Journal of the World Federation of Orthodontists 9 (2020) S31eS39

Special Review Article

Potential and limitations of orthodontic biomechanics: recognizing

the gaps between knowledge and practice
Joseph G. Ghafari a, b, Anthony T. Macari a, *, Kinan G. Zeno a,
Ramzi V. Haddad a
a
Division of Orthodontics and Dentofacial Orthopedics, Department of Otolaryngology-Head and Neck
Surgery, American University of Beirut Medical Center-Beirut, Lebanon
b
Department of Orthodontics, University of Pennsylvania, Philadelphia, Pennsylvania

a r t i c l e i n f o a b s t r a c t

Article history: The perennial goals of efficient biomechanics are to obtain more controlled and faster movement and
Received 8 August 2020 using more discrete appliances. The most recent technological advances have buttressed these goals.
Accepted 18 August 2020 Temporary anchorage devices have revolutionized orthodontic practice and loom as a solid cornerstone
Available online 30 September 2020
of orthodontic science, along with the use of light forces, facilitated by “smart” archwires for optimal
tooth movement. Accelerated tooth movement with decortication has been successful because of
Keywords:
decreasing the resistance of cortical bone but micro-osteoperforation has not matched the same results.
Biological enhancement
Clear aligners and preprogrammed regular or lingual appliances reflect the importance of three-
Biomechanics
Orthodontic anchorage
dimensional technology in appliance design based on treatment outcome. These mechanical de-
Technological advances velopments have inched the science closer to the traditional goals, but advances lack regarding their
Tooth movement enhancement by biomaterials in a system where the physical stimulus is exerted on the teeth but the
expression of tooth displacement is through the biological processes within the surrounding tissues. In
this article, present tenets, applications, and advances are explored along with the gaps between
knowledge and practice and the possibilities to bridge them. Anchorage control remains the major
widely used development but slower is the development of faster noninvasive treatment.
Ó 2020 World Federation of Orthodontists.

1. The power of statistics: central tendencies and outliers
Statistics facilitates the scientist's way of thinking because it
ranges from producing and describing precise data and accounting
for the probability (P) of incorrect results, to the possibility of
Funding: The authors have not declared a specific grant for this research from
any funding agency in the public, commercial or not-for-profit sectors.
Competing interest: The authors have completed and submitted the ICMJE
Form for Disclosure of potential conflicts of interest. None declared.
Provenance and peer review: Commissioned; Internally peer reviewed.
* Corresponding author: Division of Orthodontics and Dentofacial Orthopedics,
American University of Beirut Medical Center, P.O. Box 11e0236, Riad El-Solh, Beirut
1107 2020, Lebanon.
E-mail address: am43@aub.edu.lb (A.T. Macari).
predicting a specific outcome. Statistics exemplifies the scientific
ability to describe a problem or phenomenon, sort out the efficiency
of a new discovery, and use data when making a decision. The
fundamental clinical application of the statistical method is to
determine central tendencies, while recognizing the “outliers” to
the average track (Fig. 1).
Consider the distal movement of a molar following headgear
treatment in patients of same gender, age, malocclusion, applied
forces, and equal compliance. On average, the molar moved 3 mm
over a period of 6 months, with a deviation of 1.5 mm. However, in a
few patients the molar moved 5 to 7 mm, and in others 1 mm. These
are the outliers. The pertinent question is: what determined the
significant additional or minimal response of the outliers? If
enough of those existed, the scientific path would be to characterize
and evaluate the sources of the extreme responses. Such is the

2212-4438/$ e see front matter Ó 2020 World Federation of Orthodontists.

https://doi.org/10.1016/j.ejwf.2020.08.008
S32 J.G. Ghafari et al. / Journal of the World Federation of Orthodontists 9 (2020) S31eS39
Fig. 1. Hypothetical scattergram showing individual responses that define a central
tendency represented in a linear regression. Outliers with greater (red scatters) and
lower (green scatters) values beyond 1 standard deviation from the mean reflect better
and worse responses.
challenge of treatment and clinical research with all mechanics of
tooth movement, commonly termed biomechanics. The premise of
this article is to determine if the potentials of treatment are mostly
in “mechanics”, and the limitations are drawn mainly from the in-
dividual “biological” response. We explore this theorem with
traditional and contemporary orthodontic applications, limiting the
review to orthodontic treatment and related modeling of the
periodontal tissues, excluding the orthopedic growth modification
achieved with appliances such as headgear and functional appli-
ances (Class II) or face mask therapy (Class III) [1,2].
The goals of biomechanics are summed up primarily in
controlled and faster tooth movement [3]. The use of esthetic ap-
pliances is relevant to this discussion in relation to the efficacy of
nonetooth-attached mechanical systems (i.e., clear aligners) and
hidden lingual appliances in achieving controlled and faster tooth
Fig. 2. Potential of biomechanics represented by the movement of an impacted maxillary canine (A) 2 cm (arrow) with its axis rotated nearly 45o to be aligned in the maxillary arch
(B). The limitation is shown in another patient with a maxillary right impacted canine (C) that could not be moved for more than 4 years in proper alignment (D, E) despite the pull
against a mini-implant (arrow) and several subluxations.
displacement. Accordingly, our analysis encompasses four panels:
control, speed, biology, and health of tissues.
2. The limits and precision of tooth movement
The statistical variations reflect the potential and limitations of
tooth movement (Fig. 2). In a discipline in which gaining 1 mm may
define the outcome success, tooth movement can reach notable
amounts when a canine is moved 1 or 2 cm from its high impacted
position to the dental arch; when another canine is retracted over
the space of a premolar nearly equal to its size; when maxillary and
mandibular incisors are retracted 8 or more or proclined 4 mm or
more; when maxillary molars are distalized 8 mm with headgear or
mandibular molars distalized 6 mm after the extraction of the third
molars; and when posterior and anterior teeth are intruded more
than 2 mm [4e7].
One basic tenet overarches tooth movement: teeth must be
healthy in their immediate environment, housed in bone, protected
by normal gingival covering, and properly serving the masticatory
and other oral functions. The anatomic barriers to tooth movement
belonging to this environment include the cortical shell of bone,
alveolar width, root-cortex distance, height of the coronal cortical
bone, root height and anatomy, tooth width and length, maxillary
sinus height, proximity to the ramus in the mandible, the occlusion,
and the action of the surrounding musculature [4]. Separately or in
combinations, these characteristics account for the different rates of
tooth movement in reaction to the same force amount and direc-
tion. Accordingly, the limits of tooth movement, represented
externally by the actual range of possible displacement, are deter-
mined by the internal anatomic and biological housing.
The variation in tooth movement is also associated with the
application of diverse mechanotherapies to achieve the same goal,
such as sliding mechanics, “frictionless mechanics” (in reference to
friction within the system), segmental methods, and continuous
archwires. The major gap is in exploring the possibility of using any
 J.G. Ghafari et al. / Journal of the World Federation of Orthodontists 9 (2020) S31eS39 S33

of these approaches preferentially in different patients or maloc-
clusions. Despite the delineation of physical principles to be
implemented through the various methods in “evidence-based”
practice, and the potential to achieve excellent results in the most
complex malocclusion, tooth movement is not precise and often
relies on pragmatic applications and the practitioner's preferences,
let alone bias. The more scientific evidence is accrued, the latter
should be less tolerated practically and ethically.
3. Control of mechanics
Countless laboratory and clinical investigations have targeted
the analysis and prediction of the 2 components that define tooth
movement: force and anchorage.
other anchorage means (Fig. 5), and in the mandible with increasing
rates of early extraction of the third molars (Fig. 6). Intrusion of
posterior teeth to correct anterior open bites against miniplates
placed in the maxillary infrazygomatic area has been very effective,
but the surgical approach has limited their use compared with
mini-implants. Although the potential of mini-implants has
extended to the development of short devices that could be used in
the mixed dentition without hazards to the unerupted permanent
teeth [9], limitations comprise the risk of failure, associated with
operator and host shortcomings, but often with the nature of bone
and inflammation or infection of surrounding soft tissues.
3.2. Force direction

3.1. Consolidating anchorage and overcoming factorial resistance
The impact of introducing anchorage solidification through non-
osseointegrated mini-screws or mini-implants was the equivalent
of Angle's introduction of the edgewise bracket in its impact on the
three-dimensional (3D) control of tooth movement [8]. Temporary
anchorage devices (TADs) brought a new definition to “anchorage
preparation” and shifted the envelope of amount and type of tooth
movement to levels unachievable on a time, lacing prior “outliers”
closer to new central tendencies. Illustrating this shift is the po-
tential intrusion of posterior teeth to close an open bite (Fig. 3), the
intrusion of posterior and anterior teeth (Fig. 4), at times negating
the need for orthognathic surgery under specific conditions and
severity, the distalization of posterior teeth controlling for their
extrusion in the maxillary arch obviating the need for headgear or
The direction of an orthodontic force or a force system is defined
through the norms of physics, translated in the definition of force
delivery relative to the center of resistance of a tooth or group of
teeth, and the corresponding center of rotation. Extensive research
has been invested in finite element modeling and analysis (FEA),
the noninvasive way to reconstruct the anatomy to test various
treatment approaches. FEA is an engineering tool that dissects the
response of structures when exposed to variable loads by fracturing
a whole structure into small elements. Applications in orthodontics
have risen from testing stress distribution and tooth displacement
in a particular 3D model under various force loads to accounting for
individual variation that reflects the range of clinical responses to
the same mechanical set-up [10]. Most FEA studies relate to the
initial response within the periodontal ligament; the resulting in-
formation may be translated cautiously to clinical application,

Fig. 3. Treatment illustrating the intrusion of the maxillary posterior teeth to the level of the anterior teeth. (A, B) Pretreatment occlusal anterior and lateral views of a malocclusion
characterized by the lower occlusal position of the premolars and molars relative to the anterior teeth. (C, D) Intrusion of the posterior teeth was achieved by buccal (arrows) and
palatal forces from mini-implants. (E, F) Posttreatment photographs show the level alignment of posterior and anterior teeth. The horizontal yellow lines demonstrate the reduction
of the vertical discrepancy between the latter.
S34 J.G. Ghafari et al. / Journal of the World Federation of Orthodontists 9 (2020) S31eS39

Fig. 4. (A, B) Frontal and lateral views of Class II malocclusion with vertical asymmetry between the right side in which the buccal and anterior teeth are at a lower level of the
corresponding teeth on the left side. The canted occlusal planes were corrected to an optimal occlusion (C) with mechanics involving the intrusion of posterior and anterior teeth
against mini-implants placed buccally (D) and palatally, and the Class II through distalization of the posterior teeth against the posterior mini-implants (E) on both sides.

although more definitive applications would await further in-
vestigations of the needed time-dependent information.
Two illustrations of this transfer of knowledge are shown. One
relates to the stresses on adjacent teeth during the alignment of an
impacted canine using various appliances [11]. The FEA data sug-
gested moving the tooth vertically and distally before applying
buccal forces, and bypassing the adjacent lateral incisor to
minimize the side effects of heavy stresses on this tooth (Fig. 7A and
B). The other example relates to a study of the indirect distalization
of the maxillary posterior teeth against a mini-implant [4,10]. The
stress levels and displacements measured on the second premolar
(19%) were almost half of those at the molar (36%); a tie back on the
maxillary canine did not negate the premolar displacement.
Accordingly, rather than using a steel ligature against the canine

Fig. 5. (A, B) Class II malocclusion with a severe overbite, extruded and retroclined maxillary incisors. (C, D) The mechanics included the use of a mini-implant (per side) to anchor
both the distalization of the posterior teeth controlling for their extrusion and the intrusion of the incisors successfully despite the extraction of the maxillary first premolars. (E, F)
Pre- and posttreatment lateral cephalograms. Note the improvement in the overjet and overbite relations and the subnasal profile. (G) Superimposition on maxillary structures
shows the intrusion of the maxillary incisors.
 J.G. Ghafari et al. / Journal of the World Federation of Orthodontists 9 (2020) S31eS39 S35

Fig. 6. Distalization of the mandibular posterior teeth following the early extraction of the third molars in 13-year-old boy complaining of “lip fullness,” essentially bimaxillary
protrusion. Extraction of the hypoplastic maxillary first molars helped maintain the dentition in Class I occlusion. (A) Pretreatment panoramic radiograph. (B) Progress panoramic
radiograph following the retraction the mandibular first and second molars against mini-implants placed between the second premolars and first molars. (C) Pretreatment
cephalogram demonstrating the proclined mandibular and maxillary incisors and protruding lips beyond the E-line joining chin to nose tip. (D) Following retraction of the incisors
the lips retruded. (E, F) Pre- and posttreatment lateral occlusal views.

that may lose strength during oral functions, an active force against
the premolars helps avoid their forward reactionary displacement
(Fig. 7C and D).
Systems have been developed to titrate tooth movement
incrementally, such as the clear aligners [12] and programmed
lingual appliances [13], developed as less visible appliances. The
aligners have not reached the full 3D control of fixed appliances,
particularly in the more complicated malocclusions [14], needing
expert case selection and awareness of limitations, and the imple-
mentation of adequate sequencing to reduce the need for case
refinement. [3] The lingual braces, available in 2D and 3D, vary in
direct or planned bonding and operator difficulties. Whereas the

Fig. 7. (A) FEA illustration of stress distribution following the application of a buccal force to tract the impacted canine into the dental arch. The highest stresses shown against the
color scale were on the adjacent lateral incisor (after Zeno et al. [11]). (B) Clinical application bypassing the lateral incisor adjacent to impacted canine. (C) FEA stress analysis during
the indirect distalization of the molar teeth through an open coil spring while stabilizing the canine against an implant placed between second premolar (PM2) and first molar (M1).
Stresses and corresponding displacements against PM2 and the first premolar were nearly equal to those on M1 (Ammoury et al. [10]). (D) Clinical application on the basis of the FEA
findings. An active force through a power chain is delivered against the premolars to counteract the effect of the coil spring (yellow arrow) used to distalize the molars. (E, F) FE
model representation of simulated decortication and micro-osteoperforation. (G) Clinical representation of micro-osteoperforations among maxillary incisors and canine during
initial tooth alignment.
S36 J.G. Ghafari et al. / Journal of the World Federation of Orthodontists 9 (2020) S31eS39
high cost of these modalities limits their propagation, a compelling
appreciation of these systems, initially developed for regular or-
thodontic appliances [15,16], is the creative utilization of informa-
tion technology in programming treatment outcome in its optimal
details. Missing in this realization is the lack of precision in growth
simulation for growing patients equivalent to that of the ortho-
dontic displacement. Advances in artificial intelligence shall help in
reaching this goal through multifaceted research.
3.3. Force amount
The most significant contribution in nearly half a century has
been the incorporation of “smart” (superelastic and shape memory
nickel titanium) archwires in the orthodontic armamentarium,
optimizing force levels at least in the early stages of treatment with
the positive dividends on patient tolerance and spacing out ap-
pointments [3]. However, the delineation of the effective force
amount remains subject to individual variation, because 25 g or
50 g of force may not produce the same effect in different in-
dividuals of same age and gender [4]. The amount of force applied
in current practice is defined within a range (e.g., 40e50 g) for a
specific movement (e.g., tipping, intrusion) or force per tooth.
Historically, “optimal” force levels varied: 20 to 26 g/cm2 according
to Schwarz [17], and 83 g/cm2 as per Miura [18]. The main issue is to
recognize the individual optimal force [19]. Forces exceeding the
optimal level are presumed to cause periodontal ischemia that can
lead to root resorption.
Orthopedic research suggests that smaller force magnitude than
currently used may be appropriate for tooth movement [20,21]. A
threshold of force magnitude is necessary and sufficient for
enhanced osteogenesis [22], sustained through a “strain memory”
maintained in the bone matrix long after removal of the applied
stress. A strain-mediated change occurs in the direction of the large
proteoglycan molecules, which represent stress-sensitive elements
in the bone matrix [22]. The molecules would need nearly 48 hours
to regain their original 3D tree-like configuration. Whereas light
continuous forces prevail in orthodontic mechanotherapy because of
their longstanding efficacy and their practicality for spacing ortho-
dontic visits on monthly or bimonthly basis, interrupted or short-
term light orthodontic forces produced comparable tooth move-
ment [23e26]. They caused less damage, such as loss of anchorage or
root resorption because they generate direct surface resorption and
minimize hyalinization and its side effects. Significant amounts of
bone turnover and remodeling events continue for an indeterminate
period following appliance decay, or appliance removal [26].
A gap remains between orthodontic practice and these findings
on intermittent and low-level forces, which challenge the prevalent
practice with continuous forces. Most of the evidence from animal
research has not been transferred to the clinical set. Research
should define the most efficient movement with the least duration
of force(s) applied at various intervals, notwithstanding the chal-
lenge in developing the method of intermittent force application
that may not be practical to patient and orthodontist. Other ques-
tions should be answered such as the effect of occlusal forces on the
efficacy of short-term forces.
4. Faster movements
Various technologies aim at accelerating tooth movement to
accommodate the perpetual request by patients for shorter treat-
ment and prevent the side effects associated with long treatments
[3]. To this end, decortication was introduced as “accelerated
osteogenic orthodontics,” consisting of interproximal surgical
cortical cuts that minimize the resistance of the cortical bone sur-
rounding teeth [27]. The results revealed reduced treatment
duration, regardless of perfection of “finishing” or the possibility of
periodontal recession [3]. However, evidence is not available on
treatments longer than a few months [3], indicating that the suc-
cess of aggressive decortication is limited to a finite period and
possibly needing repeated interventions for extended treatments.
The success of decortication was initially attributed to the
regional acceleratory phenomenon (RAP) that enhances bone
turnover, but the RAP is likely more involved in the healing repair of
decorticated bone rather than the cellular osteoblastic-osteoclastic
interactions of the regular process of tooth movement in the
segmented units [4]. Decortication has not entered routine appli-
cation in orthodontics because of its invasive nature, the associated
risk of loss of the alveolar bone, gingival recession, and post-
operative discomfort [28].
Corticision and micro-osteoperforation were advanced as a less
invasive alternative to decortication, avoiding the elevation of a flap
[20,29]. Despite the initial promising results of animal and human
studies[30], several randomized trials failed to show expedited tooth
displacement [31e33]. All clinical studies used 3 perforations distal
to the maxillary canines in a canine retraction model. However, the
frequency and number of perforations have not been sorted out to
determine how many and how often they should be repeated in the
individual patient. A recent FEA conducted by our group comparing
decortication with micro-osteoperforations suggested that more
than 3 perforations are needed over the same height of decorticated
bone to reach equal tooth displacements (Fig. 7E and F).
The effectiveness of microvibrations or ultrasonic waves to
speed up tooth movement has not yet been shown [21,34]. Mini-
implants were indirectly associated with faster movement by
controlling anchorage, but this premise is not predictable in the
individual patient because of the anatomical barriers that could
slow down the movement, mainly the proximity of the cortical
bone to the roots of the teeth being displaced [4]. Dentoalveolar
distraction was advocated to forcefully retract canines in the
extracted premolar space, sometimes in conjunction with cortico-
tomy [35,36]. Successful results have not translated in common
application of this seemingly aggressive method.
Interest has increased in the past decade in applying the
noninvasive low-level laser therapy to effect tooth movement,
reduce the associated pain, and decrease orthodontic treatment
duration. Reports have been controversial regarding the accelera-
tion of tooth movement, which was supported by the most recent
systematic reviews that also indicated that the outcome is dosage
dependent [37,38] and additional research is warranted. Self-
ligation brackets have been promoted for faster movement
concomitant with lighter forces, but research has not supported the
reduction in treatment duration [39]. Departing from the regular
edgewise attachments, a “wedgewise” bracket with a triangular
rather than rectangular slot was introduced to control tooth di-
rection with light forces [40]. Definitive confirmation of these ad-
vantages is warranted. Even electrical currents were committed to
cause of expeditious outcomes, but the concept has not translated
into practical application [41,42].
Other “minor” technological advances that have replaced prior
more cumbersome practices in aiding tooth movement, possibly fall-
ing under the popular term of clinical “pearls,” have proven signifi-
cantly helpful in speeding up treatment under specific conditions.
Composite bite blocks represent a prime example of this category [43],
used in lieu of compliance-dependent removable appliances with
anterior or posterior bite plates to dis-occlude teeth (Fig. 8).
5. Enhancing the biological process
The response to the physical stimulus of an orthodontic force is
expressed biologically in the periodontium. Hence, medical logic
 J.G. Ghafari et al. / Journal of the World Federation of Orthodontists 9 (2020) S31eS39 S37

would indicate that “medication” or substances should affect this
response and interact with the cascade of tissue events known to
unfold, the way diabetic or high blood pressure medications act at
specific levels of the biological process. In orthodontics, such sub-
stances should hasten tooth movement, prevent alveolar bone loss,
and avoid iatrogenic effects such as root resorption [44,45]. The
clinical implications from the prospects of “biological enhance-
ment” are immeasurable. However, drugs can also inhibit or reduce
tooth movement, such as the nonsteroidal anti-inflammatory
drugs, prescribed to relieve pain and discomfort when orthodon-
tic appliances are activated, but also reported to decrease the
associated inflammatory process and bone resorption [46,47].
growth factors [51,53]. The findings about the ability of these
enhanced blood substances to accelerate tooth movement and
reduce side effects are controversial [49,54]. However, the tendency
of an initially accelerated movement, particularly with PRF, appears
to be sustained with repeated (“boost”) injections of the biomate-
rial. Many variables impacting potential acceleration have yet to be
explored in larger samples than available, considering repeated
versus nonrepeated deliveries, and comparing different substances,
notably various PRF types. As current research favors the surgical
approach (e.g., decortication) that breaks the physical resistance of
the compact bone, the combination of reducing the physical barrier
and the application of already or not yet investigated biological
substances should also be explored.

5.1. Biologically induced acceleration of tooth movement

Many biomolecules have been investigated to speed up tooth
movement such as prostaglandin, vitamin D, thyroid hormone, and
growth factors, acting mostly by increasing the number of osteo-
clasts that stimulate bone resorption or enhancing osteoblastic cell
differentiation and bone formation [46,48]. The effect of molecules
in the periodontal tissues may be through systemic drugs and nu-
trients or local delivery (mainly injection). Evidence is drawn from
clinical trials and experience but more closely controlled in avail-
able invasive animal studies.
Interest in blood products such as platelet rich plasma (PRP) and
fibrin (PRF) has increased with several clinical trials conducted to
sort their effects on tooth movement [49,50]. Rich in growth factors
involved in angiogenesis, wound healing, and bone regeneration
[51], PRP/F are thought to induce a RAP-like effect and promote
alveolar bone regeneration [52]. PRF has many advantages over PRP
including slower more gradual and seven times more release of the
5.2. Biomaterials influencing root resorption
Root shortening or resorption commonly occurs during ortho-
dontic treatment at a microscopic level and may reach serious
macroscopic levels under various etiologic factors acting separately
or in combination [19,21]. The incidence and amount of resorption
are not predictable with certainty particularly that the resorptive
process varies among individuals and affects different teeth in the
same person at different times. Ranking of vulnerability to
resorption places the maxillary incisors first to be insulted [19].
Injections of bio-substances to arrest ongoing resorption near the
involved roots have not been successful. The premise was that such
materials, which contain or stimulate cytokines and growth factors
that modulate the osteoblastic and osteoclastic activities [55],
would induce inhibition of osteoclasis and upregulation of osteo-
genesis. The systemic administration of thyroxine was put in

Fig. 8. Use of composite bite blocks to speed up treatment, significant spaces were left distal to the maxillary lateral incisors (A) and the overbite was deeper than optimal (B).
Accordingly, bite opening was indicated to create an overjet for the retraction of the incisors. (CeE) This goal was achieved by bonding composite (blue color) on the palatal surfaces
of the maxillary canines (yellow arrows). Space closure was achieved with closing loops. This method was termed “preventive strike” by the first author (JGG) who developed it. The
canines, which had been retracted along with the posterior teeth against mini-implants were tied back to these devices to support anchorage during the retraction. (FeH) Lateral
and front oral views posttreatment.
S38 J.G. Ghafari et al. / Journal of the World Federation of Orthodontists 9 (2020) S31eS39
Table 1
Goals of biomechanics with corresponding pertinent potential and limitations
Goals Potential
Reached mostly with
More controlled movement - Mini-implants
- Force direction
Faster movement - Decortication
Less-noticeable appliances - Clear aligners
- Lingual appliances
No damage to tissues and appearance - Movement within healthy surrounding tissues
- Light (near physiologic) forces
question as increasing the rate of alveolar bone resorption and
indirectly decreasing root resorption [56,57].
Research pathways on local and systemic dispensing of medi-
cations have yet to find a viable traction. The state of the art remains
focused on mechanotherapy and tooth anatomy [19], including the
careful application of light forces, particularly on conically shaped
singular roots; avoiding excessive intrusive and extrusive forces,
the latter shown to be more harmful [58]; and evading lengthy
treatments [19].
5.3. Biomaterials enhancing anchorage and stability
Stability (rather maintenance) of results is an individual trait.
Recalling the stages of treatment, traditionally numbered first,
second, and third, in reference to initial alignment, occlusal
correction, and finishing, respectively, the uncertain finality of
posttreatment stability earned it the label of fourth or last stage of
treatment. Thus, retention is a minimum a safety measure, pro-
vided through fixed means (typically bonded canine to canine re-
tainers, first used in the mandible but increasingly also in the
maxilla), and compliance-dependent removable appliances such as
the Hawley, wrap-around, clear aligner, or modifications thereof.
The gaps of knowledge force over retention are often in reference to
the “settling” of the results (when the somewhat indeterminate
functions of the neuromuscular system unfold), growth or aging,
the yet not unpredictable effect of erupting third molars in the in-
dividual patient, and unclear “idiopathic” factors.
Attempts at using biomolecules to enhance “stability” included
the topical administration of bisphosphonate (e.g., risedronate), a
potent blocker of bone resorption that caused a significant and
dose-dependent reduction, and inhibited relapse of tooth move-
ment in rats [59]. Tetracycline, if used in its analogue non-
antimicrobial form, has the advantage of lesser side effects than
bisphosphonate derivatives [60]. Research regadring these mole-
cules has not translated in successful clinical application.
6. Looking ahead
Clinicians, universities, and a strong industry have committed
tremendous material and human resources to achieve more
controlled and expedited tooth movement, with less noticeable
appliances. The reviewed goals along with current procedures
providing most potentials, and limitations needing focused
research are summarized in Table 1. The rate of success in more
than a century of “bracketed” orthodontics has moved by decades,
not years. Perhaps the importance of a very unique system of teeth
displacing in bone is taken for granted when one considers the
scope of achievements. The major limitation remains in discovering
efficient biological means to reach the goals and usher the era of
“medical” approaches, if ever possible. Even if biomaterials are
developed, the local application may be problematic and cause
Limitations
Requiring more investigation
- Individualized force amounts
- Acceleration with biomaterials
- Standardized “finish” across severity
- Cost
- Anatomic variations and individual response
discomfort to the patient. However, the premise is sound, and
investigation should proceed.
Treatment outcome is essentially an individual response and
treatment should be customized. The concept of personalized care,
“steering patients to the right drug at the right dose at the right
time” [3], is not applicable if one of the tripods of drug, dose, and
time is missing or unattainable. Predictable treatment results might
be achieved when the tripod elements line up for the positive
outliers and disperse the negative outliers away from defined
central tendencies. Although the quest to bridge the existing gaps
must bolster the biological response, the present state of biome-
chanics is at least satisfactory and at best serving the occlusal
“health” and general well-being of countless grateful patients [3].
7. Conclusions
1. Mechanical applications in orthodontic treatment remain
closer to central tendencies. Research should focus on identi-
fying outliers and characterize the sources of better or worse
responses. Available evidence points to the local anatomy in
limiting or improving the expression of outliers, including the
housing bone, the gingival/mucosal envelope, and the func-
tioning musculature.
2. Major advances relate to the solidification of skeletal anchorage
through orthodontic implants.
3. “Smart” wires have contributed to using light forces for more
physiologic tooth movement. This goal is already achievable
through existing technology (preplanned staged movements);
however, heavier than needed forces seem to prevail in practice
at least beyond the initial stages of treatment.
4. Personalization of systems and individual outcome simulation
require additional research potentially using artificial intelli-
gence for optimal outcome projection.
5. Biologically induced acceleration of tooth movement or inhi-
bition of side effects, particularly root resorption, are yet to be
established and applied. In this perspective, the main potential
of tooth movement systems has been in mechanical advances;
the principal limitation remains in manipulating the biologic
response through biomaterials.
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