REVIEW ARTICLE

Effect of lip bumpers on mandibular

arch dimensions
Dena Ibrahim Hashisha and Yehya Ahmed Mostafab
Cairo, Egypt

Introduction: The aim of this systematic review was to examine the effects of lip bumper therapy on
mandibular arch dimensions. Methods: A literature survey of PubMed, EMBASE, Cochrane Central, and
Cochrane Database of Systematic Reviews (www.cochrane.org) was conducted from December 1968 to
January 2007. Human studies, randomized clinical trials, prospective and retrospective studies, and studies
discussing the effect of lip bumpers on the arch and teeth were included. Two reviewers independently
selected and extracted the data. Results: Of the 52 studies found in the search, only 1 met the inclusion
criteria. Conclusions: The results showed increases in arch dimensions that included an increase in arch
length. This was attributed to incisor proclination, distalization, and distal tipping of the molars. There was
also an increase in the arch width seen in the intercanine and deciduous intermolar and premolar distances.
The long-term stability of the effects of the lip bumper need to be elucidated. (Am J Orthod Dentofacial
Orthop 2009;135:106-9)

I
n the extraction vs nonextraction debate, there has
been growing interest in nonextraction modalities
of treatment. The lip bumper (LB) can be used in
nonextraction patients. The primary purposes of an LB
have been to reduce mandibular anterior crowding,1-6
and to increase arch width and length.1,2,4,7-12 It has
also been claimed that an LB maintains the position of
the first molar and leeway space through molar anchor-
age.1,3,5,6,9-11,13
Several studies have discussed the effects of the
LB.1-18 Systematic reviews, the backbone of evidence-
based dentistry, are designed not only to identify all
relevant information in the literature, but also to eval-
uate the quality of the information and then, if possible,
to summarize the results from the strongest (or least
biased) studies.19 Therefore, it seemed important to
conduct a systematic review to interpret the results of
LB studies.
In this study, many sources were systematically
searched, assessed, and evaluated to answer the follow-
ing question: what are the effects of the LB on
mandibular arch dimensions (length, width, and perim-
eter) in adolescents compared with untreated patients?
From the Department of Orthodontics and Dentofacial Orthopedics, Faculty of
Dentistry, Cairo University, Cairo, Egypt.
a
Resident.
b
Professor and chairperson.
Reprint requests to: Yehya A. Mostafa, Department of Orthodontics and
Dentofacial Orthopedics, Cairo University, Faculty of Dentistry, P.O. Box 60,
Mina Garden Post Office, October City, Cairo 12582, Egypt; e-mail,
mangoury@usa.net.
Submitted, June 2007; revised and accepted, October 2007.
0889-5406/$36.00
Copyright © 2009 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.10.038
106
MATERIAL AND METHODS
To identify all studies about the effect of LBs, a
computer search was conducted of PubMed (http://
www.ncbi.nlm.nih.gov/sites/entrez), EMBASE, Cochrane
Central, and Cochrane Database of Systematic Reviews
from December 1968 to January 2007. The terms used in
literature search were “lip bumper, arch length, arch
width, arch dimension, arch circumference, arch depth,
incisor proclination, lip sucking, lip habits, and orth-
odontics.” The following journals was searched sepa-
rately to locate any missing articles from the PubMed
search: Angle Orthodontist, American Journal of Orth-
odontics and Dentofacial Orthopedics, Journal of
Orthodontics, and European Journal of Orthodontics.
RESULTS
Our first step was to identify eligible studies based
on their titles and abstracts; we found 52 abstracts.
When we compared the separate searches of the previ-
ously mentioned journals with the PubMed search, we
found no missing articles. The 52 studies were in-
cluded. The second step was to apply our inclusion and
exclusion criteria to each study.
Human studies, randomized clinical trials, prospec-
tive and retrospective studies, studies discussing the
effect of lip bumpers on the arch and teeth, and those in
English were included. Excluded articles were mainly
animal studies, case reports, case series, review articles,
abstracts, in-vitro studies, discussions and interviews,
articles in a language other than English, and those that
did not follow the objective of this review. The selec-
tion was made by 2 researchers separately (made by the
American Journal of Orthodontics and Dentofacial Orthopedics Hashish and Mostafa 107
Volume 135, Number 1

2 authors). Their results were compared to identify

discrepancies and reach mutual agreement.
Sixteen studies seemed to meet the inclusion crite-
ria. Their reference lists were searched for any missing
articles from the database search. Information was
extracted in a standardized manner from every retrieved
article. Each study had to have a suitable sample size
and a control group, mention the sexes and ages of the
subjects, use study casts and lateral cephalometrics, and
confirm reliability through error measurement. Fifteen
studies were rejected because of methodological errors
(Fig and Table).
If 2 or more articles had evaluated the same
technique, a meta-analysis was planned. The article by
Davidovitch et al1 was the only 1 finally selected. This
article discussed a prospective clinical trial to study the
effect of LB therapy on patients in the mixed dentition
with mild to moderate mandibular arch deficiency.
Thirty-four patients, ages 7.9 to 13.1 years with 3 to 8
mm of mandibular crowding, were divided into 2
groups: control (n ⫽ 18) and experimental (n ⫽ 16).
The experimental group underwent continuous LB
therapy, whereas the control group was monitored
without active treatment. The patients were recalled Fig. QUOROM flow diagram (RCT, randomized clinical
every 4 to 6 weeks for appliance adjustment and trial).
monitoring, with a total treatment period of 6 months.
Arch-dimension changes were assessed with study Table. Studies that fulfilled the selection criteria but
casts. Alterations of mandibular incisor position were were later rejected
measured from the lateral cephalometric radiographs.
Mandibular left first permanent molar position changes Author Year Missing criteria
were determined from both the lateral cephalometric Moin and Bishara7 2007 1, 3, 5
and tomographic radiographs. Measurements of molar Solomon et al14 2006 1, 2
movement were also compared. According to the au- Waring et al15 2005 1, 2, 5
thors, arch perimeter was the distance from the mesial Ferris et al2 2005 1, 4
contact point of the first permanent molar on 1 side of Ferro et al16 2004 1, 2, 3, 5
Vanarsdall et al17 2004 5
the mandibular arch to the same point on the contralat- Murphy et al8 2003 1
eral molar. Arch length was measured as the perpen- Sankey et al18 2000 1
dicular length of a line between the central pits of the Hasler and Ingervall9 2000 1
first permanent molars through the contacts of the O’Donnell et al3 1998 1
central incisors. Arch-width changes were measured on Grossen and Ingervall10 1995 1, 2, 5
Werner et al11 1994 1, 2
the dental casts between the deciduous molars (central Nevant et al4 1991 1, 2, 4
fossa to central fossa) and the canines (cusp to cusp). Osborn et al5 1991 1
The incisor proclination was measured as the angle Bergersen6 1972 1, 2, 5
formed by the long axis of the mandibular central Criteria: 1, control group; 2, sex; 3, age; 4, study casts and
incisor to the mandibular plane.1 cephalometric analysis; 5, measurement error.

DISCUSSION In our systematic review, we tried to collect and

Because of the increased interest in LB as an
alternative method to extraction, many studies were
conducted to determine its effects on arch width and
length. The therapeutic effects have not always been
elucidated.
analyze all data from previous articles related to our
key question: what are the effects of the LB on
mandibular arch dimensions in adolescents compared
with untreated patients? Many studies were excluded
by our exclusion criteria (Table). One study1 quantified
108 Hashish and Mostafa
the effects correctly, making it clear that the LB can
increase arch dimensions and contribute to crowding
relief in mixed dentition.
In this prospective study, to separate any influence
of other simultaneous treatment, the LB was the only
therapy used to affect the mandibular arch directly. The
tools used to measure specific tooth movement were
also evaluated. All data were analyzed independently
by 2 observers to compare interobserver reliability and
the efficacy of the radiographic imaging techniques
used.
To elucidate the true effects of LB for increasing
the arch dimensions, the following discussion is di-
vided into 3 subheads to determine the contributing
factors for increasing arch length.
Molar distalization
Davidovitch et al1 reported that quantification of
molar movement is related to the imaging technique
used. Although cephalometric data showed no statisti-
cal differences in molar position between the experi-
mental and control subjects, significant treatment ef-
fects were deterined by tomographic measurements. All
treated subjects had distal (negative) molar tipping,
regardless of the radiographic technique used for data
gathering. However, quantitative differences in this
movement were noted between the radiographic imag-
ing techniques. Tomographic data (⫺6.31° ⫾ 1.28°)
showed approximately twice the angulation changes
as measured from lateral cephalometric radiographs
(⫺3.38° ⫾ 3.67°).
Anteroposterior changes in molar position were
statistically different for treated vs untreated subjects
when compared tomographically (⫺1.66 ⫾ 0.53 mm
and ⫹0.65 ⫾ 0.59 mm, respectively), with a negative
sign indicating distal movement. No significant differ-
ence was found in comparisons with the cephalometric
data.
Bergersen6 reported that 95% of the patients
showed distalization that depended on the number of
days that the LB was used and number of times that it
was linearly advanced from the molars from both sides.
The patients who had 50 days of LB treatment showed
0.853 mm of distalization, and those who had more
than 50 days of LB treatment showed 1.00 mm of
distalization. In patients without LB advancement, the
molars moved 0.78 mm distally. Patients had a mean of
1.49 mm of lip bumper advancement, and the molars
moved 1.00 mm distally. Subtelny and Sakuda13
showed 88% distalization. Osborn et al5 and Grossen
and Ingervall10 found minimal posterior movement of
the molars, whereas O’Donnell et al3 found 0.95 mm of
distal movement of the first molars.
American Journal of Orthodontics and Dentofacial Orthopedics
January 2009
Arch width
Davidovitch et al1 found that untreated subjects had
reductions in transverse dimensions between the decid-
uous second molars (⫺0.33 ⫾ 0.67 mm) and the
permanent canines (⫺0.25 ⫾ 0.92 mm). Those treated
for 6 months with an LB showed an increase in arch
width between the second deciduous molars (⫹1.83 ⫾
1.32 mm) and the permanent canines (⫹1.80 ⫾ 0.41
mm). Osborn et al5 found average increases in inter-
molar width and widths at the first and second premo-
lars of 1.92, 2.5, and 2.43 mm, respectively.
There was no correlation between the mean changes
in arch length and length of treatment. Cetlin and Ten
Hoeve12 indicated that the increase in arch width was
the primary cause of increased arch circumference. The
increases in arch width at the molars and first premolars
were 5.5 and 4 mm, respectively. Nevant et al4 reported
the expansion to be 2.09 mm at the first premolars,
whereas Grossen and Ingervall10 measured the expan-
sion at 2.1 and 2.2 mm at the first and second premo-
lars, respectively.
Werner et al11 showed significant increases
throughout the arch but most notably at the second
premolars (average, 4.1 mm). Hasler and Ingervall9
found the main effect of the maxillary LB to be
widening of the arch at the interpremolar area, and the
intermolar and intercanine changes were negligible.
Murphy et al8 found that 50% of the total expansion
occurred within about the first 100 days, and 90% of the
total expansion was achieved during the first 300 days,
making it unnecessary to leave the appliance in place
for longer than 300 days. However, the authors did not
determine whether this increase was due to growth or
LB therapy.
Ferris et al2 reported that intercanine width in-
creased the least (1.37 ⫾ 1.7 mm) and inter-first
premolar width increased the most (4.7 ⫾ 2.6 mm).
Moin and Bishara7 found the greatest mean expansions
at the first (5.0 ⫾ 2.2 mm) and second (3.4 ⫾ 2.2 mm)
premolar widths.
From this, it is evident that an important contribut-
ing factor to arch length increase by the LB is the
increase in arch width in the buccal segment. There is
a need to quantify the amount of width increase in
relation to the total increase in arch length.
Incisor proclination
Davidovitch et al1 repoted that treated subjects had
an angular change in incisor inclination nearly 6 times
greater (3.19° ⫾ 2.40°) than did the untreated subjects
(0.5° ⫾ 1.7°). Anteroposterior changes in incisor posi-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 135, Number 1
tion measured as movement of the apex did not differ
significantly between the 2 groups.
Bergersen6 reported forward migration of the man-
dibular incisors in 95% of the subjects. There was no
significant correlation between the time that the LB was
placed or the linear advancement and the forward
movement. In 78 days, the average movement was 1.45
mm. Osborn et al5 reported that the mean increase in
arch length of 1.2 mm was largely attributed to anterior
tipping of the mandibular incisors in 78% of the
subjects. These results were similar to those of Nevant
et al,4 Grossen and Ingervall,10 and O’Donnell et al.3
Hasler and Ingervall9 found that incisor proclination
was not significant (1.4°).
With the limitations of available studies and total
samples for this systematic review, we can state that the
LB is an effective appliance for increasing arch dimen-
sions in the mixed dentition. All studies agreed that it has
a positive effect on the arch. According to Davidovitch et
al,1 the perimeter increase was caused by angular and
linear changes of molar position, passive increases in
mandibular arch transverse dimensions, and incisor pro-
clination. Molar movement and transverse increases were
found to contribute as much, if not more, to increased arch
perimeter as did incisor proclination.
CONCLUSIONS
In this systematic review, we discussed the effects
of LB treatment. The key question was “what are the
effects of the LB on mandibular arch dimensions in
adolescents compared with untreated patients?” Our
results showed increases in arch dimensions that in-
cluded an increase in arch length. This was attributed to
incisor proclination, distalization, and distal tipping of
the molars. There were also increases in arch width and
intercanine and deciduous intermolar or premolar dis-
tances. The long-term stability of the effects of the LB
need to be elucidated.
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Hashish and Mostafa 109
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