The Black Box of Orthodontic Reserch

THE BLACK BOX
OF ORTHODONTIC RESEARCH
First Edition
RAED H. ALRBATA
BDS. JBOrth. OMI Fellow
Royal Medical Services
Amman. Jordan
1
The Black Box of Orthodontic Research.
ISBN: 978-9957-67-019-1
The Hashemite Kingdom of Jordan

The Deposit Number at the National Library: (2017/6/3017)
©Raed H. Alrbata, 2017
First Edition
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system
or transmitted, in any form or by any means, without the prior permission from the author.
Raed H. Alrbata, Specialist in orthodontics, Royal medical services,

Department of orthodontics.
E-mail: raedrbata@yahoo.com
Amman, Jordan
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Preface
The black box of orthodontic research is considered as a reference for orthodontic professionals
who look for validation and optimization of their basic knowledge, experience and updated
research concerning the orthodontic field. The continuing development in orthodontic materials
and mechanics led researchers from different countries to employ their efforts and capabilities to
investigate any relation between these and their use in orthodontic treatment. Running multiple
studies scenarios for different populations, needs to be organized and ranked according to article
type and methodology incorporated to simplify the process of referencing and validating each
orthodontic procedure used.
For this, it was my honorable opportunity to give a hand in this issue. For most orthodontic
subjects encountered daily in practice, the most leading results, statements and conclusions of
concern mentioned in literature will be documented in order of publishing time. Considering
theses, beside focusing on the mentioned reference, will give orthodontists the complete picture
of the idea.
It should be stated here that more focus on the leading orthodontic journals will be noticed.
Those articles published with powerful methodology will be given a colored circle using
different colors dependent on the hierarchy of the medical research.
Raed H. Alrbata
Meta-
Analysis
Systematic
Review
Randomized
Controlled Trials
Logitudinal, Cohort
Studies
Case Studies
Expert Opinions
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4
Table of Contents
Page
Journals Abbreviations 6
Section one Cephalometrics and Radiographic Analyses 7
Section Two Materials Used In Orthodontics 13
Section Three Etiology of Malocclusion 27
Section Four Treatment Planning 35
Section Five Early Orthodontic Treatment 55
Section Six Anchorage in Orthodontics 61
Section Seven Orthodontic Malocclusions and Other Problems 75
Section Eight Orthodontic Appliances 99
Section Nine Orthodontic Biomechanics and Procedures 125
Section Ten Orthodontics and Orthognathic Surgery 143
Section Eleven Retention and Stability 151
Section Twelve Complications of Orthodontic Treatment 161
Section Thirteen Cleft Lip and Palate 179
Section Fourteen Pioneers in Orthodontics 185
Index 193
5
Journals Abbreviations
Acta Odontologica Scandinavica: AOS Journal of Oral Rehabilitation: JOR
Andrews Journal: AJ Journal of Oral and Maxillofacial Surgery:

JOMS
Australian Orthodontic Journal: AOJ
Journal of Orofacial Orthopaedics: JOO
British Dental Journal: BDJ
Journal of Orthodontics: JO
British Journal of Orthodontics: BJO
Journal of Periodontology: JP
Clinical Oral Implantology Research: COIR
Journal of Plastic and Reconstructive
Cleft Palate and Craniofacial Journal: CPCJ Surgery: JPRS
Dental Record Journal: DRJ Journal of Prosthetic Dentistry: JPD
Dentomaxillofacial Radiology: DR Journal of the American Dental Association:
International Journal of Adult Orthodontics JADA
and Orthognathic Surgery: IJAOOS Journal of the Korean Academy of
International Journal of Oral Maxillofacial Prosthodontics: JKAP
Implants: IJOMI Journal of Wonkwang Dental Research
International Journal of Paediatric Dentistry: Institute: JWDRI
IJPD Open Dental Journal: ODJ
International Journal of Prosthodontics: IJP Plastic and Reconstructive Surgery Journal:
Journal of Canadian Dental Association: PRSJ
JCDA Puerto Rico Health Sciences Journal:
Journal of Clinical Orthodontics: JCO PRHSJ
Journal of Clinical Paediatric Dentistry: Quintessence International: QI

JCPD Scandinavian Journal of Dental Research:
Journal of Craniofacial Surgery: JCS SJDR
Journal of Dental Research: JDR World Journal of Orthodontics: WJO
Journal of Esthetic Dentistry: JED
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Section one
Cephalometrics and Radiographic Analyses
Cephalometric Analyses Used in Orthodontics
Cervical Vertebral Maturation (CVM)
7
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In this section, some of the reported researches concerning cephalometric analyses along with the
technique of cervical vertebral maturation for growth prediction will be presented.
Cephalometric Analyses Used in Orthodontics
Eastman correction can be applied if SNA is high/low and SN/MxP is normal. The
correction states that for every 1 degree that the angle SNA falls below the standard value
of 81 degrees, half a degree should be added to the ANB angle and vice versa. The
correction is restricted for cases where the SN/MxP angle is the standard 8 ± 3 degrees.
Mills (1970). The application and importance of cephalometry in orthodontic treatment. The
Orthodontist 32-47
Jarabak ratio = PFH: AFH, The normal range is: 59 – 63%

If ≥ 64: low angle case, deep OB;
If ≤ 58: high angle case, reduced OB.
Jarabak & Fizzell (1972). Technique and treatment with the light wire edgewise appliance.
Mosby Year Book, St Louis
Wits appraisal: Assesses antero-posterior jaw discrepancy in relation to each other and
not to cranial base. Useful if ANB does not reflect clinical findings.
For Females: 0mm ±2mm= Class I, >2mm= Class II, <-2mm= Class III
For Males: -1mm ± 2mm= Class I, >mm= Class II, < -3mm= Class III
Jacobson (1975). The Wits appraisal of jaw disharmony. AJO 67:125-138
Esthetic Plane or ―E‖ line: Is simply a line drawn from the tip of the nose to the tip of the
chin. To have a pleasing facial profile, in the average Caucasian face, the lower lip would
be 2 mm behind the line, and the upper lip 4 mm behind the line, with variations being
normal for patients of different ethnic backgrounds.
Ricketts et al (1979). Bioprogressive Therapy, Denver, Rocky Mountain Orthodontics.
Harmony (H) line: drawn tangent to soft tissue chin and upper lip. Should bisect nose.
Lower lip to this line: -1 to +2mm.
Tip of the nose to this line: +9mm.
9
Holdaway (1983). A soft tissue cephalometric analysis and its use in orthodontic treatment
planning Part 1. AJO 84:1-28
Zero median line: Perpendicular line from Nasion though Frankfort plane.
Chin point should be at the line ± 2mm.
Gonzales-Ulloa and Stevens (1961). The role of chin correction in profile plasty. PRSJ 36:364-
73
Pitchfork analysis- superimposition of 2 or more lateral cephalometrics, registered on

stable reference points to demonstrate skeletal and dental change.
Johnston (1996). Balancing the books on orthodontic treatment: An integrated analysis of

treatment change. BJO 23:93-102
Palatal rugae landmarks are as reliable as cephalometric structures for superimposition.
Hoggan and Sadowsky (2001). The use of palatal rugae for the assessment of anteroposterior
tooth movements. AJODO 119: 482-8
Cervical Vertebral Maturation (CVM)
The CVM method is modestly effective in determining the amount of postpeak

circumpubertal craniofacial growth.
Fudalej and Bollen (2010). Effectiveness of the cervical vertebral maturation method to predict
postpeak circumpubertal growth of craniofacial structures. . AJODO 137; 59–65
Cervical vertebral maturation stages cannot accurately identify the mandibular

prepubertal growth minimum and therefore cannot predict the onset of the peak in
mandibular growth.
Ball et al (2011). Relationship between cervical vertebral maturation and mandibular growth.
AJODO 139: e455–e461
10
Cervical vertebral stage and dental age development is directly related to body mass
index (BMI) percentiles. Orthodontists should consider weight status when evaluating
growing children and adolescents because it can affect skeletal and dental development.
Mack et al (2013). Relationship between body mass index percentile and skeletal maturation and
dental development in orthodontic patients. AJODO 143: 228–234
Morphometric changes of the cervical vertebrae and the CVM method could not
accurately identify the mandibular growth peak.
Gray et al (2016). Morphometric analysis of cervical vertebrae in relation to mandibular growth.

AJODO 149: 92–98
An association exists between the dental mineralization stages and the periods of the
pubertal growth spurt, especially for second molars. Panoramic radiographs can be used
as the first diagnostic tool to estimate the pubertal growth period.
Lopes et al (2016). Utility of panoramic radiography for identification of the pubertal growth
period. AJODO 149: 509–515
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12
Section Two
Materials Used In Orthodontics
Etching Materials
Bonding Materials
Self-etching Primers (SEPs)
Light Curing Devices
Orthodontic Brackets
Self-ligating Brackets
Archwires Used in Orthodontics
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The main materials and equipments used in the daily orthodontic practice will be available in this
section. Etching materials, bonding materials, brackets, archwires and light curing devices will
be investigated for their performance, effectiveness, durability and safety.
Etching Materials
No significant difference in bond strength between etching for 15, 30, 60 and 90 seconds;
etching for longer than 90 seconds may result in lower bond strengths.
Wang and Lu (1991). Bond strength with various etching times on young permanent teeth.
AJODO 100: 72-79
Polyacrylic acid produces slight etching of the enamel surface. Calcium sulphate
dihydrate crystals are formed which bond securely to the enamel surface. These can
provide a shear bond strength above the threshold of 6-8 MPa recommended by Reynolds
but 30% lower than that achieved with phosphoric acid.
Bishara et al (2000). Effect of altering the type of enamel conditioner on the shear bond strength
of a resin-reinforced glass ionomer adhesive. AJODO118: 288-294
The most widely accepted choice for routine orthodontic bonding is the use of 37%
phosphoric acid with a 30 seconds etch time.
Gardner and Hobson (2001). Variations in acid-etch patterns with different acids and etch
times. AJODO120: 64-67
Bonding Materials
The mean linear tensile bond strength of enamel is 14.5 MPa.
Bowen and Rodriguez (1962). Tensile strength and modulus of elasticity of tooth structure and
several restorative materials. JADA 64: 378
Fractures in enamel can occur with bond strengths as low as 13.5 MPa.
Retief DH (1974). Failure at the dental adhesive-etched enamel interface. JOR 1: 265-284
15
The minimum bond strength needed for clinical use is 5.9 - 7.8 MPa.
Reynolds IR (1975). A review of direct bonding. BJO 2: 171-178
The conventional resin primer system produce higher bond strength (10.4 MPa)
compared to glass ionomer cement (6.5 MPa).
Bishara et al (1999). Shear bond strength of composite, glass ionomer and acidic primer
adhesive systems. AJODO 115: 24-28
No advantage or disadvantage of precuring the primer on the bonding strength.
Osterle et al (2004). Effect of primer precuring on the shear bond strength of orthodontic
brackets. AJODO 126: 699-702
The addition of chlorhexidine digluconate to conventional GICs does not negatively

modify the mechanical properties and may increase the antibacterial effects around the
GICs even for relatively long periods of time.
Farret et al (2011). Can we add chlorhexidine into glass ionomer cements (GICs) for band
cementation? Angle Orthodontist 81: 496-502
Light-cured composite resin was compared with chemical-cured composite resin: The
polymerization mode did not influence the bracket survival rate significantly.
Mohammed et al (2016). Comparing orthodontic bond failures of light-cured composite resin

with chemical-cured composite resin: A 12-month clinical trial. AJODO 150: 290–294
Self-etching Primers (SEPs)
Self-etching primers are moisture insensitive and work in wet and saliva contaminated
conditions whilst maintaining their initial bond strength long term.
Cinader (2001). Chemical processes and performance comparisons of Trans bond Plus self-
etching primer.
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The use of the SEP produced a significantly lower but clinically acceptable bond strength
(7.1 MPa) than Transbond XT (10.4 MPa).
Bishara et al (2001). Effect of a self-etch primer/adhesive on the shear bond strength of

orthodontic brackets. AJODO 119: 621-624
Weak evidence that the self-etching primer has a higher failure rate but is still well within
the limits of clinical acceptability.
Ireland et al (2003). An in vivo investigation into bond failure rates with a new self-etching
primer system. AJODO 124: 323-326
The use of SEP is quicker than a conventional bonding technique. No difference in

survival time between the two bonding systems.
Aljubouri et al (2003). Laboratory evaluation of a self-etching primer for orthodontic bonding.

EJO 25: 411-415
The bond strengths for the self-etching primer and Transbond XT and 35% phosphoric
acid and Enlight were compared and found similar.
Grubisa et al (2004). An evaluation and comparison of orthodontic bracket bond strengths

achieved with self-etching primer. AJODO 126: 213-219
Pumicing was found to produce a statistically and clinically significant reduction in

clinical bond failure rates when using SEPs.
Burgess et al (2006); Self-etching primers: is prophylactic pumicing necessary? A randomized

clinical trial. Angle Orthodontist 76: 114–118
The shear bond strength of flowable composites increases with filler content. However,
they have lower shear bond strength than 3M Unitek Transbond XT.
Uysal et al (2008). Microleakage under metallic and ceramic brackets bonded with orthodontic
self-etching primer systems. Angle Orthodontist 78: 1089–1094
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The effect of moisture contamination before and after the application of Transbond Plus
self-etching primer with uncontaminated bonding was investigated. The observation
period was a minimum of six months. The overall bond failure rate was 6.08% and there
were no significant differences between the contaminated and uncontaminated bondings.
Campoy et al (2010). Effect of saliva contamination on bracket failure with a self-etching

primer: A prospective controlled clinical trial. AJODO 137: 679-683
Light Curing Devices
No statistical difference in the mechanical properties of composites cured with either

LED or quartz halogen lights.
Fay et al (2002). Mechanical properties of composite cured with LED and QTH curing lights.
The IADR/AADR/CADR 80th General Session (March 6-9, 2002) San Diego, California, Dental
Materials VI: Polymer Materials – Mechanical Properties and Degradation Program
The LED, plasma arc and newer quartz tungsten halogen lights (such as the Optilux 501)
produced less intrapulpal temperature rise than the older conventional quartz tungsten
halogen lights.
Bouschlicher et al (2002). Intrapulpal temperature increases with LED, QTH and Plasma arc
photoinitiation. The IADR/AADR/CADR 80th General Session (March 6-9, 2002) San Diego,
California, Dental Materials VIII: Others – Nonmetallic.
The shear bond strength of orthodontic brackets bonded to teeth with conventional
halogen-based light-curing units and commercially available LED curing units was
compared. No significant difference in bond strength was found between the lights.
Dunn and Taloumis (2002). Polymerization of orthodontic resin cement with light-emitting
diode curing units. AJODO 122: 236-241
The bond strength generated by high power halogen lights, a plasma arc light and an LED
used for their recommended periods were compared: no difference in bond strengths
between the three lights.
Thind et al (2006). A comparison of tungsten-quartz-halogen, plasma arc and light-emitting

diode light sources for the polymerization of an orthodontic adhesive. EJO 28: 78-82
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Halogen and LED lights used for 20 seconds produced the greatest depth of cure.
Between the plasma arc light and the LED light when used for 10 seconds: no difference.
Niepraschk et al (2007). Effect of various curing lights on the degree of cure of orthodontic
adhesives. AJODO132: 382-384
A randomised controlled trial to compare LED vs halogen light curing of orthodontic

brackets: equivalent bond failure rates over a 15 month period in a contralateral quadrant
study with halogen and LED lights.
Krishnaswamy and Sunitha (2007). Light-emitting diode vs halogen light curing of orthodontic
brackets: A 15-month clinical study of bond failures. AJODO 132: 518-523
No difference in bond failure rates using 3M APC brackets cured with a conventional
halogen light and an LED light.
Mirabella et al (2008). LED vs halogen light-curing of adhesive-precoated brackets. Angle

Orthodontist 78: 935–940
Orthodontic Brackets
Andrews described different incisor bracket sets to be used for different skeletal patterns.
The amount of torque in the brackets was the only difference.
 Set A brackets: designed for Class 2 skeletal patterns had less palatal root torque
in the upper incisors and more labial crown torque in the lower incisors.
 Set C for Class 3 skeletal patterns had the reverse.
 Set S for Class 1 malocclusions.
Translation brackets: to compensate for the unwanted tooth movements that occurred
during closure of extraction spaces. Had increased tip and antirotation.
Andrews LF (1989). Straight Wire The Concept and the Appliance San Diego, L A Wells Co.
Gingival offset brackets have a risk of bond failure which is five times less than with
conventional brackets.
Tidy and Coley-Smith (1998). Gingival offset premolar brackets - a randomised clinical trial
Paper presented at the Golden Jubilee Symposium at the RCSEd.
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The relationship between bond strength and pad size with both microetched and
conventional bases was investigated:
There was no difference in shear bond strength for pads between 6.82 mm2 and 12.35
mm2 in size. No difference in shear bond strength between a manufacturer-applied
microetching process (grit blasting) and sandblasting in the surgery with a Danville
Engineering sandblaster.
MacColl et al (1998). The relationship between bond strength and orthodontic bracket base
surface area with conventional and microetched foil-bases. AJODO 113: 276-281
Minor pitting and corrosion can be seen on titanium brackets exposed to acidic fluoride
containing toothpastes but this is not likely to affect their clinical performance during the
average orthodontic treatment time.
Harzer et al (2001). Sensitivity of titanium brackets to the corrosive influence of fluoride-

containing toothpaste and tea. Angle Orthodontist 71: 318-323
Bracket prescription had no effect on the aesthetic judgments made by experienced

orthodontists from the post-treatment study models of patients treated with premolar
extractions and a fixed appliance system using either a Roth or a MBT prescription.
Moesi et al (2013). Roth versus MBT: does bracket prescription have an effect on the subjective
outcome of pre-adjusted edgewise treatment? EJO 35: 236-243
Self-ligating Brackets (SLBs)
When initially placed, an elastomeric in a figure of 8 configuration increases the friction

by a further 70-220% compared to the ―O‖ configuration.
Sims et al (1993). A comparison of the forces required to produce tooth movement in vitro using
two self-ligating brackets and a pre-adjusted bracket employing two types of ligation. EJO: 15:
377-385
Elastomerics and wire ligatures with respect to various measures of plaque quality and
quantity, gingival index, probing depth and bleeding on probing were compared:
20
The bacteriology results slightly favoured wire ligation, but not to a significant extent,
but the important sign of bleeding on probing was substantially higher with elastomeric
ligation.
Turkkahraman et al (2005). Archwire ligation techniques, microbial colonization, and

periodontal status in orthodontically treated cases. Angle Orthodontist 75: 231-236
Very little difference between cases treated with conventional and self-ligation in terms
of arch expansion or incisor proclination.
Fleming et al (2009b). Comparison of mandibular arch changes during alignment and levelling
with two preadjusted edgewise appliances. AJODO 136: 340-347
There is insufficient evidence to support the view that treatment with self-ligating
brackets is more or less efficient than with conventional ligation. Shortened chair time
and slightly less incisor proclination appear to be the only significant advantages of self-
ligating systems over conventional systems that are supported by the current evidence.
Fleming and Johal (2010). Self-ligating brackets in orthodontics – a systematic review. Angle
Orthodontist 80:575-584
Chen et al (2010). Systematic review of self-ligating brackets. AJODO 137: 726.e1-726.e18
Bracket type does not influence the duration of treatment or the number of visits
required.
Fleming et al (2010). Randomized clinical trial of orthodontic treatment efficiency with self-
ligating and conventional fixed orthodontic appliances. AJODO 137: 738–742
SLBs were no more efficient than conventional brackets in anterior alignment or passive
extraction space closure during the first 20 weeks of treatment.
Ligation technique is only one of many factors that can influence the efficiency of
treatment. Similar changes in arch dimensions occurred, irrespective of bracket type that
might be attributed to the archform of the archwires.
Ong et al (2010). Efficiency of self-ligating vs conventionally ligated brackets during initial

alignment. AJODO 138: 138.e1–138.e7
21
An alignment-induced increase in the proclination of the mandibular incisors was
observed for 2 groups of SLB and conventional ones:
No difference was identified between both with respect to this parameter. Also, an
increase in intercanine and intermolar widths was noted for both bracket groups; the self-
ligating group showed a higher intermolar width increase than the conventional group,
whereas the amount of crowding and Angle classification were not significant predictors
of post-treatment intermolar width.
Pandis et al (2010). Mandibular dental arch changes associated with treatment of crowding
using self-ligating and conventional brackets. EJO 32: 248-253
Maxillary and mandibular intercanine, interpremolar, and intermolar widths increased

significantly after treatment with the Damon system:
The mandibular incisors were significantly advanced and proclined after treatment with
this system, contradicting the lip bumper theory of Damon. Posttreatment incisor
inclinations did not differ significantly between the Damon group and the control group.
Patients treated with the Damon system completed treatment on average 2 months faster
than patients treated with a conventionally ligated standard edgewise bracket system.
Vajaria et al (2011). Evaluation of incisor position and dental transverse dimensional changes
using the Damon system. Angle Orthodontist 81: 647-652
The use of conventional or SLBs does not seem to be an important predictor of

mandibular intermolar width in nonextractions patients when the same wire sequence is
used.
Pandis et al (2011). Comparative assessment of conventional and self-ligating appliances on the

effect of mandibular intermolar distance in adolescent nonextraction patients: A single-center
randomized controlled trial. AJODO140: e99–e105
Self-ligating esthetic brackets do not promote greater or lesser S mutans colonization

when compared with conventional brackets. Differences were found to be related to the
material composition of the bracket.
Nascimento et al (2013). Colonization of Streptococcus mutans on esthetic brackets: Self-

ligating vs conventional. AJODO 143: S72–S77
22
No difference in the arch dimensional or inclination changes during alignment can be
expected between conventional brackets and either active or passive self-ligation.
Fleming et al (2013). Comparison of maxillary arch dimensional changes with passive and
active self-ligation and conventional brackets in the permanent dentition: A multicenter,
randomized controlled trial. AJODO144: 185–193
Conventional vs SLBs: Time to initial alignment was significantly shorter for the
conventional bracket than for either the active or passive self-ligating brackets. There
was no statistically significant difference in total space-closure time among the 3
brackets.
Songra et al (2014). Comparative assessment of alignment efficiency and space closure of active
and passive self-ligating vs conventional appliances in adolescents: A single-center randomized
controlled trial. AJODO 145: 569–578
No clinically significant difference in treatment efficiency between treatment with a self-

ligating bracket system and a conventional ligation system.
O'Dywer et al (2016). A multi-center randomized controlled trial to compare a self-ligating

bracket with a conventional bracket in a UK population: Part 1: Treatment efficiency. Angle
Orthodontist 86: 142-148
No clinically significant difference in pain experience between patients treated with a

self-ligating bracket system compared to those treated with a conventional ligation
system.
Rahman et al (2016). A multicenter randomized controlled trial to compare a self-ligating

bracket with a conventional bracket in a UK population: Part 2: Pain perception. Angle
No differences in maxillary arch dimensional changes or molar and incisor inclination

changes were found in conventional and active and passive SLBs used with broad
archwires.
Atik et al (2016). Evaluation of maxillary arch dimensional and inclination changes with self-
ligating and conventional brackets using broad archwires. AJODO 149: 830–837
23
Archwires Used in Orthodontics
The technique of ion implantation is used to modify surfaces exposed to corrosion or

wear.
Mizrahi et al (1991). The effect of Ion implantation on the beaks of orthodontic pliers. AJODO
99: 513-519
The use of figure of eight ligatures increases the fictional resistance by approximately
one and a half times for most working archwires and by over three times for 0.016" x
0.022" archwires.
Sims et al (1993). A comparison of the forces required to produce tooth movement in vitro using
two self-ligating brackets and a preadjusted bracket employing two types of ligation. EJO 15:
377-385
Ideal properties of thermoelastic archwires:

 Highly ductile at room temperature.
 Instantaneous activation at mouth temperature.
 Once fully activated, the wire is not further activated by the heat of the mouth.
 A narrow temperature transition range such that the wire is highly ductile at room
temperature and highly active at mouth temperature.
Bishara et al (1995). Comparisons of thermodynamic properties of three nickel titanium

orthodontic archwires. Angle Orthodontist 65: 117-122
The amount of torque loss between archwire and bracket is affected by:
 Play between archwire and bracket slot.
 Lack of stiffness of bracket structure or slot.
 Inadequate archwire stiffness.
 Incomplete ligation.
 Manufacturing variability.
Gioka et al (2004). Materials-induced variation in the torque expression of preadjusted

appliances. AJODO 125: 332-338
24
The arch form derived from the WALA points is much broader in the premolar and molar
regions. There was significant correlation between the FA and WALA points particularly
in the canine and molar regions and that the WALA points could be used to indicate basal
archform.
Ronay et al (2008). Mandibular arch form: The relationship between dental and basal anatomy.
AJODO 134: 430-438
Two orthodontic archwires (0.016‖ 35° CuNiTi and 0.016‖ NiTi) were compared for
effectiveness of resolving mandibular anterior crowding at different rates: the wire type
had no effect on the rate of resolution of anterior mandibular crowding
Pandis et al (2009). Alleviation of mandibular anterior crowding with copper-nickel-titanium vs

nickel-titanium wires: A double-blind randomized control trial. AJODO 136: 152.e1-152.e7
Most NiTi wires do not exhibit in torsion the superelastic effect traditionally described in
bending and the optimal constant moments necessary to gain third-order control of tooth
movement early in treatment are not present in a preadjusted edgewise-rectangular NiTi
archwire system.
Bolender et al (2010). Torsional superelasticity of NiTi archwires: myth or reality? Angle

Despite its antibacterial function, garlic extract increases biofilm formation by S mutans
to orthodontic wire, likely through upregulation of glucosyltransferase expression. Garlic
extract may thus play an important role in increased bacterial attachment to orthodontic
wires.
Lee et al (2011). Effect of garlic on bacterial biofilm formation on orthodontic wire. Angle
Superelastic NiTi performed significantly better than multistranded (coaxial) stainless

steel wire in the Begg appliance. However, in PEA, there was no significant difference.
Sandhu et al (2012.) Efficiency, behavior, and clinical properties of superelastic NiTi versus
multistranded stainless steel wires. Angle Orthodontist 82: 915-921
25
In low-friction mechanics, thermal NiTi wires are to be preferred to superelastic wires,
during the alignment phase due to their lower working forces. In conventional straight
wire mechanics, a low force archwire would be unable to overcome the resistance to
sliding.
Gatto et al (2013). Load–deflection characteristics of superelastic and thermal nickel–titanium

wires. EJO 35: 115-123
The 0.017 × 0.025-inch stainless steel and β-Ti archwires in the 0.018-inch slot generated
higher moments than the 0.019 × 0.025-inch archwires because of lower torque play. This
difference is exaggerated in steel archwires, in comparison with the β-Ti, because of
differences in stiffness.
Sifakakis et al (2014). Torque efficiency of different archwires in 0.018- and 0.022-inch

conventional brackets. Angle Orthodontist 84: 149-154
The three forms of NiTi wires (0.014-inch superelastic NiTi, 0.014-inch thermoelastic
NiTi, or 0.014-inch conventional NiTi) were similar in terms of their alignment
efficiency during the initial aligning stage of orthodontic fixed appliance therapy.
Abdelrahman et al (2015). A clinical comparison of three aligning archwires in terms of

alignment efficiency: A prospective clinical trial. Angle Orthodontist 85; 434-439
26
Section Three
Etiology of Malocclusion
Bruxism and Functional Occlusion
Breastfeeding and Pacifier Use
Mouth Breathing, Obstructive Sleep Apnea (OSA)
Tongue Thrusts
Protecting Teeth Surface
27
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Bruxism and Functional Occlusion
No connection between bruxism and pattern of functional occlusal contacts.
Egermark-Erikson et al (1983). The dependence of mandibular dysfunction in children on

functional and morphologic malocclusion. AJODO 83: 187-194
Parafunction and tooth wear at an early age were risk factors for TMD 20 years later.
Carlsson et al (2002). Predictors of signs and symptoms of temporomandibular disorders: a 20-

year follow-up study from childhood to adulthood. AOS 60: 180-185
Breastfeeding and Pacifier Use
Children who were breastfed for more than 12 months had a 20-fold lower risk for the
development of posterior crossbite compared with children who were never breastfed and
a 5-fold lower risk compared with those breastfed between 6 and 12 months.
Kobayashi et al (2010). Relationship between breastfeeding duration and prevalence of

posterior crossbite in the deciduous dentition. . AJODO 137; 54–58
The duration of a pacifier habit and short frenulum linguae are associated with posterior
crossbite at the age of 4 or 5 years because of the low tongue posture in the mouth.
Pediatricians and pedodontists should give precise recommendations for enhancing breast
feeding and discontinuing pacifier habits at least until the child is 18 months of age.
Melink et al (2010). Posterior crossbite in the deciduous dentition period, its relation with
sucking habits, irregular orofacial functions, and otolaryngological findings. AJODO 138:32–40
Mouth Breathing, Obstructive Sleep Apnea (OSA)
There is no one mandibular advancement device (MAD) design that most effectively
influences perceived treatment efficacy, but efficacy depends on many factors including
materials and method used for fabrication, type of MAD (Monoblock or Twin-block),
and the degree of protrusion (sagittal and vertical).
Ahrens et al (2010). Subjective efficacy of oral appliance design features in the management of
obstructive sleep apnea: A systematic review. AJODO 138: 559–576
29
The oropharyngeal (OP) airway volumes of Class II patients are smaller when compared
with Class I and Class III patients. Mandibular position with respect to cranial base affect
the OP airway volume.
El H et al (2011). Airway volume for different dentofacial skeletal patterns. AJODO 139: e511–
e521
Nasal obstruction is associated with a decrease in lip-closing force. When the severity of
nasal obstruction reaches a certain level, the lip-closing force is weakened.
Sabashi et al (2011). Nasal obstruction causes a decrease in lip-closing force. Angle

Favorable reductions in sleep variables highlight the potential of microimplant-based

mandibular advancement therapy as an alternative treatment modality for OSA patients
who cannot tolerate continuous positive airway pressure and oral appliance therapy.
Ngiam and Kyung (2012). Microimplant-based mandibular advancement therapy for the
treatment of snoring and obstructive sleep apnea: a prospective study. Angle Orthodontist 82:
978-984
Patients received adenotonsillectomy have different pattern of arch development

compared with the untreated controls.
After this procedure, the mouth-breathing children showed greater maxillary transverse
development than did the controls. The palatal vault deepened in the untreated children.
The mouth-breathing children in comparison with the nasal-breathing children have
deeper palatal vault, larger mandibular width, and larger mandibular arch length.
Caixeta et al (2014). Dental arch dimensional changes after adenotonsillectomy in prepubertal

children. AJODO 145: 461–468
Head posture show significant differences in patients with OSA. In general, the more
severe the OSA, the more extended the natural head position as indicated by increases in
the craniocervical angles. The cervical posture parameters may indicate existing OSA.
Sökücü et al (2016). Relationship between head posture and the severity of obstructive sleep
apnea. AJODO 150: 945–949
30
Orthodontic treatment in adults does not cause clinically significant changes to the
volume or the minimally constricted area of the upper airway. Dental extractions in
conjunction with orthodontic treatment have a negligible effect on the upper airway in
adults.
Pliska et al (2016). Effect of orthodontic treatment on the upper airway volume in adults.
AJODO 150: 937–944
Tongue Thrusts
Tongue spurs are effective in controlling tongue thrusts and hence closing anterior open
bites.
Huang et al (1990). Stability of anterior openbite treated with crib therapy. Angle Orthodontist
60: 17-24
Simple series of exercises can be taught to patients with a tongue thrust.

1- To put the tongue in the palate so that it is just about to produce a ―click.‖ The tongue is
held in this position and the tip of the tongue forced upwards. Should be done in sets of
10, three times a day.
2- This exercise is called the ―3-S‘s‖: slurp, squeeze, and swallow. The patient is asked to
collect saliva, which is the slurp; bring the teeth together and activate muscles of closure,
squeeze; and lastly, with the tongue in the click position, the patient swallows.
Alexander (1999). Open bite, dental alveolar protrusion, Class I malocclusion: A successful
treatment result. AJODO 116: 494-500
Measurements performed on the crib confirm the tongue adaptation to environmental

changes. Resting tongue pressures at the 12th month remained lower than the initial
values. These findings indicate adaptive behavior of the tongue to open bite closure and
the new position of the incisors.
Taslan et al (2010). Tongue pressure changes before, during and after crib appliance therapy.
Angle Orthodontist 80: 533-539
31
Protecting Teeth Surface
Bonding molars leads to better periodontal health than banding because of less plaque
accumulation.
Boyd and Baumrind (1992). Periodontal considerations in the use of bonds or bands on molars
in adolescents and adults. Angle Orthodontist 62: 117-26
The most significant contributors to the consumption of non-milk extrinsic sugars are soft
drinks, confectionery and biscuits and cakes.
Moynihan (2002). Dietary advice in dental practice. BDJ 193: 563-568
The patients using powered brushes had significantly lower plaque and calculus scores
compared to manual but no differences in attachment level.
Dentino et al (2002). Six-month comparison of powered versus manual tooth brushing for safety
and efficacy in the absence of professional instruction in mechanical plaque control. JP 73: 770-
778
Fluoride elastomers are ineffective in changing levels of streptococcal or anaerobic

growth. A prospective randomised clinical trial
Benson et al (2004). Fluoridated elastomers: effect on the microbiology of plaque. AJODO 126:
325-330
A short exposure to a low ph carbonated drink (Coca-Colas) caused a reduction in

microhardness of the enamel, the frequency of exposure to the drink was inconclusive in
microhardness reduction and that palatal and labial enamel were equally susceptible to
reduction in microhardness.
Van Eygen et al (2005). Influence of a soft drink with low pH on enamel surfaces: An in vitro
study. AJODO 128: 372-377
Topical fluorides in addition to fluoride toothpaste reduce decalcification in patients

wearing fixed appliances. There was some evidence that preparations with higher
32
concentrations of fluoride were more effective but it was not possible to determine which
topical preparation or schedule was most effective.
Chadwick et al (2005). The effect of topical fluorides on decalcification in patients with fixed
orthodontic appliances: A systematic review. AJODO 128: 601-606
A triple headed brush is more effective in removing tooth plaque, bracket plaque and
gingival health than either conventional or orthodontic toothbrushes.
Rafe et al (2006). Comparative study of 3 types of toothbrushes in patients with fixed

orthodontic appliances. AJODO 130: 92-95
The use of interdental brushes is often recommended by orthodontists but there is no

evidence that this is an effective intervention.
Goh (2007). Interspace/interdental brushes for oral hygiene in orthodontic patients with fixed
appliances. Cochrane database of systematic reviews 2007, Issue 3. Art. No.: CD005410. DOI:
10.1002/14651858. CD005410.pub2
Current evidence is insufficient to support the comparative efficacy of powered

toothbrushes in reducing gingivitis in patients undergoing fixed orthodontic appliance
therapy.
Kaklamanos and Kalfas (2008). Meta-analysis on the effectiveness of powered toothbrushes

for orthodontic patients. AJODO 133: 187.e1–187.e14
Oral health promotion during orthodontic treatment has a positive effect. Patients thought
the single tufted brush required too much force to insert underneath the archwire and the
triangular brush too little. The triangular brush was perceived as less painful and
preferred by adolescents.
Gray and McIntyre (2008). Does oral health promotion influence the oral hygiene and gingival
health of patients undergoing fixed appliance orthodontic treatment? A systematic literature
review. JO 35: 262–269
33
A prospective, randomized, observer-blind, split-mouth crossover clinical trial to
determine the effectiveness of two different types of interproximal brush – a single tufted
brush (TePe) in a long straight handle and a triangular interdental brush (No. 6) made by
elmex®:
No significant difference between the two types of brushes was seen.
Bock et al (2010). Plaque control effectiveness and handling of interdental brushes during
multibracket treatment- a randomized clinical trial. EJO 32: 408-413
Changes in mastication markedly affect mandibular condylar cartilage growth and

mandibular morphology. It is considered that dietary education at an early age is
important in order to prevent disruption of the development of the mandible.
Enomotoet al (2010). Effects of mastication on mandibular growth evaluated by microcomputed

tomography. EJO 32: 66-70
The electric toothbrush, with either brush head, demonstrated significantly greater plaque
removal over the manual brush. The orthodontic brush head was superior to the regular
head.
Erbe et al (2013). Efficacy of 3 toothbrush treatments on plaque removal in orthodontic patients

assessed with digital plaque imaging: A randomized controlled trial. AJODO 143: 760–766
A relationship exists between body mass index (BMI) and dental and skeletal
development. BMI percentile, dental age difference, and cervical vertebral stage are
weakly correlated. No significant differences existed between boys and girls in any
variables. BMI percentile and ethnicity are weak predictors of the discrepancy between
dental age and chronologic age.
DuPlessis et al (2016). Relationship between body mass and dental and skeletal development in
children and adolescents. AJODO 150: 268–273
34
Section Four
Treatment Planning
Facial analysis
Occlusal Goals
Curve of Spee
Bolton Ratios
Lower Incisor Position
Aesthetics and Incisor Position
Smile Analysis
Extraction for Orthodontic Reasons
35
36
In the following sections, multiple leading research results might be helpful when deciding the
proper orthodontic treatment planning for patients.
A- Facial analysis
The Holdaway angle in its conventional definition is between soft tissue nasion-soft
pogonion and soft pogonion-labrale superius.
It is now officially recommended by the BOS clinical effectiveness committee as one of
seven cephalometric measures to audit the outcome of orthognathic cases.
Holdaway (1983). Soft tissue cephalometric analysis and its use in orthodontic treatment
planning. Part 1. AJODO 84:1-28
Holdaway (1984). Soft tissue cephalometric analysis and its use in orthodontic treatment
planning. Part 2. AJODO 85:279-293
Johnston et al (2006). Class III surgical-orthodontic treatment: A cephalometric study. AJODO

130:300-9
Johnston reported using his pitchfork analysis that in a growing patient, a significant part
of class II molar relationship correction in a non-extraction case is due to temporary
inhibition of maxillary growth and continuing mandibular growth.
Livieratos and Johnston (1995). A comparison of one-stage and two-stage non-extraction

alternatives in matched Class II samples. AJODO 108:118-31
The chin point should lie on a vertical line drawn halfway between subnasale and A point
Bass NM (2003). Measurement of the profile angle and the aesthetic analysis of the facial
profile. JO 30: 3-9
True vertical line (TVL) through subnasale. In cases of maxillary retrusion, moving the
TVL 1 to 3 mms anteriorly is suggested. Nasal tip projection relative to TVL is (14.6-
17.4) mm in adult females and (15.7-19.1) mm in adult males.
Arnett and McLaughlin (2004). Facial and Dental Planning for Orthodontists and Oral
Surgeons Edinburgh, Mosby
37
Jordanian soft tissue norms are similar to American norms with the exception of the
former having a more prominent upper lip position in relation to the overall soft tissue
profile.
Hamdan A (2010). Soft tissue morphology of Jordanian adolescents. Angle Orthodontist 80: 80-
85
B- Occlusal Gaols
Andrews' Six Keys to normal (or optimal) occlusions.
Key 1 Correct interarch relationships

Key 2 Correct crown angulation (tip)
Key 3 Correct crown inclination (torque)
Key 4 No rotations
Key 5 Tight contact points
Key 6 Flat curve of Spee (0.0 - 2.5 mm)
Andrews LF (1972). The six keys to normal occlusion. AJODO 62: 296-309
Five degrees of incisor proclination would reduce the overbite by one mm on average.
Eberhart et al (1990). The relationship between bite depth and incisor angular change. Angle
The extra 2 degrees of tip (angulation) in the Roth prescription for the upper canine (13
degrees) compared to Andrews standard (11 degrees) requires an approximate extra 0.5
mm of arch length per side.
O’Higgins et al (1999). The influence of maxillary incisor inclination on arch length. BJO 26:
97-102
The WALA ridge (‗Will Andrews and Larry Andrews‘ WALA line) is the most
prominent point on the soft-tissue ridge immediately occlusal to the mucogingival
junction.
Andrews and Andrews (2000). The six elements of orofacial harmony. AJ 1: 13-22
38
Every 5 degrees of incisor torque increased the upper arch length by 0.92 mm. A close
linear relationship between arch length and incisor inclination over a range from 90
degrees to 130 degrees. This means that a 10 degree change in torque will alter the molar
relationship by approximately 1 mm on each side.
Sangcharearn and Hob (2007). Maxillary incisor angulation and its effect on molar
relationships. Angle Orthodontist 77: 221-225
Children with increased body mass index did not cooperate as well during multibracket
therapy as their normal-weight peers, but the treatment outcome was comparable in the
two groups.
Bremen et al (2013). Correlation between body mass index and orthodontic treatment outcome.
Angle Orthodontist 83: 371-375.
Comprehensive orthodontic treatment on average requires less than 2 years to complete.
Tsichlaki et al (2016). How long does treatment with fixed orthodontic appliances last? A
systematic review. AJODO 149:308–318
C- Curve of Spee
Allow 1 mm space for 3 mm depth of curve, 1.5 mm for 4 mm depth, and 2 mm space for
a 5 mm curve.
Kirschen et al (2000). The Royal London Space Planning: An integration of space analysis and
treatment planning, Part 1. AJODO 118:448-55
A non-linear relationship and a less than one to one ratio for curves shallower than 9 mm.
Germane and Staggers (1992). Arch length considerations due to the curve of Spee: a
mathematical model. AJODO 102: 251-5
A very deep curve of 9 mm only requires 2 mm of additional space.
Braun et al (1996). The curve of Spee revisited. AJODO 110: 206-10
39
D- Inter-arch Tooth-width Discrepancies - Bolton Ratios
The extraction of four first premolars had a statistically and possibly clinically significant
effect on Bolton ratio, whilst extraction of four second premolars had very little average
effect.
Saatci and Yukay (1997). The effect of premolar extractions on tooth-size discrepancy. AJODO
111: 428-34
Class II patients: a tendency to maxillary tooth-size excess.

Class III patients: a tendency to mandibular tooth-size excess.
Nie and Lin (1999). Comparison of intermaxillary tooth size discrepancies among different
malocclusion groups. AJODO 116: 539-44
Bolton‘s ratios only apply well to white females who probably made up Bolton‘s entire
original sample.
Smith et al (2000). Interarch tooth size relationships of three populations: ―Does Bolton‘s
analysis apply?‖ AJODO 117: 169-174
Proffit suggested 1.5 mm as a level at which a clinically significant Bolton discrepancy

effect may result.
Proffit WR (2000). Contemporary Orthodontics. Mosby Inc. St Louis page 170
The original Bolton ratio norms are unlikely to be an ideal guide to the presence or
absence of a clinically significant problem in all populations.
Alkofide and Hashim (2002). Intermaxillary tooth size discrepancies among different
malocclusion classes: A comparative study. JCPD 26: 383-388
Bolton discrepancy has very little correlation with aspects of the start or finishing
occlusion and is therefore of very little diagnostic assistance.
40
Redahan and Lagerstrom (2003). Orthodontic treatment outcome: the relationships between
anterior dental relations and anterior inter-arch tooth size discrepancy. JO 30:237-244
A significantly higher mean ratio (mandibular tooth excess) is found in class III cases and
a lower percentage of significant Bolton discrepancy in class II cases.
Araujo and Souki (2003). Bolton anterior tooth size discrepancies among different
malocclusion groups. Angle Orthodontist 73:307-313
2 mm of correction is a threshold for clinical significance and, in a random sample of

British orthodontic patients, 25% of patients required such a correction for an ideal total
arch ratio and 12% for the anterior ratio
Othman and Harradine (2007). Tooth size discrepancies in an orthodontic population. Angle
Orthodontist 77: 668–674.
2mm is a threshold for clinical significance.
Endo et al (2009). Thresholds for clinically significant tooth-size discrepancy. Angle

E- Lower Incisor Position
Leave the average incisor labiolingual position unchanged during treatment.
Mills (1968). The stability of the lower labial segment. Dental Practitioner 18: 293-306
To maximize stability of incisors relationship: Correct edge- centroid relationship (lower

incisor edge should lie anterior to the upper root centroid)
Houston (1989). Incisor edge-centroid relationships and overbite depth. EJO 11;139-143
41
The APo line is not a position of lower incisor stability. In 62% of cases the incisors
tended to return towards their starting A-P position.
Houston and Edler (1990). Long term stability of the lower labial segment relative to the A-Pog
line. EJO 12: 302-310
Cases which had been treated with an average of 2.8 mm more lower incisor proclination
than another matched group of cases, finished with slightly greater irregularity (Little‘s
index) out of retention.
Paquette et al (1992). A long-term comparison of non-extraction and premolar extraction

edgewise therapy in ―borderline‖ Class II patients. AJODO 102: 1-14
A similar tendency for incisors moved labially during treatment to return towards their
starting position, but that modest retroclination of incisors was stable or even increased
post-retention. Invasion of the space previously occupied by the tongue is more stable
than invasion of lip or cheek space.
Sims and Springate (1995). Stability of the lower labial segment following orthodontic
treatment--a comparison of treatment with Andresen and Begg appliances. BJO 22: 13-21
Lower incisor proclination might prove to be stable in those patients in whom the
mandible is expected to develop in an anterior rotational pattern according to the
morphological features described by Bjork.
Williams and Andersen (1995). Incisor stability in patients with anterior rotational mandibular
growth. Angle Orthodontist 65: 431-442
Lips cannot know which incisor is touching them, therefore we can procline the lower
incisor in class II division 2 cases to touch the lower lip at the same A-P position as was
occupied before treatment by the extruded upper incisor.
Selwyn-Barnett (1996). Class II division 2 malocclusion: A method of planning and treatment.

BJO 23: 29-36
42
Incisors proclined an average of 11 degrees or 3.2 mm retroclined an average of 8
degrees or 2.5 mm respectively in the following six months when no appliances were in
place.
Hansen et al (1997). Long-term effects of Herbst treatment on the mandibular incisor segment:
A cephalometric and biometric investigation. AJODO 112: 92-103
An approximate limit of 2 mm for labial movement of the lower incisors is feasible if

anteroposterior stability is the main factor influencing our decision.
Ackerman and Proffit (1997). Soft tissue limitations in orthodontics: Treatment planning
guidelines. Angle Orthodontist 67: 327-336
On average 70% of the proclination produced by Jasper Jumpers subsequently relapsed.
Stucki and Ingervall (1998). The use of the Jasper Jumper for the correction of Class II
malocclusion in the young permanent dentition. EJO 20: 271-281
Proclining lower incisors in class II division 2 cases leads to much more relapse of arch
irregularity than when the arch length was not increased.
Canut and Arias (1999). A long-term evaluation of treated Class II division 2 malocclusions: a
retrospective study model analysis. EJO 21: 377-386
Lower incisor inclination is linked to the subject's sex, age, and skeletal pattern. It is not
associated with symphyseal dimensions, except symphyseal depth. Factors related to
natural inclination of lower incisors should be respected when establishing a treatment
plan.
Gütermann et al (2014). The inclination of mandibular incisors revisited. Angle Orthodontist

84: 109-119
Incisor crowding reduction can be expected from the early mixed to the early permanent
dentition. The potential for crowding reduction was associated with greater initial incisor
crowding, leeway space, incisor protrusion, and maxillary width increase. A crowding
43
threshold of 2 mm was not a valid borderline condition to define the self-correction
prognosis.
Barros et al (2016). Impact of dentofacial development on early mandibular incisor crowding.

AJODO 150: 332–338
F- Aesthetics and Incisor Position
Comparing premolar and second molar extractions:

Differences in the A-P changes in incisor position but no differences in the changes in
soft-tissue facial convexity or of the upper lip relationship to a soft-tissue APo line.
Staggers JA (1990). A comparison of second molar and first premolar extraction treatment.
AJODO 98: 430-436
An average of 1.4 mm posterior movement of the upper lip when the upper incisors were
retracted by an average of 5.0 mm, an average ratio of 28%.

The average ratio of movement is 1:4 for lip: incisor change.
Kusnoto and Kusnoto (2001). The effect of anterior tooth retraction on lip position of
orthodontically treated adult Indonesians. AJODO 120: 304-307
Although larger lower incisor changes in position are less stable, lower incisor alignment
tends to deteriorate after retention whether or not the anteroposterior lower incisor
position has been maintained.
Fixed indefinite retention for lower incisors after all orthodontic treatment is needed.
Little (1990). Stability and relapse of dental arch alignment. BJO 17:235-41
Little et al (1990). Mandibular arch length increase during the mixed dentition. Post retention
stability and relapse. AJODO 97: 393-404
Little (2002). Stability and relapse: early treatment of arch length deficiency. AJODO 121:578-
581
44
Predictors of change in lip shape and NLA with upper incisor correction in class II cases.
A large range of change in NLA (40 degrees) and no correlation with incisor A-P change.
Tadic and Woods (2007). Incisal and soft tissue effects of maxillary premolar extraction in class
II treatment (2007). Angle Orthodontist 77: 808–816
G- Smile Analysis
Buccal corridor ratio = Inner commissure width Visible maxillary dentition / Inner
commissure width ×100
Frush and Fisher (1958). The dynesthetic interpretation of the dentogenic concept. JPD 8: 558-
581
Buccal corridor ratio = Frontal intercanine width/ Commissure width
Hulsey (1970). An aesthetic evaluation of lip-teeth relationships present in smile. AJODO 57:
132-144
The upper central incisors, lateral incisors and canines are in the golden proportion
(1:0.618).
Levin (1978). Dental esthetics and the golden proportion. JPD 40: 244-253
In aesthetic rank, smiles which show first molar to first molar are judged the most
attractive followed by smiles which show second premolar to second premolar and
second molar to second molar.
Tjan et al (1984). Some aesthetic factors in a smile. JPD 51: 24-28
Yoon et al (1992). A study on the smile in Korean youth. JKAP 30: 259-270
Amount of maxillary gingivae displayed is the most important feature of a smile that
affects aesthetics and is also affected by orthodontics is.
Johnson and Smith (1995). Smile aesthetics after orthodontic treatment with and without
extraction of four first premolars. AJODO 108: 162-7
45
Upper incisor exposure becomes less and lower incisor exposure becomes greater with
aging.
Chio et al (1995). A study on the exposure of maxillary and mandibular central incisor in
smiling and physiologic rest position. JWDRI 5: 371-379
Dong et al (1999). The aesthetics of the smile: a review of some recent studies. IJP 12: 9-19
Influence of animation on smile characteristics: Women show greater facial animation

than men. Orthodontically treated patients had more upper incisor exposure on smiling
and also a greater interlabial gap.
Rigsbee et al (1988). The influence of facial animation on smile characteristics. IJAOOS 3: 233-
239
Smile index: intercommisure width/ interlabial gap on smiling.
Ackerman et al (1998). A morphometric analysis of the posed smile. Clinical Orthodontics and
Research 1: 2-11
An open space between incisors had to be 2 mm wide before orthodontists perceived it as

unattractive and lay people did not notice an open gingival embrasure until it was 3 mm
long.
Kokich et al (1999). Comparing the perception of dentists and lay people to altered dental
esthetics. JED 11: 311-324
The prevalence of open gingival embrasures is 38% in adult orthodontic patients.
Kurth and Kokich (2001). Open gingival embrasures in adults after orthodontics treatment:
prevalence and etiology. AJODO 120: 116-123
The aesthetics of smiles in extraction and non-extraction cases without arch expansion
were compared and find no difference between the two groups.
Kim and Giannelly (2003). Extraction versus non-extraction: arch widths and smile aesthetics.
46
Useful information can be obtained from an oblique or three-quarter photograph. In
particular, the relationship of the occlusal plane to the curve of the lower lip and the
display of the upper maxillary teeth, including the premolars and molars which are not
visible from the frontal view.
Sarver and Ackerman (2003b). Dynamic smile visualization and quantification: Part 2. Smile
analysis and treatment strategies. AJODO 124: 116-127
The appearance of small buccal corridors is preferred by lay judges.
Moore et al (2005). Buccal corridors and smile aesthetics. AJODO 127:208-13
Excessive buccal corridors and smile arcs were rated less attractive by both orthodontists
and lay persons. In addition, flat smile arcs decreased attractiveness regardless of the
buccal corridor width.
Parekh et al (2006). Attractiveness of variations in the smile arc and buccal corridor space as
judged by orthodontists and laymen. Angle Orthodontist 76: 557-563
Both lay people and orthodontists prefer smiles with smaller buccal corridors.
Martin et al (2007). The impact of buccal corridors on smile attractiveness. EJO 29: 530-537
No relationship between BCS or upper incisor exposure and smile aesthetics as rated by
both lay persons and orthodontists.
McNamara et al (2008). Hard- and soft-tissue contributions to the aesthetics of the posed smile
in growing patients seeking orthodontic treatment. AJODO 133: 491-499
Both orthodontists and dental students preferred broader smiles (buccal corridor ratio
<10%) and that above 10%, the difference in perception became clinically significant.
Ioi et al (2009). Effects of buccal corridors on smile esthetics in Japanese. Angle Orthodontist
79: 628-633
47
Maxillary incisor display decreased with age but the smile index increased significantly.
Desai et al (2009). Dynamic smile analysis: Changes with age. AJODO
Lay judges prefer smaller BCS.
Ioi et al (2009). Effects of buccal corridors on smile esthetics in Japanese. Angle Orthodontist
79: 628-636
There is as yet no convincing evidence that buccal corridors affect smile attractiveness.
Springer et al (2011). Smile esthetics from the lay perspective. AJODO 139: e91-e101
Semi-quantitative categorization of smile line:

 < 75% of incisor crown height showing is a low smile line.
 75% to 100% of the incisor crown height showing is a normal smile height.
 Showing the total incisor crown length of a tooth and a continuous band of
gingiva (minimum of 1 mm) is classified as a high smile line
 A lip line height that showed more than 4mm of gingiva is classified as a gummy
smile line.
Van der Geld et al (2011). Smile line assessment comparing quantitative measurement and
visual estimation. AJODO 39: 174-180
A small dental midline deviation of 2.2 mm can be considered acceptable by both

orthodontists and laypeople, whereas an axial midline angulation of 10° (2 mm measured
from the midline papilla and the incisal edges of the incisors) is already very apparent.
No research on actual subjects as yet supports the view that buccal corridor sizes and
smile arc alone influences smile attractiveness.
Janson et al (2011). Influence of orthodontic treatment, midline position, buccal corridor and
smile arc on smile attractiveness. Angle Orthodontist 81: 153-161
Persons with ideal smiles are considered more intelligent and have a greater chance of
finding a job when compared with persons with nonideal smiles.
Pithon et al (2014). Do dental esthetics have any influence on finding a job? AJODO 146: 423–
429
48
H- Extraction for Orthodontic Reasons
 Planning Extractions
Extraction is minimally adopted in low angle cases as space closure is difficult.
Moller (1966). The chewing apparatus, Acta Physiol Scand, 69; Supplement 280
Avoid extraction of teeth in low MMP angle cases as space closure is difficult.
Bjork & Skieller ( 1972). Facial development and tooth eruption. An implant study at the age of
puberty. AJODO 62;339-383
As a rule of thumb, extraction of first premolars provides approximately 66% of the

space for aligning/retracting the anterior teeth, whereas extraction of second premolars
provides approximately half of the space.
Creekmore (1997). Where teeth should be positioned and how to get them there. JCO 31:586-
608
The extraction of first premolars successfully accommodates twice the crowding than do
the extraction of second premolars. The average lower incisor anteroposterior change is
not different.
Saelens and De Smit (1998). Therapeutic changes in extraction versus non-extraction

orthodontic treatment. EJO 20:225-230
Lower 1st molar: extraction timing is critical, maximum spontaneous space closure is
likely to occur when bifurcation of 2nd molar is visible on radiograph.
Sandler et al (2000). For four sixes. AJODO 117:418-34
Extraction of 1st molars may be delayed and temporized if space is required for correction
of malocclusion later. Interceptively; commonly removed between 8-10 yrs. but dental
age of patient is more important. For upper 1st molars: timing of extraction is less critical
than lower extraction as rapid mesial movement of 2nd molars due to distal angulation of
follicle.
49
Gill et al (2001). Treatment planning for the loss of first permanent molars. Dent Update 28:304-
308
More anchorage is provided in the upper arch by extraction of 4s than by extraction of 5s.
Ong and Woods (2001). An occlusal and cephalometric analysis of maxillary first and second
premolar extraction effects. Angle Orthodontist 71: 90-102
Amount of crowding affect extraction decision:

 0-4mm mild
 5-9mm moderate
 >10mm severe
Proffit WR et al (2007). Contemporary Orthodontics, 4th Ed, Mosby
Extraction of the maxillary first molars in Class II Division 1 patients results in

significant uprighting of 2nd molar and 3d molar and facilitates the normal eruption of 3d
molar.
Livas et al (2011). Extraction of maxillary first molars improves second and third molar
inclinations in Class II Division 1 malocclusion. AJODO 140: 377–382
When the inclination of the third molar is inconvenient, the tooth may remain impacted
even if there is enough retromolar space.
Türköz and Ulusoy (2013). Effect of premolar extraction on mandibular third molar impaction
in young adults. Angle Orthodontist 83: 572-577
 Extractions and Facial Aesthetics
Extraction leads to lower incisors averaging 2 mm more posterior than the in non-
extraction with lower lip further behind E line.

50
Patients treated with extractions had on average slightly more prominent lips at the end of
treatment than those treated on a non-extraction basis.
Luppanapornlap and Johnston (1993). The effects of premolar extraction: a long term
comparison of outcomes in ―clear-cut‖ extraction and non-extraction Class II patients. Angle
James (1998). A comparative study of facial profiles in extraction and non-extraction treatment.
AJODO 114: 265-76
Standards of facial attractiveness had changed with a trend towards more protrusive lips
and increase in vermilion display.
Auger and Turley (1994). Esthetic soft tissue profile changes during the 1900s. JDR 73: 2128
No difference between orthodontists and general dental practitioners in their judgments

of whether patients who had a concave facial profile had had extractions or not.
Rushing et al (1995). How dentists perceive the effects of orthodontic extraction on facial
appearance. Journal of the American Dental Association 126: 769-772
Small extra lip retraction with extractions when compared with non-extraction cases, but
since extractions had been chosen in cases with slightly more prominent lips, the final
average soft tissue profile was identical in both groups.
Zierhut et al (2000). Long-term profile changes associated with successfully treated extraction
and non-extraction Class II division I malocclusions. Angle Orthodontist 70: 208-219
Wide variety of anteroposterior changes in lower incisor position which occurs for all
combinations of premolar extractions.
Shearn and Woods (2000). An occlusal and cephalometric analysis of lower first and second
premolar extraction effects. AJODO 117:351-61
51
Two groups with equivalent starting irregularity index (averaging 5.1 and 5.8) treated
with and without premolar extractions were compared:
The increase in the area bounded by the lower labial segment relapsed more in the non-
extraction group, but the relapse in Irregularity index was the same in both groups.
Heiser et al (2004). Three-dimensional dental arch and palatal form changes after extraction and
non-extraction treatment. Part 1. Arch length and area. AJODO 126:71-81
Extraction of four premolars can be effective in decreasing the soft tissue procumbency
in bimaxillary protrusion cases.
Bills et al (2005). Bimaxillary dentoalveolar protrusion: traits and orthodontic correction. Angle
orthodontist 75;333-339
Long-term study over 25 years found that treatments involving extractions produced
much less relapse of crowding in both arches when compared with non-extraction cases,
particularly in the lower arch.
Jonsson and Magnusson (2010). Crowding and spacing in the dental arches: long term
development in treated and untreated subjects. AJODO 138:384e1-384e7
Extraction lead to an average of 2 mm greater retraction of the lower lip relative to E line
and an increase of 5 degrees in the NLA compared to no change for this angle in the non-
extraction group.
Konstantonis (2012). The impact of extraction vs. nonextraction treatment on soft tissue
changes in Class I borderline malocclusions. Angle Orthodontist
Extraction of first premolars for the treatment of bimaxillary proclination does not affect
upper airway dimensions despite the significant reduction in tongue length and arch
dimensions.
Al Maaitah et al (2012). First premolar extraction effects on upper airway dimension in

bimaxillary proclination patients. Angle Orthodontist 82: 853-859
52
Greater maxillary crowding relapse in the nonextraction cases and greater overbite
relapse in the extraction cases. Many significant and positive correlations of overjet and
overbite relapses with mandibular anterior crowding relapse and consequently between
overjet and overbite relapses.
Francisconi et al (2014). Overjet, overbite, and anterior crowding relapses in extraction and
nonextraction patients, and their correlations. AJODO 146: 67–72
There was a high prevalence of space reopening 1 year after treatment. However, these
spaces tended to decrease by 5 years after treatment.
Garib et al (2016). Stability of extraction space closure. AJODO. 149: 24–30
 Extractions and Smile Width
No evidence that orthodontic treatment involving extractions cause larger BCSs. Also no
evidence that extractions produced less attractive smiles in the opinions of lay judges.
Johnson and Smith (1995). Smile aesthetics after orthodontic treatment with and without
extraction of four first premolars. AJODO 108: 162-7
A non-extraction group was compared with an extraction of four first premolars group.
The principal finding was that post-treatment, canine, premolar and widest molar widths
were essentially the same in the two groups.
Gianelly (2003). Arch width after extraction and non-extraction. AJODO 123:25-8
At constant arch depth, the extraction group was slightly wider after treatment than were
the non-extraction group.
Gianelly (2003). Extraction vs non-extraction: Arch width and smile aesthetics. Angle
Orthodontist 73:354-358
53
No effect of extractions on the buccal corridor space (BCS).
Yang et al (2008). Which hard and soft tissue factors relate with the amount of buccal corridor
space during smiling? The Angle Orthodontist; 78: 5–11
The studies by Gianelly are good research which does indeed support the view that
premolar extractions per se do not have a detrimental effect on smile aesthetics. Based on
studies of actual subjects, BCS on its own has not yet been shown to be a factor in smile
attractiveness.
Janson et al (2011). Influence of orthodontic treatment, midline position, buccal corridor and
smile arc on smile attractiveness. Angle Orthodontist 81: 153-161
54
Section Five
Early Orthodontic Treatment
55
56
Reliability and effectiveness of early orthodontic treatment will be researched here.
Early Orthodontic Treatment
Favourable or highly favourable short-term mandibular growth was exhibited by 83% of

functional appliance cases but also by 31% of the untreated controls.
Tulloch et al (1997a). Influences on the outcome of early treatment for Class II malocclusion.
AJODO 111: 533-42
A small (0.6 degrees/year) enhancement of mandibular growth in the short term, but
none in the longer term.
Tulloch et al (1997b). The effect of early intervention on skeletal pattern in Class II

malocclusion: A randomised clinical trial. AJODO 111: 391-400
Tulloch et al (1998). Benefit of early Class II treatment: Progress report of a two-phase

randomised clinical trial. AJODO 113: 62-72
Early correction of skeletal problems: favorable changes in AP relationship achieved but

may not be clinically significant.
O'Brien et al (2003a). Effectiveness of early orthodontic treatment with the Twin-block

appliance: a multicenter randomized controlled trial. Part 1: Dental and skeletal effects. AJODO
124;234-243
Early treatment with a twin-block and no early treatment: found exactly 1 mm of average
additional horizontal mandibular growth.
O’Brien et al (2003b). The effectiveness of early treatment for Class II malocclusion with the
Twin Block appliances: A multicenter randomized controlled trial. Part 1:dental and skeletal
effects. AJODO 124: 234-43
Comparing early versus late treatment concluded: All groups experienced incisors
trauma and that very early treatment may prevent trauma but not cost effective.
Koroluk et al (2003). Incisor trauma and early treatment for Class II division 1 malocclusions.
AJODO 123;117-126
57
The psychosocial effects of early twin-block treatment:
A significant benefit from treatment in terms of increased self-concept scores and
reduced negative social experiences. Immediately after twin block treatment the profiles
of children who had received early treatment were perceived to be more attractive by
their peers than those of children who did not receive treatment.
O’Brien et al (2003c). Effectiveness of early orthodontic treatment with the twin-block

appliance: A multicentre randomized controlled trial. Part 2: psychosocial effects 124: 488-495.
AJODO 124: 488–95
Definite early benefits of early functional or headgear treatment did not result in any
shorter or simpler second phase treatment or any better final result. Early functional
treatment doubled the later rate of extractions in phase 2.
Tulloch et al (2004). Outcome in a 2-phase randomised clinical trial of early class II treatment.
AJODO 125:657-67
Early treatment is no more effective than orthodontic treatment in early adolescence.
Harrison et al (2007). Orthodontic treatment for prominent upper front teeth in children.
Cochran Database Systematic Review, CD003452
Appropriate early treatment may reduce the need for specialist orthodontic treatment
later.
Kerosuo et al (2008). The 7 year outcome of an early orthodontic treatment strategy. JDR 87:
584-588
In the long term there were no differences of skeletal pattern between those who
received early (average age 9 years) Twin-block treatment and those who had one course
of treatment in adolescence.
O’Brien et al (2009a). Early treatment for Class II Division 1 malocclusion with the Twin-block
appliance: A multi-center, randomized, controlled trial. AJODO 135:573-579
58
The early start to treatment provided no long–term advantages in terms of skeletal
pattern, self-esteem, or significant reduction in extraction rate. On the contrary, those
who had the early start to treatment had more attendances, received treatment for longer
times, had significantly poorer final dental occlusion and incurred substantially greater
costs than those who started at age 12.
O’Brien et al (2009a). Early treatment for Class II Division 1 malocclusion with the Twin-block
appliance: A multi-center, randomized, controlled trial. AJODO 135:573-579
Early orthodontic treatment did not affect the incidence of incisor injury. The majority of
the injuries before and during treatment were minor; therefore, the cost-benefit ratio of
orthodontic treatment primarily to prevent incisor trauma is unfavorable.
Chen et al (2011). Effect of early Class II treatment on the incidence of incisor trauma. AJODO
140: e155–e160
Orthodontic treatment for young children, followed by a later phase of treatment when
the child is in early adolescence, appears to reduce the incidence of new incisal trauma
significantly compared with treatment that is provided in 1 phase when the child is in
early adolescence.
There are no other advantages in providing 2-phase treatment compared with 1 phase in
early adolescence.
Thiruvenkatachari et al (2015). Early orthodontic treatment for Class II malocclusion reduces

the chance of incisal trauma: Results of a Cochrane systematic review. AJODO 148:47–59
59
60
Section Six
Anchorage in Orthodontics
Conventional Mechanics
Orthodontic Microimplants (OMIs)
61
62
This section is concerned with anchorage philosophy in orthodontics. Conventional mechanics
and the latest mechanics; orthodontic microimplants, will be available.
Conventional Mechanics
Lingual arches did not prevent mesial migration of molars even when no intra-arch
traction was applied, proclination of lower incisors occur.
Rebellato et al (1997). Lower arch perimeter preservation using the lingual arch. AJODO
112:449-456
No enhancement of vertical or horizontal anchorage when using utility arches to set up

cortical anchorage.
Ellen et al (1998). A comparative study of anchorage in bioprogressive versus standard

edgewise treatment in Class II correction with intermaxillary elastic force. AJODO 114:430-6
Slightly more anchorage loss when trans-palatal arches were used. However, they were
effective in rotating the first molars into a more favorable position for Class II correction.
Radkowski (2007). The influence of the transpalatal arch on orthodontic anchorage. Thesis
abstract from St Louis University. AJODO 132: 562
TPA does not provide a significant effect on either the anteroposterior or the vertical
position of the maxillary first molars during extraction treatment.
Zablocki et al (2008). Effect of the transpalatal arch during extraction treatment. AJODO 133:
852-860
The lingual arch is effective for controlling mesial movement of molars and lingual
tipping of incisors.
Viglianisi A. (2010). Effects of lingual arch used as space maintainer on mandibular arch
dimension: A systematic review. AJODO 138: 382.e1–382.e4
No any preference in the use of Goshgarian or Nance palatal arch, unless the slightly
reduced patient discomfort with the Goshgarian arch is considered significant.
63
Stivaros et al (2010). A randomized clinical trial to compare the Goshgarian and Nance palatal
arch. EJO 32: 171-176
Effectiveness of LLHA:
The lower incisors proclined and moved forward, and space loss of the lower primary
second molar occurred. The LLHA made of 0.9 mm SS was superior to that made of 1.25
mm SS in terms of arch length preservation.
Owais et al (2011). Effectiveness of a lower lingual arch as a space holding device. EJO 33: 37-
42
Absolute Anchorage using Orthodontic Microimplants (OMIs)
Brånemark and colleagues introduced the concept of osseointegration, using pure

titanium implants, defining osseointegration as 'living bone in direct contact with a
loaded implant surface.‘
Brånemark et al (1969). Intra-osseous anchorage of dental prostheses. I. Experimental studies

Scandinavian. JPRS 3: 81–100
Kanomi described the use of titanium mini fixation screws in 1997.
Kanomi R (1997). Mini implant for orthodontic anchorage. JCO 31: 763-767
Screw length does not seem to be a factor in stability if the screw is more than 5 mm
long (intraosseous length).
Miyawaki et al (2003), Factors associated with the stability of titanium screws placed in the
posterior region for orthodontic anchorage. AJODO 124: 373-378
Park et al (2006). Factors affecting the clinical success of screw implants used as orthodontic
anchorage. AJODO 130: 18-25
Kuroda et al (2007). Clinical use of miniscrew implants as orthodontic anchorage: Success rates
and postoperative discomfort. AJODO 131: 9-15
64
A high MM angle was reported as a failure factor in the mandible by (Miyawaki et al)
who attributed this to the thinner cortical bone in patients, but (Kuroda 2007) found no
such association with MM angle.
Miyawaki et al (2003). Factors associated with the stability of titanium screws placed in the
posterior region for orthodontic anchorage. AJODO 124: 373-378
Miniscrew implants can be used buccally and palatally in the maxilla to facilitate molar
intrusion.
Park et al (2004). Treatment of open bite with microscrew implant anchorage. AJODO 126:
627-136
Park et al (2006). Nonextraction treatment of an open bite with microscrew implant anchorage.
AJODO 130: 390-402
Nonkeratinized mucosa is a risk factor for miniscrew failure.
Cheng et al (2004). A prospective study of the risk factors associated with failure of mini-
implants used for orthodontic anchorage. IJOMI 19: 100-106
Most studies report OMI success rates between 80% and 96%
Park et al (2005). Group distal movement of teeth using microscrew implant anchorage.
AJODO 75: 602-609
The literature supports the view that impinging on cementum and dentine is followed by
repair in most instances, showed almost total repair 12 weeks after removing screws
from beagle dogs.
Asscherickx et al (2005). Root repair after injury from mini-screw. COIR 16: 575-578
To raise the success rate of 1.6mm diameter mini- implants, the recommended placement
torque is within the range from 5 to 10 Ncm.
65
Motoyoshi et al (2006). Recommended placement torque when tightening an orthodontic mini-
implant. COIR 17: 109–114
OMIs vs miniplates:
Slightly higher percentage success rate with miniplates than with OMIs, but also
significantly more discomfort associated with their insertion and the necessary flap being
raised.
No correlation between success and lack of peri-implant inflammation.

Most authors report that inflammation is more likely if screws are placed in non-attached
mucosa and advise placement in or very close to attached gingiva.
Owens et al (2007). Experimental evaluation of tooth movement in the beagle dog with the
mini-screw implant for orthodontic anchorage. AJODO 132: 639-646
An experimental study on ten patients was encouraging that any root damage shows
rapid repair once the screw contact is removed.
Kadioglu et al (2008). Contact damage to root surfaces of premolars touching miniscrews

during orthodontic treatment. AJODO 134:353-360
Smaller diameter screws are much more likely to fracture.
Chen et al (2008). Biomechanical and histological comparison of self-drilling and self-tapping

orthodontic microimplants in dogs. AJODO 133: 44-50
For intrusion of posterior teeth miniplates seem to be a very reliable technique.
De Clerck et al (2008). Biomechanics of skeletal anchorage. Part 3. Intrusion. JCO 42: 270-278
66
Generally higher bone density in the mandible than the maxilla.
Park et al (2008). Density of the alveolar and basal bones of the maxilla and the mandible.
AJODO 133: 30-37
The effects of J-hook headgear and miniscrews on incisor intrusion; there were
significantly greater reductions in overbite, maxillary incisor to palatal plane, and
maxillary incisor to upper lip in the implant group than in the J-hook headgear group;
mean intrusion for the miniscrew group was 3.6 mm and 1.1 mm for the J-hook headgear
group. Furthermore, significantly less root resorption was observed in the implant group
compared with the J-hook headgear group.
Deguchi et al (2008). Comparison of the intrusion effects on the maxillary incisors between
implant anchorage and J-hook headgear. AJODO 133: 654-660
The safest interradicular site in the maxilla is between the second premolar and the first
molar, from 6 to 8 mm from the cervical margin.
Hu et al (2009). Relationships between dental roots and surrounding tissues for orthodontic
miniscrew installation. Angle Orthodontist 79:37-45
A 21% incidence of root contact for inexperienced operators and 13 % for experienced
operators. The surgery site and clinicians' expertise had significant effects on the rate as
well as the pattern of root contacts.
Cho et al (2010). Root contact during drilling for microimplant placement. Angle Orthodontist
80:130-136
Titanium alloy microimplants with small diameters (1.2-1.3 mm) are strong enough for
self-drilling and immediate loading in thin cortical bone areas, but, to reduce the chance
of breakage, a drilling of a pilot hole is suggested in thick cortical bone areas.
Chen et al (2010). Potential of self-drilling orthodontic microimplants under immediate loading.

AJODO 137: 496–502
67
Microimplants with a diameter of less than 1.3 mm are unsuitable for insertion into a
bone with a density greater than 40 pounds per cubic foot mechanically when one is
using a self-drilling technique.
Chen et al (2010). Mechanical properties of self-drilling orthodontic micro-implants with

different diameters. Angle Orthodontist 80: 821-827.
Mini-implants for orthodontic anchorage may be effectively placed in most areas with
bone density equivalent to the palatal area if they are placed from 3 mm posterior to the
incisive foramen and 1 to 5 mm to the paramedian side.
Moon et al (2010). Palatal bone density in adult subjects: implications for mini-implant
placement. Angle Orthodontist 80: 137-144.
OMIs with larger diameters and tapered shapes caused greater microdamage to the
cortical bone; this might affect bone remodeling and the stability of the OMIs.
Lee and Baek (2010). Effects of the diameter and shape of orthodontic mini-implants on
microdamage to the cortical bone. AJODO 138: 8.e1–8.e8
To minimize root contacts, microimplants need to be inclined distally about 10° to 20°
and placed 0.5 to 2.7 mm distally to the contact point to minimize root contact according
to sites and levels, except into palatal interradicular bone between the maxillary first and
second molars.
Park HS et al (2010). Proper mesiodistal angles for microimplant placement assessed with 3-
dimensional computed tomography images. AJODO 137: 200–206
Microimplant surgery seems to be a well-accepted treatment option in orthodontic

patients, with significantly lower pain levels than for tooth extractions. Furthermore,
transgingival placement is clearly favored by patients who do not need tissue removed
before placement.
Baxmann et al (2010). Expectations, acceptance, and preferences regarding microimplant

treatment in orthodontic patients: A randomized controlled trial. AJODO 138: 250.e1–250.e10
68
For all skeletal patterns, the safest zones were the spaces between the second premolar
and the first molar in the maxilla, and between the first and second premolars and
between the first and second molars in the mandible.
Chaimanee et al (2011). ―Safe Zones‖ for miniscrew implant placement in different

dentoskeletal patterns. Angle Orthodontist 81: 397-403.
Screws of diameter greater than 1.3 mm are recommended as being suitable for
resistance to fracture with self-drilling insertion.
Barros et al (2011). Effect of mini-implant diameter on fracture risk and self-drilling efficacy.
AJODO 140:e181-e192
Orthodontic treatment for AOB with and without miniscrew assisted intrusion of molars:
Miniscrews indeed succeeded in achieving molar intrusion and reduction in the MMA
and linear face height with very little incisor extrusion
Deguchi et al (2011). Comparison of orthodontic treatment outcomes in adults with skeletal

open bite between conventional edgewise treatment and implant-anchored orthodontics. AJODO
139:S60-S68
With microimplant-aided sliding mechanics, clinicians can distalize all posterior teeth
together with less distal tipping. The technique seems effective and efficient to treat
patients who have mild arch length discrepancy without extractions.
Oh YH et al (2011). Treatment effects of microimplant-aided sliding mechanics on distal

retraction of posterior teeth. AJODO 139: 470–481
The differences in insertion torque values, Periotest values, and subjective assessments
of stability scores of self-drilling and self-tapping implants were insignificant. Self-
drilling implants had higher bone-implant contact percentages than did self-tapping
implants.
Çehreli and Arman-Özçırpıcı (2012). Primary stability and histomorphometric bone-implant

contact of self-drilling and self-tapping orthodontic microimplants. AJODO 141: 187–195
69
Modification of the mini-implant design can substantially affect the mechanical
properties. The finite element method is an effective tool to identify optimal design
parameters and allow for improved mini-implant designs.
Chang et al (2012). Effects of thread depth, taper shape, and taper length on the mechanical
properties of mini-implants. AJODO 141: 279–288
Healing of cementum takes place after an injury with a temporary skeletal anchorage
device, and it is a time-dependent phenomenon.
Ahmad V et al (2012). Root damage and repair in patients with temporary skeletal anchorage
devices. AJODO 141: 547–555
Cortical bone tends to be thicker in hypodivergent than in hyperdivergent subjects. This

explains the concomitant differences in alveolar ridge thickness. Medullary space
thickness is largely unaffected by facial divergence.
Horner et al (2012). Cortical bone and ridge thickness of hyperdivergent and hypodivergent
adults. AJODO 142: 170–178
Both outer diameter and length affect the stability of MSIs. Increases in cortical bone
thickness and cortical bone density increase the primary stability of the MSIs.
Shah et al (2012). Effects of screw and host factors on insertion torque and pullout strength.
In cases of thick cortical bone, predrilling might be an effective tool for reducing
microdamage without compromising OMI stability.
Cho and Baek (2012). Effects of predrilling depth and implant shape on the mechanical
properties of orthodontic mini-implants during the insertion procedure. Angle Orthodontist 82:
618-624
When inserting OMIs, increasing the distance from the OMI to the root surface will
significantly improve success rates.
70
Min et al (2012). Root proximity and cortical bone thickness effects on the success rate of
orthodontic micro-implants using cone beam computed tomography. Angle Orthodontist 82:
1014-1021
Clinicians should be aware of the probability of thin cortical bone plates and the risk of
mini-implant failures at:
Maxillary buccal alveolar mini-implant sites in high-angle patients.
Mandibular buccal alveolar mini-implant sites between the canine and the first premolar
in normal and high-angle patients.
Ozdemir et al (2013). Cortical bone thickness of the alveolar process measured with cone-beam
computed tomography in patients with different facial types. AJODO 143: 190–196
The quality of root repair depends on the amount of damage caused by the mini-implant:
When the damage is limited to the cementum or dentin, healing and almost complete
repair of the periodontal structure can occur.
Mini-implants that injured the pulp were less likely to result in complete repair of the
periodontal tissues.
Alves et al (2013). Root repair after contact with mini-implants: systematic review of the
literature. EJO 35: 491-499
Stainless steel and titanium alloy miniscrew implants provide the same mechanical
stability and similar histologic responses.
Both are suitable for immediate orthodontic clinical loads.
Brown et al (2014). Comparison of stainless steel and titanium alloy orthodontic miniscrew
implants: A mechanical and histologic analysis. AJODO 145:496–504
TADS might be the preferred method for reinforcing orthodontic anchorage in patients
who need maximum anchorage.
Sandler et al (2014). Effectiveness of 3 methods of anchorage reinforcement for maximum

anchorage in adolescents: A 3-arm multicenter randomized clinical trial. AJODO 146: 10–20
71
From the biomechanical perspective, cortical bone thickness (CBT) values of 1.0 to 2.0
mm might be appropriate for orthodontic microimplant treatment.
Alrbata et al (2014). Biomechanical effectiveness of cortical bone thickness on orthodontic

microimplant stability: An evaluation based on the load share between cortical and cancellous
bone. AJODO 146: 175–182
Tapered miniscrews had higher initial stability when compared to cylindrical

miniscrews, whereas the clinical success rates and removal torques were similar between
the two designs. The long-term stability is not directly affected by the miniscrew design.
Yoo et al (2014). A comparison of tapered and cylindrical miniscrew stability. EJO36: 557-562
Miniscrews placed with pilot holes show greater primary stability, but greater decreases
in stability over time, due primarily to having less trabecular bone surrounding them.
Carney et al (2014). Effects of pilot holes on longitudinal miniscrew stability and bony
adaptation. AJODO 146: 554–564
Retrieved miniscrews showed considerable surface and structural alterations such as

dullness, corrosion, and blunting of threads and tips. Their surfaces showed interactions
and adsorption of several elements, such as calcium, at the body region. A high content
of iron was found on the failed miniscrews, and cerium was seen in the head and neck
regions of retrieved MSIs.
Patil et al (2015). Surface deterioration and elemental composition of retrieved orthodontic

miniscrews. AJODO 147: S88–S100
For the purpose of diminishing orthodontic microimplant failure, an optimal force that
can be safely loaded onto a microimplant should not exceed a value of around 3.75–4.5
N.
Alrbata et al (2016). Optimal force magnitude loaded to orthodontic microimplants: A finite

element analysis. Angle Orthodontist 86: 221-226
72
The success rate of orthodontic microimplants significantly increased with higher
cancellous and total bone densities, whereas cortical bone density did not have a
significant effect.
Lee et al (2016). Bone density effects on the success rate of orthodontic microimplants evaluated
with cone-beam computed tomography. AJODO 149: 217–224
Loaded 3-mm-long miniscrews with and without flutes have high success rates.
Longitudinal flutes placed in 3-mm miniscrews increased their removal torque by 37%
and decreased the amount of bone immediately surrounding them.
Truong et al (2016). Effect of longitudinal flutes on miniscrew implant stability and 3-

dimensional bone formation. AJODO 150: 950–957
73
74
Section Seven
Orthodontic Malocclusions and Other Problems
Normal Occlusion
Teeth Count and Morphology
Class II Division 2 Malocclusion
Class 3 Malocclusion
Open Bite
Crossbite
Supernumerary Teeth
Ectopic Maxillary Canines
Loss of Central Incisors
Transposition
Primary Failure of Eruption
75
76
Normal Occlusion
On average, discrepancy between ICP & RCP is < 1 mm, but some individuals like those
with class 2 occlusions have much larger and clinically significant discrepancies.
Discrepancies of >2 mm give rise to a clinically significant cephalometric error and
should be measured and corrections to the analysis made.
Williamson et al (1978). Cephalometric analysis: Comparison between maximum intercuspation

and centric relation. AJODO 74: 672-677
Approximately 20% of orthodontic patients have a discrepancy of >2 mm prior to

treatment. Only 13% of orthodontists in the USA routinely mount their pre-treatment
study casts.
Utt et al (1995). A three-dimensional comparison of condylar position changes between centric

relation and centric occlusion using the mandibular position indicator. AJODO 107: 298-308
1.5 mm is a potentially significant A-P discrepancy.

Antero-posterior discrepancies of >1.5 mm and lateral discrepancies of >0.5 mm are
potentially significant.
Weak correlations between previous unilateral crossbite and current lateral displacements
and current TMJ clicking.
Egermark et al (2003). A 20-year follow-up of signs and symptoms of temporomandibular

dysfunction and malocclusions in subjects with and without orthodontic treatment in childhood.
Teeth Count and Morphology
In cases with missing lower 2nd premolar, maintenance of the 2nd primary molar long-
term is needed but consider reduction of mesial-distal width (premolarise).
Bjerklin and Bennett (2000). The long-term survival of the lower second primary molars in
subject with agenesis of the premolars. EJO 22;245-255
77
Missing lateral incisors, orthodontic space closure vs prosthetic replacement with
porcelain bonded to gold or resin bonded prosthesis, at an average duration of 7.1 years
after treatment were followed.
More satisfaction of patients with space closure than prostheses group and no difference
between the groups with respect to TMJ signs and symptoms. Patients with prosthetic
replacements had poorer gingival health with build-ups of plaque and calculus.
Robertsson and Mohlin (2000). The congenitally missing upper lateral incisor. A retrospective
study of orthodontic space closure versus restorative treatment. EJO 22: 697-710
Permanent tooth agenesis, maxillary lateral incisor microdontia, palatally displaced

canines, and distoangulation of mandibular second premolars are frequently associated
with maxillary lateral incisor agenesis.
Garib et al (2010). Agenesis of maxillary lateral incisors and associated dental anomalies.
AJODO 137:732.e1–732.e6
The prevalence of peg-shaped maxillary permanent lateral incisors varies by race,

population type, and sex. The prevalence rates were higher among Mongoloid people,
orthodontic patients, and women.
Although the prevalence of unilateral and bilateral lateral incisors was the same, the left
side was twice as common as the right side. Subjects with unilateral peg-shaped
maxillary permanent lateral incisors might have a 55% chance of having lateral incisor
hypodontia on the contralateral side.
Hua F et al (2013). Prevalence of peg-shaped maxillary permanent lateral incisors: A meta-

analysis. AJODO 144: 97–109
Patients with hypodontia have smaller mesiodistal and labiolingual dimensions of teeth.
The reduction in size is more excessive in the severe hypodontia cases.
The teeth showing the greatest difference in tooth dimensions are the maxillary lateral
incisor (in mesiodistal dimension) and the mandibular canine (labiolingual dimension).
Gungor and Turkkahraman (2013). Tooth sizes in nonsyndromic hypodontia patients. Angle
78
Space opening of missing laterals cases; a significant decrease in the width and height of
the alveolar ridge in patients with congenitally missing a maxillary lateral incisor who
received orthodontic treatment to create space for an endosseous dental implant.
Uribe et al (2013). Alveolar ridge width and height changes after orthodontic space opening in
patients congenitally missing maxillary lateral incisors. EJO 35: 87-92
Tooth agenesis isolated to the maxilla is frequently associated with microdontia of the
maxillary lateral incisors, whereas tooth agenesis isolated to the mandible is frequently
associated with retained deciduous molars, infraoccluded deciduous molars, and
impacted teeth.
Al-Abdallah M. et al (2015). Prevalence and distribution of dental anomalies: A comparison

between maxillary and mandibular tooth agenesis. AJODO 148: 793–798
Orthodontic space closure including first premolar intrusion and canine extrusion in
patients with missing lateral incisors does not incur risks for periodontal tissue
deterioration or TMD in the long term.
Rosa et al (2016). Congenitally missing maxillary lateral incisors: Long-term periodontal and
functional evaluation after orthodontic space closure with first premolar intrusion and canine
extrusion. AJODO 149: 339–348
Tooth-supported dental prostheses of maxillary lateral incisor agenesis had worse scores
in the periodontal indexes than did orthodontic space closure.
Space closure is evaluated better esthetically than prosthetic replacements, and the
presence or absence of a Class I relationship of the canines showed no relationship with
occlusal function or with signs and symptoms of temporomandibular disorders.
Silveira et al (2016). Prosthetic replacement vs space closure for maxillary lateral incisor
agenesis: A systematic review. AJODO 150: 228–237
Class II Division 2 Malocclusions
The lower incisors can be moved labially until they occupy the position previously
occupied by the upper incisors.
Selwyn-Barnett BJ (1996). Class II division 2 malocclusion: A method of planning and

treatment. BJO 23: 29-36
79
Some clinicians prefer to combine the incisor proclination and functional correction in
one appliance.
Dyer et al (2001). The modified twin block appliance in the treatment of class ii division 2
malocclusions. JO 28: 271-280
The upper incisor tips are indeed at a more inferior position in class II division 2
malocclusions than in class 1.
More labial pressure at the upper incisal edge than at the cervical margin in class II
division 2 and the reverse in class I.
Lapatki et al (2002). The importance of the level of the lip line and resting lip pressure in Class
II Division 2 malocclusion. JDR 81: 323-328
Class III Malocclusions
Correction of anterior crossbite involves the use of vertical cross elastics from the palatal
of the upper incisors to the labial of the lower incisors.
Reynolds (1978). The anterior crossbite: a simple method of treatment. BDJ 144: 143-146
56% of class 3 malocclusions had maxillary deficiency as one of the components of the
malocclusion.
Guyer et al (1986). Components of class III malocclusion in juveniles and adolescents. Angle
The critical factors in differentiating surgical class III patients:

 Anteroposterior discrepancy (ANB = -4°; maxillary mandibular ratio = 0.84)
 Lower incisor inclination (LI/MP = 83°)
 Soft tissue profile (Holdaway angle = 3.5°)
Kerr et al (1992). Class III malocclusion: surgery or orthodontics? BJO: 19: 21-24
80
Class III malocclusions:
Wits analysis was the most important factor in discriminating between the surgical and
non-surgical group with the surgical group having a Wits analysis value of –12.2 ± 4.3
mm and the non-surgical group -4.6 ± 1.7 mm.
Stellzig-Eisenhauer et al (2002). Treatment decision in adult patients with Class III

malocclusion: Orthodontic therapy or orthognathic surgery? AJODO 122: 27-38
Growth treatment response vector (GTRV) analysis is a method of determining whether a

class III malocclusion can be treated by camouflage or if surgical treatment will be
required at a later date.
Ngan P (2005). Early timely treatment of class 3 malocclusion. Seminars in Orthodontics 11:
140-145
The pubertal peak of mandibular growth occurred between stages CS3 and CS4 in the
Cervical vertebral maturation (CVM) method with average increases in mandibular
length of 8 mm and 5.5 mm in boys and girls respectively.
Baccetti et al (2007). Craniofacial changes in Class III malocclusion as related to skeletal and
dental maturation. AJODO 132: 2, 171.e1-171.e12
A value of 12° Holdaway angle is a discriminatory for borderline class III cases. Cases
with a greater than 12° were likely to be successfully treated by orthodontics; it is worth
noting that the population in this paper was Southern Chinese.
Rabie et al (2008). Treatment in borderline class III malocclusion: orthodontic camouflage

(extraction) versus orthognathic surgery. ODJ 2: 38-48
The upper and lower limits for incisal movement to compensate for Class III skeletal
changes were 120º to the sella-nasion line and 80º to the mandibular plane, respectively.
Burns et al (2010). Class III camouflage treatment: What are the limits? AJODO 137:9.e1-9.e13
81
Anterior and total cranial base length and cranial base angle were significantly smaller in
Class III malocclusion than in Class I and Class II malocclusions, and that they were
greater in Class II subjects compared to controls.
Gong et al (2016). Cranial base characteristics in anteroposterior malocclusions: A meta-

analysis. Angle Orthodontist 86: 668-680
Open Bite
As anterior tongue posture might be responsible for anterior open bites in cases of normal
skeletal proportions with no history of a digit sucking habit, Spurs soldered to upper
central incisor bands may produce dramatic cure of the problem.
Parker (1971). The interception of the open bite in the early growth period. Angle Orthodontist
41: 24-44
The Overbite depth indicator (ODI): defined as the angle the A-B plane makes with the
mandibular plane combined with the angle of the palatal plane to the Frankfort
horizontal. If the latter angle is positive it is added and if negative subtracted.
A value of less than 68 degrees is said to indicate an open bite tendency.
Kim YH (1974). Overbite depth indicator with particular reference to anterior open bite.
AJODO 65: 586-611
Occlusal forces in long faced children are no different from those in normal children but
that long faced adults have less occlusal force.
Proffit and Fields (1983). Occlusal forces in normal and long face children. JDR 62: 571-574
Skieller et al proposed a method for predicting future mandibular growth rotation from an
initial prepubertal lateral cephalogram. A combination of four variables accounted for
86% of the variability observed. These included: mandibular inclination, intermolar
angle, shape of the lower border of the mandible, and inclination of the symphysis.
Skieller et al (1984). Prediction of mandibular growth rotation evaluated from a longitudinal

implant sample. AJODO 86: 359-70
82
41 patients all of whom had had an anterior open bite of at least 3 mm were followed.
Ten years after treatment, 35% of patients had an anterior open bite of at least 3 mm. No
reliable predictor of post-treatment relapse could be found.
Lopez-Gavito et al (1985). Anterior open bite malocclusion: a longitudinal 10 year post

retention evaluation of orthodontically treated patients. AJODO 87: 175-186
The characteristic features of anterior open bite are;

 An obtuse mandibular plane and gonial angle.
 A palatal plane that is tipped upward and forward.
 Mesial tipping of the dentition.
Treatment should therefore be based on the extraction of terminal molars and distal
tipping of the dentition.
Kim YH (1987). Anterior open bite and its treatment with multiloop edgewise archwire. Angle
Cephalometric measurements and criteria used to diagnose open bite tendency:

 SN/MP angle 40° or greater
 OP/MP angle 22° or greater
 MxP/MnP angle 32° or greater
 AOB negative overbite
 PFH/AFH 58% or less
 UFH/LFH 0.7 or less
Dung and Smith (1988). Cephalometric and clinical diagnoses of open bite tendency. AJODO
94: 484-490
Maxillary molar vertical control: 20 nonextraction patients in which a transpalatal bar

was used for at least 5 months with similar patients in whom it was not used were
compared, no significant differences were found between the two groups.
Wise et al (1994). Maxillary molar vertical control with the use of transpalatal arches. AJODO
106: 403-408
83
Information derived from pre-treatment lateral cephalometric radiographs using the
Skieller, Björk, and Linde-Hansen method does not permit clinically useful predictions to
be made in a general population relative to the direction of future mandibular growth
rotation.
Leslie et al (1998). Prediction of mandibular growth rotation: assessment of the Skieller, Björk
and Linde-Hansen method. AJODO 114: 659-667
Multiloop edgewise archwire technique could not really intrude the molars although it did
upright the molars which could improve the inclination of the maxillary or mandibular
occlusal plane thus assisting the correction of an anterior open bite.
Chang and Moon (1999). Cephalometric evaluation of the anterior open bite treatment. AJODO
115: 29-38
Stability of anterior open bite correction following MEAW therapy during a two-year
follow-up period. Correction was very stable and relapse over a 2-year follow-up period
was less than 0.5 mm for both the growing (0.23 mm) and non-growing (0.35 mm) group.
Kim et al (2000). Stability of anterior open bite correction with multiloop edgewise archwire
therapy; a cephalometric follow-up study. AJODO 118: 43-54
Extracting further back in the arch, i.e.: first molars or second premolars compared with
first premolars, results in a reduction in the maxillary mandibular plane during treatment.
Aras A (2002). Vertical changes following orthodontic extractions in skeletal open bite subjects.
EJO 24: 407-416
Fujiki et al investigated the behaviour of the tongue during swallowing in patients with
and without anterior open bites. During swallowing and compared to patients with
normal occlusions, patients with anterior open bite have:
 Tongue tip protrusion.
 Slower movement of the dorsal part of the tongue.
 Earlier closure of the nasopharynx.
They divided swallowing into three phases:
1) Loss of contact of the dorsal tongue with the soft palate.
84
2) Passage of the bolus head across the posterior/inferior margin of the ramus of the
mandible.
3) Bolus head enters the oesophagus.
Fujiki et al (2004). Relationship between maxillofacial morphology and deglutitive tongue

movement in patients with anterior open bite. AJODO 125: 160-167
English and Olfert have reported three cases where adjunctive masticatory muscle
exercises have helped in closing anterior open bites.
English and Olfert (2005). Masticatory muscle exercise as an adjunctive treatment for open bite
malocclusions. Seminars in Orthodontics 11: 164-169
The use of occlusal adjustment may be considered under very specific circumstances in
order to close anterior open bites .
Janson et al (2008). Evaluation of anterior open-bite treatment with occlusal adjustment.

AJODO
The use of tongue spurs is currently proposed by Roberto Justus. They should be placed
approximately 3-4 mm behind the upper incisors and should be angled backwards and
downwards so that they establish a positive overlap with the lower incisors.
The effects of fixed and removable crib appliances in patients with open bite in the mixed
dentition were investigated. Both appliances produced favourable dental effects but the
fixed quad-helix with cribs produced more favourable skeletal effect which was
attributed to the lesser compliance required to wear it.
Giuntini et al (2008). Dentoskeletal changes associated with fixed and removable appliances
with a crib in open-bite patients in the mixed dentition. AJODO 133, 77-80
Tongue pressures in open bite patients with and without crib appliances were compared;
A decrease in tongue pressure in the group wearing the crib appliance was found which
was maintained two months after crib removal.
Taslan et al (2010). Tongue pressure changes before, during and after crib appliance therapy.
85
Success of both the surgical cases and non-surgical cases treatments of AOB appeared to
be greater than 75%.
Greenlee et al (2011). Stability of treatment for anterior open-bite malocclusion: A meta-

analysis. AJODO 139:154–169
No significant differences in the cervical vertebral column's morphologic deviations were

found between the skeletal and the dentoalveolar open-bite groups. Significant
differences were found in head posture between the groups and with regard to
associations with craniofacial dimensions.
This might indicate a respiratory etiologic component in children with anterior open bite.
Kim et al (2014). Cervical vertebral column morphology and head posture in preorthodontic
patients with anterior open bite. AJODO 145: 359–366
The long-faced children did not have longer upper facial heights compared with normal-
faced and short-faced children, and their long faces were mainly determined by the length
of the lower.
Ha et al (2014). Do long-faced subjects really have a long anterior face? A longitudinal study.
AJODO 145: 799–806
The fixed palatal crib (FPC) and bonded lingual spur (BLS) are simple and effective for
the treatment of anterior open bite, with the advantage given to the FPC.
Leite et al (2016). Effects of palatal crib and bonded spurs in early treatment of anterior open
bite: A prospective randomized clinical study. Angle Orthodontist 86: 734-739
Predictive malocclusal traits are associated with speech sound production errors. The
more severe or handicapping the malocclusion, the more likely that a speech sound error
will occur.
Open bites of 2 mm are associated with sound production errors. Visual inaccuracy of the
sound occurs with more frequency than auditory inaccuracy and is the most common
articulation error noted with occlusal irregularities.
Leavy et al (2016). Malocclusion and its relationship to speech sound production: Redefining
the effect of malocclusal traits on sound production. AJODO 150: 116–123
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Crossbite
Removal of premature contacts of the baby teeth is effective in preventing a posterior

crossbite from being perpetuated to the mixed dentition and adult teeth. When grinding
alone is not effective, using an upper removable expansion plate to expand the top teeth
will decrease the risk of a posterior crossbite from being perpetuated to the permanent
dentition.
Harrison and Ashby (2001). Orthodontic treatment for posterior crossbites. Cochrane Database
of Systematic Reviews 2001, Issue 1. Art. No.: CD000979. DOI: 10.1002/14651858.CD000979
Altered muscle function associated with posterior crossbite could reduce the bite force in
mixed dentition. According to EMG analysis, children with posterior crossbite had
asymmetrical muscle function during chewing or clenching, that is, the anterior
temporalis is more active and the masseter less active on the crossbite than on the non-
crossbite side.
Andrade et al (2009). Posterior crossbite and functional changes: a systematic review. Angle
The prevalence of a posterior crossbite in the primary and early mixed dentitions has
been reported to be between 8 and 22 %.
Macena et al (2009). Prevalence of a posterior crossbite and sucking habits in Brazilian children
aged 18–59 months. EJO 31: 357-361
Supernumerary Teeth
The fate of unerupted teeth after the removal of supernumeraries:
Supernumerary Type % Spontaneous Eruption
Supplemental (normal) 83.0%

Supplemental (small) 75.0%
Conical 46.0%
Tuberculate 19.0%
Odontome 32.0%
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It is sensible to start orthodontic traction to the unerupted tooth at the time of the first
surgery because a very high proportion of patients would need orthodontic treatment and
that long follow-up times are required,.
Ashkenazi et al (2007). Postoperative prognosis of unerupted teeth after removal of

supernumerary teeth or odontomas. AJODO 131: 614-619
Ectopic Maxillary Canines
Occur more commonly in females than males in the ratio of 2:1
Dachi and Howell (1961). A survey of 3,874 routine full mouth radiographs. Oral Surgery, Oral
Medicine and Oral Pathology 14: 1165-1169
The incidence of impacted maxillary canines is around 2-3%
Thilander and Myrberg (1973). The prevalence of malocclusion in Swedish school children.
SJDR 81: 12-20
Ericson and Kurol (1986). Radiographic assessment of maxillary canine eruption in children
with clinical signs of eruption disturbances. EJO 8: 133-140
High incidence associated with Class II div 2 malocclusions.
Mossey et al (1994), The palatal canine and the adjacent lateral incisor; a study of a West of
Scotland population. BJO 21 ;169-174
Impacted canine crown is palatal in 61% of cases, in the line of the arch in 34% of cases
and buccal or labial in 4.5% of cases.
Stivaros and Mandall (2000). Radiographic factors affecting the management of impacted
upper permanent canines. JO 27: 169-173
For buccally displaced canines, sexual dimorphism seems to exist. Females with buccally
displaced canines had larger incisors than a control sample. Male subjects however had
similar mesio-distal tooth widths with buccally displaced canines and in controls.
Chaushu et al (2003). Tooth size in dentitions with buccal canine ectopia. EJO 25: 485-491
88
Unilateral palatal displacement of maxillary canines was significantly associated with
aplasia of upper lateral incisors, whereas bilateral ones were associated with aplasia of
third molars.
Sacerdoti and Baccetti (2004). Dentoskeletal features associated with unilateral or bilateral
palatal displacement of maxillary canines. Angle Orthodontist 74: 725-732
(Mossey et al, Brenchley, Oliver) found no association between small upper laterals and
ectopic canines.
(Brin, Oliver et al, Becker, Langberg and Peck and Al-Nimri and Gharaibeh) did find an
association, it was not as strong or as clear cut as needed.
Mossey et al (1994). The palatal canine and the adjacent lateral incisor: a study of a west of
Scotland population. BJO 21:169-174
Brenchley et al (1997). Morphology of anterior teeth associated with displaced canines. BJO
24:41-45
Brin et al (1986). Position of the maxillary permanent canine in relation to anomalous or

missing lateral incisors: a population study. EJO 8: 12–16
Oliver et al (1989). Morphology of the lateral incisor in cases of unilateral impaction of

maxillary canine. BJO 16: 9–16
Langberg and Peck (2000). Tooth-size reduction associated with occurrence of palatally
displaced canines. Angle Orthodontist 70: 126-128
Al-Nimri and Gharaibeh (2005). Space conditions and dental and occlusal features in patients
with palatally impacted maxillary canines: an aetiological study. EJO 27:461-5
Only 6% of cases with palatally impacted maxillary canines had small upper laterals. A
higher incidence association with absent upper laterals (but still only 12%).
Al-Nimri and Gharaibeh (2005). Space conditions and dental and occlusal features in patients
with palatally impacted maxillary canines: an aetiological study. EJO27:461-5
Long term follow-up of patients with severely resorbed incisors associated with impacted
maxillary canines:
 When resorption of an incisor root occurs as the result of an impacted canine, the
process is rapid, and the patient should be treated with urgency.
89
 Treatment should be designed to move the canine away from the resorbing tooth as
quickly as possible.
 Once the impacted canine has been distanced from the root area, resorption almost
always ceases.
 The resorbed incisor can be subsequently moved orthodontically, with a minimal risk
of further resorption, although radiographic monitoring is advised as a precautionary
measure.
 The radiographic reappearance of an intact lamina dura, periodontal ligament and
bony trabeculation in the periapical area are signs of cessation of the resorption
process
 At the 1-year (and longer) post-treatment follow-up even markedly resorbed teeth are
not unduly mobile.
 Root canal treatment, as a means of reducing further resorption, is inappropriate
 The teeth were not discolored and appeared to have a fairly good long-term
prognosis.
Becker and Chausu (2005). Long-term follow-up of severely resorbed maxillary incisors after
resolution of an etiologically associated impacted canine. AJODO 127: 650-654
Bolton ratio was normal in patients with impacted canines.
Al-Nimri et al (2008). Tooth size discrepancies in female patients with palatally impacted
canines. AOJ 24:129-33
When started at an average age of 9.6 years, RME increased the percentage of erupted
ectopic canines to 66% compared to 14% in a control group.
Baccetti et al (2009). Interceptive treatment of palatal impaction of maxillary canines with rapid
maxillary expansion: A randomized clinical trial. AJODO 136:657-661
The use of rapid maxillary expansion and headgear (or headgear alone) in palatally
displaced maxillary canine cases increases the success rate of eruption of the canine
significantly (almost three times more than in untreated controls).
Armi et al (2011). Effect of RME and headgear treatment on the eruption of palatally displaced
canines: A randomized clinical study. Angle Orthodontist 81: 370-374
90
Most cases of incisor root resorption induced by ectopic maxillary canines did not
progress and teeth with root resorption showed no clinically relevant symptoms.
The prognosis for long-term survival of teeth with resorbed roots is good, but in cases
where extraction is indicated, lateral incisors with severe root resorption should be
extracted in favor of healthy premolars.
Bjerklin and Guitirokh (2011). Maxillary incisor root resorption induced by ectopic canines.
Concomitant deciduous canine and first molar extractions (compared to extraction of

deciduous canine only) proved to be more effective as a preventive approach to promote
eruption of retained maxillary permanent canines positioned palatally or centrally.
Bonetti et al (2011). Preventive treatment of ectopically erupting maxillary permanent canines

by extraction of deciduous canines and first molars: A randomized clinical trial. AJODO 139:
316–323
The shape of the maxillary arch was narrower and longer in the palatally impacted canine
group compared with the buccally impacted canine group.
The palatally impacted canine group had a deeper palatal vault than did the buccally
impacted canine group.
Kim et al (2012). Interrelationship between the position of impacted maxillary canines and the
morphology of the maxilla. AJODO 141: 556–562
The prevalence rate of buccally displaced canines (BDC) was 3.06% with a male-to-
female ratio of 1:1.
BDC subjects exhibited a significant association with hyperdivergent skeletal
relationships (38.8%), reduced maxillary intercanine width, and crowding in the upper
arch.
The presence of specific dentoskeletal characteristics can be considered as a risk indicator
for developing a buccal displacement of upper permanent canines.
Mucedero et al (2013). Prevalence rate and dentoskeletal features associated with buccally
displaced maxillary canines. EJO 35: 305-309
91
The extraction of the deciduous canine is an effective measure in PDC cases, but it must
be done in younger patients in combination with early diagnosis, at the age of 10–11
years.
Maintenance of the perimeter of the upper arch is an important step during the
observation period, and a palatal arch as a space-holding device is recommended.
Bazargani et al (2014). Effect of interceptive extraction of deciduous canine on palatally

displaced maxillary canine: A prospective randomized controlled study. Angle Orthodontist
84:3-10
Periodontal status of ectopic canines after orthodontic treatment:

Canines had increased plaque and gingival bleeding index, greater pocket depths, reduced
attached gingival width, higher gingival levels, increased crown lengths, higher electric
pulp testing scores, and reduced bone levels compared to their contra-laterals.
Evren et al (2014). Periodontal status of ectopic canines after orthodontic treatment. Angle
Sella bridging is frequently found in patients with impacted canines. Hence, sella
bridging can complement other diagnostic parameters in confirming the status of canine
impaction.
Ali et al (2014). Association between sella turcica bridging and palatal canine impaction.
AJODO 146: 437–441
The maxillary transverse dimension, both skeletally and dentally, had no effect on the
occurrence of PDC.
The higher prevalence of permanent tooth agenesis was found in the PDC group.
The mean mesiodistal width of maxillary lateral incisors in the PDC group was
significantly smaller than in the control group
Hong et al (2015). Relationship between the maxillary transverse dimension and palatally
displaced canines: A cone-beam computed tomographic study. Angle Orthodontist 85: 440-445
92
 Localization of Impacted Canines
Ericson and Kurol used conventional radiographs to assess canine position and then
conventional CT to examine possible resorption of adjacent roots.
They concluded that CT was additionally required in 27% of cases and that CT doubled
the incidence of detected root resorption to 12% of cases.
Ericson and Kurol (1987). Radiographic examination of ectopically erupting maxillary canines.
AJODO 91:483-492
Later, in a further CT study they reported a sample with resorption in 48% of cases.
Ericson and Kurol (2000). Resorption of incisors after ectopic eruption of maxillary canines: a
CT study. Angle Orthodontist 70: 415-423
The removal of deciduous canines to change the path of eruption of palatal maxillary
canines as an interceptive treatment for palatal maxillary canines in the 10-13 year old
age group was applied.
The overall success rate was 78%.
Any change in the eruption path of the permanent canine was not likely to occur later
than 12 months after the extraction of the deciduous canine.
Canines distal to the midline of the lateral incisors had a 91% chance of erupting
normally.
Only 64% of those mesial to the midline of the lateral incisor did so.
Ericson and Kurol (1988). Early treatment of palatally erupting maxillary canines by extraction
of the primary canines. EJO 10: 283-295
Poor success of interceptive extraction of deciduous canines if crowding of the palatally

displaced canine was there.
Power and Short (1993). An investigation into the response of palatally displaced canines to the
removal of deciduous canines and an assessment of factors contributing to favourable eruption.
BJO 20:215-223
93
Preda et al highlighted the use of spiral CT for the localization of impacted maxillary
canines and particularly possible contact and incisor root resorption. They confirmed that
the degree of overlap on a panoramic film and the probability of root contact or
resorption were not correlated.
Preda et al (1997). The use of spiral computed tomography in the localization of impacted
maxillary canines. DR 26: 236-241
Chaushu et al have described a method of localizing maxillary canines using only a

panoramic radiograph. This depends on the fact that objects nearer the x-ray source (and
further from the film) project a larger image than objects closer to the film and further
from the x-ray source. Thus palatal canines will appear larger than buccal canines
Chaushu et al (1999). The use of panoramic radiographs to localise maxillary canines. Oral
Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 88: 511-516
Parallax technique: Jacobs recommended increasing the vertical angulation of the x-ray
tube from 60-65 degrees to 70-75 degrees to increase the effect of parallax.
Jacobs (1999a). Localization of the unerupted maxillary canine: how to and when to. AJODO
115: 314-322
Jacobs (1999b). Radiographic localization of unerupted maxillary anterior teeth using the
vertical tube shift technique: the history and application of the method with some case reports.
AJODO 116: 415-423
Operators were unsure of the position of ectopic canines in 12% of cases using vertical
parallax and 5% of cases with horizontal parallax.
With horizontal parallax, 83% of canines were correctly located while only 68% were
correctly located with vertical parallax. The diagnostic sensitivity of the horizontal
parallax was 88% and 69% for vertical parallax for palatally displaced canines; for
buccally displaced canines, both methods performed poorly with a diagnostic sensitivity
of only 63%.
Armstrong et al (2003). Localising ectopic maxillary canines – horizontal or vertical parallax.

EJO 25: 585-589
94
The role of CBVT in imaging unerupted maxillary canines was discussed by Walker et al
(2005). In this study, 92.6% of the canines were palatal and 7.4% buccal. They found that
66.7% of the lateral incisors and 11.1% of the central incisors showed resorption.
Walker et al (2005). Three-dimensional localization of maxillary canines with cone-beam

computed tomography. AJODO 128: 418-423
Diagnosis of maxillary canine impaction is possible at 8 years of age by using geometric

measurements on panoramic radiographs.
Sajnani and King (2012). Early prediction of maxillary canine impaction from panoramic
radiographs. AJODO 142:45–51
 Exposure Techniques
Open exposure was found to require less surgical resource than closed exposure and was
just as an effective procedure. 30.7% of the closed exposures required a second surgical
procedure while only 15.3% of the open exposures required a further surgical procedure.
The average operating time for the open exposure was one third of that for a closed
exposure for a single tooth and 56% for two teeth.
Pearson et al (1997). Management of palatally impacted canines; the findings of a collaborative

study. EJO 19: 511-515
Simple exposure vs. expose, bond and close group: The average time from exposure to
debond was also the same but lengthy in both groups.
Iramaneerat et al (1998). The effect of two alternative methods of canine exposure upon
subsequent duration of orthodontic treatment. IJPD 8: 123-129
Uncover palatal impacted upper canine early (during mixed dentition) to allow
autonomously eruption
Kokich (2004). Surgical and orthodontic management of impacted maxillary canine. AJODO.
126;278-283
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The periodontal and pulpal outcomes of ectopic canines which had been exposed
surgically and those which had been allowed to erupt naturally following the creation of
excess space were compared:
There were no significant differences in the plaque index scores, the gingival index
scores or the periodontal outcomes between the impacted canines in the two groups.
Ling et al (2007a). Comparison of surgical and non-surgical methods of treating palatally

impacted canines. I. Periodontal and pulpal outcomes. AOJ 23: 1-7
Choice of surgical method is not associated with any significant differences in post-
treatment periodontal status of palatally impacted canines and adjacent teeth.
Smailiene et al (2013). Palatally impacted maxillary canines: choice of surgical-orthodontic

treatment method does not influence post-treatment periodontal status. A controlled prospective
study. EJO 35: 803-810
Evidence of an association between exposure technique and ankylosis was found.

There was evidence that the grade of impaction and the patient's age are significant
predictors of ankylosis, as is the use of rapid palatal expansion a predictor of automatic
eruption.
Koutzoglou and Kostaki (2013). Effect of surgical exposure technique, age, and grade of
impaction on ankylosis of an impacted canine, and the effect of rapid palatal expansion on
eruption: A prospective clinical study. AJODO 143: 342–352
Pre-orthodontic uncovering and autonomous eruption technique is a safe and predictable

option for treating palatally impacted maxillary canines in adolescents and adults.
Mathews et al (2013). Palatally impacted canines: The case for preorthodontic uncovering and
autonomous eruption. AJODO 143: 450, 452, 454, 456, 458
There is a periodontal impact when a unilateral palatally displaced canine (PDC) is

exposed and aligned.
This impact is small and unlikely to have clinical relevance in the short term; however,
the long-term significance is unknown. When the open and closed techniques were
compared, no difference in periodontal health was found.
96
Parkin (2013). Periodontal health of palatally displaced canines treated with open or closed
surgical technique: A multicenter, randomized controlled trial. AJODO 144: 176–184
The current literature is insufficient to determine which surgical procedure is better for
periodontal health for uncovering labially impacted canines.
Parenti et al (2016). Periodontal status after surgical-orthodontic treatment of labially impacted

canines with different surgical techniques: A systematic review. AJODO 149: 463–472
Loss of Central Incisors
Transplant with (lower first premolar or upper second premolar) when root is 2/3-3/4
formed. Good long-term results quoted
Czochrowska et al (2002). Outcome of tooth transplantation: survival and success rates 17-24
years post-treatment. AJODO 121 ;110-119
In cases with missing permanent central incisor: move lateral incisor into space and
restore. Problems with symmetry and aesthetics?
Czochrowska et al (2003). Outcome of orthodontic space closure with a missing maxillary

central incisor. AJOOO 123;597-603
Unerupted incisors are more frequent in males than in females. An association between
unerupted incisors and other inherited dental anomalies, namely ectopic teeth,
hyperdontia, and enamel hypoplasia was found.
Bartolo et al (2010). Unerupted incisors—characteristic features and associated anomalies. EJO

32: 297-301
Transposition
Mx.C.P1 incidence is 71% among other types of transpositions.
PeckS & Peck (1995). Classification of maxillary tooth transpositions, AJODO 107: 505-517
97
Mx.C.P1 has a strong association with lateral incisor agenesis (20%) and second
premolar agenesis (24%).
Camilleri (2005). Maxillary canine anomalies and tooth agenesis. EJO 27: 450-456
Tooth transposition can be regarded as an independent condition rather than a syndrome.

It can be accompanied by a variety of other characteristic features or dental anomalies,
but with no distinct associations.
Papadopoulos et al (2009). Assessment of characteristic features and dental anomalies

accompanying tooth transposition: a meta-analysis. AJODO 136: 308.e1-308.e10
Primary Failure of Eruption (PFE)
Individuals affected with PFE do not respond to orthodontic forces and can be easily
confused with ankylosis.
Proffit and Vig (1981). Primary failure of eruption: a possible cause of posterior open-bite.
AJODO 80: 173–190.
Frazier-Bowers et al (2010). Primary eruption failure and PTH1R: the importance of a genetic
diagnosis for orthodontic treatment planning. AJODO 137: e1–e7.
Distinction is made between primary failure of eruption (PFE) and mechanical failure of
eruption (MFE) – frequently ankylosis.
PFE affects only posterior teeth and all teeth distal to the affected tooth are involved. It
is frequently unilateral. A non-ankylosed tooth with PFE is likely to become ankylosed
when orthodontic force is applied.
Frazier-Bowers et al (2007). Primary failure of eruption: Further characterization of a rare

eruption disorder. AJODO 131: 578.e1-578.e11
98
Section Eight
Orthodontic Appliances
The Classic Straight-Wire Appliance
Removable Appliances
Functional Appliances
Quadhelix
RME
Protraction Headgear
Chincup
Lip Bumper
Clear aligner therapy
99
100
The Classic Straight-Wire Appliance
The combination of an ideal appliance and ideal force delivery system would reduce
treatment times for many cases to six months.
Andrews LF (1975). Accomplishing orthodontic treatment in six months with the straight-wire
appliance. In: Cook J T, ed. Transactions of the third international orthodontic congress: London.
Preadjusted edgewise appliances do not achieve ideal tooth positions with the use of
straight wires due to;
 Variation in tooth morphology.
 Inaccurate bracket placement.
 Variation in vertical and anteroposterior jaw relationships require variations in the
positions of maxillary and mandibular incisors.
 Lack of coincidence of force application and the centre of resistance of the tooth.
 Play between the archwire and the archwire slot.
 Force diminution, such as archwires never fully returning to their undeformed shape.
 The tendency for teeth to revert to their pretreatment positions.
Creekmore and Kunik (1993). Straight-Wire: the next generation. AJODO 104: 8-20
Vertical displacements of brackets less than 0.4 mm had only a modest effect on
inclination but that variations up to 1.5 mm could produce changes of 2° to 10°.
Miethke and Melsen (1999). Effect of variation in tooth morphology and bracket position on
first and third order correction with preadjusted appliances. AJODO 116: 329-335
The amount of torque expressed by the archwire and bracket depends on:
 The crown root angle.
 The labial or buccal crown morphology.
Van Loenen et al (2005). Anterior tooth morphology and its effect on torque. EJO 27: 258–262
The assessment of tooth angulation and torque remains a clinical feature that allows
some art in orthodontics.
This highlights the necessity for individual wire bending to obtain appropriate torque due
to both the variability of the crown-root angle and the crown morphology.
101
Van Loenen et al (2005). Anterior tooth morphology and its effect on torque. EJO 27: 258–262
Removable Appliances
Disinfection of baseplates of removable orthodontic appliances by using 0.12%

chlorhexidine spray once or twice a week reduced the contamination by mutans
streptococci on the acrylic surface in vivo.
Peixoto et al (2011). Evaluation of home disinfection protocols for acrylic baseplates of

removable orthodontic appliances: A randomized clinical investigation. AJODO 140:51–57
Functional Appliances
Functional appliances, headgear or no treatment: no average enhancement of mandibular

growth.
Jakobsson (1967). Cephalometric evaluation of treatment effects on Class II/I malocclusions.

AJODO 53: 446-457
There is more lower incisor proclination with Herbst than with most other functional
appliances which are less tooth-borne.
McNamara et al (1990). A comparison of the Herbst and Frankel appliances in the treatment of
class II malocclusions. AJODO 98: 134-144
The use of headgear to the functional appliance was of no additional benefit in closing
down the anterior open bite.
Weinbach and Smith (1992). Cephalometric changes during treatment with the open bite
bionator. AJODO 101: 367-374
Functional appliances are classified into: myotonic and myodynamic (Houston et al) or
to passive/ active tooth borne and tissue borne (Proffit et al).
Houston et al (1993). A Textbook of Orthodontics, 2nd Ed, Wright, Oxford.
Proffit et al (2007). Contemporary Orthodontics, 4111 Ed, Mosby.
102
No mandibular growth enhancement by Harvolds or Frankels.
Nelson et al (1993). Mandibular changes during functional appliance treatment. AJODO 104:
153-161
Using Herbst appliance: maxillary growth restraint actually increased relative to controls
after the end of active treatment.
Wieslander (1993). Long-term effect of treatment with the headgear- Herbst appliance in the
early mixed dentition. Stability or relapse? AJODO 104: 319-329
Pancherz and Anehus-Pancherz (1993). The headgear effect of the Herbst appliance: A
cephalometric long-term study. AJODO 103: 510-520
No significant maxillary restraint during functional appliance treatment.
Nelson et al (1993). Mandibular changes during functional appliance treatment. AJODO 104:
153-161
Very encouraging short-term growth enhancement, which in the long term almost
disappeared.
Wieslander (1993). Long-term effect of treatment with the headgear- Herbst appliance in the
early mixed dentition. Stability or relapse? AJODO 104: 319-329
Pancherz and Hansen (1986). Occlusal changes during and after Herbst treatment: a
cephalometric investigation. EJO 8: 215-228
Pancherz and Fackel (1990). The skeletofacial growth pattern pre- and post- dentofacial
orthopedics. A long term study of Class II malocclusions treated with the Herbst appliance. EJO
12: 209-218
Tulloch et al (1998). Benefit of early Class II treatment: Progress report of a two-phase

randomised clinical trial. AJODO 113: 62-72
A very wide range of skeletal response to functional appliances. There is a widespread

belief that children who grow vertically will respond less well to class 2 treatment, but
this is not well documented or understood.
103
Tulloch et al (1997a). Influences on the outcome of early treatment for Class II malocclusion.
AJODO 111: 533-42
Tulloch et al (1997b). The effect of early intervention on skeletal pattern in Class II

malocclusion: A randomised clinical trial. AJODO 111: 391-400
Both the Bionator and headgear treatment resulted in skeletal pattern improvement
which was maintained, but one year after active treatment, the average apical base
relationship improvement was only 0.8 mm compared to the untreated controls.
Keeling et al (1998) Anteroposterior skeletal and dental changes after early Class II treatment
with bionators and headgear. AJODO 113:40-50
The long-term results of the groups in the RCT by Keeling et al show no long-term
differences in the effect on the skeletal pattern from functional appliance treatment when
compared to fixed appliance treatment.
Dolce et al (2007). Timing of Class II treatment: Skeletal changes comparing 1-phase and 2-
phase treatment. AJODO 132:481-9
The hyperdivergent cases showed 1 mm better mandibular response than the

hypodivergent cases although this was not statistically significant.
Ruf and Pancherz (1998). Temporomandibular joint adaptation in Herbst treatment: a

prospective magnetic resonance imaging and cephalometric roentgenographic study. EJO 20:
375-388
Open-bite bionators have posterior bite blocks to prevent extrusion of the posterior teeth.
The bite is taken with just sufficient opening to allow the placement of the posterior bite
blocks. The lower lingual acrylic extends into the maxillary incisor region as a lingual
shield, without touching the upper incisors to inhibit tongue movements.
Defraia et al (2007). Early orthodontic treatment of skeletal open-bite malocclusion with the
open-bite bionator: A cephalometric study. AJODO 132: 595-598
104
The FR3 appliance induced significant improvements in both maxillary size and position,
There was an increase in effective midfacial length of 3.5 mm compared with the control
group and this continued into the post treatment phase.
There was no long-term inhibition of mandibular growth but there was closure of both the
gonial angle and the mandibular plane angle and all skeletal and dental changes were
sustained during the pubertal growth spurt.
Levin et al (2008) Short-term and long-term treatment outcomes with the FR-3 appliance of
Fränkel. AJODO 134: 513-524
Oral myofunctional therapy with orthodontic treatment was efficacious in closing and
maintaining closure of dental open bites in class I and class II malocclusions, and it
reduced the relapse of open bites in patients who had forward tongue posture and tongue
thrust by reducing these behaviours.
Smithpeter and Covell (2010). Relapse of anterior open bites treated with orthodontic
appliances with and without orofacial myofunctional therapy. AJODO 137: 605-614
The Twin-block appliance was more effective than the Dynamax appliance when overjet
was evaluated and the Dynamax appliance patients reported greater incidence of adverse
events with their appliance than those who were treated with the Twin-block appliance.
Thiruvenkatachari et al (2010). Comparison of Twin-block and Dynamax appliances for the

treatment of Class II malocclusion in adolescents: A randomized controlled trial. AJODO 138:
144.e1–144.e9
Stability of results with a Herbst appliance: the 2 mm average enhancement of

mandibular growth diminished to 0.4 mm by the end of the subsequent fixed appliance
phase.
Wigal et al (2011). Stability of Class II treatment with an edgewise crowned Herbst appliance in
the early mixed dentition: Skeletal and dental changes. AJODO 140: 210-223
The skeletal effects of removable functional appliances (RFAs) are minimal and,
probably, of negligible clinical importance.
105
The treatment of Class II malocclusion with (RFAs) is associated with a minimal
stimulation of mandibular growth, a minimal restriction of maxillary growth, and, to a
much larger extent, with dentoalveolar and soft tissue changes.
Patient- and appliance-related factors might influence the outcomes of RFA treatment.
The Twin block was the most effective appliance, when compared to others.
Vasilis Koretsis et al (2014). Treatment effects of removable functional appliances in patients

with Class II malocclusion: a systematic review and meta-analysis. EJO 2014, 1-7.
Correction of class II malocclusion remained stable 7 years after FR-2 treatment mainly
due to the stability of the skeletal changes.
Angelieri et al (2014). Long-term treatment effects of the FR-2 appliance: a prospective

evalution 7 years post-treatment. EJO 36: 192-199
Clinical evidence suggests that the FR-3 might restrict mandibular growth but not
stimulate forward movement of the maxilla.
Yang et al (2014). Treatment effectiveness of Fränkel function regulator on the Class III
malocclusion: A systematic review and meta-analysis. AJODO 146: 143–154
Removable functional appliances in Class II growing patients have a slight inhibitory

effect on the sagittal growth of the maxilla in the short term, but they do not seem to
affect rotation of the maxillary plane.
Nucera et al (2015). Effectiveness of orthodontic treatment with functional appliances on

maxillary growth in the short term: A systematic review and meta-analysis. AJODO 149: 600–11
Fixed functional appliances seem to be effective in improving Class II malocclusion in

the short term, although their effects seem to be mainly dentoalveolar rather than
skeletal.
Zymperdikas et al (2016). Treatment effects of fixed functional appliances in patients with

Class II malocclusion: a systematic review and meta-analysis. EJO 38: 113-126
106
 Incremental Advancement
No difference between the effects produced by one 6 mm advancement and two sizes of
smaller incremental advancements.
DeVincenzo and Winn (1989). Orthopaedic and orthodontic effects resulting from the use of a
functional appliance with different amounts of protrusive activation. AJODO 97: 181-190
The effects of twin-block treatment with a single advancement to an edge-to-edge bite

and the incremental advancement: No advantage for the incremental method in terms of
process or outcome of the treatment.
Banks et al (2004). Incremental versus maximum bite advancement during twin-block therapy:
A randomised controlled clinical trial. AJODO 126:583-8
The hard and soft tissue effects of a conventional twin-block with a single large
advancement and a modified twin-block named the Mini block which incorporated
progressive advancement and an incisor torquing spur were compared:
The only differences of significance were that the conventional Twin-block retroclined
the upper incisors a little more and advanced hard and soft tissue Pogonion
approximately 2mm more on average. Lower incisor proclination was very similar.
Gill et al (2002). A prospective clinical trial comparing the dentoskeletal effects of two
functional appliances. Journal of Orthodontics 29:335
Sharma et al (2002). Soft tissue changes produced by two types of twin-block appliances.
Journal of Orthodontics 29:338
In a further report on a RCT comparing these two appliances, again found no difference
in the effects on skeletal pattern.
Gill and Lee (2005). Prospective clinical trial comparing the effects of conventional twin-block
and mini-block appliances: Part 1. Hard tissue changes. AJODO 127:465-72
107
 Patient Compliance with Removable Functional Appliances
Nearly all human tooth eruption occurs between 8 pm and midnight.
Lee and Proffit (1995). The daily rhythm of human premolar eruption. AJODO 107: 38-47
Overall discontinuation rate with twin-blocks is 14% while significantly higher

discontinuation rate of 28% with the Bass appliance.
Morris et al (1998). A prospective evaluation of Bass, Bionator and Twin Block appliances. Part
II--The soft tissues. EJO 20:663-84.
9% failure to reduce overjet to < 6 mm with twin-blocks.
Harradine and Gale (2000). The effects of torque control spurs in twin block appliances.
Clinical Orthodontics and Research 3: 202-210
Failure rate with the Bass appliance is (41%) which is twice that for twin-blocks (23%)
McDonagh et al (2001). A prospective optical surface scanning and cephalometric assessment

of the effect of functional appliances on the soft tissues. EJO 23:115-126
Success rates at correction of molar relationships (not overjet) between bionators and
headgear at a relatively early age:
100% molar relationship correction was only achieved in 42% of the bionator group and
in 62% with headgear. If <¼ unit class 2 was considered a success, the success rates
went up to 83% with the bionator and 100 with headgear.
Wheeler et al (2002). Effectiveness of early treatment of class II malocclusion. AJODO 121:9-

17
Effectiveness of treatment for class II malocclusion for older patients: high failure rates
(34%). For younger patients: 19%
O’Brien et al (2003a). Effectiveness of treatment for class II malocclusion with the Herbst or
twin-block appliances: a randomized controlled trial. AJODO 124: 128-137
108
38% of the functional cases had extractions.
Tulloch et al (2004). Outcome in a 2-phase randomised clinical trial of early class II treatment.
AJODO 125:657-67
Patients with a start age of less than 12.3 years were three times more likely to complete
functional treatment with twin-blocks.
A failure rate of 25% with twin-blocks in patients in the permanent dentition.
A failure rate of 14% with either twin-blocks or mini-block appliances.
An increase in the breakage rate for Dynamax in comparison with twin-block was found
in an earlier study.
Lee et al (2007). A controlled clinical trial of the effects of the Twin Block and Dynamax
appliances on the hard and soft tissues. EJO 29:272-282
 Design of Removable Functional Appliances
Three degree reduction occurs in upper incisor retroclination with incisor torquing spurs.
109
No significant difference in upper incisor retroclination (10 degree vs 7 degrees) with or
without a labial bow.
Yaqoob et al (2011). Use of the Clark Twin Block functional appliance with and without an
upper labial bow: a randomized controlled trial. Angle Orthodontist
Modified functional appliances: e.g. cantilever springs behind the upper incisors to
procline the maxillary incisors and correct the sagittal relationship with same appliances.
Dyer et al (2001). The modified twin block appliance in the treatment of Class II division 2
malocclusions. JO 28; 271-280
Quadhelix
The quadhelix is capable of producing intermolar expansion of about 5-6 mm with

sutural opening during the deciduous and mixed dentitions.
Bell and LeCompte (1981). The effects of maxillary expansion using a quad-helix appliance
during the deciduous and mixed dentitions. AJODO 79: 152-161
A ratio of 6:1 for orthodontic: orthopaedic expansion has been reported for quadhelix in
growing orthodontic patients.
Frank and Engel (1982). The effects of maxillary quadhelix appliance expansion on
cephalometric measurements in growing orthodontic patients. AJODO 81: 378-389
The effectiveness of the quadhelix and a nickel titanium expander was compared:
Both are equally efficient but the quadhelix appeared to deliver more controlled and
predictable expansion.
Donoghue et al (2004). A clinical comparison of the quadhelix appliance and the nickel titanium
(tandem loop) palatal expander: a preliminary, prospective investigation. EJO 26: 411-420
110
Rapid Maxillary Expansion (RME)
The difference in effect between banded RME appliances and bonded appliances with
bite blocks was compared:
The use of bite blocks was found less likely to lead to a decrease in overbite than the use
of a banded appliance.
Sarver and Johnston (1989). Skeletal changes in vertical and anterior displacement of the
maxilla with bonded rapid palatal expansion appliances. AJODO 95: 462-466
No clinical differences in the amount of inferior movement of the palatal plane between
patients treated with bonded and banded appliances and that patients with high
mandibular plane inclinations did not exhibit greater vertical change than those with
lower inclinations. Overall, there is perhaps little to choose between the two methods.
Reed et al (1999). Comparison of outcomes with banded and bonded RPE appliances. AJODO
116: 31-40
Rapid maxillary expansion leads to a small immediate widening of the spheno-occipital

synchondrosis in youngsters.
Leonardi R (2010). Rapid maxillary expansion affects the spheno-occipital synchondrosis in

youngsters. Angle Orthodontist 80: 106-110.
RME and semi-rapid maxillary expansion have similar effects on dentofacial structures
both in the transverse, vertical, and sagittal planes.
Ramoglu and Sari (2010). Maxillary expansion in the mixed dentition: rapid or semi-rapid? EJO
32: 11–18
Due to greater sutural separation and bone formation, continuous forces provide a more
effective approach for separating sutures than intermittent forces.
Liu et al (2010). Continuous forces are more effective than intermittent forces in expanding
sutures. EJO 32: 371-380
111
A significant amount of relapse occurred in maxillary arch widths at the postretention
assessment, the greatest being in intercanine width.
RME significantly decreased overbite and increased overjet, and a statistically significant
decrease was observed in both overbite and overjet at the postretention assessment.
Gurel et al (2010). Long-term effects of rapid maxillary expansion followed by fixed

appliances. Angle Orthodontist 80: 5-9
Forces elicited by rapid maxillary expansion affect primarily the anterior sutures
(intermaxillary and maxillary frontal nasal interfaces) compared with the posterior
(zygomatic interface) craniofacial structures.
Ghoneima et al (2011). Effects of rapid maxillary expansion on the cranial and circummaxillary
sutures. AJODO 140: 510–519
Haas-type vs hyrax-type expanders:

Both appliances were efficient in correcting a transverse maxillary deficiency. The pure
skeletal expansion was greater than actual dental expansion. The hyrax-type expander
produced greater orthopedic effects than did the Haas-type expander, but this effect was
less than 0.5 mm per side and might not be clinically significant.
Weissheimer et al (2011). Immediate effects of rapid maxillary expansion with Haas-type and
hyrax-type expanders: A randomized clinical trial. AJODO 140: 366–376
From an orthopedic perspective, the ideal screw position might be slightly above the
maxillary first molars' center of resistance; this would generate less dental tipping.
Araugio et al (2013). Influence of the expansion screw height on the dental effects of the hyrax
expander: A study with finite elements. AJODO 143: 221–227
There was forward movement of the maxilla as a result of rapid palatal expansion
treatment.
Bonded rapid palatal expansion treatment resulted in downward displacement of the
maxilla with a greater displacement of ANS than PNS and posterior movement of the
maxillary central incisors.
112
Habeeb et al (2013). Effects of rapid palatal expansion on the sagittal and vertical dimensions of
the maxilla: A study on cephalograms derived from cone-beam computed tomography. AJODO
144: 398–403
RME always opened the midpalatal suture in growing subjects. The vertical changes
were small and transitory. In the long-term evaluation, an uprighting of anchored teeth
was observed and periodontal structures were not compromised.
Lione et al (2013). Does rapid maxillary expansion induce adverse effects in growing subjects?
A systematic review. Angle Orthodontist 83: 172-182
The use of memory screw may be advantageous because it shortens the maxillary
expansion period, provides additional expansion in the retention period, and generates
light forces relative to the conventional Hyrax screw.
Halıcıoğlu and Yavuz (2014). Comparison of the effects of rapid maxillary expansion caused by
treatment with either a memory screw or a Hyrax screw on the dentofacial structures—
transversal effects. EJO 36: 140-149
Slow maxillary expansion (SME) is effective in expanding maxillary arch, while we

cannot determine its effectiveness in mandibular arch expansion. Rapid maxillary
expansion (RME) is effective in expanding both maxillary and mandibular arches.
Furthermore, SME is superior to RME in expanding molar region of maxillary arch,
while similar with RME in mandibular arch expansion. However, we cannot compare
their effectiveness in maxillary anterior region.
Zhou et al (2014). The effectiveness of non-surgical maxillary expansion: a meta-analysis. EJO

36: 233-242
Most CVM stages can be used for the diagnosis of the stages of maturation of the
midpalatal suture, so that CBCT imaging may not be necessary in these patients.
In the postpubertal period, an assessment of the midpalatal suture maturation using
CBCT images may be indicated in deciding between conventional rapid maxillary
expansion and surgically assisted rapid maxillary expansion.
On the other hand, if the CVM stage cannot be assessed, chronologic age may be a viable
alternative to predict some midpalatal suture stages (particularly the early stages).
113
Angelieri et al (2015). Diagnostic performance of skeletal maturity for the assessment of
midpalatal suture maturation. AJODO 148: 1010–1016
Nonsurgical MARME can be a clinically acceptable and stable treatment modality for
young adults with a transverse maxillary deficiency.
Choi et al (2016). Nonsurgical miniscrew-assisted rapid maxillary expansion results in

acceptable stability in young adults. Angle Orthodontist 86: 713-720
More resorption was observed in the Hyrax expander group compared to tooth-tissue
borne rapid maxillary expansion appliances. But it was not statistically significant. Repair
was observed after 6 months of retention.
Heavy RME forces affected premolars and molar similarly.
Dindaroğlu and Doğan (2016). Evaluation and comparison of root resorption between tooth-
borne and tooth-tissue borne rapid maxillary expansion appliances: A CBCT study. Angle
All maxillary first premolars subjected to RME showed external root resorption (ERR)
and partial cementum repair. Banded teeth did not develop more ERR than nonbanded
anchorage teeth.
Martins et al (2016). Rapid maxillary expansion: Do banded teeth develop more external root
resorption than non-banded anchorage teeth?. Angle Orthodontist 86: 39-45
Patients treated with a full-coverage bonded appliance tended to develop more white spot
lesions than did the control subjects.
Yagci et al (2016). White spot lesion formation after treatment with full-coverage rapid
maxillary expanders. AJODO 149: 331–338
There are no differences for the long-term intermolar width stability in patients treated
with palatal expansion in the mixed dentition vs the permanent dentition.
Mohan et al (2016). Long-term stability of rapid palatal expansion in the mixed dentition vs the
permanent dentition. AJODO 149: 856–862
114
Overall, both the quad helix expander and the bonded rapid maxillary expander showed
minimal vertical changes during palatal expansion treatment. The differences at T2
suggested that the quad helix expander had more control over skeletal vertical
measurements.
When comparing treatment results to untreated predicted growth values, the quad helix
expander appeared to better maintain lower facial height and the bonded rapid maxillary
expander appeared to better maintain the maxillary first molar vertical height.
Piskai et al (2016). Assessment of vertical changes during maxillary expansion using quad helix
or bonded rapid maxillary expander. Angle Orthodontist 86: 925-933
 Effect of maxillary expansion on breathing
Narrow oropharyngeal airways in growing patients with maxillary constriction was

demonstrated. But there was no evidence to support the hypothesis that RPE could
enlarge oropharyngeal airway volume.
Zhao et al (2010). Oropharyngeal airway changes after rapid palatal expansion evaluated with
cone-beam computed tomography. AJODO 137: S71–S78
There is moderate evidence that changes after RME in growing children improve the
conditions for nasal breathing and the results can be expected to be stable for at least 11
months after therapy.
Baratieri et al (2011). Does rapid maxillary expansion have long-term effects on airway
dimensions and breathing? AJODO 140: 146–156
Improvement of nasal airway ventilation by rapid maxillary expansion was detected by

computational fluid dynamics.
Iwasaki et al (2012). Improvement of nasal airway ventilation after rapid maxillary expansion
evaluated with computational fluid dynamics. AJODO 141: 269–278
Rapid maxillary expansion causes significant increases in nasal cavity volume,

nasopharynx volume, anterior and posterior facial heights, and palatal and mandibular
planes.
115
Smith et al (2012). Three-dimensional computed tomography analysis of airway volume
changes after rapid maxillary expansion. AJODO 141; 618–626
RME is able to increase the transverse width of the nasal cavity, but it does not have the
same effect in the nasopharynx. Changes noted in the oropharynx may be due to the lack
of a standardized position of the head and tongue at the time of image acquisition.
Ribeiro et al (2012). Upper airway expansion after rapid maxillary expansion evaluated with
cone beam computed tomography. Angle Orthodontist 82: 458-463
In children with nasal obstruction, RME not only reduces nasal obstruction but also raises
tongue posture and enlarges the pharyngeal airway.
Iwasaki et al (2013). Tongue posture improvement and pharyngeal airway enlargement as

secondary effects of rapid maxillary expansion: A cone-beam computed tomography study.
AJODO 143: 235–245
Only the cross-sectional area of the upper airway at the posterior nasal spine to Basion
level significantly gains a moderate increase after rapid maxillary expansion.
Chang et al (2013). Dimensional changes of upper airway after rapid maxillary expansion: A
prospective cone-beam computed tomography study. AJODO 143: 462–470
After RME the total volume of the naso-maxillary complex increased by 12%, the nasal
volume by 17%, and the maxillary volume by 10.6%. The maxillary and the nasal
contributions represented 69.75% and 30.25%, respectively.
Bouserhal et al (2014). Three-dimensional changes of the naso-maxillary complex following

rapid maxillary expansion. Angle Orthodontist 84: 88-95
Rapid maxillary expansion creates a significant increase in nasal passage airway volume
but no significant change in the oropharyngeal airway volume.
El and Palomo (2014). Three-dimensional evaluation of upper airway following rapid maxillary
expansion: A CBCT study. Angle Orthodontist 84: 265-273
116
Protraction Headgear
The technique of maxillary protraction is based on work by Nanda, with young and adult
rhesus monkeys in which he showed that a force of approximately 500g could produce
anterior displacement of the maxilla.
Nanda (1978). Protraction of maxilla in rhesus monkeys by controlled extraoral forces. AJODO
74: 121-141
Maxillary protraction headgear has been popularised by Delaire and Cozzani.
Cozzani (1981). Extra-oral traction and class III treatment. AJODO 80: 638-650
The effects of providing the protraction force from the first molars or the premolar region
were compared:
Protraction from the first molars results in more anterior movement and a forward and
upward rotation of the maxilla; protraction from the premolars results in less forward
movement but less tendency to upward and forward rotation.
Ishii et al (1987). Treatment effect of combined maxillary protraction and chincap appliance in
severe skeletal class III cases. AJODO 92: 304-312
Significant dentoskeletal changes and improvements in dentofacial profile could be

obtained from 6 months treatment with maxillary expansion and protraction.
Ngan et al (1996). Soft tissue and dentoskeletal profile changes associated with maxillary
expansion and protraction headgear treatment. AJODO 109: 38-49
Ngan et al suggested that:

 Correction of class 3 malocclusion was achievable in 6-9 months and was stable 2
years after appliance removal.
 Maxillary expansion in conjunction with protraction produced greater forward
movement of the maxilla.
 Significant and beneficial soft tissue profile change can be expected during
treatment.
 Treatment works best in patients with retrusive maxilla and hypodivergent growth
patterns.
117
Ngan et al (1997). Treatment response and long-term dentofacial adaptations to maxillary
expansion and protraction. Seminars in Orthodontics 3: 255-263
The effects of facemask expansion therapy in three age groups (4-7 years, 7-10 years and
10-14 years) were compared:
Generally, more treatment change occurred in the younger groups than in the older
groups.
Kapust et al (1998). Cephalometric effects of face mask/expansion therapy in class III children:
a comparison of three age groups. AJODO 113: 204-212
Early treatment (6 years 9 months at T1) and a later treatment group (10 years 3 months
at T1) were compared:
Patients were treated with a bonded maxillary expander and a Petit type protraction
headgear. The early treatment group showed effective forward displacement of the
maxillary structures whereas the late treatment group showed no change compared with
controls.
Baccetti et al (1998). Skeletal effects of early treatment of class III malocclusion with maxillary
expansion and face-mask therapy. AJODO 113: 333-343
Protraction headgear was less effective in patients older than 10 years of age. Patients
who did not have palatal expansion had longer treatment times and ended up with more
upper incisor proclination - i.e.: more dental change and less skeletal change.
Kim et al (1999). The effectiveness of face mask therapy: a meta-analysis. AJODO 115: 675-
685
Early (mean age 9 years 8 months) and late treatment (mean age 12 years 6 months)
groups were compared with a control (mean age 9 years 5 months):
Although no differences were found between the two treatment groups, the improvement
in facial aesthetics produced psychosocial advantages that favored early treatment.
Yüksel et al (2001). Early and late facemask therapy. EJO 23: 559-568
118
No differences between maxillary protraction cases of either expansion or nonexpansion
groups in any cephalometric variable, in overall treatment time, or in the time for initial
crossbite correction.
Without other reasons for expansion, such as maxillary width or space deficiency,
expansion does not significantly aid in Class III correction.
Vaughn et al (2001). The effects of maxillary protraction therapy with or without rapid palatal
expansion: a prospective, randomized clinical trial. JDR 80: SI: 541(0117)
A long term follow up of patients who had been treated with rapid maxillary expansion
and reverse pull headgear:
After a follow-up period of 8.2 years, only two thirds of the patients had positive overjet.
In the patients that relapsed, mandibular growth was four times that in the maxilla.
Hägg et al (2003). Long-term follow-up of early treatment with reverse headgear. EJO 25: 95-
102
It was possible to achieve a 2 mm advancement of the maxilla that would withstand the
active growth period if RME and protraction head gear was undertaken in the deciduous
dentition or early mixed dentition.
Franchi et al (2004). Postpubertal assessment of treatment timing for maxillary expansion and
protraction therapy followed by fixed appliances. AJODO 126: 555-568
Significant and similar changes in ANB and the Wits appraisal (up to almost 4 degrees or
mm) could be obtained from the use of protraction facemasks with or without RME.
Vaughn et al (2005). The effects of maxillary protraction therapy with or without rapid palatal
expansion: A prospective, randomized clinical trial. AJODO 128: 299-309
Class III patients treated with protraction headgear and a facemask well before the
pubertal growth spurt (CS 1 or CS 2) have a different outcome to those treated at the peak
of the pubertal growth spurt (CS 3).
Prepubertal treatment is effective in both the maxilla and the mandible whereas treatment
at puberty is only effective at the mandibular level.
119
Baccetti et al (2005). The Cervical Vertebral Maturation (CVM) method for the assessment of
optimal treatment timing in dentofacial orthopaedics. Seminars in Orthodontics 11: 119-129
The low angle cases demonstrate more forward displacement and size increment of the
maxillary body.
Yoshida et al (2007). Effects of treatment with a combined maxillary protraction and chincap
appliance in skeletal Class III patients with different vertical skeletal morphologies. EJO 29:
126-133
The pronounced anterior movement of point A demonstrates that the

Activation/Deactivation-RPE procedure positively affects maxillary protraction.
Isci et al (2010). Activation–deactivation rapid palatal expansion and reverse headgear in Class
III cases. EJO 32: 706-715
The surgically assisted FM treatment was more rapid and effective in maxillary
protraction compared to the RME + FM treatment.
Küçükkeleş et al (2011). Rapid maxillary expansion compared to surgery for assistance in

maxillary face mask protraction. Angle Orthodontist 81: 42-49.
In the long term, rapid maxillary expansion and facemask therapy led to successful
outcomes in about 73% of the Class III patients. Favorable skeletal changes were mainly
due to significant improvements in the sagittal position of the mandible. No significant
differences in maxillary changes were recorded.
Masucci et al (2011). Stability of rapid maxillary expansion and facemask therapy: A long-term
controlled study. AJODO 140: 493–500
Forward movement of the maxilla can be obtained in young adults after face mask
treatment. However, there was no difference in this phenomenon between the FM and
RME+FM groups.
Halicioglu et al (2014). Effects of face mask treatment with and without rapid maxillary
expansion in young adult subjects. Angle Orthodontist 84: 853-861
120
In the short term, statistically significant maxillary advancement was achieved with
surgically assisted maxillary protraction.
However, in the long term, these sagittal changes were not stable, whereas RME and FM
provided stability.
Nevzatoğlu and Küçükkeleş (2014). Long-term results of surgically assisted maxillary

protraction vs regular facemask. Angle Orthodontist 84; 1002-1009
No scientific evidence that would allow for the definition of adequate parameters for
force magnitude, direction, and duration for maxillary protraction facemask treatment in
class III patients.
Yepes et al (2014). Optimal force for maxillary protraction facemask therapy in the early
treatment of class III malocclusion. EJO 36: 586-594
Both groups; Group I (FM started after the completion of the Alt-RME) and Group II
(FM started simultaneously with the Alt-RME) showed similar results.
Waiting until completion of the Alt-RME procedure for the FM treatment is not
necessary.
Canturk and Celikoglu (2015). Comparison of the effects of face mask treatment started
simultaneously and after the completion of the alternate rapid maxillary expansion and
constriction procedure. Angle Orthodontist 85: 284-291
Facemask maxillary protraction with RPE/Constriction might positively affect the

forward movement of the maxilla compared with facemask protraction with RPE alone in
the early treatment of maxillary retrusive patients.
Liu et al (2015). Effect of maxillary protraction with alternating rapid palatal expansion and
constriction vs expansion alone in maxillary retrusive patients: A single-center, randomized
controlled trial. AJODO 148: 641–651
121
Chincup
Chincups cause lingual tipping of the lower incisors and clockwise rotation of the
mandible.
Thilander (1963). Treatment of Angle class III malocclusion with chin-cap. Transactions of the
EOS 39: 384-398
Chincup therapy was effective in reducing mandibular prognathism before puberty but
this advantage was then lost. The final skeletal profile with respect to the anteroposterior
position of the mandible was no different between the experimental and control groups.
Sugawara et al (1990). Long-term effects of chincap therapy on skeletal profile in mandibular

prognathism. AJODO 98: 127-133
Patients with significant anteroposterior discrepancy, lower incisor decompensation and

open bite tendency had results with chincup therapy that were not subsequently
maintained.
Ko et al (2004). Determinants of successful chincup therapy in skeletal Class III malocclusion.

AJODO 126: 33-41
Lip Bumper
Lip bumpers produce an overall increase in arch circumference of approximately 4.1 mm

(range 0.7 mm - 8.8 mm). Some increase in arch length occurred (1.2 mm due to
proclination of the lower incisors (2.92 degrees increase in IMPA). Passive increases in
interpremolar and intercanine width occurred of about 2.5 mm.
Osborn et al (1991). Mandibular arch perimeter changes with lip bumper treatment. AJODO 99:
527-532
Shield type lip bumpers produced higher resting forces than wire lip bumpers and that
greater force was produced when the lip bumper was 4 mm rather than 2 mm in front of
the clinical crown and gingival rather than in the middle of the crown.
Hodge et al (1997). Forces produced by lip bumpers on mandibular molars. AJODO 111: 613-
622
122
The effects of continuous lip bumper treatment on mild to moderate crowding cases in
the mixed dentition over a six month period:
 45-55% incisor proclination.
 35-50% molar distalisation and tipping.
 5-10% transverse increase in canine and premolar width.
Davidovitch et al (1997). The effects of lip bumper therapy in the mixed dentition. AJODO 111:
52-58
Clear aligner therapy (CAT)
CAT aligns and levels the arches; it is effective in controlling anterior intrusion but not
anterior extrusion; it is effective in controlling posterior buccolingual inclination but not
anterior buccolingual inclination; it is effective in controlling upper molar bodily
movements of about 1.5 mm; and it is not effective in controlling rotation of rounded
teeth in particular.
Rossini et al (2015). Efficacy of clear aligners in controlling orthodontic tooth movement: A

systematic review. Angle Orthodontist 85: 881-889
Orthodontic treatment with clear aligners tends to increase the mandibular intercanine
distance with little change in inclination in contrast to treatment with fixed appliances,
which leaves the intercanine distance unchanged but leads to more upright mandibular
canines.
Grünheid et al (2016). Effect of clear aligner therapy on the buccolingual inclination of

mandibular canines and the intercanine distance. Angle Orthodontist 86: 10-16
No difference in the amount of mandibular incisor proclination produced by clear

aligners and fixed labial appliances in mild crowding cases.
Hennessy et al (2016). A randomized clinical trial comparing mandibular incisor proclination

produced by fixed labial appliances and clear aligners. Angle Orthodontist 86: 706-712
123
124
Section Nine
Orthodontic Biomechanics and Procedures

Pre-bonding Preparation
Bonding to Fluorosed, Bleached and Non-enamel Surfaces
Indirect Bonding Technique
Bracket Placement
Differential Force Theory
Friction
Tipping and Uprightening Teeth vs. Bodily Movement
Interproximal Enamel Reduction
Levelling Techniques
Opening and Closing Spaces
Intraoral Auxiliaries
Distalization Techniques
Debonding Procedures
125
126
Pre-bonding Preparation
No evidence to support the practice of pumice prophylaxis before etching to obtain adequate
bond strength with conventional etching.
Cleaning of the teeth before bonding is recommended in order to perform gross plaque
removal.
Lindauer et al (1997). Effect of pumice on the bond strength of orthodontic brackets. AJODO
111: 599-605
Fluoride varnishes do not appear to affect bond strength either with conventional
adhesives (Todd et al) or with self-etching primers (Kimura et al).
Todd et al (1999). Effect of a fluoride varnish on demineralization adjacent to orthodontic

Kimura et al (2004). Effect of fluoride varnish on the in vitro bond strength of orthodontic
brackets using a self-etching primer system. AJODO 125: 351-356
Self-etching primers do require prophylaxis pumicing.
Burgess et al (2006). Self-etching primers: is prophylactic pumicing necessary? A randomized

clinical trial. Angle Orthodontist 76: 114–118
Although the use of a premedication to induce hypo-salivation before orthodontic

bonding appeared to be an acceptable procedure to most patients and their parents, there
was no statistically significant effect on the observed bond failure rates.
Ponduri et al (2007). Does atropine sulphate improve orthodontic bond survival? A randomized
clinical trial. AJODO 132: 663-670
The use of antisialogogues for dental procedures in general is questionable due to their
systemic effects which exceed the time taken for bonding procedures.
Kuipjers et al (2010). The effect of antisialogogues in dentistry. A systematic review with a

focus on bond failures in orthodontics. JADA 141: 954-965
127
Bonding to Fluorosed Teeth
The use of an adhesion promoter (3M Scotchbond Multipurpose Plus Primer) is

recommended to bond to fluorosed teeth.
Noble et al (2008). In vivo bonding of orthodontic brackets to fluorosed enamel using an

adhesion promotor. Angle Orthodontist 78: 357–360
The use of Reliance Enhance LC to fluorosed enamel surfaces significantly increased the
shear bond strength but was not significantly different from the control group.
Adanir et al (2008). Effects of adhesion promoters on the shear bond strengths of orthodontic
brackets to fluorosed enamel. EJO 31: 276-280
Fluorotic enamel affects the adhesion of bonded molar tubes.

The use of overetching in cases of moderate fluorosis and the combination of
microabrasion and etching in severe fluorosis provides a suitable adhesion for fixed
appliance therapy.
Benítez et al (2013). Shear bond strength evaluation of bonded molar tubes on fluorotic molars.
Bonding to Bleached Surfaces
Treatment with sodium ascorbate reverses the negative effects of bleaching on enamel.
Lai et al (2002); Reversal of compromised bonding in bleached enamel. JDR 81: 477-481
Bonding to Non-enamel Surfaces
Sandblasting increases bond strengths to non- enamel surfaces during bonding procedure.
Millett et al (1995). The effect of sandblasting on the retention of first molar orthodontic bands
cemented with glass ionomer cement. BJO 22: 161-169
Miller and Zernick (1996). Sandblasting of bands to increase bond strength. JCO 30: 217-222
128
Using a silane primer lead to higher bond strengths on roughened surfaces.
Kocadereli et al (2001). Tensile bond strength of ceramic brackets bonded to porcelain surfaces.
AJODO 119: 617-620
Indirect Bonding Technique
Direct bonding technique had a lower failure rate than indirect bonding.
Zachrisson and Brobakken (1978). Clinical comparison of direct versus indirect bonding with
different bracket types and adhesives. AJODO 74: 62-78
Thomas technique; uses set composite on custom bracket bases which are then placed on
the teeth using only a primer as the final stage adhesive. This avoids the need to place
composite on the bracket bases immediately before tray insertion.
Thomas RG (1979). Indirect bonding: simplicity in action. JCO 13: 93-106
Clinical failure rates of 4.5% for the indirect technique and 5.3% for the direct technique.
Aguirre et al (1982). Assessment of bracket placement and bond strength when comparing
direct bonding and indirect bonding techniques. AJODO 82: 269-276
Using the Thomas technique, no difference in in vitro bond strength between the indirect
and direct bonding techniques.
Hocevar and Vincent (1988). Indirect versus direct bonding: bond strength and failure location.
AJODO 94: 367-371
No mean difference in the accuracy of bracket placement with either a direct or indirect
technique but the variability of placement was less with an indirect system.
Hodge et al (2004). A randomized clinical trial comparing the accuracy of direct versus indirect
bracket placement. JO 31: 132-137
129
No differences in bond failure rate using direct and indirect technique in a large sample
followed over one year.
Thiyagarajah et al (2006). A clinical comparison of bracket bond failures in association with

direct and indirect bonding. JO 33: 198-204
The indirect bonding technique is twice as accurate as the direct technique for all teeth in
both labial and lingual techniques. This is valid for both torque error and rotational error.
Shpack et al (2007). Bracket placement in lingual vs labial systems and direct vs indirect
bonding. Angle Orthodontist 77: 509–517
Indirect bonding is faster than direct bonding of mandibular fixed retainers, with both
techniques showing similar risks of failure.
Bovali et al (2014). Indirect vs direct bonding of mandibular fixed retainers in orthodontic

patients: A single-center randomized controlled trial comparing placement time and failure over
a 6-month period. AJODO 146: 701–708
Bracket Placement
Holdaway (1952): Bonding of brackets is related to anterior vertical discrepancy:
 Anterior open bite: gingival third of the crown.

 Overbite is normal: middle third of the crown.
 Deep bite: occlusal third of the crown.
Tweed (1966): Brackets should be placed a specified distance from the incisal edge.
Saltzmann: Brackets should be placed in the middle third of the crown.
Jarabak: Crown form is a predictor to where to place brackets:
 Ovoid crowns: middle third of the crown.

 Tapering crowns: 1-2 mm from the incisal edge.
 Square crowns: as close to the incisal edge as possible.
Andrews: The base point of each bracket should be positioned over the FA point of the
corresponding tooth with the bracket aligned parallel to the FACC.
130
McLaughlin and Bennett (1995): Using theoretical bracket placement charts, the ideal bracket
placement positions should be based on the midpoint of the clinical crown.
Adjusting the position of a bracket vertically on the flat surface of an incisor tooth will
have little effect on the torque transmitted to the teeth. However, changes in vertical
position on teeth with curved buccal surfaces will result in significant alterations in the
torque delivered by the appliance.
Sondhi (2003a). The implications of bracket selection and bracket placement on finishing
details. Seminars in Orthodontics 9: 155-164
Bracket placement methods using the center of the clinical crown and measurement from
the incisal edge were compared:
Measurement from the incisal edge was marginally better on incisors but less good on
premolars; however there was little difference between the two techniques. Bracket
placement errors occur regardless of which technique is used therefore archwire bends or
bracket repositioning is necessary to achieve acceptable treatment results.
Armstrong et al (2007). A comparison of accuracy in bracket positioning between two

techniques- localizing the centre of the clinical crown and measuring the distance from the
incisal edge. EJO 29: 430-436
Pitts places brackets more gingivally than normal and using the mesiodistal contact points
of the teeth as a reference line.
Pitts TR (2009). Begin with the end in mind: bracket placement and early elastics protocols for
smile arc protection. Clinical Impressions 17: 2-11
Differential Force Theory
The relationship between force applied and tooth movement remain insufficiently
understood or documented.
Ren et al (2003). Optimum force magnitude for orthodontic tooth movement: a systematic
literature review. Angle Orthodontist 13:86-92
131
Canine retraction and anchorage loss with a light (50 gm) and heavy (300 gm) forces
over a 12 week period were compared:
The 300 gm force produced significantly more movement of both the canine and the
anchorage unit and the percentage of anchorage loss was significantly higher (62%) with
the heavy force than with the light force (55%). This supports the differential force
theory.
Yee et al (2009). Rate of tooth movement under heavy and light continuous orthodontic forces.
AJODO 136:150.e1-150.e9
Friction
Rectangular wires produce more friction than round wires, nickel titanium and beta
titanium archwires produce more friction than stainless steel or cobalt chromium wires,
ceramic brackets generate significantly more frictional resistance than stainless steel
brackets.
Angolkar et al (1990). Evaluation of friction between ceramic brackets and orthodontic wires of
four alloys. AJODO 98: 499-506
Surface topography and frictional characteristics of ceramic brackets:

 Monocrystalline brackets (MCA) have a smoother slot finish than polycrystalline
brackets (PCA).
 The frictional characteristics of MCA and PCA are comparable.
 Archwire material has more effect on friction than bracket material.
Saunders and Kusy (1994). Surface topography and frictional characteristics of ceramic
The use of sintered brackets can reduce frictional resistance by 40% to 45%.
Vaughan et al (1995). Relative kinetic frictional forces between sintered stainless steel brackets
and orthodontic wires. AJODO 107: 20-27
The least friction is generated by all metal brackets followed by ceramic brackets with a
metal slot and then ceramic brackets with a ceramic slot.
132
Nishio et al (2004). In vitro evaluation of frictional forces between archwires and ceramic
Different types of ceramic bracket we tested against a control stainless steel bracket:
The ceramic bracket with a silica coating in the slot generated the least frictional
resistance of all the ceramic brackets and sometimes less than the stainless steel bracket.
Cha et al (2007). Friction of conventional and silica-insert ceramic brackets in various bracket-
wire combinations. Angle Orthodontist 77: 100-107
Tipping and Uprightening Teeth vs. Bodily Movement:
Bodily retraction of a canine consumes the same anchorage as tipping followed by

uprighting and is more rapid.
Shpack et al (2008). Duration and anchorage management of canine retraction with bodily
versus tipping mechanics. Angle Orthodontist: 78: 95–100
Proclination of maxillary incisors accompanied by backward movement of incisor root

apex caused posterior movement of point A. However, this posterior movement does not
significantly affect the SNA angle.
Bicakci et al (2013). Does proclination of maxillary incisors really affect the sagittal position of
point A? Angle Orthodontist 83: 943-947
Interproximal Enamel Reduction
The optimal amount of enamel reduction per tooth surface is 0.5 mm.
Sheridan (1985). Air-rotor stripping. JCO 19:43–59
Posterior interproximal enamel reduction does not appear to expose the enamel to
pathological changes that could lead to caries, but rather to a period of demineralization,
followed within nine months of the stripping by remineralization.
El-Mangoury et al (1991). In-vivo remineralization after air-rotor stripping, JCO 25:75-78.
133
Reduction of interproximal enamel to resolve crowding is usually limited to the
mandibular incisors. Conversely, Air Rotor Stripping (ARS) is primarily, but not
exclusively, targeted at reducing the thicker dimensions of buccal-section interdental
enamel.
Sheridan (1997). The physiologic rationale for air-rotor stripping. JCO 31:609-612.
The acid enhanced stripped proximals can be finished to a surface that‘s even smoother
than natural enamel.
Rossouw and Tortorella (2003). Enamel reduction procedures in orthodontic treatment. JCDA
69:378-383
It is possible to generate about 8mm of buccal space while adhering to the ARS limitation
of reducing only 1mm per contact point, and that‘s without reducing the anterior teeth.
Sheridan (2008). John J. Sheridan, DDS, MSD, on air-rotor stripping. JCO 42: 381-8
Interdental enamel reduction using extra fine diamond disks with air cooling, followed by
contouring with triangular diamond burs and polishing did not result in increased caries
risk in posterior teeth.
No evidence that proper mesiodistal enamel reduction within recognized limits and in
appropriate situations will cause harm to the teeth and supporting structures.
Zachrisson et al (2011). Dental health assessed after interproximal enamel reduction: Caries risk
in posterior teeth. . AJODO 139: 90–98
Levelling Techniques
The movement of the gingival margin is a 1:1 linear relationship with tooth intrusion or
extrusion.
Kokich (1993a). Esthetics and anterior tooth position: an orthodontic perspective. Part 1: Crown
length. JED 5: 19-23
No significant differences in the cephalometric changes produced by either curves of

Spee, utility arches or Tweed anchorage preparation wires and step up/step down wires
found.
134
Parker et al (1995). Skeletal and dental changes associated with the treatment of deep overbite
malocclusion. AJODO 107:382-93
The effectiveness of rectangular wire in preventing lower incisor tipping during arch
levelling was investigated:
Using 0.016" x 0.022" rectangular wires in 0.018" slot result in no less labial tipping than
with round wires.
AlQabandi et al (1999). A comparison of the effects of rectangular and round arch wires in
levelling the curve of Spee. AJODO 116: 522-9
The long-term effects of levelling the lower curve of Spee using continuous arches with
reverse curves were investigated:
The largest contributor to overbite reduction was premolar extrusion with a smaller
component from incisor intrusion.
Bernstein et al (2007). Leveling the curve of Spee with a continuous archwire technique: A long
term cephalometric study. AJODO 131: 363-371
Opening and Closing Spaces
Spontaneous space closure has been clearly shown to be highly related to the rate and
amount of remaining growth.
Stephens and Houston (1985). Factors affecting the rate of spontaneous space closure at the site
of extracted mandibular first premolars. EJO 7: 157-62
Ceramic brackets produce more friction than SS brackets.
Kusy and Whitley (1990). Coefficients of friction for archwires in stainless steel and
polycrystalline alumina brackets. AJODO 98: 300-312
Elastomeric ligation is a large factor in friction generation in vitro. Nickel-titanium

archwires produce higher frictional forces in vitro and are therefore less suitable for
sliding mechanics.
135
Ireland et al (1991). Effect of bracket and wire composition on frictional forces. EJO 13: 322-
328
Mesio-distal orthodontic tooth movement into edentulous areas definitely occurs and
causes no loss of periodontal support. Such space closure may however be slower than
usual.
Lindskog-Stokland et al (1993). Orthodontic tooth movement into edentulous areas with

reduced bone height. An experimental study in the dog. EJO 15: 89-96
A loss of 50% to 70% of the force of elastomeric chain in the first day with only 30% to
40% remaining at 3 weeks. Pre-stretching the chain in order to reduce the rapid decay in
force only increased the residual force at 3 weeks by 5% - clinically insignificant.
Baty et al (1994). Synthetic elastomeric chains: A literature review. AJODO 105: 536-542
The ‗9 mm‘ coils (3 mm of actual coil spring) should not be stretched by more than 9 mm
if a fairly flat superelastic plateau is to be maintained.
Manhartsberger and Seidenbusch (1996). Force delivery of Ni-Ti coil springs. AJODO 109:
8-21
Nickel titanium coils produce more consistent space closure than elastomeric modules.
‗150 g‘ coils produced significantly faster space closure than ‗100 g‘ coils, but increasing
the force to ‗200 g‘ produced no further increase in rate of closure. 150 g coils are
therefore recommended.
Samuels et al (1998). A clinical study of space closure with nickel titanium closed coil springs
and an elastic module. AJODO 114:73-9
Space closure with NT coils, elastic chain and ‗active ligatures‘ (a single elastic module
activated with a ligature) was compared. The NT coils produced more space closure per
unit time.
Dixon et al (2002). A randomised clinical trial to compare three methods of orthodontic space
closure. JO 29:31-36
136
Intraoral Auxiliaries
Mesial rotation of the upper first molars is present in many class 2 cases. Derotation of
the molars may produce 1-2 mm of arch length gain as the first molars rotate about their
palatal roots.
Lamons and Holmes (1961). The problem of the rotated maxillary first permanent molar.
AJODO 47: 246-272
Lacebacks may be used for the following reasons:

 To control mesial movement of the canines during alignment and levelling. This
prevents incisor extrusion during these stages of treatment.
 To retract canines in cases with labial segment crowding during alignment and
levelling.
 Protection of flexible archwires in extraction spaces.
 Centerline correction by unilateral canine retraction in one or both arches.
McLaughlin and Bennett (1989). The transition from standard edgewise to preadjusted
edgewise appliance systems. JCO 23: 142-153
Crimping TP hooks to 0.019" x 0.025" archwires: male operators used a higher crimping
force than females and hooks were more firmly crimped when attached out of the mouth.
Johal et al (2001). A clinical investigation into the behavior of crimpable archwire hooks. JO
28: 203-205
Canine lacebacks prevent approximately 1mm of upper incisor proclination and have
minimal effect on mesial molar movement.
Usmani et al (2002). A randomised clinical trial to compare the effectiveness of canine

lacebacks with reference to canine tip. JO 29: 281-286
The lower incisors retroclined a similar amount in four premolar extraction cases with
and without lacebacks and that lacebacks were mildly but significantly anchorage
consuming.
Irvine et al (2004). The effectiveness of laceback ligatures: a randomised controlled clinical

trial. JO 31: 303-311
137
Open coils might need to be compressed by more than one-third of their original length to
produce the labeled forces.
Bourke et al (2010). Force characteristics of nickel-titanium open-coil springs. AJODO 138:

142.e1–142.e7
The Forsus Fatigue Resistant Device protocol is effective in correcting Class II

malocclusion with a combination of skeletal (mainly maxillary) and dentoalveolar
(mainly mandibular) modifications.
Franchi et al (2011). Effectiveness of comprehensive fixed appliance treatment used with the
Forsus Fatigue Resistant Device in Class II patients. Angle Orthodontist 81: 678-683
Since latex elastic force decays significantly during a patient‘s use, elastics should be
selected with initially higher forces than desired.
Oesterle et al (2012). Perceived vs measured forces of interarch elastics. AJODO 141: 298–306
Based on the current literature, we can state that Class II elastics are effective in
correcting Class II malocclusions, and their effects are primarily dentoalveolar.
Therefore, they are similar to the effects of fixed functional appliances in the long term,
placing these 2 methods close to each other when evaluating treatment effectiveness.
Little attention has been given to the effects of Class II elastics on the soft tissues in Class
II malocclusion treatment.
Janson et al (2013). Correction of Class II malocclusion with Class II elastics: A systematic

review. AJODO 143: 383–392
The use of lacebacks has neither a clinically nor a statistically significant effect on the
sagittal position of the incisors and molars during initial orthodontic alignment. There is
no evidence concerning the use of lacebacks on chairside time or periodontal health.
Fleming et al (2013). The effectiveness of laceback ligatures during initial orthodontic

alignment: a systematic review and meta-analysis. EJO 35: 539-546
138
Chlorhexidine show no significant influence on the force degradation of chain elastics.
Pithon et al (2013). Does chlorhexidine in different formulations interfere with the force of
orthodontic elastics? Angle Orthodontist 83: 313-318
Nickel-titanium closed-coil springs do not deliver constant forces when used intraorally,
but they still allow for space-closure rates of approximately 1 mm per month.
Cox et al (2014). In-vivo force decay of nickel-titanium closed-coil springs. AJODO 145: 505–
513
AdvanSync and intermaxillary elastics were effective in normalizing Class II

malocclusions during comprehensive fixed orthodontics.
AdvanSync produced its effects through maxillary skeletal growth restriction and
mandibular dentoalveolar changes. Class II elastics worked primarily through
dentoalveolar changes in both the maxilla and the mandible.
Jayachandran et al (2016). Comparison of AdvanSync and intermaxillary elastics in the

correction of Class II malocclusions: A retrospective clinical study. AJODO 150: 979–988
Elastics with latex 1/8″ in diameter sustained a higher level of final force than the
corresponding type without latex. The 1/4 and 5/16 elastics with and without latex were
not different at the end of the evaluation period.
Pithon et al (2016). Force decay of latex and non-latex intermaxillary elastics: a clinical study.
EJO 38: 39-43
Distalization Techniques
With Pendulum; a relatively high force of 230 g/ side was reported and the anchorage
loss was around 2.6 mm or 0.75 mm for every 1 mm of distal movement of the molars.
Ghosh and Nanda (1996). Evaluation of an intraoral maxillary distalisation technique. AJODO
110: 639-46
139
For every 2.8 mm of distal molar movement with distalizing coil springs, approximately
1 mm of mesial movement of all ten anterior teeth occur.
Gulati et al (1998). Dental and skeletal changes after intraoral molar distalisation with sectional
jig assembly. AJODO 114: 319-27
Effectiveness of Nudger and cervical headgear:

Gentle activation (2-3 mm) of the finger springs is needed.
An average of 3.6 mm distal movement of the molars compared to untreated controls
with an average of 0.7 mm increase in overjet.
The anchorage loss was therefore 19% of the distal movement.
Ferro et al (2000). Sagittal and vertical changes after treatment of Class II Division I
malocclusion according to the Cetlin method. AJODO 118: 150-8
Distal jet and pendulum appliances were compared: more distal movement and less
anchorage loss in the distalisation phase with the pendulum.
Chiu et al (2005). A comparison of two intraoral molar distalisation appliances: distal jet versus
pendulum. AJODO 128: 353-65A
With distal jet; the corresponding amount of distal tip to the molar crown appears to
range from 3-7 degrees.
The magnitude of tipping is often less than with other popular distalizing devices (e.g.,
Pendulum: 8-16 degrees; Jones Jig: 7-8; GMD: 7; Wilson modular technique: 8; cervical
headgear/sagittal appliance: 13; repelling magnets: 7 degrees).
Ferguson et al (2005). A comparison of two maxillary molar distalizing appliances with the
Distal Jet, WJO 6:382-390
Carano and Bowman (2006). Non-compliance Class II treatment with the Distal Jet. In
Papadopoulos MA, editor: Orthodontic treatment for the Class II noncompliant patient: current
principles and techniques, Edinburgh, Elsevier, pp 265-289.
Headgear therapy is more effective before the eruption of the maxillary second molar.
Once it erupts, the distalization pace of the maxillary first molar is reduced, but it can
nevertheless be pursued at a slower pace when the maxillary second molar is present.
140
Shpack et al (2014). Long- and short-term effects of headgear traction with and without the
maxillary second molars. AJODO 146: 467–476
Debonding Procedures
The optimum method of debonding:

 Use of fluted tungsten carbide bur to remove gross adhesive.
 Use abrasive points or cups to remove residual adhesive.
 Final polish with prophylaxis paste or pumice slurry.
Campbell (1995). Enamel surfaces after orthodontic bracket debonding. Angle Orthodontist 65:
103-110
High speed ultrafine diamond burs and white stone finishing burs were found to be
unsuitable for removing composite adhesive.
The high-speed tungsten carbide bur produced the smoothest surface but was fourth in
the Composite Remnant Index.
Hong and Lew (1995). Quantitative and qualitative assessment of enamel surface following five
composite removal methods after bracket debonding. EJO 17: 121-128
The least enamel was removed using a slow speed tungsten carbide bur (up to
approximately 5μm) and the most with an ultrasonic scaler or high speed tungsten carbide
bur (up to approximately 30μm).
Ireland et al (2005). Enamel loss at bond-up, debond and clean-up following the use of a
conventional light-cured composite and a resin modified glass polyalkenoate cement. EJO 27:
413–419
Adhesive removal without water cooling caused some vascular and pulpal tissue
alterations, but these were tolerated by the pulpal tissues, so the changes were reversible.
Bicakci et al (2010). Histopathologic evaluation of pulpal tissue response to various adhesive

cleanup techniques. AJODO 138: 12.e1–12.e7
141
142
Section Ten
Orthodontics and Orthognathic Surgery
Surgically-Assisted Rapid Palatal Expansion
Orthognathic Surgery
Orthodontic Tooth Movement Acceleration
143
144
Surgically-Assisted Rapid Palatal Expansion (SARPE)
Surgical expansion of the maxilla is the least stable of all orthognathic procedures.
Proffit and Fields (2000). Contemporary Orthodontics 3rd edition Mosby St Louis Missouri.
An average of 17 mm expansion of the molars could be produced by SARPE, of which

an average of 13mm was stable.
Anttila et al (2004). Feasibility and long-term stability of surgically-assisted rapid maxillary

expansion with lateral osteotomy. EJO 26: 391-395
No consensus about either the extent or the procedure for SARPE. There is a large range
of potential adverse sequelae with these procedures.
Suri and Taneja (2008). Surgically assisted rapid palatal expansion: A literature review.
AJODO 133: 290-302
Because most of the air we breathe passes over the lower nasal floor, SARPE is likely to
improve nasal breathing.
Deeb et al (2010). Changes in nasal volume after surgically assisted bone-borne rapid maxillary
expansion. AJODO 137: 782–789
The use of a transpalatal arch as a retaining device after surgically assisted rapid palatal
expansion does not improve dento-osseous stability.
Prado et al (2014). Stability of surgically assisted rapid palatal expansion with and without
retention analyzed by 3-dimensional imaging. AJODO145: 610–616
SARPE with or without pterygomaxillary disjunction is an effective technique to treat

maxillary transverse deficiency in adolescent and adult patients. Pterygomaxillary
disjunction is advised in periodontally compromised patients.
Sygouros A et al (2014). Surgically assisted rapid maxillary expansion: Cone-beam computed

tomography evaluation of different surgical techniques and their effects on the maxillary
dentoskeletal complex. AJODO 146:748–757
145
Orthognathic Surgery
Surgery should precede orthodontic treatment if a satisfactory interarch relationship can

be reached surgically.
Skaggs JE (1959). Surgical correction of prognathism. AJODO 45:265-71.
Surgery to correct open bite has a 42.9% relapse rate.
Denison et al (1989). Stability of maxillary surgery in openbite versus non openbite

malocclusions. Angle Orthodontist 59: 5-10
20-25% risk of permanent altered sensation with BSSO.
Tucker et al (1991). Rigid Fixation for Maxillofacial Surgery, JB Lippincott, Philadelphia.
Similar relapse with BSSO and VSS, approximately 10%, BUT VSS relapse is in
posterior direction whereas BSSO is in anterior direction.
Proffit et al (1991a). Stability after surgical-orthodontic correction of skeletal Class Ill

malocclusion. I. Mandibular setback. IJAOOS 6: 7-18
Surgical Class II case:

 Non-growing patient.
 OJ > 10mm.
 Po-zero meridian line is > 18mm.
 Go-Po < 70mm.
 Total face height > 125mm.
Proffit et al (1992). Surgical versus orthodontic correction of skeletal Class II malocclusion in

adolescents: effects and indications. IJAOOS 7: 209-220
During the healing process after orthognathic surgery, there is an increase in blood flow
above the pre-surgical levels which facilitates the healing process and stimulates bone
turnover which can potentially speed up orthodontic tooth movement.
Justus et al (2001). Human gingival and pulpal blood flow during healing after Le Fort I
osteotomy. JOMS 59: 2-7
146
Postoperative skeletal changes are similar between surgery first and conventional
treatment of Class III malocclusions.
Baek et al (2010). Surgery-first approach in skeletal class III malocclusion treated with 2-jaw
surgery: evaluation of surgical movement and postoperative orthodontic treatment. JCS 21: 332-
8
Liao et al (2010). Presurgical orthodontics versus no presurgical orthodontics: treatment

outcome of surgical-orthodontic correction for skeletal class III open bite. PRSJ 26: 2074-83
Malocclusions cause decreased masticatory performance, especially as it relates to

reduced occlusal contacts area. The influence of malocclusion treatment (orthognathic
surgery) on masticatory performance is only measurable 5 years after treatment.
Magalhães et al (2010). The influence of malocclusion on masticatory performance. Angle

The maintenance of a deep bite prior to mandibular advancement surgery induces an

opening rotation of the mandible reducing chin prominence and increasing lower anterior
face height post-surgically.
Coul et al (2010). Maintenance of a deep bite prior to surgical mandibular advancement. EJO
32: 342-345
Orthodontic-surgical treatment of anterior open bite improves the overbite, but an

excellent treatment outcome with normal overjet and overbite and proper incisal contact
was achieved in only 40% of the subjects.
Jensen and Ruf (2010). Success rate of anterior open-bite orthodontic-orthognathic surgical
treatment. AJODO 138: 716–719
Indications of surgery first: the malocclusion accompanying the skeletal deformity

represents mild to moderate crowding, normal to mild proclination and retroclination of
upper and lower incisors, and minimal transverse discrepancies.
Liou et al (2011). Surgery-first accelerated orthognathic surgery: orthodontic guidelines and

setup for model surgery. JOMS 69: 771-780
Liou et al (2011). Surgery-first accelerated orthognathic surgery: postoperative rapid orthodontic

tooth movement. JOMS 69: 781-785
147
Clinically significant advancement (≥2 mm) of the maxilla significantly increased the
airway dimension at the nasopharyngeal level and to some extent compensated for the
effect of mandibular setback at the hypopharyngeal level.
Jakobsone et al (2011). The effect of maxillary advancement and impaction on the upper airway
after bimaxillary surgery to correct Class III malocclusion. AJODO 139: e369–e376
After surgery, the masseter muscle measurements of skeletal Class III asymmetry
patients showed no significant differences compared with the control group within the 4-
year follow-up period, indicating adaptation to the new skeletal environments and
increased functional demand.
Lee and Yu (2012). Masseter muscle changes following orthognathic surgery. Angle
Excessive forward movement of lower incisors during presurgical orthodontic treatment

could cause alveolar bone loss around the lower incisors; thus, special care should be
considered in individuals with mandibular prognathism.
Lee et al (2012). Alveolar bone loss around lower incisors during surgical orthodontic treatment
in mandibular prognathism. Angle Orthodontist 82: 637-644
Effect of maxillary advancement surgery:

Soft to hard tissue horizontal ratios increased progressively from pronasale to stomion
superius.
Alar base cinch and VY closures increased these further.
Maxillary incisor display changes were partly explained by presurgical upper lip
thickness and soft tissue manipulation.
Nasolabial angle increased, and cinch sutures seemed to increase this further.
Alar base width increased significantly, and the cinch sutures did not significantly limit
this.
Khamashta and Naini (2015). Prospective assessment of maxillary advancement effects:

Maxillary incisor exposure, and upper lip and nasal changes. AJODO 147: 454–464
148
The surgery-first approach is a new treatment paradigm for the management of
dentomaxillofacial deformity. Studies have reported satisfactory outcomes and high
acceptance.
Guijarro et al (2016). Surgery first in orthognathic surgery: A systematic review of the

literature. AJODO 149: 448–462
Orthodontic Tooth Movement Acceleration
Corticotomy is effective and safe to accelerate orthodontic tooth movement.

Low-level laser therapy was unable to accelerate orthodontic tooth movement.
Current evidence does not reveal whether electrical current and pulsed electromagnetic
fields are effective in accelerating orthodontic tooth movement, and dentoalveolar or
periodontal distraction is promising in accelerating orthodontic tooth movement but lacks
convincing evidence.
Long et al (2013). Interventions for accelerating orthodontic tooth (A systematic review). Angle
Micro-osteoperforation is an effective, comfortable, and safe procedure to accelerate

tooth movement and significantly reduce the duration of orthodontic treatment.
Alikhani M et al (2013). Effect of micro-osteoperforation on the rate of tooth movement.

AJODO 144: 639–648
Evidence based on the currently available studies of low-to-moderate quality showed that
surgically facilitated orthodontics seems to be safe for the oral tissues and is
characterized by a temporary phase of accelerated tooth movement. This can effectively
shorten the duration of orthodontic treatment.
Hoogeveen et al (2014). Surgically facilitated orthodontic treatment: A systematic review.

AJODO 145:S51–S64
No significant increase in tooth movement by applying low-frequency mechanical

vibration when compared to control.
Yadav et al (2015). Effect of low-frequency mechanical vibration on orthodontic tooth

movement. AJODO 148: 440–449
149
In combination with light orthodontic force, application of vibratory stimuli using an
electric toothbrush enhanced the secretion of IL-1β in GCF and accelerated orthodontic
tooth movement.
Leethanakul et al (2016). Vibratory stimulation increases interleukin-1 beta secretion during

orthodontic tooth movement. Angle Orthodontist 86: 74-80
The AcceleDent Aura appliance had no effect compared with no appliance on increasing
anterior arch perimeter, or reducing irregularity or perceived discomfort during initial
alignment with fixed appliances, although more subjects used pain killers at 24 hours in
the no-appliance group.
Miles and Fisher (2016). Assessment of the changes in arch perimeter and irregularity in the
mandibular arch during initial alignment with the AcceleDent Aura appliance vs no appliance in
adolescents: A single-blind randomized clinical trial. AJODO 150: 928–936
150
Section Eleven
Retention and Stability
Retention Philosophy and Appliances
Permanent Retention
Procedures to Aid Retention
151
152
Retention Philosophy and Appliances
Small contact points between teeth are unstable and that reshaping the contact point may
aid stability.
Tuverson (1980). Anterior interocclusal relations. AJODO 78: 361-393
Long-term stability of bimaxillary proclination correction is unpredictable, depends on

lip pattern adapting to incisor retraction, i.e. lower lip covering more of 21/12, and
becoming competent.
Keating (1986). The treatment of bimaxillary protrusion. A cephalometric consideration of

changes in the inter-incisal angle and soft tissue profile. BJO 13;209-220
Retention should be continued in males until the mid-20s and in females until the early
20s.
Behrents (1989). The consequences of adult craniofacial growth In orthodontics in an aging

society Ed. Carlson DS, Monograph 22, Craniofacial growth series, centre for human growth and
development, University of Michigan, Ann Arbor pp 53-100
Interincisal angulation is only a very partial explanation of the depth of overbite. Paying
more attention to the relationship between the upper incisor centroid and the lower
incisor tip is needed because this has a stronger correlation with depth of overbite.
Houston (1989). Incisor edge-centroid relationships and overbite depth. EJO 11: 139-143
Greater stability of premolar expansion during treatment than of canine expansion.
Gonzales and Neilsen (1992). Stability of dental arch form changes in patients treated with the
Straight-Wire archform and preadjusted fixed appliances. AJODO 102: 573
Essix retainer is a variation of vacuum formed retainers and are fitted only from canine to
canine and worn at nights only.
Sheridan et al (1993). Essix retainers: fabrication and supervision for permanent retention. JCO
27: 37-45
153
During retention period, a horseshoe shaped baseplate considerably improves speech,
particularly in adult patients.
Stratton and Burkland (1993). The effect of maxillary retainers on the clarity of speech. JCO
27: 338-340
Duration of seven days of wearing retainers is needed to which speech distortions will be
either disappeared or become minimal.
Haydar et al (1996). Effects of retainers on the articulation of speech. AJODO110: 535-540
The intercanine and intermolar width over the same time period:
 Between six weeks and two years of age, significant increases in anterior and
posterior arch widths occurred in both male and female children
 Maxillary intercanine width increased from 3 to 13 years and then started to
decrease.
 Mandibular intercanine width increased until the age of eight years and then
started to decrease gradually. No increase in mandibular intercanine width occurs
after the eruption of the lower incisors.
 Maxillary intermolar width increases steeply until 13 years and then stays
relatively static in males but decreases a little in females
 Mandibular intermolar width follows a similar pattern to maxillary intermolar
width peaking at around 13 years.
Bishara et al (1997). Arch width changes from 6 weeks to 45 years. AJODO111: 401-409
The arch length from six weeks to 45 years using a 6 week to two year sample and a three
to 45 year sample:
 Males had significantly greater arch lengths than females.
 Arch length increases from six weeks to two years.
 Maxillary arch length increases from three to 13 years.
 The increase in mandibular arch length was complete by eight years.
 From eight to 13 years, mandibular arch length started to decrease.
 Between 13 and 45 years maxillary arch length decreased significantly.
Bishara et al (1998). Arch length changes from 6 weeks to 45 years. Angle Orthodontist 68: 69-
74
154
It is very unlikely that the removal of third molars has a clinically significant effect on
later incisor irregularity.
Harradine et al (1998). The effect of extraction of third molars on late lower incisor crowding:
a randomised controlled trial. BJO 25: 117-122
A significant decrease in arch length in males takes place during the third decade. Total
face height increased and there was a significant increase in lower face height and
overbite in females.
Agkul and Toygar (2002). Natural craniofacial changes in the third decade of life: a
longitudinal study. AJODO 122: 512-522
Transverse changes in the buccal segments require the use of removable retainers; for
optimum retention, clear overlay retainers and fixed retainers can be combined.
Lang et al (2002). Retention and stability--taking various treatment parameters into account.
JOO 63: 26-41
Retention for one year would seem to be more effective than retention for six months.
Destang and Kerr (2003). Maxillary retention: is longer better? EJO 25: 65-69
Relapse in extraction and non-extraction cases was compared at least two years post
retention: there was no difference in the incisor irregularity index (IRI) postretention.
Erdinc et al (2006). Relapse of anterior crowding in patients treated with extraction and
nonextraction of premolars. AJODO 129: 775-784
The effectiveness of vacuum formed and Hawley retainers over a six month period was
compared:
The vacuum formed retainers were more effective than Hawley retainers at maintaining
correction of the maxillary and mandibular labial segments.
Rowland et al (2007). The effectiveness of Hawley and vacuum-formed retainers: A single-

center randomized controlled trial. AJODO132: 730-737
155
Vacuum formed retainers were more cost-effective than Hawley retainers from all
perspectives. The majority of subjects showed a preference for vacuum formed retainers
compared with Hawley retainers and there were also fewer breakages than in the vacuum
formed compared with the Hawley group.
Hichens et al (2007). Cost-effectiveness and patient satisfaction: Hawley and vacuum-formed

retainers. EJO 29: 372-378
Over a six month period following debonding, patients who wore Essix retainers part-
time experienced similar levels to those patients who wore them full-time with respect to
dental alignment and occlusal changes..
Gill et al (2007). Part-time versus full-time retainer wear following fixed appliance therapy: a
randomized prospective controlled trial. WJO 8: 300-306
Hawley retainers full- or part-time:

Since both retention regimens were equally effective during the 1 year retention period, it
would seem clinically acceptable to ask patients to wear their retainers at night only.
Shawesh et al (2010). Hawley retainers full- or part-time? A randomized clinical trial. EJO 32:
165-170
The most common type of retainer used in the United States of America was a Hawley
retainer in the maxillary arch and a fixed retainer in the lower arch.
Valiathan and Hughes (2010). Results of a survey-based study to identify common retention
practices in the United States. AJODO 137: 170-177
Full or part-time wear of thermoplastic retainers:

No statistical difference between the two groups for overjet, arch length, intermolar
width, intercanine width and irregularity index for each time period. Part-time retainer
wear could be advised for patients who had undergone fixed appliance treatment with
extractions.
Thickett and Power (2010). A randomized clinical trial of thermoplastic retainer wear. EJO 32:
1-5
156
Retention with thermoplastic retainers might create oral conditions conducive to S
mutans and Lactobacillus colonization on dental surfaces.
Türköz et al (2012). Influence of thermoplastic retainers on Streptococcus mutans and

Lactobacillus adhesion. AJODO141: 598–603
Permanent Retention
The failure rate amongst bonded retainers was 22.9% and the majority of failures
occurred during the third year of observation.
Årtun et al (1997). A 3-year follow-up of various types of orthodontic canine-to-canine

retainers. EJO 19: 501-509
Zachrisson favors bonding to mandibular canines only using a 0.032" stainless steel or
0.030 gold-plated wires and claims a failure rate of only 8.4% or 4.2% of bonded sites.
Zachrisson (1997). Important aspects of long-term stability. JCO 31: 562-583
Optimum bond strength for fixed retainers is achieved with the use of a straight 0.030"
stainless steel wire with no terminal bend but a microetched end.
Oesterle et al (2001). Enhancing wire-composite bond strength of bonded retainers with wire
surface treatment. AJODO 119: 625-631
Multistrand wire fixed retainers vs. polyethylene ribbon-reinforced resin composite:

The ribbon reinforced retainers remained in place for an average of 11.5 months while
the multistrand retainers remained in place for 23.6 months.
Rose et al (2002). Clinical comparison of a multistranded wire and a direct-bonded polyethylene

ribbon-reinforced resin composite used for lingual retention. QI 33: 579-583
The use of flexible spiral wire or twistflex retainers bonded to all mandibular anterior
teeth may result in unwanted labiolingual movement or torque of lower anterior teeth.
Katsaros et al (2007). Unexpected complications of bonded mandibular lingual retainers.

AJODO132: 838-841
157
Two fixed retention groups (single strand wire bonded to the lingual surfaces of both
lower canines and multistrand retainer bonded to the lingual surfaces of all lower anterior
teeth) were compared at least 12 months after debonding:
No significant differences between the plaque index and the gingival index between the
two groups.
More plaque was found on the distal surfaces of the lower anterior teeth in the group with
multistrand wire retainers.
The lower anterior teeth were significantly more irregular in the group with round wire
retainers compared to the group with multistrand wire retainers.
Although the multistrand wire retainers fractured more frequently than the round wire
retainers the difference was not statistically significant.
Multistrand wire retainers were better at maintaining incisor alignment than single strand
wire retainers.
Al-Nimri et al (2009). Gingival health and relapse tendency: a prospective study of two types of
lower fixed retainers. AOJ 25: 142–146
Multistranded retainers should remain the gold standard for orthodontic retention,
although periodontal complications are common.
The use of glass fibre reinforced retainers should be discouraged in daily practice.
Tacken et al (2010). Glass fibre reinforced versus multistranded bonded orthodontic retainers: a
2 year prospective multi-centre study. EJO 32: 117-123
The forces generated by lingual canine to canine fixed retainers using three different
multistrand wires showed that the forces recorded from the lingual retainer wires during
0.2 mm simulated intrusion-extrusion and buccal-lingual movements might generate high
forces exceeding 1 N and be large enough to produce unwanted tooth movement during
retention.
The only significant determinant of the generated forces was the amount of wire
displacement and not the type of wire used.
Sifakakis et al (2011). In-vitro assessment of the forces generated by lingual fixed retainers.
AJODO 139: 44-48
158
Stability of the maxillary anterior alignment 5 years posttreatment did not appear to be
influenced by choice of retention protocol.
Mandibular anterior alignment was significantly better for the group using a fixed
retainer compared with the group where the retainer was removed 3 years posttreatment.
Bjering et al (2015). Anterior tooth alignment: A comparison of orthodontic retention regimens

5 years posttreatment. Angle Orthodontist 85: 353-359
A bonded retainer for maintaining closure of a maxillary midline diastema can last an
average of 17 years or more, with a yearly 2% chance of breakage and with no expected
adverse effects on the periodontal health of the maxillary central incisors.
Moffitt and Raina (2015). Long-term bonded retention after closure of maxillary midline
diastema. AJODO 148:238–244
Some relapse is likely after fixed appliance therapy irrespective of retainer choice, and
this is minimal in most patients at 6 months after debond.
Bonded retainers have a better ability to hold the mandibular incisor alignment in the first
6 months after treatment than do vacuum-formed retainers.
O'Rourke et al (2016). Effectiveness of bonded and vacuum-formed retainers: A prospective

randomized controlled clinical trial. AJODO 150: 406–415
Procedures to Aid Retention
Circumferential supracrestal fiberotomy (CSF) appeared to reduce relapse more in the

first 4-6 years after treatment than in the subsequent period.
Edwards (1988). A long-term prospective evaluation of the circumferential supracrestal

fiberotomy in alleviating orthodontic relapse. AJODO 93: 380-387
Rotational relapse: in cases where there is little attached gingivae, the papillae dividing
procedure may be preferred.
Ahrens et al (1981). An approach to rotational relapse. AJODO 80: 83-91
159
160
Section Twelve
Complications of Orthodontic Treatment

Effect on Periodontium
Effect on TMJ
Root Resorption
Pain Associated with Orthodontic Treatment
White Spot Lesions
Ni Allergy
161
162
Effect on Periodontium
Controlled increase in arch length could be successfully achieved without significant risk
of recession in the presence of good oral hygiene.
Allais and Melsen (2003). Does labial movement of lower incisors influence the level of the
gingival margin? A case-control study of adult orthodontic patients. EJO 25: 343-352
Orthodontic treatment does not aggravate gingival recession; in contrary it may improve
it. Risk factors for the development of dehiscences include thin gingival biotype, visible
plaque and the presence of inflammation.
Melsen and Allais (2005). Factors of importance for the development of dehiscences during
labial movement of mandibular incisors: A retrospective study of adult orthodontic patients.
AJODO 127: 552-561
The prevalence of gingival recessions steadily increases after orthodontic treatment. The
recessions are more prevalent in older than in younger patients. No variable, except for
age at the end of treatment, seems to be associated with the development of gingival
recessions.
Renkema et al (2013). Development of labial gingival recessions in orthodontically treated

patients. AJODO 143: 206–212
Effect on TMJ
The studies by Egermark and Thilander (1992), Wadhwa et al (1993), Kremenak et al (1992),
Sadowsky et al (1991) and the review by Sadowsky (1992) have all failed to find any harmful
effects of orthodontic treatment on TMJ in the short or long term.
Extractions cause ―over-retraction‖ of the upper incisors and this leads to the condyles
being forced posteriorly and hence the articular disc becomes anteriorly placed and hence
mandibular dysfunction.
Witzig and Spahl (1987). The clinical outline of maxillofacial orthopaedic appliances. 1st ed.
Littleton, Mass: PSG Publishing: 167-216
Bowbeer (1987). The sixth key to facial beauty and TMJ health. Functional Orthodontics 4: 10-
35
163
Extraction of premolars causes a loss of vertical dimension and this causes mandibular
dysfunction.
Bowbeer (1987). The sixth key to facial beauty and TMJ health. Functional Orthodontics 4: 10-
35
Premolar and second molar extractions: No TMJ effect.
Staggers JA (1990). A comparison of second molar and first premolar extraction treatment.
AJODO98: 430-436
Anterior open bite - which is the antithesis of a mutually protected occlusion - is a modest
predisposing factor to mandibular dysfunction.
Pullinger and Seligman (1991). Overbite and overjet characteristics of refined diagnostic
groups of temporomandibular disorders. AJODO 100: 401-415
No difference in condylar position between those treated with the extraction of four
premolars and those receiving no orthodontic treatment.
Gianelly et al (1991a). Condylar position and maxillary first premolar extraction. AJODO 99:
473-476
Gianelly et al (1991b). Longitudinal evaluation of condylar position in extraction and non-

extraction treatment. AJODO 100: 416-420
The temporary effect of orthodontic treatment on condylar position is highly correlated

with the mesial movement of buccal segments but not at all with the retraction of
incisors.
Luecke and Johnston (1992). The effect of maxillary first premolar extraction and incisor
retraction on mandibular position: testing the central dogma of ―functional orthodontics‖.
AJODO 101: 4-12
164
Effect of extraction non-extraction philosophy on TMD:
No differences between groups treated with loss of upper premolars, four premolars and
non-extraction.
Kremenak et al (1992). Orthodontic risk factors for temporomandibular disorders (TMD) 1:

premolar extraction. AJODO 101:13-20
No difference in the craniomandibular index (CMI) values for non-extraction cases and
extraction cases.
Beattie et al (1994). The functional impact of extraction and non-extraction treatments: A long-
term comparison in patients with ―borderline‖, equally susceptible Class II malocclusions.
AJODO 105: 444-9
Condylar position was unchanged by treatment in both non-extraction and extraction

groups.
Major et al (1997). Condyle displacement associated with premolar extraction and non-
extraction orthodontic treatment of Class I malocclusion. AJODO 112: 435-40
No difference in change in vertical facial dimensions between cases treated as non-

extraction and others treated with first premolar extractions.
Kocadereli (1999). The effect of first premolar extraction on vertical dimension. AJODO 116:
41-45
A trend for those who had received orthodontic treatment in childhood to have less
symptoms of TMD.
Egermark et al (2003). A 20-year follow-up of signs and symptoms of temporomandibular

dysfunction and malocclusions in subjects with and without orthodontic treatment in childhood.
165
No convincing evidence that occlusal adjustment prevents or treats TMD better than no
treatment or placebo treatment.
Huang et al (2004). Occlusal adjustment for treating and preventing temporomandibular

disorders. AJODO 126:138-139
Very low incidence of TMD in patients who had received orthodontic treatment as in
those who had not.
Egermark et al (2005). A prospective long-term study of signs and symptoms of

temporomandibular disorders in patients who received orthodontic treatment in childhood. Angle
Root Resorption
Nail biters had more root resorption both before and after orthodontic treatment.
Odenrick and Brattström (1985). Nailbiting: frequency and association with root resorption
during orthodontic treatment. BJO 12: 78-81
Apical root resorption classification:

 Grade 1: Indicates an irregular root outline
 Grade 2: < 2 mm root resorption (minor)
 Grade 3: > 2 mm to one third of root length (severe)
 Grade 4: > one third of root length (extreme)
Levander and Malmgren (1988). Evaluation of the risk of root resorption during orthodontic
treatment: A study of upper incisors. EJO 10: 30-38
Roots with abnormal shape or size such as, short, blunted, bent (dilacerated) or pipette
shaped roots have a higher susceptibility to orthodontically induced inflammatory root
resorption (OIIRR).
Levander and Malmgren (1988). Evaluation of the risk of root resorption during orthodontic
treatment: A study of upper incisors. EJO 10: 30-38
166
The most vulnerable teeth to OIIRR are:
 Maxillary lateral incisors
 Maxillary central incisors
 Mandibular incisors
 Distal root of mandibular first molars
 Mandibular second premolars
 Maxillary second premolars
Brezniak and Wasserstein (1993b). Root resorption after orthodontic treatment: Part 2.
Literature review. AJODO 103: 138-146
Transplanted teeth are no more susceptible to OIIRR than normal teeth provided the
transplant is without complication and the orthodontist waits three months before
attempting tooth movement.
Paulsen et al (1995). Pulp and periodontal healing, root development and root resorption
subsequent to transplantation and orthodontic rotation: a long term study of auto-transplanted
premolars. AJODO 108: 630-640
Diminutive and peg-shaped lateral incisors are not more susceptible to OIIRR.
Mirabella and Årtun (1995a). Prevalence and severity of apical root resorption of maxillary
anterior teeth in adult orthodontic patients. EJO 17: 93-99
Patients with hypodontia and mutilated occlusions where the occlusal load is not
distributed evenly across a sufficient number of teeth may exhibit root resorption.
Levander et al (1998). Apical root resorption during orthodontic treatment of patients with
multiple aplasia: a study of maxillary incisors. EJO 20: 427-434
A longitudinal radiographic survey of root length from early to mid-adulthood: no

evidence of systematic root shortening as a result of age.
Bishara et al (1999). Changes in root length from early to mid-adulthood: resorption or

apposition. AJODO 115: 563-568
167
Asian patients had significantly less post-treatment orthodontically induced inflammatory
root resorption (OIIRR) than either white or Hispanic patients.
Sameshima and Sinclair (2001a). Predicting and preventing root resorption: Part 1. Diagnostic
factors. AJODO 119: 505-510
External apical root resorption (EARR) is influenced by factors other than the force
levels during orthodontic treatment. The IL-1B gene contributed a significant
predisposition to this problem and 15% of the total variation of maxillary incisor EARR.
Al-Qawasmi et al (2003). Genetic predisposition to external root resorption. AJODO 123: 242-
252
Superelastic archwires generally move teeth more rapidly than stainless steel archwires
with significantly more root resorption (140%).
Weilland (2003). Constant versus dissipating forces in orthodontics: the effect on initial tooth
movement and root resorption. EJO 25: 335-342
Properties of root cementum:

 No difference in calcium (Ca), phosphorus (P) and fluoride (F) concentrations
between buccal and lingual surfaces of the root except that the F concentration was
higher in the cervical region of the buccal surface.
 A decreasing concentration gradient for Ca, P and F from cervical to apical third.
 An increasing concentration gradient for Ca and P from the outer to the inner third of
the root at the cervical and middle thirds of the root.
 A decreasing concentration gradient from the outer to the inner third of the root along
the entire length of the root.
Rex et al (2005). Physical properties of root cementum: Part 4. Quantitative analysis of the
mineral composition of human premolar cementum. AJODO 127:177-185
The average hardness of cementum in the middle third of the root is 0.24 GPa and the
average modulus of elasticity is 3.3 GPa
Srivicharnkul et al (2005). Physical properties of root cementum: Part 3. Hardness and elastic
modulus after application of light and heavy forces. AJODO 127: 168-176
168
Intrusion of teeth causes approximately four times as much root resorption as no vertical
movement or extrusion.
Han et al (2005). Root resorption after orthodontic intrusion and extrusion: an intraindividual
study. Angle Orthodontist 75: 912-918
Increased observation period and deviated or long root form were risk factors for
resorption whereas normal or wide root form seemed to be protective factors.
The use of rectangular archwires, incisor irregularity and a history of trauma were not
identified as risk factors.
Smale et al (2005). Apical root resorption 6 months after initiation of fixed orthodontic
appliance therapy. AJODO 128: 57-67
No evidence that teeth with short blunted roots were an indication for root resorption and
although atypical root shape was a risk for increased resorption at 6 months, the
association did not exist at twelve months.
Patients with detectable root resorption in the first six months are more likely to have root
resorption in the following six months than those without.
Årtun et al (2006). Apical root resorption six and 12 months after initiation of fixed orthodontic
appliance therapy. Angle Orthodontist 75: 919–926
Treatment of malocclusions with increased overbites with accentuated curves of Spee

results in more root resorption compared with the treatment of patients with normal
overbites.
Chiqueto et al (2008). Effects of accentuated and reversed curve of Spee on apical root
resorption. AJODO 133: 261-268
No difference in the amount of root resorption between conventional and self-ligating

appliance systems which averaged 1.3 mm.
Pandis et al (2008). External apical root resorption in patients treated with conventional and
self-ligating brackets. AJODO 134:646-5
169
Root resorption after orthodontic treatment is underestimated when suing an OPT
compared with cone beam CT.
Dudic et al (2009). Detection of apical root resorption after orthodontic treatment by using
panoramic radiography and cone-beam computed tomography of super-high resolution. AJODO
135: 434-437
Increased incidence and severity of OIIRR is found in patients undergoing

comprehensive orthodontic therapy.
Heavy force application produced significantly more OIIRR than light force application
or control.
There is evidence to support the use of light forces, especially with incisor intrusion.
Weltman et al (2010). Root resorption associated with orthodontic tooth movement: A

systematic review. AJODO 137:462-76
There are more teeth with root resorption and abnormal root shape in open bite cases than
in normal bite cases, and more teeth with abnormal root shapes and root resorption in
hypofunctional teeth than in functional teeth.
Motokawa et al (2013). Open bite as a risk factor for orthodontic root resorption. EJO 35: 790-
795
The highest frequencies and the most significant apical root resorption (ARR) occurred in
incisors and distal roots of first maxillary and mandibular molars.
Castro et al (2013). Apical root resorption due to orthodontic treatment detected by cone beam
computed tomography. Angle Orthodontist 83: 196-203
Root-filled teeth do not appear to be more susceptible to orthodontically induced external

apical root resorption than their analogous vital teeth.
Walker et al (2013). Radiographic comparison of the extent of orthodontically induced external

apical root resorption in vital and root-filled teeth: a systematic review. EJO 35: 796-802
170
Positive correlations exist between increased force levels and increased root resorption,
as well as between increased treatment time and increased root resorption.
Moreover, a pause in tooth movement seems to be beneficial in reducing root resorption
because it allows the resorbed cementum to heal.
Roscoe et al (2015). Association of orthodontic force system and root resorption: A systematic
review. AJODO 147: 610–626
Root-filled teeth appear to be associated with significantly less EARR than are
contralateral teeth with vital pulp.
The possible complication of EARR in root-filled teeth may not be an important
consideration in orthodontic treatment planning, and root canal treatment can be
considered for stopping or decreasing EARR when severe EARR occurs during
orthodontic treatment.
Lee and Lee (2016). External root resorption during orthodontic treatment in root-filled teeth
and contralateral teeth with vital pulp: A clinical study of contributing factors. AJODO 149: 84–
91
Pain Associated with Orthodontic Treatment
Pain related to orthodontic appliances was initiated approximately two hours after initial
archwire placement.
90% of patients experienced pain in the first week and that the mean pain intensity
peaked at 24 hours and thereafter gradually declined over 7 days.
Erdinç and Dincer (2004). Perception of pain during orthodontic treatment with fixed
appliances. EJO 26: 79-85
A telephone call from orthodontic provider can reduce patient‘s self-reported pain and
anxiety scores.
Bartlett et al (2005). The influence of a structured telephone call on orthodontic pain and
anxiety. AJODO 128: 435-441
171
The mean pain intensity in the first week after initial archwire placement is lower with
the Damon passive self-ligating appliance than with conventional appliances.
Pringle et al (2009). Prospective randomised clinical trial to compare pain levels associated with
two orthodontic fixed bracket systems. AJODO 36: 160-167
In adolescents, the bite-wafer is a nonpharmacologic option for pain management after

orthodontic procedures that is at least as effective as over-the-counter analgesics.
Murdock et al (2010). Treatment of pain after initial archwire placement: A noninferiority

randomized clinical trial comparing over-the-counter analgesics and bite-wafer use. AJODO
137:316–323
Ibuprofen was superior to the placebo in relieving post-separator pain as measured by the
VAS pain summary scores, whereas acetaminophen and naproxen sodium did not
significantly differ from the placebo.
Patel et al (2011). Effects of analgesics on orthodontic pain. AJODO 139: e53–e58
Both chewing gum and viscoelastic bite wafers are effective for pain reduction in
orthodontic patients and can be recommended as suitable substitutes for ibuprofen.
Farzanegan et al (2012). Pain reduction after initial archwire placement in orthodontic patients:
A randomized clinical trial. AJODO 141: 169–173
Low-intensity laser therapy is a good option to reduce treatment duration and pain.
Gauri et al (2012). Efficacy of low-intensity laser therapy in reducing treatment time and
orthodontic pain: A clinical investigation. AJODO 141: 289–297
Physical activity has a significant influence on orthodontic pain perception and analgesic
consumption in adolescents undergoing orthodontic treatment.
Sandhu and Sandhu (2015). Effect of physical activity level on orthodontic pain perception and
analgesic consumption in adolescents. AJODO 148: 618–627
172
Patients wearing lingual appliances have more pain, speech difficulties, and problems in
maintaining adequate oral hygiene, although no differences for eating and caries risk
were identified.
Ali A et al (2016). Adverse effects of lingual and buccal orthodontic techniques: A systematic
review and meta-analysis. AJODO 149: 820–829
Analgesics and lasers are effective in the management of orthodontic pain at its peak
intensity.
Sandhu et al (2016). Comparative effectiveness of pharmacologic and nonpharmacologic

interventions for orthodontic pain relief at peak pain intensity: A Bayesian network meta-
analysis. AJODO 150: 13–32
The use of a sugar-free chewing gum may reduce the level of ibuprofen usage but has no
clinically or statistically significant effect on bond failures.
Ireland et al (2016). Comparative assessment of chewing gum and ibuprofen in the management
of orthodontic pain with fixed appliances: A pragmatic multicenter randomized controlled trial.
AJODO 150: 220–227
White Spot Lesions (WSL)
WSL Index of Gorelick et al:

 Stage 0 (none): Striated weakly whitish discolorations.
 Stage 1: A slight rim.
 Stage 2: A broad rim.
 Stage 3: Cavitation.
Gorelick et al (1982). Incidence of white spot formation after bonding and banding. AJODO 81:
93-98
The use of a weak fluoride solution or simply fluoride toothpaste causes the reversal of
many white spot lesions in four to six months.
Zachrisson (1986). JCO/ Interviews Dr Bjorn Zachrisson on excellence in finishing part 2. JCO
19: 536-556
173
The reported incidence is highly variable ranging from:
15% to 85% (Mitchell 1992)
61% in low caries population with an intensive preventive programme (Øgaard et al
2001)
23% in a study by Fornell and Twetman (2004).
Mitchell (1992). Decalcification during orthodontic treatment with fixed appliances. BJO 19:
199-205
Øgaard et al (2001). Effects of combined application of fluoride varnishes in orthodontic

patients. AJODO 120: 28-35
Fornell and Twetma (2004). Prediction of enamel demineralization during orthodontic

treatment with fixed appliances. Orthodontics 1:121-125
The use of toothpaste and gel with a high fluoride concentration of 1,500-5,000 ppm or of
complementary chlorhexidine during orthodontic treatment showed a demineralization-
inhibiting tendency.
Derks et al (2004). Caries-inhibiting effect of preventive measures during orthodontic treatment

with fixed appliances: a systematic review. Caries Research 38: 413-420
Daily 0.05% sodium fluoride mouth rinse could prevent white spot formation and the use
of a glass ionomer cement for bracket bonding could reduce the prevalence and severity
of white spot lesions.
Benson et al (2004) Fluorides for the prevention of white spots on teeth during fixed brace
treatment Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD003809. DOI:
10.1002/14651858. CD003809.pub2
Approximately 50% of patients develop white spot lesions during orthodontic treatment
compared with 11% of controls.
Sandvik et al (2006). Caries and white spot lesions in orthodontically treated adolescents- a
prospective study. EJO 28: e258
174
Casein phosphopeptide amorphous calcium phosphate (CPP-ACP) allows freely available
calcium and phosphate ions to attach to enamel and reform calcium phosphate crystals.
Willmot (2008). White spot lesions after orthodontic treatment. Seminars in Orthodontics
14: 209-219
White spots with a broken surface can be treated with remineralisation, abrasion of the
enamel surface (microabrasion) bleaching or restoration.
Donly and Sasa (2008). Potential remineralisation of postorthodontic demineralised enamel and
the role of enamel microabrasion and bleaching for aesthetics. Seminars in Orthodontics 14: 220-
225
Risk factors for the development of incipient caries during orthodontic treatment were:
Young age (preadolescent) at the start of treatment.
Number of poor hygiene citations during treatment.
Unfavorable clinical outcome score.
White ethnic group.
Inadequate oral hygiene at the initial pretreatment examination.
Chapman et al (2010). Risk factors for incidence and severity of white spot lesions during
treatment with fixed orthodontic appliances. AJODO 138: 188–194
A sharp increase in the number of WSLs during the first 6 months of orthodontic
treatment that continue to rise at a slower rate to 12 months.
Tufekci et al (2011). Prevalence of white spot lesions during orthodontic treatment with fixed
appliances. Angle Orthodontist 81: 206-210.
The frequent use of fluoridated miswaks had a remineralizing effect on WSLs.
Baeshen et al (2011). Effect of fluoridated chewing sticks (Miswaks) on white spot lesions in
postorthodontic patients. AJODO 140: 291–297
175
Microabrasion is an effective treatment for cosmetic improvement of long-standing white
spot lesions.
Akin and Basciftci (2012). Can white spot lesions be treated effectively? Angle Orthodontist 82:
770-775
Patients, parents, orthodontists, and general dentists have similar perceptions regarding
the significance, prevention and treatment of white spot lesions.
Patients are the most responsible for the prevention of white spot lesions.
Communication among patients, parents, orthodontists, and general dentists needs to
improve to decrease the incidence of white spot lesions in the orthodontic population.
Maxfield et al (2012). Development of white spot lesions during orthodontic treatment:

Perceptions of patients, parents, orthodontists, and general dentists. AJODO 141: 337–344
There is a lack of reliable evidence to support the effectiveness of remineralizing agents

for the treatment of post-orthodontic white spot lesions.
Chen et al (2013). Effect of remineralizing agents on white spot lesions after orthodontic
treatment: A systematic review. AJODO 143: 376–382
No significant effect of fluoride-releasing primer in reducing demineralization.
Tüfekçi et al (2014). Efficacy of a fluoride-releasing orthodontic primer in reducing

demineralization around brackets: An in-vivo study. AJODO 146: 207–214
To prevent WSL during treatment of fixed orthodontic appliances:

Daily use of high-fluoride toothpaste may be recommended.
Sonesson et al (2014). Effectiveness of high-fluoride toothpaste on enamel demineralization

during orthodontic treatment- a multicenter randomized controlled trial. EJO 36: 678-682
Periodic application of fluoride varnish can offer some protection against white spots, but
not to a statistically significant degree if the patients have excellent oral hygiene.
176
Pirrini et al (2016). Caries prevention during orthodontic treatment: In-vivo assessment of high-
fluoride varnish to prevent white spot lesions. AJODO 149: 238–243
Of the various patient-related and tooth-related factors examined, age, time since
appliance removal, length of orthodontic treatment, tooth type (central or lateral incisor),
WSL surface area, and brushing frequency had significant associations with WSL
improvement.
Kim et al (2016). Predicting improvement of postorthodontic white spot lesions. AJODO 149:
625–633
After removal of the orthodontic brackets, some natural remineralization of white spot
lesions occurred, and daily use of fluoride toothpaste may be helpful for this process.
However, not all patients experienced this remineralization, and treatment with fluoride
varnish or fluoride film induced greater remineralization of white spot lesions.
He et al (2016). Comparative assessment of fluoride varnish and fluoride film for

remineralization of postorthodontic white spot lesions in adolescents and adults over a 6-month
period: A single-center, randomized controlled clinical trial. AJODO 149: 810–819
Ni Allergy
Nickel sensitivity is significantly more difficult to develop across mucosa than skin and
so many patients who are sensitive to nickel on their skin can wear orthodontic
appliances without difficulty.
Kerosuo et al (1995). In vitro release of nickel and chromium from different types of simulated
orthodontic appliances. Angle Orthodontist 65: 111-116
Stainless steel alloys such as Remanium and Noninium have only tiny proportions of
nickel (less than 0.2%).
Matasa (1995) Trends: good bye Ni; welcome Co, Mn The Orthodontic Materials Insider 8: 4:
1-6
177
Orthodontic treatment does not appear to increase the risk of nickel sensitization.
Janson et al (1998). Nickel hypersensitivity before during and after orthodontic therapy.
AJODO 113: 655-660
Mobile phone usage has a time-dependent influence on the concentration of nickel in the
saliva of patients with orthodontic appliances.
Saghiri et al (2015). Effect of mobile phone use on metal ion release from fixed orthodontic
appliances. AJODO 147: 719–724
Patients treated with nickel-free braces had better gingival health and smaller blood
changes than did those treated with conventional braces. All abnormalities tended to be
eliminated after the removal of the braces.
Pazzini et al (2016). Nickel-free vs conventional braces for patients allergic to nickel: Gingival
and blood parameters during and after treatment. AJODO 150: 1014–1019
178
Section Thirteen
Cleft Lip and Palate
179
180
Cleft Lip and Palate (CLP)
The exact etiology is unknown. However, polygenic and multifactorial implications

including environmental causes have been reported.
Coboume (2004). The complex genetics of cleft lip and palate. EJO 26:7-16
Little al (2004). Tobacco smoking and oral clefts: a meta-analysis. Bull World Health Organ,
82; 213-218
De Ia Vega and Martinez (2006). Seasonal variation in the incidence of cleft lip and palate
based on the age of conception. PRHSJ 25:343-346
 Classification:
Davis and Ritchie Classification (1922): Classified congenital clefts based on the
position of the cleft in relation to the alveolar process.
 Group I-Pre alveolar clefts: Lip clefts only with subdivisions for unilateral, median,
bilateral.
 Group II-Post alveolar clefts: Degrees of involvement of soft and hard palate to be
specified till the alveolar ridge, submucous clefts included.
 Group III-Alveolar clefts: Is complete clefts of palate, alveolus ridge and lip with
subdivisions for unilateral, median, bilateral.
Soft palate, soft and hard palate, unilateral CLP, bilateral CLP
Veau (1931). Treatment of the unilateral hare-lip, Trans of 8th Inter Dent Cong, Sec Xll;126-130
Based on embryology:
 Clefts of primary palate - alveolus up to incisive foramen
 Clefts of secondary palate - soft and hard palate, up to incisive foramen
 Clefts of primary and secondary palate - complete/incomplete, unilateral/bilateral
Kernahan and Stark (1958). Classification of cleft lip and palate, JPRS 22; 435-444
Descriptive classification by describing the affected part.
181
Hodgkinson et al (2005). Management of children with cleft lip and Palate: a review describing
the application of multidisciplinary team working in this condition based upon the experiences of
a regional cleft lip and palate centre in the United Kingdom, Fetal and Maternal Medicine
Review 16:1-27
The maxilla of CLP children subjected to infant orthopaedics may reach the same
dimensions of five-year-old normal children, and that the plate allowed for a reduced
deformity of nasal septum.
Kozelj (2000). The basis for presurgical orthopedic treatment of infants with unilateral complete
cleft lip and palate. CPCJ 37: 26-32.
No significant differences in the occlusal relationship in CLP patients with orthopaedics

or without.
Chan et al (2003). The effects of active infant orthopedics on occlusal relationships in unilateral
complete cleft lip and palate. CPCJ 40: 511-517.
Only differences in speech and palatal dimensions were found at age of 2.5 years for
patients with orthopaedics. While either in feeding or in labial esthetics there was no
difference at this age.
Prahl et al (2003). A randomized prospective clinical trial of the effect of infant orthopedics in
unilateral cleft lip and palate: prevention of collapse of the alveolar segments. CPCJ 40: 337-342.
At age of six years, no differences either in maxillary arch dimensions or in maxillary

growth were found between patients received orthopaedics or not.
Bongaarts et al (2009). Infant orthopedics and facial growth in complete unilateral cleft lip and
palate until six years of age. CPCJ 46: 654-663.
In terms of speech, although the burden to benefit ratio seems to be favorable to the use
of orthopaedic plates, no differences any longer exist at age of 6 years.
Konst et al (2003). Language skills of young children with unilateral cleft lip and palate
following infant orthopedics: A randomized clinical trial. CPCJ 40: 356-362.
182
The need for some presurgical orthopaedics in most bilateral CLP cases is universally
accepted.
Posnick (1996). Orthognathic surgery for the cleft lip and palate patient. Seminars in
Orthodontics 2: 205-214.
Naso-alveolar molding (NAM) protocol produces normal columella and a better nose
projection, however, wider nose width and nasolabial angle is also accompanied and
nasal anatomy is still not ideal.
Meazzini et al (2010). Photometric evaluation of bilateral cleft lip and palate patients after
primary columella lengthening. CPCJ 47: 58-65.
Brustai and Meazzini (2011). Primary columella lengthening in bilateral cleft lip and palate
patients: 10 year follow up. BAOMS meeting Nice.
For patients with unilateral CLP, the use of such protocol is not mandatory. Supportive
psychological therapy is needed for parents at this stage.
Meazzini et al (2011). Craniofacial anomalies: surgical-orthodontic management. Edizioni

Martina, 1st edition.
 Protocols for CLP patient management:
Oslo protocol: 2 stage protocol

 No presurgical orthopedics used.
 Lip closure using Millard technique: 3 months.
 Soft palate closure using a modified von Langenbeck technique: 18 months.
 Alveolar bone grafting: 7-10 years.
Warsaw protocol: one stage protocol

 No presurgical orthopedic treatment.
 During one operation, lip, hard and soft palate are closed: 6-15 months.
 Alveolar bone grafting: 9-12 years.
183
Zurich protocol:
 Passive plates worn for 16-8 months.
 Plate changed every 6 months.
 Lip closure: 6 months of age.
 Soft palate: 18 months.
 Hard palate: 4-5 years.
Nether lands protocol:

 Presurgical orthopedic treatment appliance – birth to 1 1/2 years.
 Lip closure: 5-6 months.
 2 stage palatal closure – soft palate: 12-18months, hard palate: 6-9 years of age.
 Bone grafting of alveolar cleft.
184
Section Fourteen
Pioneers in Orthodontics
185
186
Pioneers in Orthodontics
In this section, pioneers of the most common orthodontic procedures, concepts and basics will be
presented using the following table. The references will be outlined at the end of this section.
Orthodontic Items Pioneers with Reference Notes

Parallax technique. Clark (1910)1 Using two periapical radiographs
and a horizontal tube shift.
Bolton ratios. Bolton (1958,1962)2,3
Circumferential Supracrestal Edwards (1970)4 A simple procedure that is
Fiberotomy (CSF). recommended where teeth have been
rotated during treatment by more
than 30° carried out at least four
weeks before the fixed appliances
are removed.
Buccal corridors. Hulsey (1970)5
Straight-Wire Appliance. Larry Andrews (1972)6
Indirect bonding. Silverman et al (1972)7
Transpalatal bars. Robert Goshgarian (1972)
Technique of Maxillary Nanda (1978)8 A force of approximately 500g could
protraction basics. produce anterior displacement of the
maxilla of young and adult rhesus
monkeys
Protraction headgears McNamara (1993)
technique description.
Correction of anterior Reynolds (1978)9 Involves the use of vertical cross

crossbite (Reynolds method). elastics from the palatal of the upper
incisors to the labial of the lower
incisors.
2 x 4 Appliance. McKeown and Sandler (2001)10 21/12 bonded, 6/6 banded and
continuous archwire.
Magnets. Blechman and Smiley (1978)11
Quad helix. Ricketts (1979)12
Primary failure of eruption. Proffit and Vig (1981)13
Twin-block appliance. William Clark (1982, 1988)14,15
Fixed twin-block appliance. Mike Read (2001)16
Functional appliances for the Frankel and Frankel (1983)17
management of open bite. Weinbach and Smith (1992)18
Air Rotor Stripping (ARS). Sheridan (1985)19

Lip bumpers. Ten Hoeve (1985)20
Tip-Edge appliance. Peter Kesling (1988)21
Snap-release headgears. Postlethwaite (1989)22

Stafford et al (1998)23
187
Plastic safety straps and the Samuels et al (2000)24
customized facebow locks.
Lacebacks. McLaughlin and Bennett

(1989)25
3-point landing surgery. Eberhart et al (1990)26
Surgery first approach. Brachvogel (1991)27 The goal is reducing some of the
disadvantages and inconveniences of
pre-surgical orthodontics.
Precisely adjusting the shape Creekmore and Kunik (1993)28 To overcome the natural variability
of the adhesive underneath the of tooth dimensions and requires the
bracket pad. use of indirect bonding and slot
machine to customize bracket
position.
Acid/pumice microabrasion Welbury & Carter (1993)29 For treatment of post orthodontic
technique. decalcification.
Micro-screws as orthodontic Kanomi(1997) He showed that 1.2mm diameter of

anchorage. micro-screw is enough for intrusion
of anterior teeth.
First practical use of Park & Bae (1999) Used surgical micro-screws
microimplants. (D=1.2mm) to retract anterior teeth
after placing them between the roots
of upper 2nd premolars and 1st
molars.
Technique of Hemisection. Northway (2004)30 Primary 2nd molars could be

preserved by this technique in cases
of missed 5.
True Vertical Line (TVL). Arnett and McLaughlin (2004)31 Through subnasale. In cases of
maxillary retrusion, they suggest
moving the TVL 1-3 mms anteriorly.
They describe nasal tip projection
relative to TVL as being 14.6 mm to
17.4 mm in adult females and 15.7
mm to 19.1 mm in adult males.
Acrylic jig for multistrand Becker and Chausu (2004)32
wire.
Securing retainers using small Shah et al (2005)33
elastic bands prior to bonding.
Botulinum toxin A. Polo M (2008)34 Botox (BTX-A) to reduce gingival
display.
Passive infant orthopaedics McNeil (1950)35
with acrylic plates.
188
Naso-alveolar molding Grayson and Cutting (1996)36 Used for primary columella
(NAM) protocol. lengthening along with gradual
retraction of the premaxilla (two
nasal stents supporting nostrils).
Classifications and Indices

Incisor Classification Ballard & Wayman (1964)
Skeletal Classification Houston et al (1993)
Occlusal lndex Summers (1971)
Handicapping malocclusion Salzmann (1968)
assessment record (HMAR)
Index of Treatment Need Brook & Shaw (1989)
(IOTN) Evans & Shaw (1987)
Index of Treatment Daniels & Richmond (2000)
Complexity, Outcome and
Need (ICON)
Little's Irregularity Index Little (1975)
Peer Assessment Rating Richmond et al (1992)
(PAR)
Craniomandibular Index Fricton & Schiffman (1986)
Helkimo Clinical Dysfunction Dibbets & van der Weele (1991)
Index
 References
1- Clark (1910). A method of ascertaining the relative position of unerupted teeth by means
of film radiographs proceedings of the royal society of medicine odontological section 3:
87-90
2- Bolton WA (1958). Disharmony in tooth size and its relation to the analysis and
treatment of malocclusion. AJODO 28:113-30
3- Bolton WA (1962). The clinical application of tooth size analysis. AJODO 48:504-529
4- Edwards JG (1970). A surgical procedure to eliminate rotational relapse. AJODO 57:
35-46
5- Hulsey CM (1970). An aesthetic evaluation of lip-teeth relationships present in smile.
AJODO 57: 132-144
6- Andrews LF (1972). The six keys to normal occlusion. AJODO 62: 296-309
7- Silverman et al (1972). A universal direct bonding system for both metal and plastic
189
8- Nanda (1978). Protraction of maxilla in rhesus monkeys by controlled extraoral forces.
AJODO 74: 121-141
9- Reynolds IR (1978). The anterior crossbite: a simple method of treatment. BDJ 144:
143-146
10- McKeown and Sandler (2001). The two by four appliance: a versatile appliance, Dental
Update 28; 496-500
11- Blechman and Smiley (1978). Magnetic force in orthodontics. AJODO: 435-443
12- Ricketts et al (1979). Bioprogressive Therapy Denver, Rocky Mountain Orthodontics
13- Proffit and Vig (1981). Primary failure of eruption: a possible cause of posterior open-
bite. AJODO 80: 173–190.
14- Clark WJ (1982). The twin-block traction technique. EJO 4:129-38
15- Clark WJ (1988). The Twin-Block traction technique: a functional orthopaedic
appliance system. AJODO 93: 1-17
16- Welbury & Carter (1993). The hydrochloric acid-pumice microabrasion technique in
the treatment of post orthodontic decalcification. BJO 20;181-186
17- Fränkel R and Fränkel C (1983). A functional approach to treatment of skeletal open
bite AJODO 84: 54-68
18- Weinbach and Smith (1992). Cephalometric changes during treatment with the open
bite bionator. AJODO 101: 367-374
19- Sheridan (1985). Air-rotor stripping. JCO 19:43–59
20- Ten Hoeve A (1985). Palatal bar and lip bumper in non-extraction treatment. JCO 19:
272-291
21- Kesling PC (1988). Expanding the horizons of the edgewise slot. AJODO 94: 26-37
22- Postlethwaite (1989). The range and effectiveness of safety headgear products. EJO 11:
228-234
23- Stafford et al (1998). Characteristics of headgear release mechanisms: Safety
implications. Angle Orthodontist 68: 319-326
24- Samuels et al (2000). A clinical evaluation of a locking orthodontic facebow. AJODO
117: 344-50
25- McLaughlin and Bennett (1989). The transition from standard edgewise to preadjusted
edgewise appliance systems. JCO 23: 142-153
26- Eberhart et al (1990). The relationship between bite depth and incisor angular change.
AO 60;55-8
27- Brachvogel et al (1991). Surgery before orthodontic treatment: a concept for timing the
combined therapy of skeletal dysgnathias. Dtsc Zahn Mund Kieferheilkd Zentralbl 79:
557-63.
28- Creekmore and Kunik (1993). Straight-Wire: the next generation. AJODO 104: 8-20
29- Read (2001). The integration of functional and fixed appliances. JO 28:13-18
30- Northway (2004). Hemisection: one large step toward management of congenitally
missing lower second premolars. Angle Orthodontist 74: 792-799
190
31- Arnett and McLaughlin (2004). Facial and Dental Planning for Orthodontists and Oral
Surgeons Edinburgh, Mosby
32- Becker and Chausu (2004). Non-invasive periodontal splinting with multistrand wire
following the realignment of periodontally migrated teeth. Orthodontics 1: 159-167
33- Shah et al (2005). How to place a lower bonded retainer. JO 32: 206-210
34- Polo M (2008). Botulinum toxin type A (botox) for the neuromuscular correction of
excessive gingival display on smiling (gummy smile). AJODO 133: 195-203
35- McNeil (1950). Orthodontic procedures in the treatment of congenital cleft palate. DRJ
(London) 70: 126-132.
36- Cutting et al (1998). Presurgical columellar elongation and primary retrograde nasal
reconstruction in one-stage bilateral cleft lip and nose repair. PRSJ 101: 630–609.
191
Great thanks to the latest Excellence in Orthodontics courses
by David Birnie and Nigel Harradine
for which some of my book ideas, orthodontic subjects and
outlines were based on.
Together, hand by hand,
Orthodontics, is a real, well-supported
and scientifically enriched branch of dentistry.
Raed Alrbata
BDS, JBOrth. OMI Fellow
192
Index
A
D
Absolute anchorage · 64
Acceledent aura appliance · 150 Damon system · 22
Adenotonsillectomy · 30 Debonding procedures · 125, 141
Advansync · 139 Differential force theory · 125, 131
Andrews' six keys · 38 Distal jet · 140
Apo line · 42, 44 Distalization techniques · 125, 139
Archwires · 13, 24
E
B
Early orthodontic treatment · 5, 55, 57
Bleached surfaces · 128 Eastman correction · 9
Body mass index (BMI) · 10, 34 Ectopic maxillary canines · 75, 88
Bolton ratios · 35, 40 Esthetic plane · 9
Bond failure · 17, 18, 19, 127, 130 Etiology of malocclusion · 5, 27
Bond strength · 15, 16, 17, 18, 20, 127, 128, 129, 157 Exposure techniques · 95
Bonding materials · 13, 15
Bracket placement · 125, 130
Breastfeeding · 27, 29
F
Bruxism · 29
Buccal corridor · 45 Facial analysis · 35, 37
Fixed palatal crib · 86
Fluoride elastomers · 32
C Fluorosed teeth · 128
Friction · 125, 132, 133
Central incisors · 75, 97 Functional appliances · 99, 102, 108, 109
Chemical-cured composite · 16
Chin point · 37
Chincup · 99, 122
G
Chlorhexidine digluconate · 16
Circumferential supracrestal fiberotomy · 159 Gingival embrasures · 46
Class II division 2 · 75, 79, 80 Gingival recessions · 163
Class III malocclusions · 80 Golden proportion · 45
Classic straight-wire appliance · 99, 101
Clear aligner therapy · 99, 123
Cleft lip and palate (clp) · 181
H
Closed-coil springs · 139
Cortical bone · 70, 71 Haas-type · 112
Corticotomy · 149 Halogen lights · 18
Crossbite · 75, 87 Harmony (h) line · 9
CuNiTi · 25 Hawley retainers · 155, 156
Curve of spee · 35, 39 Head posture · 30
CVM method · 10, 11 Headgear · 58, 67, 90, 102, 103, 104, 108, 117, 118, 119,
120, 140, 141, 190
Hypodontia · 78, 167
Hyrax-type · 112
193
I O
Incisal trauma · 59 Obstructive sleep apnea · 27, 29

Incremental advancement · 107 Occlusal adjustment · 85, 166
Indirect bonding technique · 125, 129 OMI · 65, 70
Interdental brushes · 33, 34 Open bite · 75, 82
Intermaxillary elastics · 139 Opening and closing spaces · 125, 135
Interproximal enamel reduction · 125, 133 Orthodontic bonding · 15, 17, 127
Intraoral auxiliaries · 125, 137 Orthodontic brackets · 13, 19
Orthognathic surgery · 5, 6, 143, 146
J
P
Jarabak ratio · 9
Pacifier use · 27, 29
Palatal rugae · 10
L Panoramic radiographs · 11
Parallax technique · 94, 187
LED · 18, 19 Peg-shaped · 78, 167
Levelling techniques · 125, 134 Pendulum · 139, 140
Light-cured composite · 16 Permanent retention · 151, 157
Lingual arches · 63 Pitchfork analysis · 10
Lip bumper · 99, 122 Planning extractions · 49
LLHA · 64 Plasma arc · 18, 19
Localization of impacted canines · 93 Polyacrylic acid · 15
Lower incisor position · 35, 41 Primary failure of eruption · 75, 98
Protocols for CLP patient management · 183
Protraction headgear · 99, 117
M Pumicing · 17
Mastication · 34
Microimplants · 68 Q
Micro-osteoperforation · 149
Miniplates · 66 Quadhelix · 99, 110
Miniscrews · 66, 67, 72, 73
Missing laterals · 79
Missing lower 2nd premolar · 77 R
Mouth breathing · 27, 29
Multiloop edgewise · 84 Rapid maxillary expansion · 111
Relapse · 105, 155
Removable appliances · 99, 102
N Root resorption · 161, 166
Ni allergy · 161, 177

NiTi · 25, 26 S
Non-enamel surfaces · 125, 128
Nudger · 140 Self-etching primers · 13, 16
Self-ligating brackets · 13, 20
Shear bond strength · 17, 20
Smile analysis · 35, 45
Smile index · 46
194
Smile width · 53 True vertical line (TVL) · 37
Stainless steel · 25, 26, 71, 132, 133, 135, 157, 168
Supernumerary teeth · 75, 87
Surgically-assisted rapid palatal expansion · 143, 145 V
Vacuum formed retainers · 156

T
TADs · 71 W
Thermoelastic archwires · 24
Thermoplastic retainers · 156, 157 WALA points · 25
TMJ · 77, 78, 161, 163, 164 WALA ridge · 38
Tongue spurs · 31 White spot lesions (WSLs) · 173
Tongue thrusts · 27, 31 Wits appraisal · 9, 119
Tooth agenesis · 78, 79, 92, 98
Tooth movement acceleration · 143, 149
Topical fluorides · 32 Z
Transpalatal arch · 63, 145
Transposition · 75, 97 Zero median line · 10
Treatment planning · 5, 35
195
ISBN: 978-9957-67-019-1

The Black Box of Orthodontic Reserch

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The Black Box of Orthodontic Reserch

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THE BLACK BOX

Royal Medical Services

The Hashemite Kingdom of Jordan

©Raed H. Alrbata, 2017

Raed H. Alrbata, Specialist in orthodontics, Royal medical services,

Acta Odontologica Scandinavica: AOS Journal of Oral Rehabilitation: JOR

Andrews Journal: AJ Journal of Oral and Maxillofacial Surgery:

Journal of Clinical Paediatric Dentistry: Quintessence International: QI

Journal of Dental Research: JDR World Journal of Orthodontics: WJO

Journal of Esthetic Dentistry: JED

Cephalometrics and Radiographic Analyses

Cephalometric Analyses Used in Orthodontics

Cervical Vertebral Maturation (CVM)

Cephalometric Analyses Used in Orthodontics

Jarabak ratio = PFH: AFH, The normal range is: 59 – 63%

Jacobson (1975). The Wits appraisal of jaw disharmony. AJO 67:125-138

Ricketts et al (1979). Bioprogressive Therapy, Denver, Rocky Mountain Orthodontics.

Pitchfork analysis- superimposition of 2 or more lateral cephalometrics, registered on

Johnston (1996). Balancing the books on orthodontic treatment: An integrated analysis of

Palatal rugae landmarks are as reliable as cephalometric structures for superimposition.

Cervical Vertebral Maturation (CVM)

The CVM method is modestly effective in determining the amount of postpeak

Cervical vertebral maturation stages cannot accurately identify the mandibular

Gray et al (2016). Morphometric analysis of cervical vertebrae in relation to mandibular growth.

Materials Used In Orthodontics

Self-etching Primers (SEPs)

Light Curing Devices

Archwires Used in Orthodontics

The mean linear tensile bond strength of enamel is 14.5 MPa.

Reynolds IR (1975). A review of direct bonding. BJO 2: 171-178

No advantage or disadvantage of precuring the primer on the bonding strength.

The addition of chlorhexidine digluconate to conventional GICs does not negatively

Mohammed et al (2016). Comparing orthodontic bond failures of light-cured composite resin

Self-etching Primers (SEPs)

Bishara et al (2001). Effect of a self-etch primer/adhesive on the shear bond strength of

The use of SEP is quicker than a conventional bonding technique. No difference in

Aljubouri et al (2003). Laboratory evaluation of a self-etching primer for orthodontic bonding.

Grubisa et al (2004). An evaluation and comparison of orthodontic bracket bond strengths

Pumicing was found to produce a statistically and clinically significant reduction in

Burgess et al (2006); Self-etching primers: is prophylactic pumicing necessary? A randomized

Campoy et al (2010). Effect of saliva contamination on bracket failure with a self-etching

Light Curing Devices

No statistical difference in the mechanical properties of composites cured with either

Thind et al (2006). A comparison of tungsten-quartz-halogen, plasma arc and light-emitting

A randomised controlled trial to compare LED vs halogen light curing of orthodontic

Mirabella et al (2008). LED vs halogen light-curing of adhesive-precoated brackets. Angle

Harzer et al (2001). Sensitivity of titanium brackets to the corrosive influence of fluoride-

Bracket prescription had no effect on the aesthetic judgments made by experienced

Self-ligating Brackets (SLBs)

When initially placed, an elastomeric in a figure of 8 configuration increases the friction

Turkkahraman et al (2005). Archwire ligation techniques, microbial colonization, and

Chen et al (2010). Systematic review of self-ligating brackets. AJODO 137: 726.e1-726.e18

Ong et al (2010). Efficiency of self-ligating vs conventionally ligated brackets during initial

Maxillary and mandibular intercanine, interpremolar, and intermolar widths increased

The use of conventional or SLBs does not seem to be an important predictor of

Pandis et al (2011). Comparative assessment of conventional and self-ligating appliances on the

Self-ligating esthetic brackets do not promote greater or lesser S mutans colonization

Nascimento et al (2013). Colonization of Streptococcus mutans on esthetic brackets: Self-

No clinically significant difference in treatment efficiency between treatment with a self-

O'Dywer et al (2016). A multi-center randomized controlled trial to compare a self-ligating

No clinically significant difference in pain experience between patients treated with a

Rahman et al (2016). A multicenter randomized controlled trial to compare a self-ligating

No differences in maxillary arch dimensional changes or molar and incisor inclination

The technique of ion implantation is used to modify surfaces exposed to corrosion or