ORIGINAL ARTICLE

Predictable method to deliver physiologic

force for extrusion of palatally impacted
maxillary canines
Michele Tepedino,a Claudio Chimenti,a Francesco Masedu,a and Maciej Iancu Potrubaczb
L'Aquila, Italy

Introduction: Orthodontic treatment of palatally impacted maxillary canines raises many difficulties; to minimize
complications, careful planning of orthodontic extrusion and the use of physiologic force are crucial. The aim of
this study was to quantitatively evaluate a simple and reproducible system for orthodontic extrusion of impacted
canines that can provide the correct amount of force. Methods: Ten specimens were constructed, consisting of a
cantilever made with a 0.6-mm or 0.7-mm stainless steel wire modeled around a transpalatal bar with 3, 5, or 7
loops in the shape of a helical torsion spring. A mechanical testing machine was used to measure the force
produced by the cantilever at 3, 6, 9, 12, and 15 mm of activation. Results: The force values ranged from
1.24 6 0.13 N for the 0.7-mm wire with 3 loops to 0.48 6 0.04 N for the 0.6-mm wire with 7 loops. The forces
measured for the 0.6-mm wire with 3 loops and the 0.7-mm wire with 7 loops were similar at 15 mm of
deflection. Conclusions: The proposed system has a simple and robust design, is easy to construct and
manage, and can provide the desired amount of force by changing the wire diameter and number of loops.
(Am J Orthod Dentofacial Orthop 2018;153:195-203)

O
rthodontic treatment of impacted teeth is often
challenging for both the patient and the clinician
because of prolonged treatment time, the need for
surgical intervention to expose the tooth, and difficult
biomechanics.1-3 The treatment of a palatally impacted
canine involves accurate anchorage preparation, careful
planning of orthodontic traction vectors to prevent root
contact, management of the arch space, and special
attention during the finishing phase.4,5 Some risks that
can accompany orthodontic extrusion and alignment of
an impacted canine include loss of vitality, loss of
periodontal attachment, and root resorption of both the
canine and the adjacent teeth.6 To reduce the risk of
complications, it is important to respect bone biology
and use light forces that should range between 0.4 and
0.6 N according to the literature.7,8 In addition to the
magnitude of the applied force, biomechanical and
a
Department of Biotechnological and Applied Clinical Sciences, University of
L'Aquila, L'Aquila, Italy.
b
Private practice, L'Aquila, Italy.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Michele Tepedino, V. le S. Salvatore, Edificio Delta 6,
L'Aquila 67100, Italy; e-mail, m.tepedino@hotmail.it.
Submitted, February 2017; revised and accepted, May 2017.
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2017.05.035
directional control of the canine movement is necessary;
poorly controlled orthodontic extrusion while the
impacted tooth is near other roots may lead to root
resorption and introduce moments that cause unwanted
rotations of the maxillary canine.9
Several methods have been described to perform
orthodontic extrusion of a palatally impacted canine.
The use of cantilevers, springs, elastomeric chains, and
double archwires (ie, piggyback) are all effective tech-
niques. Despite their diffusion and wide clinical use,
none of these appliances or systems has been adequately
quantified clinically. In a study, 3 commonly used systems
were analyzed, and all of them showed force entities far
beyond the physiologic limit for orthodontic extrusion,
which ranges from 2.35 to 2.57 N.7 Since the impacted
canine moves according to the applied orthodontic force
system, quantification of this force is important for the
validation and selection of 1 system over the others.
The appliance that is used at the Department of
Biotechnological and Applied Clinical Sciences, Univer-
sity of L'Aquila, L'Aquila, Italy, for orthodontic extrusion
of maxillary palatally impacted canines is made of a
stainless steel cantilever welded to a transpalatal bar.
The free end of the cantilever wire is rolled multiple times
around the transpalatal bar. This device is defined as a
helical torsion spring and is described by the following
equation10:
195
196
Fig 1. Schematic diagram of a helical torsion spring: D, radius of the loop; d, diameter of the wire; n,
number of loops; R, length of the arm; F, force produced by the spring; b, the angle at which the arm
is bent.
bd4 E
F5
64DnR
where F is the force produced by the spring, D is the
radius of the loop, d is the diameter of the wire, n is
the number of loops, R is the length of the arm, E is
the elastic modulus, and b is the angle at which the
arm is bent (Fig 1).
The purpose of this study was to precisely quantify
the forces produced by this type of appliance for ortho-
dontic extrusion of an impacted maxillary canine, and to
give the clinician useful information about a system that
is simple and easy to construct and manage, and how to
use it to provide the appropriate and desired force levels.
MATERIAL AND METHODS
The appliance was made of a fixed transpalatal bar
made of 0.9-mm stainless steel wire with a distal loop
soldered to 2 molar bands. A cantilever, which can be
made of stainless steel wires with different diameters,
was then welded to the transpalatal bar after wrapping
it with a variable number of loops; the opposite free
end had an eyelet that was used for ligature ties (Fig 2).
To measure the force exerted by this appliance, spec-
imens made of a 50-mm straight segment of 0.9-mm
stainless steel wire (Leowire; Leone S.p.a., Sesto Fioren-
tino, Firenze, Italy), with a 30-mm cantilever welded
perpendicular to it, were prepared. The cantilever was
constructed using either a 0.6- or 0.7-mm stainless steel
February 2018  Vol 153  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Tepedino et al
wire; for both wire diameters, different specimens were
constructed with 3, 5, or 7 loops around the 0.9-mm
wire (Fig 3). The loops had an inner diameter of
1.4 mm. For each wire diameter and loop number
combination, 10 samples were prepared, for a total of
60 samples. To improve accuracy, the mechanical prop-
erties of the wire were obtained from the technical sheet
of the specific lot of production.
To measure the force produced by the different types
of cantilever, a mechanical testing machine (3365 series;
Instron, Norwood, Mass) with a loading cell of 100 N was
used, and a specific support for the cantilever specimen
was designed and manufactured ad hoc (Fig 4). The
specimen was positioned and firmly secured into the
vise using the support of 6 screws; to prevent rotation
of the specimen, 1 side of the vise was flat, and the other
had a groove that partly housed the 0.9-mm wire. A flat-
headed bit was connected to the crosshead of the testing
machine and positioned at a fixed distance of 20 mm
from the center of the cantilever's loops. The crosshead
was set to run for 17 mm pushing over the cantilever at a
speed of 5 mm per minute, and the force produced was
recorded at 3, 6, 9, 12, and 15 mm. The cantilever arm
was bent in the same direction used for the fabrication
of the loops. The loading cell was calibrated before every
test sequence.
Statistical analysis
The Shapiro-Wilk normality test, indicated for small
samples, was performed to assess the data distribution
Tepedino et al 197

Fig 2. A, lateral and occlusal views of an example of the proposed appliance for orthodontic extrusion
of palatally impacted maxillary canines; B, the same appliance with occlusal rests added; note that the
cantilever arm has an omega loop added for the possibility of modifying the position of the free end of
the cantilever by acting on the omega loop, to better adapt the eyelet to the canine's crown attachment
after surgical exposure. The addition of this loop will slightly decrease the cantilever load-deflection
rate.

(P \0.05). One-way analysis of variance (ANOVA) was
conducted to examine the effect of the different combi-
nations of wire diameter and number of loops on the
force values measured at 15-mm deflection. The Levene
test was used to test the assumption of equal error vari-
ance. The Tukey Honestly Significant Difference test or
the Games-Howell test was performed for the post hoc
analysis. After applying the Bonferroni correction for
multiple tests, first-type error was set at 0.008.
RESULTS
The mechanical properties of the stainless steel wires
are provided in Table I. Descriptive statistics are reported
in Table II. Force value increases as the cantilever bends,
although not in a linear fashion as described by the equa-
tion, or if a stiffer wire is used; in addition, the force value
decreases as the number of loops increases (Fig 5). The
highest force values were produced by the cantilever
made of 0.7-mm wire with 3 loops, which were as high
as 1.24 6 0.13 N when the cantilever arm was bent at
15 mm; the lowest forces (0.48 6 0.04 N at 15 mm of
deflection) were measured using the 0.6-mm wire with a
7-loop cantilever. The forces measured for the 0.6-mm
wire with 3 loops and the 0.7-mm wire with a 7-loop
cantilever at 15 mm of deflection were similar
(0.74 6 0.08 N and 0.77 6 0.05 N, respectively).
The Shapiro-Wilk normality test showed that all
measurements were normally distributed, except for the
0.6-mm wire with 3 loops at a deflection of
3 mm (P 5 0.022). There was a statistically significant
difference between the force values at the 15-mm deflec-
tion using the different cantilevers as determined by 1-way
ANOVA (F [5] 5 112.2; P \0.001; adjusted R2 5 0.90)
and reported in Table III. The Levene test showed that
the error variances were not equal between groups
(P 5 0.003); therefore, the Games-Howell post hoc test

American Journal of Orthodontics and Dentofacial Orthopedics February 2018  Vol 153  Issue 2
198 Tepedino et al

Fig 3. Specimens used in this study: A, 0.6-mm wire with 3 loops; B, 0.7-mm wire with 3 loops; C, 0.6-
mm wire with 5 loops; D, 0.7-mm wire with 5 loops; E, 0.6-mm wire with 7 loops; F, 0.7-mm wire with 7
loops.

was used. All comparisons were statistically significant
(P\0.008), except between the 0.6-mm wire with 3 loops
and the 0.7-mm wire with 7 loops, and between the 0.6-
mm wires with 5 loops and 7 loops (Table IV).
DISCUSSION
According to the available literature, the recommen-
ded force for orthodontic extrusion should not exceed
0.6 N because excessive force may be associated with
loss of vitality and root resorption.8 However, as high-
lighted in a systematic review by Ren et al,11 there is
no sound scientific evidence supporting precise force
values that can be clearly suggested for orthodontic
tooth movement.
Han et al12 applied 1.0 N of extrusive force on maxil-
lary first premolars and then measured the root surface
using scanning electron microscopy. Although they
found that extrusive forces can provoke root resorption,
because 1.28% 6 1.24% of the root surface was affected
by resorption, there was no statistically significant dif-
ference between the extruded and control teeth. In addi-
tion, even with 0.5 N of force, described as the ideal
magnitude, minor root resorption can be observed.13
Few studies have investigated and quantified the
forces clinically used for the orthodontic extrusion of
impacted canines. Yadav et al7 measured the forces
expressed by 3 commonly used systems—a Kilroy spring,
an elastomeric chain, and a ligature wire—and found
that their values were about 2.4 to 2.6 N, far beyond
the recommended range. This means that, in many
patients with impacted maxillary canines, a largely
uneven force is applied. Oue results show that the force

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Tepedino et al 199

Fig 4. The support specifically designed for testing, positioned in the mechanical testing machine. The
picture shows how the specimen was firmly secured to the support.

The cantilever appliance described here is based on

Table I. Mechanical properties of the stainless steel the principle of a helical torsion spring (Fig 1), and the
wires from each production lot force produced depends on the radius of the loop (D),
the diameter of the wire (d), the length of the cantilever
Tensile Yield strength Elongation at
Wire diameter strength (Mpa) 0.2% (Mpa) 100 mm (%) arm (R), the mechanical properties of the wire (E, elastic
0.6 mm 1901-1938 1517-1569 0.8-1.6 modulus), the angle at which the arm is bent (b), and the
0.7 mm 1904-1953 1400-1579 1.2-1.8 number of loops (n), as can be seen in the equation:
Values reported as minimum and maximum. bd4 E
F5
64DnR
levels—the highest being 1.24 N for the 0.7-mm wire with This behavior is interesting because having the same
3 loops at the maximum deflection of 15 mm—can be material, wire and loop dimensions, arm length, and
lowered to within the physiologic range by increasing amount of bending but increasing the number of loops
the number of loops or using a smaller wire (Table II), will reduce the amount of force, and vice versa; this is
with a force of 0.48 N obtained using a 0.6-mm wire evident in the results shown in Table II. This means
with 7 loops at a maximum deflection of 15 mm. Similar that playing with the wire diameter and the number of
forces could also be reached with a properly designed loops provides the desired force level. For example,
cantilever made of beta titanium with a much lower based on the results in Table IV, it is possible that having
elastic modulus.9 However, stainless steel is easier to a 0.7-mm wire with 7 loops or a 0.6-mm wire with 3
weld, stiffer, and less prone to breakage than beta tita- loops results in a similar amount of force; in fact, the dif-
nium,14,15 and the design of this proposed appliance is ference between the force measured for those combina-
particularly simple and easy to manage. tions is not statistically significant. From a clinical

American Journal of Orthodontics and Dentofacial Orthopedics February 2018  Vol 153  Issue 2
200 Tepedino et al

Table II. Force values (N) measured at different activation distances (mm) for every cantilever type (n 5 10)
Activation

3 mm 6 mm 9 mm 12 mm 15 mm

Cantilever Minimum- Minimum- Minimum- Minimum- Minimum-

type Mean 6 SD maximum Mean 6 SD maximum Mean 6 SD maximum Mean 6 SD maximum Mean 6 SD maximum
0.6-mm wire, 0.27 6 0.03 0.24-0.32 0.47 6 0.04 0.42-0.53 0.61 6 0.07 0.54-0.72 0.67 6 0.09 0.55-0.84 0.74 6 0.08 0.65-0.89
3 loops
0.6-mm wire, 0.22 6 0.02 0.19-0.25 0.38 6 0.03 0.34-0.42 0.47 6 0.04 0.4-0.55 0.52 6 0.05 0.45-0.6 0.54 6 0.05 0.48-0.64
5 loops
0.6-mm wire, 0.17 6 0.02 0.13-0.2 0.3 6 0.02 0.25-0.34 0.4 6 0.02 0.34-0.43 0.45 6 0.04 0.4-0.52 0.48 6 0.04 0.43-0.54
7 loops
0.7-mm wire, 0.44 6 0.03 0.4-0.51 0.79 6 0.06 0.71-0.88 1.04 6 0.09 0.94-1.16 1.18 6 0.1 1.01-1.35 1.24 6 0.13 1-1.39
3 loops
0.7-mm wire, 0.36 6 0.03 0.31-0.42 0.62 6 0.05 0.54-0.7 0.82 6 0.07 0.7-0.91 0.93 6 0.09 0.77-1.04 0.99 6 0.12 0.78-1.12
5 loops
0.7-mm wire, 0.29 6 0.03 0.25-0.33 0.5 6 0.04 0.44-0.57 0.66 6 0.05 0.58-0.74 0.74 6 0.05 0.66-0.85 0.77 6 0.05 0.69-0.84
7 loops

Fig 5. Graph showing the force values (N) measured at each distance at which the cantilever was bent
(mm) for every type of wire diameter-loop number combination.

perspective, this has great importance because a 0.7-mm
stainless steel wire is much stiffer and less prone to
breakage or deformation than is a 0.6-mm wire; yet by
simply adding more loops, it is possible to combine
this advantage with the lighter forces typical of a 0.6-
mm wire. It is simple to tell the technician the desired
specifications for the appliance because no complicated
bends are required to reach the desired force level.
On the other hand, when the force is lighter—ie, for
the 0.6-mm wire with 5 and 7 loops—adding more loops
does not lead to significant improvement: the difference
in force values between these 2 cantilever types was not
statistically significant (Table IV). In the plots in Figure 5,
force values for increasing deflections did not change in
a perfect linear fashion, as the equation would suggest,
and this was more evident for the smaller 0.6-mm wires.
In our experimental setup, the distance between the
loops and the point of force application (ie, length of
the cantilever arm) was set at 20 mm; this was chosen
as the mean value for the distance between the first
molar and a hypothetical impacted canine's attachment.
In a clinical environment, however, this distance can vary
and should be considered. The force changes as the
cantilever is more activated (ie, bent); therefore, force
values were measured at 3, 6, 9, 12, and 15 mm of acti-
vation. However, only the values recorded at 15 mm
were used for the statistical analysis to better depict
the general behavior of the cantilever and because a

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Tepedino et al 201

Table III. One-way ANOVA for force values (N)

measured at 15 mm of activation for all cantilever
types
Sum of Mean Partial eta
Source squares df square F P squared
Cantilever 4,025 5 0.805 112,206 \0.001 0.912
type
Error 0.387 54 0.007
Total 42,128 60

R2 5 0.912 (adjusted R2 5 0.904).

Table IV. Games-Howell post-hoc pairwise compari-

son for 1-way ANOVA
Fig 6. Schematic diagram showing the forces and mo-
99.2% CI
Mean ments produced by the cantilever: CR, Center of resis-
difference Se P Lower Upper tance; F1, the extrusive force acting on the canine; F2,
0.6-mm wire, 3 loops vs 0.19 0.03 \0.001* 0.06 0.32 the reactive force transmitted to the molars; M1, the
0.6-mm wire, 5 loops moment for the canine; M2, the applied moment for the
0.6-mm wire, 3 loops vs 0.25 0.03 \0.001* 0.13 0.38 molars; d1, the distance between the points of force appli-
0.6-mm wire, 7 loops cation on the molars and the canine; d2, the distance be-
0.6-mm wire, 3 loops vs 0.51 0.05 \0.001* 0.71 0.31 tween the point of force application on the canine and its
0.7-mm wire, 3 loops center of resistance.
0.6-mm wire, 3 loops vs 0.25 0.04 \0.001* 0.44 0.06
0.7-mm wire, 5 loops
0.6-mm wire, 3 loops vs 0.03 0.03 0.872 0.16 0.09
0.7-mm wire, 7 loops
0.6-mm wire, 5 loops vs 0.06 0.02 0.091 0.03 0.15
0.6-mm wire, 7 loops
0.6-mm wire, 5 loops vs 0.7 0.04 \0.001* 0.89 0.51
0.7-mm wire, 3 loops
0.6-mm wire, 5 loops vs 0.44 0.04 \0.001* 0.62 0.27
0.7-mm wire, 5 loops
0.6-mm wire, 5 loops vs 0.23 0.02 \0.001* 0.32 0.13
0.7-mm wire, 7 loops
0.6-mm wire, 7 loops vs 0.76 0.04 \0.001* 0.95 0.57
0.7-mm wire, 3 loops
0.6-mm wire, 7 loops vs 0.51 0.04 \0.001* 0.68 0.33
0.7-mm wire, 5 loops
0.6-mm wire, 7 loops vs 0.29 0.02 \0.001* 0.37 0.21
0.7-mm wire, 7 loops
0.7-mm wire, 3 loops vs 0.26 0.05 0.002* 0.03 0.48
0.7-mm wire, 5 loops Fig 7. Schematic diagram showing the effect of the
0.7-mm wire, 3 loops vs 0.47 0.04 \0.001* 0.28 0.67 tongue on the transpalatal bar and the molars: CR, Center
0.7-mm wire, 7 loops of resistance; Ft, the force transmitted by the tongue to the
0.7-mm wire, 5 loops vs 0.22 0.04 0.001* 0.04 0.39 transpalatal bar; d, the distance between the point of force
0.7-mm wire, 7 loops application and the center of resistance; Mt, the moment
produced by the force applied by the tongue.
*Statistically significant, P \0.008.

allows the canine to extrude until reaching the occlusal

smaller activation is unlikely to be used in an in-vivo
situation and was judged to be unimportant from a clin-
ical point of view. Based on our experience, intraoral
activation of the cantilever arm is not comfortable for
either the patient and the clinician; therefore, it is pref-
erable to make it preactivated for the desired amount of
movement, and 15 mm is an adequate distance that
plane from its initial position.
Another factor influencing the final characteristics of
the cantilever is the mechanical characterization of the
wire material: a stainless steel wire was used because it
can be easily welded to the transpalatal bar, allowing for
greater stability compared with a slot-wire connection
type, and has optimal resistance to breakage or

American Journal of Orthodontics and Dentofacial Orthopedics February 2018  Vol 153  Issue 2
202 Tepedino et al

Fig 8. Example of the clinical application of the device, from a patient with a monolateral maxillary
canine impaction: A, pretreatment panoramic radiograph; B, surgical exposure by opercolectomy
and start of orthodontic extrusion; C, the canine extruded to the level of the occlusal plane; D, intraoral
occlusal photograph at the end of treatment.

deformation. The properties of the wires used were
obtained from the manufacturer's information relative to
the specific lot used in this study; because material proper-
ties can vary among lots,16 this ensured increased precision.
Regarding the biomechanics of this system (Fig 6),
the impacted canine is exposed to an extrusive force
and a rotational moment because the point of force
application does not coincide with the center of resis-
tance of the tooth. This results in a moment that keeps
the canine's crown away from the roots of the incisors
during extrusion. If needed, this rotational effect can
be increased by lengthening the distance between the
canine's center of resistance and the cantilever's free
end. On the other hand, the molars receive an intrusive
force and a moment that moves the crowns mesially
(Fig 6). The transpalatal bar increases anchorage on
the molars, and occlusal rests can be added on the first
and second premolars to better counteract this mesial
rotation of the molars, when a maximum posterior
anchorage is needed. However, in such a case, a possible
intrusive effect on the premolars should be also consid-
ered. In addition, the tongue applies a certain amount of
force to the transpalatal bar: during deglutition, that
happens nearly 2400 times per day,17 with pressure
ranging from 0.97 to 2.23 N/cm2 recorded by Chiba
et al.18 The pressure exerted by the tongue depends on
the vertical and sagittal position of the loop of the trans-
palatal bar. It has been demonstrated that the transpala-
tal bar is effective in constraining the extrusion of the
molars19; therefore, the action of the tongue should be
taken into account. In light of these considerations, it
is recommended to have the loop of the transpalatal
bar distally oriented, as shown in Figure 7. Because the
loop is positioned at a distance from the center of resis-
tance of the molar, the pressure of the tongue onto the
loop produces a moment; if the loop is positioned
distally, the effect of this moment will be the distal rota-
tion of the molar's crown. This will counteract the mesial
moment produced as a reactive effect of the cantilever
(Fig 7).
An example of the clinical application of the
described device is provided in Figure 8, where the treat-
ment sequence of a monolateral canine impaction is
shown. In this 12-year-old boy, orthodontic traction
lasted 3.5 months, and a satisfactory final result was
achieved.
CONCLUSIONS
The cantilever appliance for the orthodontic extru-
sion of palatally impacted maxillary canines described

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Tepedino et al
here included a transpalatal bar with a distal loop and an
active soldered stainless steel cantilever arm with multi-
ple loops surrounding the 0.9-mm wire of the transpala-
tal bar. This design recalls a helical torsion spring; by
having the same arm length, angle of deflection, and
loop radius, it is possible to have a different force magni-
tude depending on the diameter of the wire or the
number of loops. The wire diameter should have a
greater effect on the final force exerted, but changing
the number of loops on a stiffer wire can lead to similar
force values produced by a smaller wire. The force values
measured were much lighter than those reported in the
literature for a commonly used system and could be
applied in the physiologic range of 0.4 to 0.6 N.
Further studies are needed to prove the clinical
efficacy of this appliance.
ACKNOWLEDGMENTS
We thank Leone S.p.A., Centro Bioricerche Marco
Pozzi, Gabriele Scommegna, Elia Ladani, and Lorenzo
Lorenzin for granting permission to use their laboratory
instrumentation; and GEO Ortodonzia dental laboratory
(Rome, Italy), Massimiliano Bucceri, Soluzioni Odonto-
protesiche dental laboratory (L'Aquila, Italy), A. Bafile,
R. Pezzopane, and M. Pezzopane, for manufacturing
the cantilever samples.
REFERENCES
1. Becker A, Chaushu S. Success rate and duration of orthodontic
treatment for adult patients with palatally impacted maxillary
canines. Am J Orthod Dentofacial Orthop 2003;124:509-14.
2. Pavoni C, Franchi L, Lagana G, Baccetti T, Cozza P. Management
of impacted incisors following surgery to remove obstacles to
eruption: a prospective clinical trial. Pediatr Dent 2013;35:364-8.
3. Iancu Potrubacz M, Tepedino M, Chimenti C. Maxillary canine-
first premolar bilateral transposition in a Class III patient: a case
report. Angle Orthod 2016;86:509-19.
4. Kokich VG. Surgical and orthodontic management of impacted
maxillary canines. Am J Orthod Dentofacial Orthop 2004;126:
278-83.
American Journal of Orthodontics and Dentofacial Orthopedics
203
5. Crescini A, Nieri M, Buti J, Baccetti T, Prato GP. Orthodontic
and periodontal outcomes of treated impacted maxillary
canines: an appraisal of prognostic factors. Angle Orthod
2007;77:571-7.
6. Blair GS, Hobson RS, Leggat TG. Posttreatment assessment of
surgically exposed and orthodontically aligned impacted maxillary
canines. Am J Orthod Dentofacial Orthop 1998;113:329-32.
7. Yadav S, Chen J, Upadhyay M, Jiang F, Roberts WE. Comparison of
the force systems of 3 appliances on palatally impacted canines.
Am J Orthod Dentofacial Orthop 2011;139:206-13.
8. Bishara SE. Impacted maxillary canines: a review. Am J Orthod
Dentofacial Orthop 1992;101:159-71.
9. Fleming PS, Sharma PK, DiBiase AT. How to.mechanically erupt
a palatal canine. J Orthod 2010;37:262-71.
10. Schmid SR, Hamrock BJ, Jacobson BO. Fundamentals of machine
elements (SI version). 3rd ed. Boca Raton, Fla: Taylor & Francis;
2014.
11. Ren Y, Maltha JC, Kuijpers-Jagtman AM. Optimum force magni-
tude for orthodontic tooth movement: a systematic literature
review. Angle Orthod 2003;73:86-92.
12. Han G, Huang S, Von Den Hoff JW, Zeng X, Kuijpers-Jagtman AM.
Root resorption after orthodontic intrusion and extrusion: an
intraindividual study. Angle Orthod 2005;75:912-8.
13. Reitan K. Effects of force magnitude and direction of tooth move-
ment on different alveolar bone types. Angle Orthod 1964;34:
244-55.
14. Kapila S, Sachdeva R. Mechanical properties and clinical applica-
tions of orthodontic wires. Am J Orthod Dentofacial Orthop
1989;96:100-9.
15. Murakami T, Iijima M, Muguruma T, Yano F, Kawashima I,
Mizoguchi I. High-cycle fatigue behavior of beta-titanium ortho-
dontic wires. Dent Mater J 2015;34:189-95.
16. Pompei-Reynolds RC, Kanavakis G. Interlot variations of transition
temperature range and force delivery in copper-nickel-titanium
orthodontic wires. Am J Orthod Dentofacial Orthop 2014;146:
215-26.
17. Straub WJ. Malfunction of the tongue, part II. The abnormal swal-
lowing habit: its causes, effects, and results in relation to ortho-
dontic treatment and speech therapy. Am J Orthod 1961;47:
596-617.
18. Chiba Y, Motoyoshi M, Namura S. Tongue pressure on loop of
transpalatal arch during deglutition. Am J Orthod Dentofacial
Orthop 2003;123:29-34.
19. DeBerardinis M, Stretesky T, Sinha P, Nanda RS. Evaluation of the
vertical holding appliance in treatment of high-angle patients. Am
J Orthod Dentofacial Orthop 2000;117:700-5.
February 2018  Vol 153  Issue 2