Professional Documents
Culture Documents
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1Clinical
Professor of Orthodontics
and Dentofacial Orthopedics, University of Pittsburgh, School of Dental
Medicine, Pittsburgh, Pennsylvania,
USA.
2Research Associate, Department of
Orthodontics, School of Dentistry,
University of Western Australia, Nedlands, Western Australia; private
practice, Perth, Australia.
CORRESPONDENCE
Sanjivan Kandasamy
Department of Orthodontics
Oral Health Center of Western Australia
University of Western Australia
17 Monash Avenue
Nedlands, Western Australia 6009
Australia
E-mail: sanj@kandasamy.com.au
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Fig 1 Diagram illustrating the correct lingual inclinations of the mandibular and
maxillary first molar crowns compared to
the inclinations advocated by the expansionists/nonextractionists.
Mandibular
molar
30 degrees
Mandibular
molar
10 degrees
tion these molars and the rest of the buccal segments (molars and bicuspids) to a
normal upright position. . . .
In a similar light, some influential
nonextraction orthodontists2,3 appear to
be arguing for a new paradigm in orthodontics that supports the view that lowfriction self-ligating brackets can magically allow arches to be expanded
(without the need for maxillary arch
palatal suture expansion) or developed
to accommodate severe tooth-sized arch
length discrepancies.
Damon wrote, 3 Extensive clinical
results indicate that clinicians now can
maintain most complete dentitions, even
in severely crowded arches, by using very
light-force, high tech arch wires in the
passive Damon appliance that alter the
balance of the forces among the lips,
tongue, and muscles of the face. This
alteration creates a new force equilibrium that allows the arch form to reshape
itself to accommodate the teeth; the
body not the clinician determines where
the teeth should be positioned . . . this
compelling research calls for a significant shift in thinking and treatment planning, reducing and even eliminating the
need for molar distalization, extractions
(excluding those deemed appropriate for
bimaxillary protrusive cases), and rapid
palatal expansion.
Although such nonextraction thinking
is argued as new and contemporary, it
seems that it is an argument Angle
offered some 100 years ago.9,10 If one
studies 2 figures in the textbook these
clinicians referenced, some illuminating
information can be extricated.1 For example, when one looks at the first diagram
that illustrates what the author1 believes
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Fig 2 Diagram illustrating lingual inclinations of the mandibular and maxillary first
molar crowns, as well as the inward (lingual) tilt of the mandibular corpus.
Maxillary
molar
9 degrees
Mandibular
molar
30 degrees
taken from the midpoint of the facial surface of the clinical crown: . . . a line perpendicular to the occlusal plane and a
line tangent to the middle of the labial or
buccal long axis of the clinical crown.14
Andrews found that all posterior teeth
(maxillary and mandibular as judged
from the clinical crowns of the teeth) are
lingually inclined, and this is clearly illustrated in his Six Keys article. 14 Concerning the inclination of the mandibular
posterior teeth, Andrews wrote,14 A progressively greater minus crown inclination (approximately 11 to 35 degrees)
existed from the lower canines through
the lower second molars. Parenthetically, this finding of Andrews is in line
with that of a renowned anthropologist B.
Holly Smith, 15 who wrote Hominoid
molar teeth are progressively tilted. The
normal/ideal facial-lingual inclination for
the clinical crowns of the mandibular
first molars (in Caucasians) as developed
in the bracket prescription of the original
Andrews (A-Company) appliance 46 is
30 degrees (Fig 2). The typical straightwire (preadjusted) prescription for the
mandibular first molars for most orthodontic companies and practitioners is
30 degrees (plus or minus several
degrees; some prescriptions have 25
degrees). Lee and Rinchuse16 found that
the inclination of the mandibular first
molar crowns for Asians (Koreans) was
26.96 degrees.
This 30-degree inclination angle for
the mandibular first molar is the same
as what Vardimon and Lambertz7 inidicate. Furthermore, the classic 1963
study by Dempster et al8 of 11 male dry
skulls (India) with typical occlusions
demonstrated that the inclination of the
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Line of force
Appliance prescription
Fig 3 Diagram illustrating the inward
motion and movement of the mandible on
the right working side during the trituration
phase of mastication.
Mandibular function
Humans chew unilaterally, and the chewing pattern shape (after the food is
incised) is described as elliptical and
tear-dropped when judged from the
frontal plane.25 Because the mandible
on the working side circles inward at an
angle of 20 to 35 degrees (depending
upon an individuals chewing characteristics during mastication), the mandibular
posterior molars also have to be lingually
inclined at a similar angle to best receive
an inward direction of force. It therefore
makes sense that the mandibular first
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Stability
Nonextractionists who argue for the correctness of a more upright inclination for
the mandibular first molars (12 to 15
degrees as opposed to 30 degrees) in
order to give the tongue more room often
cite as evidence the so-called equilibrium
theory.28 According to this theory,28 the
position of teeth within the arches is significantly influenced by the tongue, muscles, soft tissues of the cheeks, and
occlusal function. This theory has merit,
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Bite opening
Besides the issue of stability, one must
consider the potential negative side
effects of simple orthodontic arch expansion (as opposed to orthopedic expansion), such as an untoward bite opening.
That is, buccal crown tipping and extrusion may predispose to unnecessary bite
opening and possible negative overall
facial or lip esthetic outcomes. This is
especially critical in patients that exhibit
skeletal open-bite tendencies, large interlabial gaps, and severe Class II open-bite
skeletal patterns.50
CONCLUSIONS
The long-held belief and evidence suppor ting the concept of the relative
immutability of the perimeter of the
mandibular arch appears to be ignored
in favor of orthodontic therapies that are
indiscriminately nonextraction. The previous evidence-based notion that supports
the view that the mandibular intercanine
and possibly intermolar arch width
should generally not be expanded
beyond very modest limits is now being
challenged by some contemporary orthodontic treatments and philosophies. Stability, as well as stomatognathic function,
seems to be of little concern and has
given way to the allures of big, broad
smiles and the at-all-costs nonextraction
approach. In this regard, there are many
premises and fads in orthodontics that
have not withstood the test of time. Even
the great Dr Edward Hartley Angle was
deemed to be incorrect in his thinking
concerning the universal recommendation for nonextraction orthodontic treatment. One of Angles students, Dr
Charles Tweed, retreated approximately
100 of his own relapsed, nonextraction
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REFERENCES
1. Alpern MC. The Ortho Evolution: The Science
and Principles Behind Fixed/Functional/Splint
Orthodontics. New York: GAC International,
2003:104105, 271.
2. Borkowski R. The Damon system of self-ligating
brackets. Presented at the University of Pittsburgh, Nov 11, 2005.
3. Damon DH. Treatment of the face with biocompatible orthodontics. In: Graber TM, Vanarsdall
Jr RL, Vig KWL (eds). Orthodontics: Current
Principles and Techniques, ed 4. St Louis: CV
Mosby, 2005:753831.
389
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