, which is activated by either the doctor or
the patient. Most screws provide I mm of tooth movement per one complete revolu-
ti on. A single quartcr-tum of the screw would produce 0. 25 mm of expansion. Be-
cause this type of space gaining through lipping is very unstable and relapse is hi gh.
the rate of active tooth movement should not exceed I mm/ month and not more than
a few millimeters of total expansion.
224 Part E AdjrmClil'/' Applianus
E4.1
Figures E4.1 through E4.3 A si ngle tooth crossbi te in the
anterior maxillary region. such as the right upper lateral
incisor presented in thi s case, may easil y be corrected with
a Hawley-type retainer with a helical spring made of 0.0 14-
inch round stainless steel wire and activated as much as the
tooth needs to come out of the crossbi te. This case is ideal
for this treatment because not only is there space mesi al to
the lateral, but also because thi s tooth is too upright com-
pared to its contralateral counterpart, thus allowing the tip-
ping movement provided by the spring retainer to bring it
to its correct inclinati on. The appliance shown here is from
another patient for correcti on of the centrals. The labial
wire is an O.030-inch round retainer wire. The lingual
springs are made ofO.OI6-i nch round wire.
E4.2
F'9UrtlS E4.4 and E4.5 After 3 months of full ti me appliance
,,;ear. Note the excellent incl inatio n of the later"l incisor.
Fl(lure E4.6 A lower spring retainer placed on lower an teri
on with minor crowding ( I to 2 mm). It should be reo
D\O\'ed at night to avoid swallowing.. The wire is a O.O3().
inch round retainer wire.
References
E4.S
I. Proffil WR: COfllertlporary OrthodQflI;cs. 51. Louis. MO: C. V. Mosby Co . t986.
Ch.plt'r 4 Removable A,Jpliances 225
2. GT1lber TM. and Swain SF: OrthodOfllics; Currenl Pr;1JClpln und Thn;ques. 51. Louis. MO: c.v.
Mosby Co., 1985.
1. Moyers RE: Ifulldbook o!Orl hvdolJlics. lrd edilion. Chicago: Year Book Mcdicall' ublishcrs. 1984.
======C:i:,;a Ie r
Functional Appliances
Gro"'th modification is theoretically expressed in the following three ways: I (I) by an increase
or decrease in the size of the jaws: (2) by redirecti on. even if tne absolute sile
remained the same; and (3) by acceleration of growth. Although histologicall y evident
and statistically significant, an absolute change in size is clinically insignificant. Redi-
recting growth in another direction has been shown to be of some value. A patient
with a severely prognathic mandible might benefit from redirection of his or her
growth in a more downward than forward manner. ' Acceleration of growt h shortens
treatment time and provides a better jaw relationship sooner. Correcting a skeletal
problem through growth modification should begin I to 3 years before the adolesccnI
growth spurt, so that the maximum effect may be obtained in the shortest possible
time frame. This is done by usage of functional
l
-
lO
and extraoral appliances. I
The term " functional appliance" refers to a variety of rcmovable appliances de-
signed to alter the arrangement of the various muscle groups that influence the
function and position of the mandible in order to increase its length. A number of
clinicians believe that this is best achieved by 2 to 3 mm incremental advancements of
the mandible every 4 to 5 months, because Ihis decreases the risk of muscular fatigue
as each new forward position of the mandible results in renewed growth stimulation of
the condyle.
21
In general, the use of functional appliances remains very controversial. Minimal
bone growth increase (2 mm), along with the creation of dual bites in patients., put
them in an unfavorable position in the armamentarium of the modern practitioner.21
Most functional appliances induce mandibular function in a predetermined posi-
tion, usually 3 to 8 mm anteriorly to the centric relation position (class II
correcti on).I2- I' This stretches the soft tissue and muscles, which in tum transmit the
resulting forces to the tceth (dentoalveolar changes) and to the skeletal substrate.
22
Functional appliances may retard maxillary growth in the same modality as head-
gear.
n
In addition, it has been shown histologically that new bone is formed in the
posterior aspect of the glenoid fossa, which usually resorbs after the stimulus (anterior
reposit ioning of mandible) is taken away.
The correlation between condylar growth and Ialeral pterygoid muscle activity was a
constant fmding in animal studics.'- IO It was proven that increased activity of this
muscle was correlated with increased condylar growth. Rather, it might be the tension
in the posterior part of the condylar capsule-caused by the activity of the lateral
pterygoid muscle-that may be responsible for increased condylar growth.
22
The
resultant tension of structures in the posterior part of the capsule decreased after a
maximum level of activity 6 to 8 weeks after the start of treatment. A constant
reactivation may, therefore, be important in obtaining a maximum condylar growth
response.
22
Tipping of teeth and dentoal veolar changes are the effects of functional appli-
ances.
21
Class II correction comes from nearly 50% skeletal and 50% dental changcs.
22
Functional appliances that promote a class II dentoalveolar correction arc the Activa-
228 Par1 [ AdJ1I1ICfit1' Appliancn
Figures E5.1 and ES.2 The Bionat or funct ional appliance.
Note the anterior (end-to-end) position of the mandi ble
relati ve to the maxilla. The patient bites into this anteriorl y
directed posi tion and thus theoreticall y stimulates bone
growth. Also note the bul ky acrylic in the patient's mouth.
ES.2
ES.3
Figure ES.3 The Frtinkel functional appliance has bucai
and lip pads to keep the softtissuc pressures off the tttth
and thus promote arch development. It, like the bionatOf,
keeps the mandible in a more anterior position.
tor, the Bionator (Figs. E5. 1 and E5.2), the Fronkcl (Fig. E5.3), the Herbst, and the
Jasper Jumper (Figs. E5. 4 through E5.7). The last two arc fixed-not removable-
appliances. Appliances that help to correct a class III problem use li p and buccal shield
pads to relieve the maxillary dentoal veolar complex from any extreme pressure, so
that it may grow to its full potential (Frankel III ). Such appliances require extreme
patient cooperation to have any effect. A number of studies have shown that the
average increase in mandibular growth was 2 mm,,
12
-
16
,22 At the end of t reatment
with functi onal appliances, one might achieve a mean growth modification of 2 mm,
which is clinically insignifi cant (6 mm of bone growth to correct a full class II maloc-
cl usion into a class 1).23
Flgu,.. ES.4 and ES.S The Herbst appliance is a fIlted func-
tional appliance (cemented onto the teeth with bands or
kl}'lic) that solves the problem of paticnt cooperation. Its
drect in actual bone growth is, like all othcr functional
appliances. questionable for the majorit y of patients.
,.".. ES.6 and ES.1 The Jasper Jumper (American) appli.
mer is a modification of the Herbst appliance. It is actually
attached onto the main archwire and, like the previous
appliances, keeps the m(lndible in (I forward position.
Ch'pler S Funcri ono/ Appii anaJ 229
The best controlled clinical studies of functional appliance therapy have been
unable to show clinically useful increases in mandibular length.
2
.( Recently. it has
been shown that bone formation at a histologic level docs take place in the glenoid
fossa after functional appliance therapy. The increased fibrous tissue of the disk
posterior to the condyle appears to stabili ze the anterior condylar displacement. This
fibrous overgrowth (in conjunction with possible muscle splinting) may explain why
the mandible cannot be manipulated back after functional appliance therapy, thus
giving the false impression of a class II correction. Within a matter of months, such
fibrous tissue resorbs and the mandible partially returns to its origi nal JX>Si tion.
2
'(
230 I'lirt E Adjllnclil'C' Applia//CC'J
The dramatic results shown in some European studies required more Ih:m 2 years
of full-time appliance wear.I-S Other studies
24
-
29
have demonstrated the effects of a
headgear/ functional appliance combi nation wi th similar results: improvement of Ihe
occlusal discrepancies, but wit h great cooperat ion and the necessity to use fixed
appliances to finish the cases ideall y. If this type of therapy is to be attempted. then
the growth potential in the early mixed dentition would be as favorable or even better
than in the pubertal age groups.2
The full correction of class II, division 2 malocclusions inlo a class I through the
use of the bionator functional appli ance has been demonstrated in the literature; but,
agai n, after very lengthy treatments of as much as 7 years (8 to 15 years of age) with
15 to 18 hours of wear a day.J' Arch expansion gained wi th the Frankel appliance
through the acti on of the vestibular shields (that displace the attachment of the lips
and cheeks at the sulci in an outward direction, thus allowing the development of the
apical base) seems to be more stable than expansion seen with fixed appliance treat-
ment. Again, the major disadvantage of the Frankel therapy is the length of full-time
wear (2.5 to 4 years) of a bulky appliance to obtai n this desired result .
In a recent study on the changes in mandibul ar length before. during. and after
successful orthopedic corrl'Ction of class II malocclusions using a functional appliance,
it was found that there is no significant di flcrence after 4 years between the control
and treated individuals.
20
In addition, it was concluded that the greater the result, the
greater the relapse potentia1.
lO
The mai n causes of relapse after Herbst treatment were
a persisting lip- tongue dysfuncti on habit and an unstable cuspal interdigitation after
treatment.
JS
In general, functional appliances have onl y a temporary impact on the
existing skeletofacial growth pattern.
lO
In other words, the inherent morphogenetic
pattern domi nates over the treatment procedure.
lO
Functional appliances have been shown to be of clinical use in certain cases of
hemifacial microsomia.
36
- lf: The generat ion of normal muscle balance in the absence
of a condyle results in suffi cient bone apposition to restore symmetry. It is speculated
that the less severe the deformit y. the greater the likelihood of a fa vorable response.
Although st ill cont roversial, persons who have small mandibles may benefit more
from functional appliance therapy than patients with normal-sized mandibles.
l9
A functional appliance that is simple and not bulkier than a pair of upper and
lower Hawley retainers is the modified Chateau (Great Lakes) appliance.
40
It si mpl y
has a wi re configuration that comes down from the maxillary Hawley appliance
toward the lingual of the lower incisors and slides down the acrylic of the lower
Hawley on the lingual side. thus forcing the mandible to be in a protruded posi ti on.
The patient believes that he or she has retainers and does not object to wearing the
appliance 24 hr/day (see Figs. FI .30 through FI.35).
References
I. Proffit WR: COfItI.'lPlfKJ'ary' OrthOOQl'lllo. St. Louis. MO: C. V. Mosby Co .. 1986.
2. Fn\nkel R: The treatment o( class II . division I malocclusion with functional corm:tors. Am J Orthod
SS:265 -27S. 1969.
3. Frllnkel R: Guidance of eruption wi lhout edrat lion. Transactions. European Orthodontic Society
303-3 15. 1911.
4. Frllnkel R: Decrowding during erupt ion under Ihe screening inl1uence of vestibutar shields. Am J
Onhod 65:372 - 406. 1974.
5. Frllnkd R: A functional approach to trtlltment of skek:tat open bite. Am J Orthod 84:54-68. 1983.
6. StockJi rw. and Willen HG: Tissue reactKlns in the temporomandibular JOint resulting (rom anterior
displacement o(the mandible in the monkey. Am J Orthod 60: 142- 15 5. 1971.
7. McNama1'll. JA. Jr.: and Skl'lt1al AdaPiotioru /0 Altered Oro/acilll Function Ann Arbor.
MI: Monograph I. C1'lI.niofaciai Growth Series. Center for li uman Growth and Development. Unhcr
si ty of Michigan. 1972.
8. McNamarn JA. Jr .. Connelly T, and McBride Me: IIIJlo{ogico{ Slrwws 0/ 'n 'mporomorrd,bulor Jmm
AdaPialimu. Dl1rrminoms of Mandibular I-"orm arid Gf(, ... th Ann Arbor. MI: MonogrJph 4. Cranio-
facial Growth Serit'S, Center (or Human Gro .... "th and Development, Unhersit) of MIChigan. t975.
Chapler 5 FUllcl/(Hlal Appliallces 231
9. McNamara JA. Jr., and Carlson DS: QuaOli lalive anal ysis of temporomandibular joint adaptations 10
protrusive fu nction. Am J OrIhod 76:593 - 6 1 1, 1979.
10. MeNamar.l JA, Jr.: Funelional detenninants of craniofacial sia and shape. Eur J Orthod 2: IJ I - 159.
1980.
II. Wic:slander L. and 1 L.: 'The effect of activatOf" treatment on class II maloa:lusions. Am J
Orthod 75:20 - 26, 1979.
12. Panchen: H: Treatment of class II malocdusions hy jumping the bite with the Herbst appliance: A
cephalomet ric in vestigation. Am J Orthod 76:423- 441. 1979.
13. Panchen: H. and Anehus-Pancherl J: MU5de aclivily in claM II. divisron I malocclusions ITeale<! by
jumping the bite with the Herbst appliance: An eiectromyosrJphic study. Am J OrIhod 78:32 1- 329.
1980.
14. P'Jnchen: H, and Anehus- Panchen J : The effect of oonlinuous bite jumping with the Ilcrbsl apphance
on the mast icatory system: A functional analysis of treated class II malocclusions. Eur J Onhod
4:37_ 44.1982.
15. Langford NM. Jr.: The lIerbst appliance. J Clin Onhod 15:558- 561. 19111.
16. Langford MN. Jr.: Updat ing fahrication of the Herbst appliance. J Cl in OrthOO 16:173- 174,1982.
17. Howe RP: The bonded Herbst appliar"K:e. J Oin Orthod 16:663 - 667. 1982.
18. Ekstrom C: Facial growth' mte and its relation 10 somalk matumtion in htalthy children. S .... -ed Dent J
(Suppl ll ) 1982.
19. Panchen H. and Fackel V: The skeletofacial growt h pauem pre and post-dentofacial orthopaedics. A
Iong-Ienn study of dass II malocclusions treated with the Herbst appliance. Eur J Onhod 12:209- 218.
1990.
20. DeVincen7.Q JP: Changes in mandibular length before. during and after successful ort hopedic oorrtetion
of Class " malocclusions, using a funclional appl iance. Am J OnhOO Dentofarial Onhop 99:241 - 257.
1991.
21. Bishara SE, and Ziaga RR: Functional appliancc:s - A review. Am J Onhod Ikntofacial Onhop
95:250-258.1989.
22. Wieslander l.; [kntofacial orthopedia: lleadgrar-Herbst lreatmenl in the miled dentition. JOin
Onhod 18:551 - 564. 1984.
23. Melsen B: C llffl'lII COlllfOl"I"Jil'S in OrthodOlllicJ. Chicago: Quintessence Publishing Co., 1991 .
24. Woodside 00, Metallas A. and Altuna G: The innuence of fu nctional appliance therJPY on glenoid
fossa remodeling. Am J Onhod Dcntofacial Onhop 92: 18 1- 189, 1987.
25. Teuscher U: An appraisal of growth and reaction to extraor'JI Am J On hOO 89: II 3- 121 .
1986.
26. Teuscher U: A gro .... 'h-rdated concept for skeletal class II lreatment. Am J Onhod 74:258 - 275. 1978.
27. Teuscher U. and Stockli P: Combined activator. headgear on hopediC"$. In Orthodonlil'j ' Current Prlnci -
pit'S onO Ter;hrllquN. SI. Louis. MO: C.V. Mosby Co .. 1985. pp 405- 480.
28. Van Beek H: Combinat ion headgcaractivator. JOin OnhOO 18:185- 189, 1984.
29. Chabrc C: Venical control with a headgcar8l'livator combinati on. J Oin OnhOO 24:6 18 - 624. 1990.
30. Valant JR, and Sioclair PM: Treatment effects of the Herbst appliance. Am J OrIhOO Dcntofacial
Onhop 95:1J8- 147. 1989.
3 1. Ruiter RR. and Witt E: Corrttl.ion ofclass II. division 2 malocclusions through the u.sc of the bionalor
appliance. Am J Onhod Dentofacial Onhop 97: 106- 112, 1990.
32. Frankel R: Decrowding during CfIlption under Ihe scrttning inRlK; nce of shields. Am J
Onhod Dcntofacial On hop65:372- 406, 1974.
33. Hi nc DL, and O ..... en AH III : The stabi lity of the arch expansion elfeets of Frankel appliance therJPY.
Am J Onhod Ocntofacial Onhop 98:437 - 445. 1990.
34. Ul ackwood 1-1 0 III: Clinical management or the Jasper Jumper. J Clin OnhOO 25:755- 760. 1991 .
35. Panehen H: A cephalometric long-term investigation on the nature of class II relapse after Herbst
appliance treatment. Am J Orthod DenlofaciaJ Orthop 100:220- 233. 1991.
36. Kaplan RG: Induced cond)'lar growth in a patient with hemifacial microsomia. Angle Onhod 59:85-
90, 1990.
37. Mel.scn B. Bjerrejaard J, and Bundgaard M: The effect of treatment with functional appliance on a
pathologic growt h pal1em of the oondyk. Am J OnhOO 90:503. 1986.
38. Epker BN. and Fish LC: /)('tIfo/aciaJ l)(formlli es: I ntf'gfOlt'd Or/hot/mille alld S/lrgirnJ COff('C/ IQII. vol.
II . S .. Louis. 11.1 0: C. v. Mosby Co. 1986.
39. Mamandras All , and Allen l P: Mandibular response to onhodontic treatment wi th the hionator
appliance. Am J On hOO Dentofacial Onhop 97: 113- 120. 1990.
40. 11.1 : Orthopt>dil' Dmlo/al'iaJe. BaJl'j f "'or!d0l1l('tIfaJN. Paris: Julien Prtlat. 1975 .

Clta l e r
ChinCup Therapy
Strong orthopedic forces in the range of 400 to 800 g might be used to reduce a mandibular
prognathism with the usc of the "chin-<: up" appliance
l
-
1o
(Fig. E6. 1). Alt hough a
number of significant craniofacial alterations have been noted in patients who under-
went orthopedic chin-<: up therapy (i.e .. retardation of mandibular growth).,,6 it seems
that a complete inhibition of m:lOdibular growth is difficult to achieve.' Growth
always conti nues when a chin cup was worn for 12 to 14 hours per day. which seems
to be the most practical length of time to expect most patients to wear this
appliance.
I
-
4
,B Alteration of the directi on was limited to the period that the force was
applied.' Inheri ted growt h direction seems to be maintained and to recover when the
mechanical intervention is removed.'
Chin-<: up therapy docs not necessari ly guarantee positive correcti on of skeletal
profile aftcr complete growth, because t he skeletal profi le is greatly improved during
the initial stages of chin-cup therapy but is often not maintained thereafter.' In order
to have any permanent results, the patient would have to wear the appliance for ma ny
years, well past the completion of growt h, Although there have been promising reports
in the literature on the combination of chin-cup therapy foll owed by headgear for
vert ical control (open-bite cases), the long-tcrm effects of chin-cup therapy for class III
treatment is still questi onable.' In addition, although in a recent study it was con-
cluded that chin-cup therapy docs not seem to present a functi onal ri sk.IO one cannot
ignore the fact that its posteriorl y directed force puts a strain on the temporomandib-
ular joint (especially if the chin cup is worn for a number of years), The chin-cup
appliance needs to be worn well past the cessation of mandibular growth (about 10
years of wear, from 5 to 15 years of age or even more!), something that may not be
very practical or easily accepted by the patient. Alternative treatment methods cer-
tainl y need to be investigated.
234 Part .: AdJuncti)'/, Appliances

'61
Figure E6.1 Chin-cup appl iance in place.
References
I. hie M. and Nakamura S: Orthopedic approach to 5CVCTl: skeletal class III malocclusion. Am J Orthod
67:377-392. 1975.
2. Mi13ni H: Occlusal and craniofacial growth changes during puberty. Am 1 Orthod 72:76-84. J 977,
3. Sakamoto T: Effective timing for the application oforthopc<lic force in the skeletal class III malocclu-
sion. Am 1 Orthod 80:411 - 416. 1981 .
4. Mi13ni H: Prepubertal growth of mandibular prognathism. Am J Orthod 8O:546-S53. 1981.
5. Grnbf-r L W: Olin cup therapy for mandibular prognathism. Am J Orthod 72: 23-41. 1977.
6. Wendell PD. Nanda It. Sakamoto T. and Nakamurn S: lk dfects of chin cup therapy on the
mandible: A longitudinal study. Am J Orthod 87:265-274. 1985.
7. Mitani H. and Sakamoto T: Chin cup foTCt to a growing mandible. Angle Orthod S4:93- 122. 1984.
8. Sugawara 1. Asano T. Endo N. and Mitani B: Long-tenn effects of chin cup therapy on skeletal profile
in mandibular prognathism. Am J Orthod Dcntofacial Orthop 98: 127 - 133. 1990.
9. Pearson LE: Vertical control in full y-banded orthodont ic treatment . Angle Ort hod 2OSR-224. 1986.
10. Gavakos K. and Witt E: The functional status of ort hodontically treated prognathic patients. Eur J
Ort hod 13: 124- 128. 1991.

Thumb Sucking and Habit Control
lroJonged digit- or pacifier-sucking and tongue-thrusting habits have long been believed to be
causative factors in a variety of maloccl usions. The most common form of digit
sucking is thumb sucking. l-s Graber
l
points out that three modifyi ng factors-
duration, frequency, and intensit y- are extremely important and must be recogni zed
and evaluated before the question of damage to the teeth and the ti ssues is answcred,2
Dental effects include ( I) labial inclination or displacement of maxillary incisors with
increased overjet , (2) ovcrerupt ion of posterior teeth, (3) decreased overbite or anterior
open bite, (4) linguoversion of mandibular incisors, (5) posterior crossbite, and (6)
class II molar relationship. Skeletal effects include a lowered mandibular posture and
autorotation. Spontaneous correction of some components of dental malocclusion is
likely if the habit stops by the early mixed dentition.
Tongue thrusting may be defined as an abnormal tongue, perioral, and facial
muscle posture and activity during deglutiti on or at rest. A di rect cause-and-effect
relationship between tongue posture, tongue thrust, swall owing, and malocclusion
certainly must be questioned:' With the increase in overj et that accompanies so many
finger-sucking habits, normal swallowing patterns become increasingly difficult. Peri -
oral muscle aberrations, compensatory tongue thrust during swall owing, and abnormal
mentali s activity may accelerate the malocclusion.
l
Treatment for chronic digit sucking and tongue thrusting during the mi xed dent i-
tion should begin with the si mplest form of therapy. For digit-sucking habits, behavior
modification may be attempted first , usi ng rewards, encouragement, and reminders.
The success of these treatment modalities is judged by both cessati on of the habit and
significant improvement of the malocclusion. In their article on the effectiveness of
vari ous methods of treatment of thumb sucki ng, Haryell et aLl suggest that palatal
crib treatments are more effective than psychologic treatment or palatal arch treat-
ment. They also found that the majori ty of those treated with the crib stopped the
habit in 7 days, and mannerisms did not develop more frequentl y than in those
subjects whose habits had remained active. It should be noted that good rapport with
the patient might reduce the incidence of mannerisms and arrest other associated
habits. These findings are in accordance with Graber's view that thumb sucking is a
si mple learned habit (learning theory) without an underl ying emotional disturbance.
If thc simple attempts fail , then one may try the Thumbsucking Control Appliance
(TCA) (GAC) (Figs. E7. 1 through E7.7). It can be vcry easil y constructed by bending
two to three consecuti ve loops on an O.036-inch wire that is designed to fit into the
lingual sheaths of the upper first molar bands. j ust like a regular transpalatal arch
(TPA).' This requi res minimal ehairsidc time (3 to 5 minutes) and can be adjusted to
cover the whole span of the patient's open bite, making insertion of the thumb in the
mouth vcry difficult. It is also available in various sizes (preformed).
Bands are fitted on the first maxillary molars and the TeA is inserted late on a
Friday aft ernoon. The child is advised that if he or she quits the habit. the TeA wi ll
be removed Monday morning before he or shc goes 10 school, but the bands will be
236 Part E Ar;pliancf'$
E7.1
Figure fl. 1 The TCA (GAC) appliance.
E7.3
Figure E7.2 Open bite from chroni c thumb sucking and
subscqUCnl tongue thrust.
E7.'
FtgUre E7.3 The TCA (GAC) in place. The loops block the
entrance of the thumb (or any other object) in the mouth.
The patient may still eat comfortably from thc side.
Figure E7.4 The appliance comes passively over the lown
incisors (wi thout touching them) and tcrminates at the ves-
tibule (without contacting the soft ti ssue). The palatal seg.
ment of the wire behind the upper incisors prevcnu an)'
tongue thrust.
left in place for at least I to 2 months. If the habit is initiated again, it is very easy to
re-insert the same appli ance in the mouth. The child usuall y complies with this
treatment and looks forward to Monday morning. The open bite from the habit
should show improvement after cessation of the thumb sucking, within 2 to 4 months.
Oral hygiene instructions. along with the recommendation that the parent watch the
patient on occasion during sleeping hours to make sure that the patient is not sucking
his or hcr thumb, arc part of the thempy plan.
It should be noted that this appliance will work if there is significant overbite and a
marked overjet . There must be enough so that it will not interfere with mandibular
function. The clinician should be cautioned not to allow the lower incisors to impinge
on the wire; ot herwise, a functional retrusion would be enhanced.
The TCA can also serve as a tongue block, as the tongue contacts the palatal wire
of the appliance upon swallowing (tongue thrust prevention). It can also be expanded
to alleviate any crossbites in the first molar region. just like a transpalatal arch (TPA).
When used as a tongue thrust control appliance. the TCA should be left in place for 2
to 4 months (so that the tongue can " learn" to obtain a new position upon swallowing).
FIgure E7.5 The patient dislikes Ihe appliance, but he can
!Iill hide il upon smil ing.
E1.6
FigIK .. E7.6 and E7.7 A 3-mm open bile was significantl y
rtduccd within 3 months after insertion of the habit appli -
lllC'e and cessati on of the habit. ( Reproduced from Viazis
AD; The Triplc-loop corrector (TLC): A new thumbsuck-
1111 habit control appliance. Am J Orthod Dcntofacial
Orthop lul y:9 1-92, 1991. With permission of Mosby- Year
Book, Inc.)
Chapler 7 Thllmb Sucking and Habit Comro/ 237
238 Part E Adjuncti,'!" AjJp/i anc!"s
References
I. Graber TM: Thumb and finger sucking. Am J Orthod 45:259- 264, 1959.
2. Popovich F. and Thompson GW: Thumb and finger sucking: Its relation to maloccl usion. Am J Orthod
63: 148- 155, 1973.
3. Uarycu RD. ct at: Chronic Ihumbsucking: The psycholos.ical effocls and relative effectiveness of various
mc:thodsoftreatment. Am J Orthod B :569- 585, 1967.
4. American Association of Onhodonlists: Oral habits: Non-nutritive sucking and tongue throsting. Onh()<-
dontic Dialogue 4:2- 3. 1991.
5. Viazis AD: The triple-loop corrector. Am J Onhod Dentofacia.l Onhop 100:91 - 92. 1991 .

C" (I
Protraction Facemask

l' laxillar)' deficiency occurs in a large percentage of class III skeletal malocclusions (20% to
50%}.1.2 h is indicated by a straight vertical shadow from the infraorbital margin.
through the alar base of the nose. to the corner of the mouth. The reverse-pull
facemask in combinati on with a fi xed palatal expansion appliance is proposed as the
treatment method of choice for earl y interception of class III malocclusions
'
-
'o
(Figs.
Eg.1 through E8.6). Treatment should Ixgin as soon as the ma.xi ll ary central and
lateral incisors and ma.xilJary first molars have completely erupted.' Rapid palatal
expansion can produce a slight forward movement of point A and a slight downward
and forward movement of the malti lla.
l
.
4
The effect of such expansion is to disrupt the
maxillary sutural system, thus possibly enhanci ng the ort hopedic ellect of the facial
mask by making sutural adjustments occur morc readily.'
Several investigators have demonstrated the dramatic skeletal changes that can be
obtai ned in animals with continuous protraction forces to the maxilla.)-J The entire
maxilla is displaced anteri orly, with significant effects as far posteriorl y as the zygo-
maticotemporal suture.
l
-
S
The facial mask is secured to the face by stretching elastics from the hooks on the
maltillary splint to the crossbow of the facial mask. Heavy forces are generated, usually
through the use of i-inch, 14-oz elasti cs bilaterall y. The current version of the facial
mask is made of two pads that contact the soft tissue in the forehead and chin
regions.' -'
In instances in which no transverse change is necessary. the expansion appliance is
acti vated once a day for a week to produce a disruption in the sutural system that
facilitates the action of the facemask. A week later. the facemask therapy is initiated.
The position of the crossbar is si milarl y adjusted in the vert ical dimension to all ow the
clastics to pass through the interlabial gap without producing discomfort to the patient.
The elastics travel in an inferomedial direction anteriorly from the hooks on the splint
to the crossbar (Fig. E8.5}.10 If the tendency of an anterior open bite is suspected in a
patient . an anterior si te of protrJction is required (bicuspid or even in front of the
cuspid) (Fig. E8.4). Care must Ix taken that the clastics do not cause irritation to the
comers of the mouth. The patient should wear the facemask on a full-time basis.
except during meals. Young patients (5 to 9 years old) can usuall y follow this regimen.
panicularly if the patient is told that the full-time wear will last only 3 to 5 months.
The patient should be secn every 3 or 4 weeks to check on the condition of the
splint and to evaluate the hard- and soft-tissue changes. The facial mask is usuall y
worn unti l a positive overj et of 2 to 4 mm is achieved interi ncisally.
The possible treatment effects include' -' a forward and downward movement of the
maxilla, a forward and downward movement of the maxillary dentition. and a down-
ward and backward redirection of mandibular growth.
Although several investigators have claimed definite orthopedic adva ncement of the
maxilla wi th reverse-pull mechanics, the proof of such movement is somewhat ques-
tionable because the same results have also been observed in patients who had only
palatal expansion. The increase in maxi ll ary length could also be attributed to growth. 10
240 ''an t: AdJllooivf' Appil(JtI("('s
Figures ES.2 and E8.3 A class III occlusion. Note the end-to..
end incisor relat ionship. Also note the flared upper incisors
(this is a contraindication to further dental tipping to
correct the malocclusion).
Figure E8.t Patient with a slightly deficient maxilla, which
can be detected clinicall y by bl ocking out the mandi ble and
noticing a straighl li ne that comes vert icall y from the C)'t-
brows to the cheek contour- normall y the cheek should
project 3 10 4 mm in front of this imagi nary line.
Figure E8.4 Bonded rapid maxillary expansion (RME) with
hook in front of the cuspid to receive the elastics.
E8.6
F"9We E8.6 The patient's profile shows improvement 3
mont hs into treatment .
ClUlp' t'r 8 ProtractIOn Fact'mask 241
E8.S
Figure E8.S The prolrnction facemask In place. Note the
inferior direction of the elastics.
24 2 PaI1 t: AdJllnctil1' App/lofICt'S
References
I. Guyer EC. Ellis EE. McNamara JA. and RG: Components of class I[ malocclusion in
juvenilc:s and adolescents. Angle Orthod 56:7 -30. 1986.
2. Elli5 E. and McNamara JA: Components of adult class III malocclusion. J Oral Maxillofac Surg
42:295-305.1984.
3. Jackson GW. Kokk h VG, and Shapiro PA: response to anteriorly diTe(:tro force
in young Macaw nt'IIIt's/rina. Am J Onhod 75:319- 333. 1979.
4. Kambara T: IkntofaciaJ changes produced by u tra-oral forward force in the Macaea /fUf Am J
Orthod 7 1:249 - 277, 1977. .
5. Nanda R: Protraction of maxilla in rhesus monkeys by controlled extraoral forces. Am J Orthod
74: 121-13 1. 1978.
6. Turl cy PK: Ort hopedic correction of class III malocclusion wit h palatal expansion and custom protrac-
tion headgear. JOin Onhod 22:314 -325.1988.
7. Nanda R: 8iomechanical and cli nical considerations of a modilied protraction headgear. Am J Onhod
78: 125-138,1980.
8. McNamara JA: An orthopedic approach to the treatment of class III malocclusion in young patients. J
O in Orthod 21:598-608, 1987.
9. Campbell PM: The dilemma of class III treatment. Angle Ort hod 53: 175- 191. 1983.
10. Mermigos J. Full CA. and Andreasen G: Protrnct ion of the maxillofacial complex. Am J Onhod
Dentofacial Or1hop 98:47 -55, 1990.
ell fer
Active Vertical Corrector
The characteristics of skeletal open bite may be recognizable at early ages, especially in
patients with long lower faces,,
4
Such patients would benefit from earl y treatment
and force distribution designed to hold, restrict, or redirect vert ical growth,4 especiall y
because these subjects appear to reach their adolescence at an earl y age. The timing of
initiati on of treatment in long faces in this sense is similar to that for a class III
malocclusion. Conversely, deep-.bite patients experience late pubertal growth spurts
and can be Ireated laler. They onen require prolonged retention to ride t he wave of
continued post-adolescence growt h.4
Treatment of skeletal open bites at young ages can be done with magnetic
appli,mces.' - 14 The most popular one is the Active Vertical Corrector (AVC) appli
anee. The A VCI is a si mple, fixed (24 hr/ day) orthodontic appliance wit h magnets
that intrudes the posterior teeth in both the maxilla and mandi ble by reci procal forces'
( Figs. E9. 1 through E9.4). By the use of effective posterior intrusion of tccth, the
mandible is allowed 10 rotate in upward and forward directions. The uniqueness of
this appliance is that it allows the clinician to correct anterior opcnbite problems by
actuall y reducing anterior facial height. The AVe is an adaptation of present-day
bite-block therapy. The Ave works as an energized bite block. The energy system is
obtained by the repell ing foree of samari um cobalt magnets. A specially designed
headcap and chin strap may be worn during sleep and at all other limes deemed
sociall y fitting by the patient to help keep the mouth closed. Followup on cases 3
years oul of AVe treat ment has shown little tendency for teeth to rc-crupt. A high-
pull headgear can be used in the retention phase for 6 to 12 months.
It has been found that posterior teeth intrude an average of 1.5 mm, thus resulting
in an average of 3 mm of anterior open-bite closure over an 8-month treatment period
(600 g of repell ing force/side).M.1l.14 Addi ti onal significant cont ribut ions to the correc-
tion of the open bite were due to maxi llary incisor eruption and lingual tipping
combined with mandibular incisor lingual movement." A small amount of mandib-
ular bite-closing rotation and a decrease in anterior facial height have been noted. but
there were only minimal skeletal changes in the sagittal direction attributable to AVe
therapy.' 14 Any side effects of Ave therapy (i.e .. creation of buccal crossbites from the
repelling force system) could possibly be diminished by using a less powerful magnet
system or decreasi ng the treatment time. LJ Treatment of severe open bites that are
skeletal in nature has been reported in the literature,ll-16

2 44 Part E Adjuncti)" App!iancN
Agure E9.1 The A ve appliance is bonded by etching the
buccal and lingual surfaces of the posterior teeth (just like
a bonded rapid maxillary expansion (RME) appli ance).
FiglKe E9.3 The lower bonded AVe in place.
E9.2
Figure E9.2 Adhesi ve is placed in Ihe buccal and lingual
sides of the appliance and is laler lighl< ured in the moulh.
E9."
Figure E9." The complete AVe in place. The rtpcllins
forces from the magnets will intrude the posterior teet h I
to 2 mm over 3 10 5 months of wear.
Ch.ptCOf 9 Aam' IIfT1ical Corrtxtor 245
References
I. Nanda SK. and Rowe TK: Circumpubenal growth spun related to ' "nticaJ dysplasia. Angle Onkod
59:11]-122.1989.
2. Chafari J. Clark RE, Shofcr FS, and Bernan PI I: Dental and occlusal characterist ics of children with
neuromuscular disease. Am J Onhod Dentofacial Onhop 9]: 126 - 1 ]2, 1988.
] . Nanda SK: Patterns of venical growth of the faces. Am J Onhod Dentofacial Onhop 9]: ]03- ! 16, 1988.
4. IJishara SE, Jami son JE. Pcterson LC. and DeKock WH: Longitudinal chanllt:S in standinll height and
mandibular parametcors between the ages of 8 and 17 years. Am J Onhod 80: I 15- 1]5, 1981 .
5. Kalra V, BUrstODC CJ . and Nanda R: Elfecu of a lUed magnetic appliance on the dentofa(ial
Am J Orthod Dentofacial Onhop 95:467 - 478. 1989. .
6. Pearson LE.: Vutical control through use of mandibular posterior intrusi'e foras. Ang,Ie Onhod
4] :194-200.197J.
7. Pearson LE: Vertical eontrol in treatment of pali ents having backward-rotational growth tendencles.
Angle Orthod 48:132- 140, 1978.
8. Delli nger EL: A clinical assessment of the Active Venical Corrector-A nonsurg.ic,:al alternative for
skeletal open bite treat mcnt . Am J Onhod Dentofadal Orthop 89:428-436. 1986.
9. Kalra V. Bumone CJ . and Nanda R; Elfects ofa magnetk appliance on the dentofacial
Am J Onhod Denlofacial Orthop 95:467 - 478. 1989.
10. Vardimon AD. Graber TM, Voss LR. and Verrusio E: Magnetic versus mechanical expansion with
dilferent force thresbolds and points of force application. Am J Onhod Dentofacial Onhop 92:455 -
465. 1987.
! I. Vardimon AD, Graber TM. and Voss LR: Stability of magnetic versus mechanical palatal expansion.
Eur J Orthod II : 107 - 115. 1989.
12. Woods MG. and Nanda RS: Intrusion of posterior teeth with magnets. An experi ment in gro .... ing
baboons. Angle Onhod 58:136- 1 SO. 1988.
I] . Kilaridis S, Eat lillark I. and Thilandcr B: Anterior open bite treatment ... -jth magnets. Eur J Onhod
12:447- 457.1990.
14. Barbre RE. and Si nclai r PM: A cephal omctric evaluation of anterior open bite correction with the
magnetic active vertical corrector. Angle Orthod 61 :93- 102. 1991.
15. Martina R, Laino A. and Michelotti A: CIas.s I maloccl usion ""; th severe open bite skeletal pattcrn
treatment. Am J Orthod Dentoracial Orthop 97:]63-]7]. 1990.
16. Takeyama H, HouUlwa O. HOUlki T. and Ki yomura II: A case of open bite with Tumer ' s syndrome.
Am J Orthod Dentofacial Orthop 97:505- 509, 1990.
Orthodontic Treatment
Modalities
Par I

e ll t e r
Early Treatment

Early orthodontic treatment at J to 8 )'ears of age is directed toward preventing dysplastic
growth of both the skeletal and dentoalveolar componcnts.
l
.2 It alleviates functional
posteri or crossbites that can develop from cuspal interferences and the mandibular
shift that accompanies the crossbitcs. It prevents habits that can develop as a result of
tooth interferences and incorrect occlusion. Because crossbiles are seldom self-
correcting owing 10 Ihe relati onship of the pennanent to the primary predecessors,
earl y treatment can re-establi sh proper muscle balance and thus prevent adjustment of
the jaw muscles on the position that results from the habitual posturing of the
mandible (Figs, FI.I through FI.20).
Early treatment (phase I) can also prevent potential injury of protruding incisors in
severe overjet class II cases (Figs, FI.21 through F1.29). The clinician can also take
advantage of the juvenile growt h spurt to attempt functional appliance or headgear
therapy at age 8 to 10 years (Figs. FI.JO through FUS). Early treatment may be done
for esthetic considerati ons as well (Figs. FI .36 through FI.38).
250 "'rl t Orlht!donlic Treatment Moduli/lel
Figure Fl .l Dislodging a second molar stuck underneath the
distal surface of the first molar is quite easy to accompli sh.
Figure F1 .3 If the second molar maintains its excessive me
sial inclination. molar bands may be fitted on the two
teeth. and a flexible O.OI6inch NiTi wire will slowl y
upright the second molar in 2 months.
FIgure F1 .2 Pl acement of an onhodontic elastic separator
between these two teeth.
F1.4
Figure F1 .4 Posllreatment periapical radiograph showing tnt
uprightcd second molar.
FtgUre Fl .S This patient is in the mi xed dentition and demo
onstrJtes a labiall y displ aced ri ght cent ral incisor due to a
habit. whi ch has been discont in ued.
Agure Fl .7 Occlus:l.1 view. The wire is rull y engagt.-d without
Iny derormation. Its clastic pull will gradually bring the
tooth into alignment with the rest orl he inciwrs.
(bllpll'r I Early TrI.'Qlfllenl 251
Figure Fl .G A si mple 2 X 4 appliance (2 bands on the upper
first permanent molar tl:cth and 4 brackets on the upper
permanent inciwrs) with a O.016inch round ncxible NiTi
wire in place.
F1.8
Ftgure FUI Arter 1 month ortrealmenl.
252 Part F Orthodontic 1"l'Ottnf'nt ModulitiN
Fig,,", Fl .1 After 3 months of treatment. A four-uni t clastic
chain (C-chain) has been placed to close the existing spaces.
The later.lis (the most outer teeth of t he C-chain) have been
wire lied wi th ligature lies to prevent any undesirable rota-
tion of those teeth.
Ft .tt
Figure Fl .1l Plastic tubes may be placed to prevent irri ta-
tion of the cheeks from the long wire span.
FI .I O
Figure Fl .l0 After space closure is completed. the teeth art
tied together in a figure-8 fashion and held in place (from
another patient).
Figure Fl .12 A 3-year-old boy presented a complete anterior
crossbite from lat eral to lateral with a I-mm negati ve over
jet. Upon manipulati on of the mandible. the incisors 0b-
tained an end-to-end relationship. indicative of a ckntal
problem. ( Reproduced from Vadiakas G. and Viazis AD:
Anteri or crossbite correction in the early primary dentiti on.
Am J Orthod Dentofacial Orthop 102: 160- 162. 1992.
With permission of Mosby-Year Book. Inc.)
figure F1.13 A fixed (due to the age of the patient) W arch
with extcnded arms to the maxillary incisors was inscnt"d.
The arms were activated 1.5 mm in an anterior di rection.
(Reproduced from Vadiakas G, and Viazis AD: Anteri or
cros.sbi te correction in the earl y primary dentition. Am J
Onhod Dentofacial Onhop 102:160- 162, 1992. Wi th per
missi on of Mosby Year Book, Inc.)
FtguHI Fl .1S Six mont hs after the appli ance was removed,
the patient's bite was qui te normal wi th an improved over
bite relationship. ( Reproduced from Vadiakas G, and
Viazis AD: Anterior crossbite correcti on in the early pri
mary dentition. Am J Onhod Dentofacial Onhop
102:160- 162, 1992. Wi th permission of Mosby-Year Book,
Inc.)
Ctu. pt" I Early rrl'Ulmenl 253
Figure Fl .14 After 4 months, the pat ient was out of cross-
bite through tipping of the anterior maxillary leet h. (Rc.
produced from Vadiakas G, and Viazis AD: Anterior cross-
bite correcti on in the early primary dentiti on. Am J Onhod
Dcntofacial Onhop 102: 160-162, 1992. With permission
of Mosby. Year Book. Inc. )
254 Part'" Orthodontic 1"rt'tl/nu'n/ Modalllit'5
FI .16
Figure. FI .16 through Ft.16 This patient in the mixed denti-
tion has an end-to-end incisor relati onship that slides into
an ant eri or crossbite (underbite:). giving him a pseudo class
III mandibular prognathi sm appearance.
Ft.18
-
F1.17
Fl .t9
Figure Ft.11 A 2 X 4 appliance (2 bands on the: two 6rst
permanent molars and 4 brackets on the: incisors) and an
O.OI4-inch stainless steel archwire were inserted. A Slop
(si milar to the one used to hold the molars back after (!Kir
distal movement wi th coil springs) was placed in the arcll-
wire next to the molars, whieh kept the wire 2 mm anterior
to the brackets. It took 2 months for the activated ..... ill: to
bring the four teeth out of crossbite. Note the uneven inci
sal edges of the central incisors due to incorrttt bracket
placement on the left central incisor.
Ft .20
Agur. Fl .20 Patient after treatment. Note the improvement
of the pat ient's profile. Had this crossbite not been
rorrected, the functional effect of the forced position of the
paticnf s mandi ble anteri orl y could have resulted in a sig-
nifi cant skeletal probl em a few years later.
f l.22
figures Fl .22 and Fl .23 The pat ient presents with a 16-mm
o\'erjet, a full step class II molar relati onship. a linguall y
displ aced permanent lateral inci sor. and uneven gingi val
contours of the upper anteri or teeth.
Ch.pll'r t Early Tr!'atffl l'nt 255
Fl .2t
Figure Fl .21 The severe class II , division I malocclusion of
this case made a phase I treatment imperat ive for this pa-
tient.
256 rar1 F Orthodontic rrootml.,rt Modalllin
Figure Fl .24 A 2 X 4 appliance wi th a 0.016 X 0.022 inch!
rectangular Neoscntalloy NiTi wire and elasti c chains were
all that was needed to alleviate the generali zed spacing and
.Sf.were overjet. The right three-uni t elasti c chain is used to
dcrotate the left cent ral and close the midline diastema.
Note that the wi re in the right lateml is wire tied to the
bracket to prevent rotation of this tooth. The contralateral
central is not tied in order to have just that elft.oct of rotation.
Fl .26
Figure Fl .28 Two months later, the anterior spaces are
closed. Note t he second-ordcr bend placed to bring the left
lateral into proper alignment with the incisal edges of the
rest of the permanent anteriors. The bracket on this tooth
is placed too fa r incisally, due to the gi ngi val overgrowth in
that area.
Fl .2S
Figure Fl .25 The left clastic chain is placed along the mair
arehwi re and serves to bring the lefl laterJ.1 labially.
Figure Fl .27 At this point, the patient was referred to the
periodontist. The uneven gingival contours before perio-
dontal plastic surgery gi\'e this patient a very unpleasant
smile.
Flgur. Fl .28 After periodontal pl ast ic surgery. Note the dif-
fere nce in the gi ngival contours.
Ft .30
Figure Fl .30 After the 2 X 4 phase I treatment, t he overjet
is reduced but is still significant because or the mandibular
retrognathism.
Chapter t 1::arly Trea/II1I'1Il 257
F " ~ u r . Fl .2t The smile has improved significantl y.
F1.3t
Figure F1 .31 The patient is given a runctional appliance that
is composed or maxillary and mandibular Hawley retainers
(modified Chateau).
258 Part f' OrthodOllIlC Trt'tllml'n/ Modaillin
Figure Fl .32 The maxillary Hawley has a O.036-ineh round
wire that comes out of two tubes emtx:dded in the acrylic
and is directed toward the nom of the mouth. The wire can
corne out of the tubes, if desired.
F'SIure Fl.34 The appliance in place. Note the nonnal over-
bite and overjet relationship. The acrylic should be adj usted
occasionall y to facilitate tooth eruption.
Figure Fl.33 As the patient closes his mouth. the wire slides
along the lingual side of the lower Hawley, thus directinl
the maodibl e ant eriorl y.
F1 .35
Figure F1 .3S Not e the dramatic improvemcnt of the pa.
ticnt's profile with the appliance in place.
Fl .36
F"lfIUre Fl .36 This patient could not afford a rull onhodontic
treatment. Her chi ef complaint was the severely rotated
right central maxillary incisor (almost 90 degrees).
Fl .38
F"lQure Fl .38 In j ust J mo nths, the chief complain! was
addressed. The patient was extremely happy, and the pa-
tient's mother was graterul for the treatment.
References
Chllptc-T I Early .,-r('a/I1l1'nI 259
Fl ,37
FI9IJre Fl .37 A simple 2 X 4 appliance with a single arch-
wire (O.0 16-inch round NiTi) was used ror a minimal trcat-
mcnt ree.
I. Graber LW: Onhodonti cs-Statc of the An. Es.sencc of the Science. 51. Louis, MO: C. v , Mosby. 1986.
2. Proffit WR, and White RP: Surgical Orthodon/ic TrOOlll1C-ni 51. louis. MO: Mosby Year Book. 199t.
Tooth Guidance
(Serial Extraction)
The premature extract ion or deciduous tef!lh to correct thc alignment of the permanent incisors
is done under thc assumption that it is possible to predict at a very carl y age that thc
al veolar ridge wi ll not develop sufftcientl y to accommodate all thc permanent tccth,l
Rccontouring thc proxi mal surfaces of deciduous teeth instead of extractions is based
on thc same as.sumption,l Once serial extracti on is initiated, more often than not
bicuspids will have to be extracted owing 10 a deficiency in arch lengt h, I whi ch
probably is the dircct result of thc extracti on of Ihc primary tccth.
Ali gnment of Ihc permanent lower incisors depends morc on arch width (intcrcus-
pid width) than on arch length. I It appears that thc deciduous cuspids have a signifi-
cant influence on the developmcnt of the alveolar arches by maintaining integrit y of
contact from the permanent mola rs forward. I Extraction of the deciduous cuspids
causes a break in the contact with apparent adverse infl uence on the development of
the alveolar arch. The embryonic position of the lower lateral incisors is to the lingual.
and thus lower lalcml incisors erupt ing linguall y should be known as anatomicall y
corrcct.
1
As the latcml incisors move labially, the deciduous cuspids will be made to
move sideways, which creates more space for the accommodating of all anteri or teeth.
The profile of a patient wi th a long lowcr face. high mandibular plane angle, an
open-bile tendency, and severe crowding is an ideal case for a tooth-guidance proce-
dure ( Figs. F2. 1 through F2.7). It must be emphasized that the exact same situat ion in
a patient wi th a deep bite (short lower face height) would be a contraindicat ion for
serial extractions. In such a case, mechanics to gai n arch length through expansion or
di stal movement of the posterior teeth should be the treatment of choice, Ixx:ause
extraction even of only the primary cuspids would deepen the bite.
In a tooth-guidance procedure, teeth adjacent to the extraction sites do nOl move
equall y into the extraction space. Teeth anterior to the extraction sites move distall y
about twice as much as posterior teeth move mesially.2 In addition, there is no
advantage in early removal of bicuspids.
1
262 Put F Orthodontic 1 rMIlI/rlll ModalilU!s
Figures F2.1 through F2.4 Patient with a long lower face,
minimal to 0 mm overbit e, and severe crowding. This is an
ideal case for a tooth. guidance pr<>CWuTt.
F2.2
F2.4
F2.S
Figure. F2.S through F2.7 Arter extraction of the primary
cuspids, fixed appliances were pill ced (O.OI6-inch NiTi in a
2 X 4) to align the upper incisors. Note that Ihe lower
incisors align on their own as space is provided for thenl .
Also note thc positive overbite relationship that was ob-
tainm. The extraction of the primary first molars and first
bicuspids will follow later in lrealmcnl.
F2.7
References
Chllpler 2 To()/h Guidol/ce (SI' rial E.r:lrocl;OIl) 263
F2.6
I. Lee PK: Ikhavior of ttlIp'ing crowded lower inci50rL Jain Orthod 1980.
2. Creekmore TD: Tr:.:: lh want to be strnight. J Clin Orthod 764, 1982,
Clrapler
= =--
Tooth Recontouring
Interproximal reduclion ~ ' a s once limited to the mandibular incisors but has recently been
extended to the posteri or teeth with a technique called air-rotor st rippi ng (ARS).1.2 I
prefer to call this technique tooth recontouring (TR). This meth<xl resolves mild (I to
3 mm) to moderate (4 to 7 mm) crowding by reducing enamel where thc greatest
amount of enamel is present-distal to the cuspids.
,

2
A fine diamond bur is used to
remove 0.25 mm to 0.5 mm from each side of the posterior teeth. after adequate
space has been opened up with a Scntalloy (GAC) coil spri ng. As much as 0.5 to
I mm is removed from each tooth, thus allowing for about 3 mm of space in each
quadrant. This space is used to alleviate anterior crowding ( Figs. F3. 1 through F3.1 7).
There arc two ways to protect the recontoured surfaces.
1
-
1
One is by polishing with
an instrument such as a superfine diamond bur or a paper disc. followed by applica-
ti on of nuoride. The other is to apply a sealant after etching. 5 The second techni que is
much faster but raises questions such as how long the sealant lasts and what condition
the enamel will be in oncc the sealant has dissipated. Results of a recent study indicate
that the roughness produced by recontouring does not predispose to caries.' Remi ner-
alization appears a ft er 9 months. ' These findings substantiate those of other studi es
that found no increased susceptibilit y to cari es or pcri<xlontal disease after stripping.
II

1
Therefore. a sealant would only delay the remineralization that occurred between 6
and 9 months.' However, topical application of nuoride after recont ouring should be
encouraged.'
266 Plire t' Orthodontic Treatmt'tII Modo/llle.f
Figure Fl.1 The moderate crowding of this lower arch
(S mm) makt-s it ideal for tooth recontouring.
Figure Fl.l A scaler pushes the coil spring between the two
bicuspids.
F3.2
Figure Fl.2 In the TR technique, an Ni Ti coil spring is
placed fmt between the first molar and the second bicus-
pid. After 2 weeks, a 2-mm space has been created. The
mesial of the molar and the distal of the second bicuspid
are rccontoured with a fine diamond bur, 0.25 mm of
enamel is remo\'oo from each side. The next step is to
place the coi l spring between the first and second bicuspid.
Note the coil spring in its passive state. It extends from the
mesial of the second to the mesial of the first bicuspid.
F3.4
FlgUle Fl . Occlusal view from another case, showing tM
eompressed coil spring between the IwO bicuspids.
F3.5
rlgUr. Fl.5 T h ~ f i n ~ diamond bur as it recontours t h ~ teeth
(care should be taken to avoid undercuts and steps at the
gingival margin).
F3.7
Figure Fl.7 Patient with a class 11 SO% cuspid and class [
molar relationship due to oversized bicuspids.
Chapler 3 TOOl}, Rj'('()fj/ormng 267
F3.6
Figure F3.6 The case presented in Figure F3. 1 after comple-
t ion orTR.
F3.8
Figure F3.8 After TR, a space is created distal to the cuspid.
Elasti c chains wi ll bring it into a class I occlusion.
268 Put F Orthodontic Treatment Moda/iM!
F3.9
Figure F3.9 Rccontouri ng of indi vidual lL'Cth can be done in
the space provided by I wl'Ck of wear of a separator.
F3. t t
Flgurel F3.10 through F3.13 This patient demonstrates a class
J occl usion. a normal growth pattern, and moderat e c r o ~ d
ing in both arches (5 to 6 mm). The tooth recontouring
technique was the t reatment of choice for this case.
F3.13
Otapltr J TOtxh RtTOmourmg 269
F3.14
Figur" Fl.14 through Fl.17 AI the end or the orthodontic
treatment, a little over a year lat er. Note thc solid class I
cuspid rcl3tionship. The anterior tccth were rctrJctcd postc-
riorly, in the spaces provided from Ihc recontouring of the
posterior teeth.
F3.1S
References
I. Sheridan JJ: Air-rotor st ri pping. J Cli n Onhod 19:43-59, 1985.
2. Sheridan JJ: Air-rotor stripping update. J Oin Orthoo 21:781-788. 1987.
3. Philippe T: A met hod of enamel redudion for rorrcction of adult archlength di screpancy. JOin Or1hod
25:484 - 489, 1991.
4. EI. Mangoury NH, Moussa MM. MOSl.1lfa VA. and Girgis AS: Invho remineraliZll tion ancr ARS. J Oin
Or1hod 25:75-78. 1991.
5. Sheridan JJ , and Ltdou.l. PM: Air-rowf Slripping and pro.l.imal sealants-An SEM evaluation. JOin
Ort hoo 23:790- 794, 1984.
6. Crain G. and Sheridan JJ: Susceptibility to caries and periodontal disease after posterior air-rotor
st ripping. J O in OtI hod 24:84 - 85, 1990.
7. Radlansld RJ. Jager A. Schwestka R, and Bertzbach F: Plaque accumulation caused by interdental
Sl ripping. Am J Or1hod 94:416- 420. 1988.
8. Carter RN: Rq,ro.l. imation and m:ontourinr. made simple. J Oin Orthod 23:636 - 637, 1989.
=======C.;; h (l pte r
Treatment Planning in the
Permanent Dentition

The first lind foremost objective in orthodontics is the altainment of a class I cuspid relation-
Class I
ship after treatment, when the upper cuspid occludes in the embrasure between the
lower first bicuspid and cuspid. With this goal in mind. the following general treat-
ment patterns may be applied in onhodontics.
I
-
ll
The majority of patients with class I cases who seek orthodontic therapy have minor.
moderate. or severe crowding.. accompanied by various intra-arch discrepancies that
arc easily corrected orthodontically (Figs. F4.1 through F4.33), Minor and moderately
crowded cases are usually resolved with the tooth rccontouring (TR) technique. When
we have a class I extract ion case (severe crowding, impacted teeth. himaxilJary pro-
trusion. dental open bite or open-bite tendency cases), the objective is the presence of
the class I cuspid and molar relationship (Figs. F4.34 through F4.59). If there is
severe crowding in both arches. extracti on of all first bicuspids
ll
will alleviate the
problem and the class I cuspid and molar relationship can be If there
is severe crowding on the upper or lower arch only. then the first bicuspids in both
arches may need to be extracted in order to preserve a class I cuspid relationship.
Class II
Class II cases are either division I (flared upper incisor, excess overjet ) or division 2
(retroclined upper centml incisors. labially displaced laterals, and no overjet). By
uprighting the relrocli ncd upper central incisors in a division 2 case. we turn it into a
di vision I case. Therefore, the treatment approach for both is similar. The treatment
strategy with such cases depends on the patient's age.IJ-U In mixed dentition. nonex-
traction mechanother ... py that would move the upper posterior teeth distall y is the
treatment of choice. In the adolescent permanent dentition, some clinicians may try
to do the same as in the mixed dentition, whereas others would extract the upper fIrst
bicuspids and fini sh a class II molar and class I cuspid relationship. In the adult
patient. the ideal treatment in most cases would be nonextraction. uprighting of the
central incisors, followed by a mandibular advancement onhognathic surgic ... 1 proce-
dure that would improve facial esthetics. (Class 11 patients usuall y have a retrognathic
mandible.) If the patient refuses surgery, the treatment of choice would be extracti on
of the upper first bicuspids.
If the crowding is in both arches. extraction of all first bicuspids is necessary (Figs.
F4.60 through F4.81). Because we are extracting in both arches in order to cnd up
with a class I cuspid relationship, we must also end up with a class I molar relO3tion-
ship. This is what makes these cases very difficult in modern practice; if we have a
full class II molar relationship to start with. in order to obtain a final class I relation-
ship of these tccth. we must achi eve a total of 7 mm (the width of a cusp or the
difference between a class I and 3 class II ) of molar movement. This is usually done
by mesial movement of the mandibular first molar in the range of 3 to 4 mm along
with distal movement of the maxillary molar in the mnge of 2 to 3 mm. either with a
Ted conllnued on page 293.
272 l>art.' Or/hot/anlil' Trt'a/men/ Mot/ali/in
F4.1
Figure F4.1 Limited orthodontic treatment of the adult den-
titi on may be attempted when the patient has realistic ex-
pectations and the chief complaint is simple enough. This
midline diastema requires minor tooth tipping for correc-
tion. In this case, as can be Sttn from the palatal view.
correction of the diastema would provide adequate space in
the rest of the anterior area for the alleviation of the minor
rotations of the left lateral and cuspid teeth.
Agure F4.3 The diastema is dosed in 3 mOnlhs.
F4.2
Figure F4.2 A 2 X 6 appliance (two bands on the first
molars and six brackets on the anterior teeth) with a Nco-
sentalloy (GAC) light ( IOO g) 0.016 X 0.022 inch2 rectan-
gular NiTi wire along with an elastic chain from cuspid to
cuspid was all it took to correct the discrepancy. The cus-
pid teeth are not wire tied to allow for their rotation from
the pull of the elastic chain.
F4.4
Figure F4.4 Patient after appli ance removal.
F"tgUI'e F4.S A permanent retainer wire is ronded on the
lingual of the central incisor teeth.
Figure F4.7 Four brackets placed from the upper first molar
to the ipsilateral cuspid tooth and a O.OI6-inch round NiTi
.... i re followed by a 0.016 X 0.022 inchl stainless steel seg-
mental wire was all it took to bring the bi cuspid out of the
crossbite. ote that. because of the gingival overgrowth
over that tooth. the bracket is nOI high enough on the
bicuspid. A step downbcnt (second order) in the archwire
compensated for the improper bracket placement.
Chaptet " Trl.'alml'lII PlallmllK i n /11/' PI'rmalll'lII VI'nli/i on 273
Figure F4.! Single-tooth crossbite of the upper first bi cuspid
in an otherwise ideal class I occlusion. A limited treatment
may be rendered.
F4.8
Figure F4.8 Use of 24-hour box elastics for I week brought
the teeth into a solid int ercuspation .
274 Par1 F Orthodofl/it rrt.'Q/I/ll'rJI Moduli/It!
F4.9
Figure F4.9 T olal treatment time: 2 momhs.
F . ll
Figure F4.11 Ant erior view before treatment. Note the mid-
line diastema, which was the patient's chief complaint.
Figure F4.10 Right buccal view before treatment. Note the
"super" class I molar relati onship (20% class III) and the
retained mandi bul ar second primary molar. The upper cus-
pid is in lingual crossbite with the first bicuspid and in a
class I relationship with the lower cuspid.
F . 12
Figure F . 12 Left buccal view before Imument. Note the
class I molar relationship and the retained mandibular src
ond primary molar.
F4.13
F''IIut8 F4.13 Upper occl usal view showing a lotal of 4 mm
of spaci ng.
Flgurel F4.15 through F4.17 Immediatel y after bracket place-
ment. Due to the minor movements planned for this case
and thc absence of a deep bite. ceramic appliances wert
placed even on the lower teeth, well away from the line of
occl usi on. in order to avoi d abr.asion of the maxillary teeth:
O.OI2-inch initial round stainl ess steel arc,hwires wert
placed on bot h arches for initial alignment and leveling..
Chapler" TrI'U/lflfflt " lam,,,,/( in Ihi.' ""Iam'nt ih!flliliQII 275
F4.14
Figur. F4.14 Lower occl usal view showing a total of 3 mm
of croWding.
276 " S r 1 ~ ' Orthodontic rrt'Q/IIlrnt Motia/mrs
Ftgures F4.18 through F4.20 Round O.OI4-inch archwire
were placed 10 continue with the al ignment and leveling
The cl inician may proceed 10 the next size of wires wheE
they can be placed in the brackets without deformation 0
the wires.
F'lQur F4.21 ttvough F4.23 Round O.OI6-ineh archwircs
complete the alignment and leveling. All of the stainless
steel arehwires used up to now could have been substituted
with an O.OI6-inch round NiTi wire or ewn the new rec-
tangular superelastie Ncosentalloy (GAe) NiTi wires. whieh
gi\e torque and root control from the stan of treatment.
Note the dastomeric chains (power or C.chains) from the
upper right cuspid to the left central incisor and from the
lower left first bicuSI>id to the left first mandibular molar.
The purpose is to bring the upper left incisor closer to the
midline and to alleviate the crowding in the lower left area
by bringing the bicuspid back 2 mm into the space: that has
ittn made available after the extracti on of the Es. The
ligature wire that tics around the right cuspid, left incisor,
and the lower left bi cuspid prevents those teeth from rotat-
ing from the pull of the clastic chains. Ideall y, we would
place elastic chains when we are in rectangular wires. but
because the tooth movements that are attempted in this
case are minor (I to 2 mm). we can save some treatment
time by using only secti onal C-chai ns on round wires. Even
if the teeth tip a little, root uprighting will occur when we
place the fini shing rectangular wires.
a._pler;l TTl'Ulmf;'rl/ Pfannlng In Ihl:' Permanl'PII Denlilion 277
278 Part F OrlhfK/(mlic TTI'UIINI'n! Modalilit's
Figures F4.24 through F4.26 Rectangular 0.016 X 0.022 inch
z
finishing archwires placed in the arches with 5(.'(;ti onal Co
chains. Not e the closure of the cent ral diastema and the
correction of the upper midline (the lower midline was on
from the begi nning). Also note the correcti on of the right
crossbi te bet ..... ttn the upper right cuspid and the lo ..... er first
bicuspid. This was obtained graduall y through the archwire
changes. Elasti c chains (from molar to molar) will close any
remaining spaces over the next 4 106 months to finish the
oue.

F4.26
F427
Flgur F4.27 through F4.31 The patient's occl usion immedi
ately after debonding. Note the slight gingival inflamma-
tion. despi te the patient's excellent oral hygiene coopera-
tion. The space provided by the extracti on of the lower
primary molars was used to alleviate the lower
crowding as well as to retract the lower teeth to create
2 mm of overjet and thus all the retraction of the upper
teeth to close the spaces in the maxillary arch. (Due to the
minimal overjet initially. closure of the midline diastema
\liQuid not have bt.'cn possibl e.) Total treatment time was a
li t11 e over a year.
4 Trf'tllmt'nt PialJl'ung In Ihl' Pl'I'mannll DI.>nlition 279
F4.28
280 P. Tt F Orthodonti C rfM/fllml Modo/IIIN
Figure F4.32 The patient's occlusion I week after debondi ng.
Figures F4.34 and F4.35 This is a dental open bite wi th
significant flaring of the ant eri or teeth. It is obvious that
the anteri or teeth need to be retmcted to their ideal posi.
tion over the basal bone. The crowding is minor (3 mm)
and moderate (6 mm) on the upper and lower dental
arches. respectively.
Flgure F4.33 The maxillary and mandi bular Hawley rt
tainers provide posttreatment stabil ity. Note the acryl ic to
preserve the lower E space unt il the patient has prosthetic
work done.
F'tgUf.' F4.36 and F4.37 Exuaction of the first bicuspids fa-
cilitated the retraction of the anterior tccth with upper and
lower 0.0 16 X 0.022 inch! Neoscntall oy (GACj wires and
elastomeri c chains. Note the normal OB and OJ relation-
ship of 2 mm that has been established early in treatment
(within 3 months).
F4.3S
Flgur F4.38 and F4.39 The bile is continuing to close as
further leveling (especiall y of the upper arch on the right
side) is lak.ing place.
ChaplH 4 Trf!Qlmenl Planning in fhe Permon/'nl iJenllfion 281
282 Part F Orthodonlic '''rlOllllt'lII Modufitit's
F4.40
Figures F4.40 Ind F4.41 Finishing !.Iainlcss sIL"C1 rectangular
wires (0.016 X 0.022 inchZ) arc used 10 place compcns:lIing
bends as space closure conli nues wi th elastomeric chains.
F4.42
Figure F4.42 Toward the end of treatment with space clo-
sure almost completed.
FU3
FIgures F4.43 through F4.4e Patient's occlusion before treat-
ment. Note the class I molar relationship. the open bi te
tendency, and the mesi ally tipped bicuspids and cuspids,
which make them appear in a class I relationshi p versus a
class II 50% (end-to-end) if they were upright. The crowd-
ing is minor (about 3 mm for each arch).
F4.45
o.pter" rrealmml Planning in the I'tmUl1I,nl Dentition 283
F4.44
F4.46
284 r l l 1 ~ ' OflhodUfltic Treatment Modafitil'!
F4.47
Figures F4.47 and F4.48 Although this case could have been
treated wi th TR, the therapy plan here was elttmction of
the upper first and the lowcr second bicuspids. This extmc-
ti on pattern was necessitated by the patienl 's long lower
facial paltern with an open-bite tendency (see Fig. 4.44).
Immediately after bracket plllccment , init ial O.OI75-i nch
braided stai nless steel archwi res are used (an O. 12-inch
stainless steel wire could have been used as well).
FlSJures F4,49 and F4,5Q After having gone through the usual
stainless steel round archwire sequence presented previ ously
(0.0 14-inch, 0.016-inch), 0.0 16 X 0.022 inch2 fini shing rec-
tangular stainless steel archwires were used. The mechanics
used for space closure are elastomeri c chains from molar to
molar and class II elastics (from Ihe lower molar to the
upper cuspid), worn full-time or at least al night Oass II
elasti cs were used 24 hours a day for over 3 months (from
the lower molar to the upper cuspid), and have a tendency
to extrude the lower molars while flaring the lower and
tipping back the upper anterior teet h. Elastics should be
used onl y with rectangular archwires to minimize t he afore-
ment ioned side effects and to maximize their use, whi ch is
for bodil y mesial movement of the lower posterior seg-
ments and di stal movement of Ihe upper anteri or segment.
F4.48
f'19ures F . 51 and F . 52 After the posterior spaces ha .... e
closed and a class I cuspid and molar relationship has been
achie .... ed, C-chains from molar to molar will consolidate
toot h contacts and close any remaining spaces: 0.016 X
0.022 inch
1
stainless sleel archwires wilh accentuatt.'d and
re\'el"SC.' curve of Spee on the upper and the lower arches.
rtSpttti .... el y. are used. These will counteract the lingual lip-
ping of the anterior segments due 10 the constant pull of
the elastic chains over the months of treatment. If thi s side
elfect Slans 10 occur, the clinician will notice the creation
ofan open bite in the bicuspid area and excessive relroclin-
Ilion of the anterior segments.
Chaptet" Trrotme"t Planning in the Pe"nan(,nI IJentullJf1 285
286 Plrt t' O"hodtJmk l'reaJmerrl Motialilin
F ~ r e s F4.53 through F4.56 Patient after appliance removal.
Note the 2- mm overbite relationship that has been achieved.
F4.54
FIgure F4.57 This patienl demonstraled a palatally impacted
cuspid that was brought in the arch with a slight modifica-
tion of the " ballista spring system" (Jacoby H: The " bal-
lista spring" system for impaett.'d teeth. Am J Orthod
75: 143- 151. 1979). The double-loop spring for initial acti -
vat ion of palatall y impacted cuspids is made of 0.0 16 X
0.022 inch! wire. It s posterior end is inserted into the auxil -
iary buccal tube of the molar band. while its middle
segment forms a 45-degrce angle with the main arehwire.
F4.59
Figure F4.59 The activation of the spring helps guide the
impacted tooth to its final position in the arch, where elas-
tics may compl ete its movement.
Chapl"" Trt'fJlmelll Pio"'''''R If! Ihf' Pf"fmol'lt'lII Dt'I'Imwn 287
Figure F4.58 The anterior segment of the spri ng fom s a
9O-degree angle with the rest of the appliance and intersects
the occlusal plane toward the palate. where it hooks onto
tbe loop of the ligat ure t ie wire of t he bracket that was
bonded to the cuspid upon its surgical unco\'ering.
288 Part F Orthodonlic TrOOl menl Modaillln
F4.60
Figures F4.60 through F4.63 A case with class II 50% rela-
tionship with severt maxillary (16 mm) and mandibular
(8 mm) crowding. The crowding C'dn \'ery easi ly be calcu-
lated by eye-balling the arches: the cuspid width is about
8 mm. whereas each incisor overlap is about 2 mm of
crowding. With such severe lack of space. extractions are
necessary in both arches. This means that, in order to end
up wit h a class I cuspid relat ionship, we must secure a class
I molar relationship as well. In other words, we must make
surt t hat the mandibular first molars come 3 to 4 mm
anteriorly, while keeping the maxillary ones where they are,
so that a class J relationship may be achieved. The combi-
nation of upper first bicuspid and lower second bicuspid
extractions brings us closer to our goals: the maxillary cus-
pids can easi ly be brought into the space of the f,Tst bicus-
pids. and the mandibular molars can slip anteriorl y with
sliding mechanics. As shown in the diagram. if we had a
full class II ( l ~ ) molar relationship, then the total tooth
mo\'ement would have been even more difficult. because
the lower molar would have to move anteriorl y even more
and the upper cuspid 7 mm distall y .


F4.61
" ..
Figura. F4.64 and F4.aS After banding and bonding, initial
O.I1S inch. round, braided archwircs are used wilh a slight
mlicai activation 10 the uncovered maxillary cuspid wired
1I>11h a ligature wiTe tic. (Rectangular 0.016 X 0.022 inch
l
suptrelastic ini tial wires would be used today.)
Figwn F".66 and F4.f7 The second SCI of wires are 0.014-
inch round stai nless steel. An elastic chain pulls the maxil -
lary cuspid distally inlo the extraction space.
CIuIplrr" Trrofffli'fli Plonning III/he Permanl.'tll fJ/mliliQrl 289
F4.65
F4.67
290 Pan F Orrhodonlic Tr,'atm!'1II Modalili!'$
F4.68
F"lgYf F4.S8 and F4.69 The thi rd sct ofwi rcs are 0.016 inch
round stainless steel. Note the correcti on of the crossbi te in
the molar regi on that was accomplished with the act ivation
of the TPA. Al so note the mesial movement of the man
dibular molar that has brought this tooth into a class I
relat ionship with the upper molar. as well as the leveli ng
that has taken place. All the changes that have been
achieved up to now in this case with the aforementioned
sequence archwi res would now be achieved with only one
initial archwire: a rectangul ar Ni Ti 0.016 X 0.022 i n c h ~ suo
perelastic Neosentall oy (GAC).
F4.70
F"tgUf F4.70 and F4.71 Finishi ng archwires-O.OI6 X 0.022
inchl stai nless steel wi th elastic chai ns- to elose any reo
malnlng spaces.
F4.69
FU2
FIgures F4.72 and F4.73 The occlusion :It the time or appli.
ance remov:l1. Note the solid intercuspation or the cuspid
teeth in :I class I rel:ltionship.
FU 4
FIgure. F4.74 and F4.75 This class II ~ (endto-end) adult
rase is si milar to the previous one, but it is treated a lillie
jifferentl y in the finishing stages.
Chapter 4 Trt'tllml'lU Planning ill Ihe PermanelU DemiliQ" 291
292 Part F Orthodontic Tr.'Utnlt'rI/ Modalitif'J
Figures F4.76 and F4.77 After alignment and leveling had
been completed. a fi nishing 0.016 X 0.022 inch! rectangular
stainless steel arch wire with a loop in front of each cuspid
was used with class II elastics. This type of mechanotherapy
achie\'es a twofold goal: it protrncts the lower molar
mesially while it pulls on the whole upper anterior segment
(through the loops) di stall y.
Figures F4.78 and F4.79 A class I molar and cuspid relation
is achieved wi th the use of the reciprocal forces exened by
the clasti c. Elastomeric chains are used to consolidate any

remammg spaces.
ChaplH 4 Trt'Olml'm Pfannmg In Ihl' Permam'tfl DenliliOl1 293
F4.80 F4.81
f'tgurll F . SO and F . 8t Occlusion after appliance removal.
It should be pointed out that this case was treated before
the introducti on of the Neosentalloy (GAC) coil spri ngs
(for nonextraclion treatments). The patient was reluctant to
l10u r a headgear appliance. and thus the extraction of teeth
110'2$ the most appropriate opti on for securing a class I cus-
pid relationship.
coi l-spring apparatus' or headgear appliance"" (Figs. F4.82 through F4.88). In an
adult, this would be done with a 7-mm mandibul ar advancement orthognathic proce-
dure. If the initial relationship was a class II 50%, then the total correcti on is much
easier (3 to 4 mm of total molar movements).
If there is crowding in the maxillary arch onl y, extraction of the upper fIrst
bicuspids is the extraction pattern of choice. This would result in a class I cuspid
occlusion a nd a class II molar relationship (i.e . the molars are left in class II ) (Figs.
F4.89 through F4.96). If there is crowdi ng in the mandibular arch onl y. the extraction
of the lower front bicuspids would leave us with two options: (I) to align the lower
tccth and perform a mandibular advancement procedure' that will result in the class I
cuspid relationship or (2) to extract in the upper arch as well and try to ftnish in a
class I occlusion (similar to the class II situation with upper and lower severe crowd-
ing). The extracti ons in the upper arch would be necessary because the upper cuspids
would have to be retracted in order to end up with a class I cuspid relat ionship. This
would be a very diffi cult treatment.
Tart conllnul on page 298.
294 Part F Orthodontic TrttJlml'fII Moda/ilin
F4.82
Figures F4.82 through F . I. This is a characteri stic denial
asymmetry case caused by the previous extracti on of the
upper left first bicuspid years ago. As a result. the upper
denial midline shifted to the left by 4 mm. and the right
cuspids ended up in a full step class II relationship, whereas
the left ones are in a class I relationship. Had the bicuspid
extraction not taken place. there would have been no mid-
line deviation and the cuspids would both be in a class II
50% (end-to-end) relationship. Because the left side is now
in a class I cuspid and a solid class II molar relationship
without any crowding, the treatment plan should have as a
primary objective preservation of these relations on the left
side while at the same time attempting to shift the midline
toward the right and obtaining a class 1 cuspid relationship
on the right si de (from a full class II ).
F4.83
F4.84
F4.85
f'tgure F4.85 It is obvious that by extract ing the upper right
6rst bicuspid. the aforementioned goo.ls would be achieved.
The patient also hod a 6.5 mm lower crowding. The
choices were to extract a lower incisor and end up with a
slightly increased overjet (see Chapter 5) or to extrJC\ the
lower right socond bicuspid and end up with a class I molar
rtlationship on the right side and compromise the lower
midline toward the right side (as we all eviate the crowding)
but end up with an ideal 08 and OJ of 2-mm. The latter
approach was chosen. In retrospect. extnaction of a lower
incisor might ha"'e been a better plan. The patient W'olS also
given a high-pull (occipital ) headgear to wear at night onl y
to try to influence the vertical dimension by keeping the
upper molars from extruding (and thus opening more the
bite anteriorly) during orthodonti c mechanotherapy. (Re-
member: Teeth always extrude when fixed appliances with
continuous or segmental arehwires are placed on them.
even if the cl inician keeps any leveli ng of the occlusion to a
minimum.)
F4.87
Chapter 4 T,eOlmeru Plonning If! Ihe Pcrmon .. ru {>lmlilion 295
F4.86
Figures F4.86 through F4.88 The patient underwent the nor-
mal sequence of round archwire changes (0.0 12-. 0.014-.
0.016-inch stai nless steel). When the finishing 0.016 X
0.022 inch
l
stainl ess steel archwires were placed on both
arches. elastomeric chains and asymmetri cal clastics were
used for 4 months to close spaces and secure a class I
cuspid relat ionship on the left side. Th<: class III elastic
used on the left side (from the upper molar to the lower
cuspid) brings the upper and lower teeth slightl y anteriorl y
and posteriorl y. respectively. On the right side. the me-
chanotherapy used is a little different. The class II elastic
(from the lower molar to the upper cuspids, thus having
the opposite effect of the class lIls) has a vertical compo-
nent to it (by including the lower bicuspid) in an effort to
obtain as great an int ercuspat ion as possibl e during the
anteroposterior retraction. The class I elastic (from the
upper first molar to the upper cuspid) aids the elastomeric
chain during space closure wi thin the same arch (in this
case. the space distal to the cuspid). This case will fi nish far
from ideally wit h a class II 30% right cuspid relationship.
Headgear cooperation was fair.
F4.88
296 I"ut F Orthodontic Trl'allnt'nt Modalitit's
f4.89
Figures F4.89 through F4.92 Typical class II , division 2 mal
occlusion in an adult. Note the lingually retroclined upper
central and labiall y displaced lateml incisors. Although the
ideal treatment would have been correction of the inclina-
tion of the central incisors and a 7-mm mandibular ad-
vancement , cxtraction of the first bicuspids was done m-
stead btcause the palient refused the surgical option.
F4.92
:tgures F . i3 through F4.i6 Posttreat ment occl usion. Note
he class 11 molar with class I cuspid relationship.
95
--.. --------------
Chllpler 4 Tfl'tllm/!fll Planning In ,",, 1'('1"mUIU'tlI [)('ntillOn 297
298 Part F Orthodontic Tft'Ulmt.7ll Mexia/lilt'S
Class III
In a recent investigation of 302 adult class III individuals, it was reponed that almost
one third of the sample had a combination of maxillary retrusion and mandibular
protrusion.
16
Maxill ary skeletal retrusion with a normally positioned ma ndible is
found in 19.5% to 25% of class II patients.
1
,1 Mandibul ar protrusion, commonly cited
as the major skel etal aberration in individuals with class III malocclusion, was found
in only 18.7% of the total sample.
In another study, a combination of maxillary retrusion and mandibular protrusion
was found in 22.2% of the sample.
11
Fony-one percent of i his enti re sample (59 of
144) also had long lower face height. Clearly, even in children and adolescents, a class
III malocclusion does not indicate some typical facial skeletal pattern. Rather, it can
be the result of any of several combinations of aberrations in the craniofacial com-
plex. A tendency ~ x i s t s for a morphologic difference between the mandibles of class
III and class I individuals. This difference occurs earl y. The increase in venicaJ lower
anterior facial growth occurs later and is not typicall y present in earl y childhood.
16
, 11
In young patients (5 to II years of age) with maxillary deficiency, the treatment of
choice is protracti on facemask therapy (see Figs. E8. t through E8.6). In patients with
mandibular prognathism, it is best to wai t until completion of growth for a mandibu-
lar setback onhognathic procedure. This eliminates the possibility of a second surgery
due to late or excessive growth of the mandible in the late teens or early twenties,
especiall y in boys. In the event that any dental problem exists. onhodontic therapy
alone may be undenaken (depending on the case), followed by retainers (Figs. F4.97
through F4. 11 5).
Figures F4.17 through F4.102 This class III mal occlusion pa-
ti ent has severe crowding of the upper arch (14 mm) and
minor crowding in the lower. Note the fullness of the lower
third of the face. indicating mandibular prognathism. Also
note the end-to-end relationship of the ret roclined incisors..
also indicative of a class III malocclusion. In order 10 avoid
possible impaction of the upper cuspids (note that the
upper first bicuspids have erupted next to the lateral inci-
sors), extracti on or all fi rst bicuspid teeth was done (Ihe
lower first bicuspids were eltlractcd in order to achieve a
class I cuspid relationship).
7e" continued on ~ g e 304.
Chapl er of T'I'Ulmfflf Pfannmg m fne Pl'I'mam,"1 DenflflQ/1 299
300 ,"tIrt F Or/hodOlltic Trt'atml'fl( MlJoalilil.'s
Figurel F4.103 and F4.104 The upper cuspids erupted within
2 months in to the space that was provided for them. Fixed
appliances were placed to align and level the arches. As
soon as this is done. retainers will keep the tttth in their
position in the arches unlil completi on of any funher man-
dibular growth. The class III problem of this patient may
remain mild; then again, it may turn out that his mandibl e
will grow excessively. Hi s pn..-scnt mild condition justifies
an attempt to finish thi s case with a positive overbit e rela
tionship. A conservati ve approach will include class III
elastics (3/4.inch, 2-oz) during the day, followed by chin-
cup therapy at night. The objecti ve of the conservati ve
onhodontic mechanotherapy would be to obtain a posi ti ve
overbi te of at least I mm (from Ihe present end-to-end
anterior occlusion). The fixed appliance treatment should
last about I year. The chin cup should be worn at night
until well after the patienfs pubenal growth spun. 0 at-
tempt should be made to retain the teeth in a positive
Oo/OJ relationship with fixed appliances and elass III elag.
tics past I year of treatment because if the mandible grows
abnormally, the dental compensations would be too great
of a compromise with extrusion of the lower anterior teeth
and severe periodontal problems.
F'tgurel F4.105 through F4.107 This is a typi cal class III 50%
malocclusion wi t h a minimum overbit e relationship. A
constricted upper arch and a normal wide mandibular arch
resulted in a bilateral end- to-end posterior crossbite. The
patient is circumpuhertal.
etu. plfl" 4 Tutllml'nl Piannlllg In Iht' Pt'I'mum'n/ [)'.'nlillOfl 301
302 Part " Onhodol1lic Trf'O(ment Modalit ies
F4. 108
Figure F4.108 An RME appliance was used to expand the
upper arch to correct the crossbite and at the same time
provide space for the upper cuspids.
F4. 109
Figure. F4.'og and F4.110 The expansion was discontinued
prematurely (alier 12 days) because the acrylic was embed-
ded in the soli tissue of the Palate as it moved laterally
from the activation of the screw of the appliance.
F,UI!
Figure F . 111 The palatal soft ti ssue healed within a week
after appliance removal. The cKpansion was held in the
molar region only with a TPA,
figure F . 113 After bracket placement, a 0.016 X 0,092
inchl Neosental loy (GAC) rectangular NiTi wire was in-
sened in all teeth, with the exception or the lateral incisor
teeth, to avoid any unnecessary tipping,
Chapttr 4 Treatment Planning in the PermUlU'nI Dentilion 303
F4, 112
Figure F . 112 Two weeks later, the midline diastema had
closed rrom the pull or the transeptal fibers,
304 l'arl I- Orthodoflli c'l ft'tlflllt'llf Modaliti es
Figure F4.114 Within 5 weeks. the cuspids had reach<. 'd the
occlusal plane. At this point. the laterals were wire tied to
thc archwi re.
Figure F4.115 Afl er 2 mont hs. thc latcr.ll s were out orcro:ss-
bi le. Note t he increase in the o\'crbitc relationship by
I mm as a result or the RME. Al so note the residual con-
struction in t hc postcrior f<.'gion, especiall y in the bicuspid
area. An RME appliance ror a second timc would be indi-
cated at this point. It may not be necessary to place appl i-
ances in the lower arch in some or these cases.
If the crowding is in both arches. extraction of all bicuspids woul d lead to a class I
cuspid and molar relationship' - ( Fig. F4.1 16). Ir it is in the upper arch only,
extractions or the upper first bicuspids would alleviate the crowding but worsen the
class III situation ( because the anteri or teeth would have to be retracted further
posteriorl y). Thus. the options available to us are (I) maxillary adva ncement or
mandibular setback surgery' to obtain a class J cuspid relationship, or (2) lower f i ~ t
bicuspid extracti ons to end up with a class I occlusion.
The above situation is exactl y the opposite. in terms of extraction patterns. to the
class 11 lower severe crowded CaSCo If the crowding is in the lower arch only, extrac-
ti on of the lower fI rst bicuspids will result in a class I cuspid and a class III molar
relationship (Fig. F4. 11 7).
t
- >
.. .
116
f4. 117
Me F4.tt6 Class 111 malocclusion with crowdi ng in both
lCS. (I) If the case is t reated wi th orthodontic means
le, providing Ihal the skeletal problem is minor. then
anterior teeth would have \ 0 be tipped (cllr"'l'd arrows)
the upper posteriors prot racted anteriorly to secure a
$ I cuspid relationship, ote the compromised conca\'c
file and the compensating inclinations of the anterior
h. (2) If Ihc case is treated with orthognat hic surgery. no
lpensating denial lipping needs to take place. In fact
3mpcns:nion of possible existing t ipped posi t ions of
h may need \0 take place. The teeth can be moved
il), to thei r posi ti ons wi th ei ther a maxill ary or mandib-
surgical procedure (or bolh) to provide the patient with
)rthognathi c profile.
F;gur. F4.117 Class 111 malocclusion with crowding in the
lower arch only. Extraction of the lower fi rst bicuspids wi ll
allow for a class 1 cuspid relationship after treatment.
References
I. Graber TM. and Swain SF: Orthodolllicr: Cllm,"/ Principll's alld 'f't'Chmqul'.f. SI. Louis. MO: c.v.
Mosby Co .. 1985.
2. Johnston LE: N{'W Vis/(u ill Of/hot/omics. Philadelphia: Lea & Febiger. 1985.
3. Proffit WR: COlllemporarJ' Onhodooticr. SI. Louis. MO: C. V. Mosby Co .. 1986.
4. Graber LW: Orthodontia. Stalt of/he Art. Enmu ofthl' SriI'I1U. SI. Louis.. MO: C. V. MoWy Co .. 1986.
S. Alexander RG: The All'xandt'1 IJlscipiinl'. COfIlImlpofary ConceplJ alld Philosophy. Glendora. CA:
Ormoo Co .. 1986.
6. Proffit WR, and White RP: Surgi((J/-Onlwdol1lic Trea/ml'IIt 51. Louis, MO: Mosby-Year Book, 1991.
7. Miura F. Masakuri M. and Yasuo 0 : New application of the supcreLastic NiTi rectangular wire. J ain
Onhoo 24:S44 -S48. 1990.
8. Bell WH: 5l1r/(iool CtJfr('CIion of IJt>lIIofacial lJt>/onnitil's. vol . II. St. Louis. MO: C. V. Mosby Co .. 1986.
9. Burstone CR: Deep overbite COf'TCCtion by intrusion. Am J On hoo 72:1-22. 1977.
10. Mclaughlin RP. and Bennett JC: AncIK:Jrage control during Ie"ding and aligning with a preadjusted
appliance: s)'Stem. Jain Onhod 25:687 -696. 1991 .
I\. Droboclcy OB. and Smith RJ : Otangcs in facial profile during onhodontjc treatment with e.\lroction of
four first bicuspids. Am J Ort hod Dcntofadal OrIhop 95:220-230, 1989.
12. Arvystas MG: Noncxtr.lction treatment of sevcre class II . division 2 malocclusions. Am J Orthod
DentofaciaIOnhop97:SIO-S21.1990.
13. Arvystas MG: NOneJltraction treatmenl of s e ~ r e cJass 11. division 2 malocclusions. Am J Onhod
Oentofacial Orthop 99:74-84, 1991.
14. Lilt RA. and Nielsen IL: aass II, division 2 maloccl usion: To turnC! or not u tr.lC!? Angk Ort hod
54: 123- 138, 1984.
IS. Selwyn-Bamen &I : Rationale or treatment for class II. division 2 malocclusi on. Dr J Ort hod IS:I73-
ISI,I991.
16. Ellis EE 111 . and McNamara JA. Jr.: Components or adult class 111 malocclusion. J Or'!1 Mu)(ilJofac
5urg 42:295- ]OS. 1984.
17. GU)'Cf EC. Ellis EE 111. McNamlr;l JA, 1r . and Behrents RG: Components of Class 111 malocclusion in
juveniles and adoIesccnts. Angle Onhod 56:7 - 30. 1986.
Incisor Extraction/Missing Incisor/
Second Molar Extraction Therapy
C il a fer
The intentional extraction of a lower incisor can enable the orthodontist to produce enhanced
functional occlusal and cosmetic results with minimal orthodonti c manipulation'
(Figs. FS. I through FS.20). If the Bollon anal ysis shows a lower anterior excess. the
extraction of a lower incisor might have a positi ve effcct (sec Figs. F4.2 1 through
F4.2S).
Enamel removal can be distri buted among 10 maxillary interproximal surfaces (the
mesial surfaces of both cuspids and proximal surfaces of the four incisors) to compen-
sate for lower incisor extracti on and reduce any excess overjet at the end of treatment.
The proximal enamel is usuall y thickest on the mesial surfaces of the cuspids and the
distal surfaces of the central incisors. whereas the mesial surfaces of lateral incisors
may have onl y 0.5 mm of enamel. ' If the interproximal surface is indiscriminately
flattened, the interproxi mal contact will be lengthened gi ngi vall y, further reduci ng the
space for the gingival papilla.'
Extruding the lower incisors to mai ntain occlusal contact in centric occl usion is
advised.' If the maxillary anterior tooth siu excess is managed successfull y. one can
usuall y still achieve a cuspid-protected occlusion. In some cases it is impossible to
adequately compensate for the tooth size imbalance, so it may not be possible to
achieve a cuspid rise. In these cases. group function may be produced orthodonticall y
and by equilibration to eli minate cross-arch balancing interferences.
Often, patients present with congenitall y missing upper lateral incisors (Figs. F5. 17
through F5.53). The treatment approaches in such cases are ( I) movement of the
cuspid teeth in place of the laterals, followed by recontouring of their surfaces to
appear like laterals, while at the same time the upper fIrSt bicuspids arc placed in a
class I relalion with the lower cuspid tccth (group functi on is suggested for such cases):
and (2) attainment of a full class I cuspid relation by opening up the spaces for
bridgework or implants to substitute the lateral incisor teeth.
A number of orthodontists consider extraction of second molars to be unjustifIed
because tooth material is being removed away from the area in which crowding occurs
(usuall y the incisor) and space is created at the end in the dental areh.2-4 Extraction of
second molars assumes not only that the mesioangularly erupting third molar will
erupt. but also that it will do so without an abnormal mesial inclination. Even if
excellent root parallelism exists, an acceptable contact relati on is unlikely between fIrst
and third molars.
4
-
6
The differences would allow for food impaction and increased
plaque. Marginal ri dge discrepancies and faulty contacts create high-risk areas that arc
more susceptible to dl'Struetive periodontal disease.
4
.
6
The alveolar ridge is not as wide
buccolinguall y at the bicuspid area and docs not lead to food impaction as readily as
the wider interproxi mal bone, located more distall y in the areh.4.6 The effect of the
extractions on the third molars cannot be evaluated until the patients are older..6
First molars can be moved distall y in second molar extracti on cases with t raditional
fixed appliance mechanics with as much as 4 to 6 mm of distal movement. with an
average of 2 mm on each side. A study of patients treated with functi onal appliances
showed virtuall y no distal movement of the first molar.l The resulting facial profi le
after extraction of second molars appears to be no different from that obtained after
extracti on of first bicuspids.
7
308 Part 10" OnhodQII/lr Trl'Qlm('nl ModallliN
FtgUres F5.1 through F5.4 This is a class II molar occl usion
with previous extraction of the upper first bicuspids and a
deep overbit e. Due to the significant crowding in the lowcr
arch (7 mOl) and the al ready existing class I cuspid relati on
(which should be preserved). 1hc only treatment option was
extraction of one lo ..... cr incisor and levcling of thc arches to
decrease the o\crbite.
F5.4
Chapter 5 Incuor .xlf(l('/iofl/ Musiflg Iflci.ror/ Sn:ofld Molar F.xlraC/wn Tllt'rapy 309
FIgure. FS.5 and FS.S Aftcr aJignment and most or the \Cvcl-
ing were completed with thc archwire sequcnce or round
stai nlcss steel wires, as described in previous cases,
0.0 16 X 0.022 inch' rectangular stai nless steel wires were
placed with elastic chains to close and consolidate any re-
maining spaces. Oass II elastics (shown on the patient's
right side) are used ror 4 to 6 weeks toward the end or
treat ment to alleviate possible anteroposterior discrcpancies
and allow a solid intercuspation of teeth.
FS.7
Figure. FS.7 and FS.a Paticnt after treatment. Note the
sli ghtl y increased overjet. This is a normal consequence of
lo ..... er incisor extraction therapy due to the tooth size dis--
crepancy that has been created from Ihe removal or a 5-
mm lower central incisor.
310 Pin t' Oflhodolllic rrwml'nJ Madalitin
Figures FS. 9 through FS.12 This is a full-s tep class II, division
I case with a mutilated posterior dentition, moderate
crowding in both arches (5 to 6 mm), flared upper and
lower anterior teeth, .50% overbite, and a 6- mm overjet,
Even though this patient would have benefi ted from a
mandibular advancement onhognathic procedure to aug-
ment her retrognathic lower jaw, it was decided to treat the
case onhodontically onl y because the patient refused the
surgical option. The upper second (not the first) bicuspids
were cxtl"' dcted because of thei r large restorations, along
with one lower incisor. The objccti ves were to preserve the
class II molar relation, move the maxillary cuspids distall y
into a class I relati on with the lower, and alleviate the
lower crowding (which was mainl y located in the anterior
region). A headgear appliance (maximum anchorage) was
given 10 the patient to wear al night onl y 10 keep the
anteroposteri or position of the upper first molars and pre-
vent them from drifting anteriorl y into t he avai labl e space
of the second bicuspids..
F5.11
Chapl" 5 I nciJ(Jr E.:arUC/IOfI/ Mming I ncirorj Sorui Molur EX/ruction Thl'rapJ' 31 1
Figure. FS.13 and FS.14 After the sequence of round wires
described in previous cases, and a few months into treat
ment with the alignment and leveling completed, fini shing
0.016 X 0.022 inch
l
rectangular stainless steel archwires
were placed with elastic chains to close any remaining
spaces. It must be emphasized that closure of the lower
incisor elltl1lction space was initiated on the ini ti al round
wires (i.e., 0.014.inch). We want to prevent the collapse of
the thin buccal and lingual cortical platt.'S in this area and
also prevent the formation of a thin alveolar ridge that may
not resorb as easil y later on. This may lead to the creation
of a gi ngi val cleft that is very unesthctic when the patient
smiles.
FIgUre. F5.15 and F5.1S After space closure. ote the tight
contacts of the lower anterior teeth.
F5.t6
312 ".n F Oflhot/OfIlic 11M/lllt'l ll Mot/alilit's
F5.17
Figures F5.17 through F5.20 After appliance removal. Note
that a class I occlusion or the cuspids has been achieved
(the cuspid is 20% class III ). th us reducing the overjet that
would have otherwi se existed due 10 the tooth size discrep-
ancy (see previous case).
F5.18

Chapler S Indwr E>:trQ('fIOnj Mming In(lsorjSlYond Mo/ar Extraction Therapy 313
Agur.s F5.21 through F5.25 This adult patient has a class III
SO% molar relation with class I cuspids and small upper
laterals. The pointed cuspid teeth gave the patient a dis-
pleasi ng appearance. The crowding was moderate for both
arches. 3 mm for the upper and 5 mm for thc lower.
F5.2S
314 PlIrt.' Orthodontic rrl'alml'ni Modalilil'of
FS.26
Figures F5.26 through F5.28 A lower cent ral incisor extrac-
tion (5 mm in width) pattern resulted in a n acceptable
occlusion. The small u p ~ r laternls contributed to the at-
tainment of a normal overjet relationship (had they been of
normal size, we would have ended up wit h excess overjet).
The same sequence of wires was followed as shown prevI-
ously.
FS.27
Clapter S f fICiSOf ExuaClion/Missing ffIC/S(K/Srrortd Molar ExtractlOll Therapy . 315
F5,29
Figures F5.29 through F5.32 This child is bimaxillary protru-
sive and is mi ssi ng the two upper laterals in the permanent
dentition. If she were to have a full complement of teeth,
ext racti ons of the first bicuspids would be indicated. Be-
cause she is al ready missing two teeth in the maxillary arch.
extraC1ion of the lower fu'St bicuspids would help us reach
the same goal. The cuspids will be recontoured toward the
end of treat ment to make them look like laterals and the
upper first bicuspids will occlude in a class I relation wit h
the lower cuspids. (EKtensive cuspal. labial. lingual, and
interproximal recontouring by the gri nding of young teeth
associated with orthodontic treatment can be performed
without discomfort 10 the patients and wi th only minor or
no long-term clinical and radiographic reactions: Thordar-
son A. Zachrisson BY. a nd Mj6r IA: Remodeling of cus-
pids to the shape of lat eml incisors by grinding: A long-
term clinical and rddiographic evaluation. Am J Ort hod
Dentofacial Orthop 100: 123- 132. 1991 .)
FS.30
316 Part F' Orthodontic Trl'Otmrnt Modalities
Figures F5.33 through F5.36 The patienl was given fixed ap-
pliances, and a set of 0.016 X 0.022 inch
2
superelastic Neo-
sentalloy (GAC) NiTi rectangular archwires were insened
for initial al ign ment and leveling, as well as clastic chains
to initiate space closure.
CJgpter 5 Ind JQr Extraction/ Aim ing IMiJ()T/ &cond Molar f::X,raction Therapy 317
F"19ur F5.37 through FS.40 At the end or treatment, the
cuspids have been reconlourcd to resemble lateral incisors.
Note the class I upper bicuspid- lower cuspid relation.
Group runction (i n order 10 avoid eKcessive rorces along
the first bi cuspid root) guides the occlusion in excursive
movements..
318 J>.r1 F OrthQdOfltil' 1 rtalm('rlt M o J a l l l l ~ s
FS.41
Figures FS.41 through FS.43 This adult patient has a class I
molar occlusion but a class II 50% cuspid relation and mild
upper and lowcr crowding with Cltct.'SS overjct, dl.'CP over-
bite. and a deep curve of Spee on the mandibular arch. The
upper len lateral incisor along wi th the lower left second
bicuspid had been extracted previously. Treatment objec-
tives incl uded moving the upper left cuspid into thc posi-
tion of the previously cxtracted left lateral incisor and. after
termination of treatment. placing a porcelain crown on the
cuspid with the morphology of a lateral incisor. The upper
left first bicuspid would then occlude in a class I relation
with the lower left cuspid.
FS.42
FS.43
Chapter S incisOT EXJracl iOIi/ MlJSi ng incisOT/ St"-'(Jlld Molar EXfroCli OIi Therapy 319
FS.44
Figure, F5.44 through FS.47 All teeth were bonded with ce-
rdmic appliances with the exception of the first molars,
which were cemented with stainless steel bands. The regular
stainless steel wire sequence mentioned previously was fol-
lowed here as well . Due to her deep bite, this patient had
clinica1l y visible abrasion of the left tim bicuspid cusp tip
rrom contact with the opposing ceramic bracket. The upper
left lateral incisor ponti c was grddually reduced mesiodis-
tally as the spaces were closed with the elastomcri c chain.
320 Put"- OnhoJontic Trl'tllml'n/ Modalities
F5.48
Figure. FS.48 through FS.SO A year int o treatment, the elas-
lomenc chain space closure is continued. Note that due to
the small size of the lower incisor ceramic appliances, the
elastic modules slip off the brackets. As the lateral incisor
space closure continues, bodily movement of the cuspid
occurs very slowly (3 mm of movement up to this point).
The pontic was removed but the esthetic bracket was left
tied to the wire. Also note the improved overbite relation
as the occlusion is leveled.
Chapler 5 I,,('/JOT E.>:lfac/iOllj Missmg b/('lw rjSlnmd Molar E.:aTac/iOll Tnl'rapy 321
Figure. F5.51 through F5.53 Nine months later. Ihe lateral
incisor space is almost closed. The upper left firsl bicuspid
is now occl uding in a class I relati on with the lower cuspid.
During this period. space: closure was achi eved with
monthly change of the elastomeric module chains. Every 3
months, the wires were taken OUI of the mouth and accen
tuated curve of Spec for the upper and increased reverse
curve for the lower arch were placed to counteract the
lingual tippi ng of the teeth during space closure. At prescnt.
the reverse eUfVe NiTi wires c.l. n be used inslcad. wi thout
any additional activation throughout the entire treatment.
ote that the lower incisor ceramic brackets were substi -
tuted with metal ones to avoid enamel abrasion of the
opposi ng teeth.
322 " art ,"' Orthot/Olltic Tleatnlt'nt Modalitie!
References
I. Kokich VG. and Shapiro PA: Lower incisor extlllction in orthodontic treat ment . Angle On hod 54: 139-
154, \984.
2. Liddle DW: Second molar eJr.lractKm in onhodontic treatment. Am J Onhod 72:599-616. 1977.
1 Whitney E. and Sinclair P: Combination second molar extraction and functional appliance therapy. Am
J Onhod Dentofacilll Orthop 91 : 18) - 192, 1981.
4. Vanarsdall RL, and White RP. Jr.: Second molar extraction1 Int J Adult Onhod Onhog Surg 6:] , 1991 .
S. Romanidcs N. Scrvoss J M, K1einrock S, and Lohner J: Anteri or and posterior dental changes in second
molar eJr.lraction cases J ain Onhod 24:559- 563. 1990. .
6. Proffit WR: COtIImJporary OnhotiOtllia. SI. Louis. MO: C. V. Mosby Co . 1986.
7. S l ~ ' ! r r s JA: A comparison of rt:5ull5 of second molar aDd first bicuspid extr.tction treatment. Am J
Onhod Dentofaciai Onhop 98:430- 436. 1990.
Intrusion Mechanics/Compromised
Periodontium Therapy
e lla l e r
Incisor intrus ion mechanics can be implemented in a number of ways.I-4 The simplest ap-
proach is with the 2 X 6 appliance (bands on the molars and 6 brackets on the
anterior tecth) 4 (Figs. F6. 1 through F6.7) or the base-arch appliance
1
.
4
(Figs. F6.8
through F6. 11). It is possible to int rude teet h wi th periodontal bone loss as long as
regul ar curettage during treatment takes place. A meticul ous oral hygiene and a
healthy gingival status are prcr:onditions for a ravorable result .! The mechanotherapy
of choice ror such cases is the 2 X 6 appliance with a slight intrusive component in the
anterior region.
I
-
4
In a recent study on the intrusion or incisors in adult palienls wi th
margi nal bone loss, it was concl uded that the utilit y and base arches monitor the
appliance to a low and constant rorce, rangi ng rrom 10 to 25 g per tooth. The cli nical
crown length is genemlly reduced by 0.5 to 1.0 mm. Intrusion in such cases is best
performed when the line or rorce passes through the center or resistance or the incisors
(slightly behind the centrals, at the line orlhe cuspids) 1_4 (Figs. F6. 12 through F6.22).
324 Part'" Orthodontic T:I'Q/IIlI'nt Modalitlf's
Figure F6.1 The 2 X 6 appli ance (two bands on the two first
molars with six brackets on the six anterior teeth) is used
primarily when the anterior teeth are malal igned and while
at the same time the bicuspids are in an already excellent
intereuspati on position.
F6.3
Agoras F6.2 through F6.4 This patient. with a class I occlu-
sion and good posterior occlusion, demonstrated minor
(3 mm) upper and lower crowding.
F6.4
Ch.pltr 6 intru.fion MochaniC5/CQmpromi$('(i Periodontium Therapy . 325
F6.S
F i g u ~ F6.S Upper a nd lower 2 X 6 appliances corrected thc
malali gnmcnI of teeth in 6 months. Initi al .OI6-i nch, round
Senlalloy NiTi wires were used for initial alignment and
leveling, followed by .0 16 X .022 inch
l
stainless steel rec-
tangular finishing wires (shown hen:).
F6.6
F"tgUfVS F6.6 and F6.7 Maxillary and mandibular arches after
treatment.
326 P1Ir1 r Orthodontic T't:YJtmmt Modmitin
rlgUre. FlU snd Fri.!! This patient has a very deep bite and
a significant gummy smile that requires intrusion of thc
upper anterior teet h (as thc teeth intrude. thc gum line
moves upward, thus decreasing the gummy smil e).
F6. tO
FIgure. F6.l0 end F6.11 Intrusion is accomplished with a
base arch made of 0.016 X 0.022 inch
l
stai nl ess steel wire
that is insened in the auxiliary tube of the molar bands.
The main archwire is a rectangular 0.016 X 0.022 inch
l
NiTi or stainless steel wire as well. Note the position of tt\(
base arch in its passive state: it is o\'er the soft tissue at tt\(
level of the middle third of the roots of the anterior leelh,
This will produce a total force of l()() to 125 g necessary to
intrude the four incisor teeth. It is preferable to int rude the
two central incisors to the level of Ihe laterals before in-
truding all four teeth at once. This should be done wit h a
2 X 2 appliance (thc wire extending from the two molars 10
the two centrals). If continuous wires incorporate Ihe lateral
incisors, then these teeth wi ll ext rude (agai nst air) bcfol't
the centrals intrude (against bone). When it is ac\ivated, it
is brought down and wire tied onto the main archwire
distal 10 Ihe laterals on either side. In this manner, the
intrusive force should pass through the ecnter of resistanct
of atJ four incisors. It is important to tic back thc intrush'C
arch, as well as the main archwire, to prevent the incison
from protruding. The loop of Ihe base arch is used for its
acti vation and increased intrusive effect (if desired) on thc
anterior segment. Note the significant decrease of the ov-
bite relationship after 6 months of treatment.
Cbapl er' Intrusion !IIechanics!Compronused Pl!1'iodonlmm Therapy . 327
Figures F6.12 and F6.13 This patient's occlusion has been
severely arrected by periodo ntal d isease and significa nt bone
loss. Orthodont ic treat ment may be att empted onl y after
extensive pcri ooontal treatment has result ed in a healthy
periodontium (absence of inflammat ion. healthy ti ssues).
Note the displaced incisor teeth.
F6.14
figures F6.14 and F6.15 A 2 X 6 appl ia nce (wi th brackets
instead of bonds on the molar teeth to avoid unnecessary
initation of the ti ssues) wit h initial O.OI6-inch, round Sen-
tall oy (GAC) very light wires was used. An elast ic thread
was placed around the brackets in a figure-8 pattern to
ini tiate space closure .
.............. ~ - - - - ~ ~ ~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
328 Part F Orthodontic Trl'almt'n1 Modali/in
F6.16
Ftgures F&.1& through F6.1& As soon as the rotations had
been corrected (withi n 3 months), a 0.016inch round
stainless sleel arch wire was inserted. A slighl bend was
placed next to the molars (shown here from another pa-
lient). which resulted in an intrusive activation in the ante
rior region. In its passive state. the archwire should lie
passively at the level of the eEl of the incisor teeth. Note
the amount of intrusion that was achieved. Forces are kept
very low with this slight activati on of the wire (40 to SO g
in the whole anterior region or 10 to IS g per tooth). The
spaces were closed with light elastomeric chains.
F6.17
Chllptcr 6 Intrusion Mechanics/Compromised Periodontium Therapy 329
F6.19
Figures F6.19 and Fe.20 Toward the end of treatmcnt. Notc
the slight irritation of the gingiva despite the absence of
fixed appliances on the bicuspids. The objectives of thi s
case wcre simply to align the tccth, improve the overbite
relation, and close all spaces. No anteroposterior changes
were attempted (the pat ient wi ll fini sh wi th a class II cuspid
rel ation on the right side and a class I on the left . which
explains the midline deviation to the left).
Figures FS.21 and FS.22 If a posterior tip-back bend is left in
for a long period of lime (as in this case. after 6 months).
the extrusive elrcet on the molar tooth will tip the tooth
distall y and extrude it mesially.
330 (>art.' Orthodootic Tfealment Modalities
References
I. Mc:lx n B, Agerbaek N, Erikx n J, and Ttrp S: New attachment through pcriodont.al treatment and
Otthodontic intrusion. Am J Orthod Dentofaciat Ort hop 94:104- 106. 1988.
2. Mc:lx n B, Agerback N. and Markenstam G: Intrusion of incisors in adult patients wit h marginal bone
loss. Am J Orthod Dentofacial Orthop 96:232-241, 1989.
3. Woods MG: The mechanics of lower incisor int rusion: in nongrowing baboons. Am J
Ort hod Dcntofacial Orthop 93: 186- 195, 1988.
4. Mull igan T: Common senx mechanics (Parts 1 to 16). J Clin Orthod (Part 1) 13:588-594; (Part 2)
13:676-683; (Part 3) 13:162- 766; (Part 4) 13:808- 815; (Part 5) 13:53 -57; (Part 6) 13:98- 103; (Part 7)
13:180-189; (Part 8) 13:265- 272; (Part 9) 13:336-342; (Part 10) 13:412 - 416; (Part 11) 1):48 1- 488;
(Part 12) \3:546-553; (Part \3) 13:637- 641; (Part 14) 13:116-12]; (Part 15) \3:188-195; (Part 16)
13:855-868, 1980.
ella
Retention

O"er the past 30 years., a number of studies have dealt with the stability of orthodontic
treatment after the retenti on phase.
l
-
l
) Two thirds of 65 patients exami ned JO years
postretcntion, previously treated in the permanent dentition slage with first bicuspid
extracti ons and traditional edgewise mechanics, had unsati sfactory lowcr antcrior
alignment after retention.
2
In a foll ow-up study 20 years postretention, only 10% of
the cases were j udged to have clinicall y acceptablc mandibular alignment (compared to
30% at the 10-year phase).'- Thc tccth of patients who had undergone serial extrac-
tion plus comprehensive treatment and retention were no better aligned postretention
than were those in latc extraction cases.' There is considcrable long-tcrm stability for
the majority of cases of mild to moderate malocclusions treatcd without extractions.' 20
Arch length shows signifIcant reduction postretenlion. si milar to that of untreated
normals and extracti on cases (2 to 2.5 mm).20
In untreated normals. we .see decreases in arch length and intercuspid width; mini-
mal ovemll changes in intermolar width, oveljct, and ovcrbite, and increases in incisor
irregularit y. Furthermore, no associations or predictors of clinical value arc known in
regard to assessing stability or relapse. Matumtional changes in the permanent denti-
tion of a sample of untreated normals appear, in general, to be similar in nature to
those of a postretention sample of treated cases. IS Orthodontic therapy may temporar-
ily alter the course of the continuous physiologic changes and possibly, for a time,
even reverse them; however, following mechanotherapy and the period of retention
restraint. the developmental maturation process resumes."
In order to mi nimize the relapse potcntial of a case, we should not alter the
mandibular arch form; lower incisor apices should be spread distal to the crowns, and
the apices of the lower lateral incisors must be spread more than those of the central
incisors.
16
The apex of the lower cuspid should be positioned distal to the crown as
well.
16
This angulation of the lowcr cuspid reduces the tendcncy of the cuspid crown
to ti p forward into the incisor space. All four lower incisor apices must be in the samc
labiolingual plane. The lower cuspid root apex must be positioned slightly buccal to
the crown. If the apex of the lower cuspid is lingual to the crown at the end of
treatment, the forces of occlusion can more easily move the crown linguall y toward
the space reserved for the lower incisor because of these functional pressures, plus a
natural tendency for the crown to upright over its root apex. \6 Even if a lower cuspid
with abnormal lingual position of the apex is supponed for many years wi th a fixed
retainer, the crown would eventuall y move lingually when the restraint is removed.
16
If
the apex is not moved buccall y along wit h thc crown while moving the cuspid distally.
lingual relapse of the crown into the incisor area is likely.
There is little doubt that relapse of orthodonticall y rotated teeth is primarily due to
the displaced supra-alveolar connective tissue fibers. A simple surgical method of
severing all supracrestal fibrous attachment (circumferential supracrcstal flberotomy;
CSF) to a rotated tooth has been demonstrated to significantly al1eviate relapse fol-
lowing rotation, with no apparent damage to the supporting structures of the teelh. 10_ 12
332 Part F Trt'tJImMl Moduli/in
Foll owing CSF, the most stri king feature is an increase in mobility of the tt'Cth.
This increased mobility is due to the cUlling of transeptal fibers that splint tooth to
tooth. However. mobilit y gl"3duall y diminishes within a 2- to 4-weck period. A slight
overcorrection of tooth rotations should be accomplished at least 6 months before CSF
to ensure normal contact point relationships and principal fi ber realignment. Reproxi-
mation,I1I'( precisel y and conservatively performed. increases the long-term stability of
the mandibular anterior segment. The majorit y of all reproxi malions is performed
early in treatment and within 6 months of band removal.if no lower retention is
employed.
Il
.
I
Serial reproximation during the postlreatment peri od is often nccessary,
especiall y on patients experienci ng marked horizontal growth or where the lower arch
form has been signific-.mtly altered, especiall y in the mandibular incisor-cuspid areas.
The efficacy of the CSF procedure would appear to be somewhat less in the
mandibular anterior segment than in the maxillary anterior segment when observing
cases 12 to 14 years after active orthodontic treatment.
1I
This observation mi ght be
explained by the greater complexit y and multifactor potential for relapse inherent in
the mandibular anterior arch. The CSF procedure may be more efficient in alleviating
pure rotational relapse than in other types of tooth movement.
11
A comparison of
elcctrosurgery with conventional flbcrotomies on rotational rel apse and gingival ti ssue
in an a nimal sample showed that there is no significant difference between the two
techniques.
21
Teeth that are orthodont ically moved together after extraction of an adjacent tooth
do not move through the gingival tissue but appear to push the gi ngi va ahead to
create a fold of epithelial and connective ti ssues.
12
After the final closure of an
extraction si te, this excess gi ngival ti ssue appears in papillary form buccall y and
linguall y between t he approximated teeth. By surgi call y removi ng the excess gingiva
between properly approximated teeth, relapse can be alieviated.
11
Third molar absence or presence, impaction. or eruption does not seem to contrib-
ute to relapse.,n Neither first nor second bicuspid extraction makes much difference.
Arch development, a popular concept today, has only a 10% sati sfactory result. with
almost all arch-length increase cases worse off in the end than the other samples.'
Instabi lity should be assumed, because it is the more likely pattern. Permanent
retent ion, either with fixed or removable retainers, seems to be the logical answer.'
Patients and parents shoul d be informed of the risk of relapse and the limitations of
treatment before treatment begi ns, and patients should expect to remai n in retent ion
long term, with monitoring continuing throughout the patient' s adult life.
8
Bonding a thi n, fl exible spiral wire linguall y to each tooth in a segment is proposed
as a si mple and effecti ve way to retain anterior teeth.
22
Lingually bonded retainers arc
made of 0.0 195-inch or 0.0215-inch braided spiral wire.
22
Impressions are made with
brackets and archwires, and working models are poured in hard stone.
ll
Retainer
wires are carefull y contoured to the work.ing models to provide an intimate adapta-
tion to the criti cal areas of the lingual surfact'S.ll The retainer wire is then bonded
onlO the anterior tccth with composite resin. Every patient is instructed to rinse dail y
wi th a fluoride solution for as long as the retainer is in place. Exccllent long-term
success rates for six-unit mandibular and four-unit maxillary retainers have been
reported
u
(Figs. F7. 1 through F7.3). Wi re fatigue fractures could become a problem
in the long run, but this could be solved by remaking retainers at, perhaps, 10-year
intervals.
22
Chl pt .. r 7 Rr.'It'ntiOll . 333
F7.1
F7.2
Agure F1.1 A bonded 2-2 maxi llary retainer wi re. Figure F7.2 A bonded 3-3 mandibular relainer wire.
Agur. F7.3 A bonded I- I retai ner wi re.
334 P u t ~ ' Orthodontic Trl'tltment Modalities
F7.4
The patient is also given a set of Hawley retainers, one maxillary and one mandib-
ular ( Figs. F7.4 through F7.6). The maxillary is a wraparound retainer made of
O.036-inch round wire that encompasses all the tccth of the upper arch. The pati ent is
instructed to wear this retainer 24 hr/day for the first 6 months after treatment,
foll owed by 6 months of night-time wear (during sleep hours): after that, twice a week
for 6 months, once a week for another 6 mont hs, and, finall y, once a month for the
rest of the patient' s lifc. Of course, the maxillary bonded wire should also provide
lifetime retention of the anterior teeth. The mandi bular Hawley retainer should be
worn only if the bonded one breaks, until the patient may come to the office for
another one. Otherwise, it is not as ntx:essary as the maxillary one because of the
minimal changes we may have induced in the mandibular molar and cuspid widths.
F7.'
Figure F7.4 A maxillary Hawley retainer with circumferen-
t ial clasps and the cuspid wire over the occlusal surface.
This type of retainer is not recommended. A wraparound
retai ner is preferred because it does not allow for any wires
o\'er the occlusal table that may result in premature tooth
contacts.
Figure F7.S A mandibular Hawley retainer.
F7.6
Figure F1.6 Anterior view.
Chapttf 7 Reft'nlioo . 335
In open-bile cases, a tooth positioner may be used for 6 to 8 weeks of night-time
wear (or as much as the patient may be able to wear it. depending on his or her daily
activities) (Figs. n .7 through F7.9). This appliance places elastic forces to the teeth
and brings them into a predetermined ideal position (the tooth positioner is fabricated
to this position). It helps keep the open bite closed as the teeth are pulled in a venical
direction. Bonded fi xed and Hawley rctainers are also given to these patients for
long-term retention. One should make sure, however. that the mandibular anterior
teeth do not contact the acrylic of the maxillary Hawley appliance, b;eca use this would
open the bitc in the posterior and promote tooth extrusion, which would open the
bite funhcr. On the contrary. if the patient possesses a deep bite at the beginning of
treatment, a bile plane is built into the retainer.2J
Figure F7.7 Plastic caps over the brackets aid in the applica-
tion of the tooth jXlSitioner.
Figure F1.9 Tooth posi tioner (occlusal view).
,
F7 .
Figure F7.B Tooth posi ti oner (side view).
336 Part.' OrlhodfHllic T,ealllll'fII Modalilil'J
F7.10
In most cases, the maxillary second molars are not bonded during treatment. In
most instances. provided that the mandibular second molars are in good position and
acrylic has been relieved from the lingual side of the retainer. the pressure of the
buccinator muscles and normal eruption wi ll move the maxillary second molars into
proper position.
23
Finally, if the patient is suspected or being a tongue thruster. a 5-mm hole should
be made with an acrylic bur in thc antcrosupcrior palatal portion of the maxillary
Hawley acrylic. The lip or the tongue should rest on this hole as the patient develops
a correct swall owing pattern.21 .
The fabrication or the maxillary Hawley wraparound retai ner requires step-by-step
attention to detail that j ustifies its long-term purpose (Figs. F7.1 0 through F7.3 1). It is
vel)' important that the patient leaves the offi ce with a passive appliance that will
ensure the retention or the excellent orthodonti c result and the beautiful smile that
has been attained.

F7.11
Figure F7.1D The fi ni shed cast is cleaned of any bubbles or
ani facts.
Figures F7.11 through F7.14 A O.036-inch round wire is gen-
tl y bent crossed over and manipulated wi th the thumb to
obtain the shape of the dental arch.
C'hIpttr 7 Rf'tl'''/IOII . 337
1
F7. 12 F7.13
F7.14
338 Part.' Orrhodoolic Tr/'tJtm('nt ModalitiN
Figures F7.15 through F7.17 The wire is marked at the mid-
point of the cuspid tooth and a loop is bent around the
round part of the birdbeak pliers.
F7.17 F7.18
Figur. F7.18 The wire should contact the bi cuspids at the
level of the gingi val margins.
F1.19
Figure. F1.l9 through F7.23 The wire is bent inward to con
tact the first molar and curve around the second molar.
F1 .21
Cb.iplt'f 7 Rffl.'ntion . 339
F7.20
F7.22
340 Pan F DnhodQfl1ic Trralml'nt Moduli/ies
Figure F7.24 The wire ends on the palatal side of the bicus-
pid roolS on both sides.
F7.26
F7.25
Figures F7.2S through F7.27 After the cast is soaked in water
for 15 minut es, the " salt-and-pepper" technique is used to
plllcc thc acrylic over the palatal surface: of the wires.
F7.27
Figure F7.28 A sharp instrumcnt is used to define the mar-
gi ns of the acrylic.
Figure F7.lO It is then trimmed with an acryl ic bur and
thoroughly polished.
Chapl er 7 RI'/t'II/WI1 . 341
F1.29
Figure F7.29 Aftcr the material has sct, the retainer is re-
mOiled from the cast.
F7.31
FigUfe F7.31 The finished wraparound maxilla!), Hawley re-
tainer. A tight fil on the east ensures a good fi l in the
patient's mouth as ""'tn,
342 Part f' OrthotiOtl/k Tft'Cllmelll Motiaillit's
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