HOME

Vol 7, No 1 March 2001

W B. Saunders Company • A Harcourt Health Sciences Company

Seminars in
ORTHODONTICS
EDITOR: Seminars in Orthodontics provides current and timely information on a single
P. Lionel Sadowsky, topic of interest to the clinical orthodontist four times a year. But just how practical
DMD,BDS,DipOrth,MDent is Seminars in Orthodontics? Take a look at the topics for 2001:

MARCH Clinical Biomechanics (S.J. Lindauer)

JUNE The Alexander Philosophy (R.G.Alexander)
SEPTEMBER Three-Dimensional Diagnosis and Treatment in Orthodontics
(R. Boyd & S. Baumrind)

DECEMBER Biostatics for the Orthodontic Clinician

(R.D. Sheats)

Individual issues are in themselves valuable surveys of their topics, going into
greater depth than traditional journals. Moreover, Seminars in Orthodontics
synthesizes conflicting data in the literature on strategies that are changing and
developing. As you build your collection of issues, you will have an up-to-date
library of orthodontics — a reference so well organized that you can locate informa-
tion that you need immediately.

Annual Subscription Rates

INDIVIDUAL: $125.00 INSTITUTION: $154.00 STUDENT*: $72.00
To receive the student rate, orders must be accompanied by the dates of your term of study and
the signature of your academic advisor on school letterhead. Orders will be billed at the individual
rate until proof of student status is received.

TO ORDER, PLEASE CALL:

1-800-654-2452,7:30 am - 7:00 pm, ET.

FOR MORE INFORMATION OR FOREIGN PRICES, CONTACT:

W-B. SAUNDERS
Harcourt Health Sciences
The Curtis Center, Independence Square West, Philadelphia, PA 19106-3399
Attention: Periodicals Marketing

OR VISIT OUR HOME PAGE: www.harcourthealth.com

©2001 W.ß. Saunaers. All prices subject to change without notice. Prices valid in USA only.
ISSN 1073-8746 Please add the applicable sales tax for your area.
 Seminars in Orthodontics
EDITOR
P. Lionel Sadowsky, DMD, BBS, DipOrth, MDent
Professor and Chairman
Department of Orthodontics
University of Alabama
1919 Seventh Avenue South
Birmingham, AL 35294
Fax: (205) 975-7590
Seminars in Orthodontics (ISSN 1073-8746) is published
quarterly by the W.B. Saunders Company. Months of issue are
March, June, September, and December. Corporate and
Editorial Offices: The Curtis Center, Independence Square
West, Philadelphia, PA 19106-3399. Accounting and Circulation
Offices: 6277 Sea Harbor Drive, Orlando, FL 32887-4800.
POSTMASTER: Send change of address to: Seminars in
Orthodontics, W.B. Saunders Company, Customer Service, 6277
Sea Harbor Drive, Orlando, FL 32887-4800.
Editorial correspondence should be addressed to:
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent, Editor,
Seminars in Orthodontics, Professor and Chairman, Department
of Orthodontics, University of Alabama, 1919 Seventh Avenue
South, Birmingham, AL 35294-0007; fax: (205) 975-7590.
Correspondence regarding subscriptions or change of
address should be directed to Seminars in Orthodontics, W.B.
Saunders Company, Periodicals Department, P.O. Box 628239,
Orlando, FL 32862-8239.
Change of address notices, including both the old and new
addresses of the subscriber and the mailing label, should be
sent at least 1 month in advance.
Customer Service: 1-800-654-2452
Yearly subscription rates: United States and possessions:
individual, $125.00; institution, $154.00; student and resident,
$72.00; single issue, $47.00. All other countries: individual
$156.00; institution, $186.00; student and resident, $94.00;
single issue, $47.00. For all areas outside the United States and
possessions, there is no additional charge for surface delivery.
For air mail delivery, add $16.00. To receive student/resident
rate, orders must be accompanied by name of affiliated
institution, date of term, and the signature of program/residency
coordinator on institution letterhead. Orders will be billed at
individual rate until proof of status is received.
Prices are subject to change without notice. Current prices
are in effect for back volumes and back issues. Single issues,
both current and back, exist in limited quantities and are
offered for sale subject to availability. Back issues sold in
conjunction with a subscription are on a prorated basis. Checks
should be made payable to W.B. Saunders Company and sent
to Seminars in Orthodontics, W.B. Saunders Company, Periodicals
Department, 6277 Sea Harbor Drive, Orlando, FL 32887-4800.
Copyright © 2001 by W.B. Saunders Company. All rights
reserved. No part of this publication may be reproduced or
transmitted in any form or by any means, electronic or
mechanical, including photocopy, recording, or any information
storage and retrieval system, without permission in writing from
the Publisher. Printed in the United States of America.
Correspondence regarding permission to reprint all or
part of any article published in this journal should be
W.B. SAUNDERS COMPANY
A Division of Harcourt Brace & Company
addressed to Journal Permissions Department, W.B. Saunders
Company, 6277 Sea Harbor Drive, Orlando, FL 32887-4800.
Telephone number: 1-407-345-2500.
The appearance of the code at the bottom of the first page
of an article in this journal indicates the copyright owner's
consent that copies of the article may be made for personal or
internal use, or for the personal or internal use of specific clients,
for those registered with the Copyright Clearance Center, Inc.
(222 Rosewood Drive, Danvers, MA 01923; (508) 750-8400;
www.copyright.com). This consent is given on the condition that
the copier pay the stated per-copy fee for that article through the
Copyright Clearance Center, Inc. for copying beyond that
permitted by Sections 107 or 108 of the US Copyright Law. This
consent does not extend to other kinds of copying, such as
copying for general distribution, for advertising or promotional
purposes, for creating new collective works, or for resale. Absence
of the code indicates that the material may not be processed
through the Copyright Clearance Center, Inc.
Advertising representative: MJ. Mrvica Associates, Inc,
2 West Taunton Ave, Berlin, NJ 08009. Telephone (609) 768-
9360. Fax (609) 753-0064.
Publication of an advertisement in Seminars in Orthodontics
does not imply endorsement of its claims by the Editor(s) or
Publisher of the journal.
The contributors have checked generic and trade names and
verified drug doses for accuracy according to the standards
accepted at the time of publication. The ultimate
responsibility, however, lies with the prescribing physician.
Please convey any errors to the Editor.
The ideas and opinions expressed in Seminars in
Orthodontics do not necessarily reflect those of the Editor or the
Publisher. Publication of an advertisement or other product
mention in Seminars in Orthodontics should not be construed as
an endorsement of the product or the manufacturer's claims.
Readers are encouraged to contact the manufacturer with any
questions about the features or limitations of the products
mentioned. Neither the Editor or Publisher assume any
responsibility for any injury and/or damage to persons or
property arising out of or related to any use of the material
contained in this periodical. The reader is advised to check the
appropriate medical literature and the product information
currently provided by the manufacturer of each drug to be
administered to verify the dosage, the method and duration of
administration or contraindications. It is the responsibility of
the treating physician or other health care professional, relying
on independent experience and knowledge of the patient, to
determine drug dosages and the best treatment for the patient.
Seminars in Orthodontics is indexed in the Cumulative
Index to Nursing and Allied Health Literature® print index
and the Cinahl® database.
Editor-in-Chief:
Patrick M. Lloyd, DDS, MS
Journal of
Prosthodontics
Official Journal of the American
College of Prosthodontists
Each quarterly issue of Journal of
Prosthodontics brings you vital information
on every aspect of the specialty, including
implant prosthodontics, dental prosthetics,
fixed and removable prosthodontics, geriatric
dentistry, and craniomandibular dysfunction.
Journal of Prosthodontics provides you with
today's most significant articles on basic sci-
ence, clinical research, academics and educa-
tion, practice management, and technology.
Journal of Prosthodontics keeps you
informed of the latest advances in all areas
of prosthetic dentistry.
Several superb sections are included in each
peer-reviewed issue. The Clinical Research
and Basic Research sections report the results
of recent investigations and work-in-progress.
The Clinical Science section features reports
of clinical or laboratory procedures that docu-
ment treatment results. You'll find concise
and clearly illustrated articles that present
step-by-step outlines of techniques and
procedures and discuss the advantages and
disadvantages of new techniques. These
articles provide comparisons with alternative
methods. The Academics and Education
section presents articles on new approaches
for particular instructional problems and
unique programs and teaching techniques.
The Topics of Interest section consists of
articles, essays, and reviews on current
prosthodontics issues.
In addition, the Journal is the first in the den-
tal literature to provide an Abstracts section
preceding each article. These structured
abstracts summarize current literature and
direct you to key areas of research. This
allows you to immediately assess the clinical
relevance of the research to your own practice
and research endeavors. Finally, the Meetings
of Interest section keeps you informed of
upcoming events in the specialty.
| TO ORDER, CALL TOLL-FREE
I 1 ""800-654-2452 7:30am-7:OOpmET
! SUBSCRIPTION RATES (4 issues)
\ Individual $125.00 Institution $175.00 Student* $90.00
: *To receive the student rate, orders must be accompanied by the name of
: affiliated institution, dates of program, and signature of institution official
: on institution letterhead. Orders will be billed at the Individual rate until
: proof of status is received.
FOR MORE INFORMATION OR FOREIGN PRICES, CONTACT:
V\W.&. SAUNDERS
t Harcourt Health Sciences
The Curtis Center • Independence Square West
Philadelphia, PA 19106-3399
Attention: Periodicals Marketing
OR VISIT OUR HOME PAGE: www.harcourthealth.com
ISSN 1059-941X
©2007 W.B. Saunders. Prices valid in USA only. All prices subject to
change without notice. Add the applicable sales tax for your area.
<<    
     Article
      >>
Seminars in Orthodontics
EDITOR
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent
EDITORIAL BOARD
Richard G. Alexander, Arlington, TX
Rolf G. Behrents, Memphis, TN
Samir E. Bishara, Iowa City, IA
Robert Boyd, DDS, San Francisco, CA
Larry M. Bramble, Cypress, CA
John S. Casko, Iowa City, IA
Harry L. Dougherty, Van Nuys, CA
T.M. Graber, Evanston, IL
Robert J. Isaacson, Richmond, VA
Alexander Jacobson, Birmingham, AL
Lysle E.Johnston, Jr., Ann Arbor, MI
Gregory J. King, Seattle, WA
Vincent G. Kokich, Tacoma, WA
Steven J. Lindauer, Richmond, VA
INTERNATIONAL
Zeev Abraham, Herzliya, Israel
W.G. Evans, Johannesburg, South Africa
Roberto Justus, Mexico City, Mexico
Home | TOC |          
Index
James A. McNamara, Jr, Ann Arbor, MI
Robert N. Moore, Morgantown, WV
Ravindra Nanda, Farmington, CT
Perry M. Opin, Milford, CT
Sheldon Peck, Newton, MA
William R. Proffit, Chapel Hill, NC
Cyril Sadowsky, Chicago, IL
David M. Sarver, Birmingham, AL
T. Michael Speidel, Minneapolis, MN
William J. Thompson, Bradenton, FL
James L. Vaden, Cookeville, TN
Robert L. Vanarsdall, Jr., Philadelphia, PA
Katherine Vig, Columbus, OH
C.B. Preston, Buffalo, NY
Shinkichi Namura, Tokyo, Japan
George Skinazi, Paris, France
Björn U. Zachrisson, Oslo, Norway
<<    
     Article
      >>
Complete Your Medical Library
with Back Issues of
Seminars in
ORTHODONTICS
EDITOR:
P. Lionel Sadowsky,
DMD,BDS,DipOrth,MDent
©2001 W.B. Saunders.
All prices subject to change
without notice. Prices valid
in USA only. Please add
the applicable sales tax for
your area.
ISSN 1073-8746
Home | TOC |          
Index
Back issues of Seminars in Orthodontics provide practical, timely information on a single topic of interest
to the clinical orthodontist. Individual issues are in themselves valuable surveys of their topics, going into
greater depth than traditional journals. Moreover, Seminars in Orthodontics synthesizes a variety of
data on emerging or changing techniques and strategies. As you complete your collection of issues, you'll
have an up-to-date library of orthodontics—a reference that no clinician should be without.
Order these valuable issues — while supplies last!
SINGLE ISSUE PRICES
INDIVIDUAL: $31.25 INSTITUTION: $38.50 STUDENT*: $18.00 NON-SUBSCRIBER: $47.00
*To receive the student rate, orders must be accompanied by the dates of your term of study and the signature of your
academic advisor on school letterhead. Orders will be billed at the individual rate until proof of student status is received.
To ORDER, PLEASE CALL: 1-800-654-2452,7:30 am - 7:00 pm, ET
FOR MORE INFORMATION OR FOREIGN PRICES, CONTACT:
]W.B. SAUNDERS
Harcourt Health Sciences
The Curtis Center, Independence Square West, Philadelphia, PA 19106-3399
Attention: Periodicals Marketing
OR VISIT OUR HOME PAGE: www.harcourthealth.com
2000 TOPICS "- 1999 TOPICS i
MARCH Objective Driven Orthodontics: MARCH Distraction Osteogenesis
Effectiveness of Mechano- (B.Graym& P. Santiago)
therapy (C. Sadowsky) JUNE Evidence Based Orthodontic
JUNE Molar Distalization (G. Cismros) Practice (M.G.Hans)
SEPTEMBER Biology of Orthodontic Tooth SEPTEMBER Stability & Long-Term Change
Movement: Clinical (PL Rossouw)
Implications (B. Shroff) DECEMBER Current Philosophies in
DECEMBER Psychological Issues Related Orthognathic Surgery
to Orthodontic Treatment & (LBaüey)
Patient Compliance
(P.Sinha,R.Nanda,R.Fillingim)
<<    
     Article
      >> Home | TOC |          
Index

Seminars in Orthodontics
VOL 7, NO 1 MARCH 2001

Clinical Biomechanics
Steven J. Lindauer, DMD, MDSc
Guest Editor

CONTENTS

Introduction
Steven J. Lindauer

The Basics of Orthodontic Mechanics

Steven J. Lindauer

Leveling and Aligning: Challenges and Solutions 16

Bhavna Shroff and Steven J. Lindauer

Biomechanics of Deep Overbite Correction 26

Charles J. Burstone

Closing Anterior Open Bites: The Extrusion Arch 34

Robert J. Isaacson and Steven J. Lindauer

Space Closure and Anchorage Control 42

Andrew J. Kuhlberg and Derek N. Priebe

Root Correction During Orthodontic Therapy 50

Bhavna Shroff
<<    
     Article
      >> Home | TOC |          
Index

Seminars in Orthodontics
Future Issues

Vol 7 No 2 (June 2001)

THE ALEXANDER PHILOSOPHY
KG. Alexander, DDS, MSD, Guest Editor
Vol 7 No 3 (September 2001)
THREE-DIMENSIONAL DIAGNOSIS AND TREATMENT IN ORTHODONTICS
Robert Boyd, DDS, MEd and Sheldon Baumrind, DDS, MS, Guest Editors
Vol 7 No 4 (December 2001)
BIOSTATISTICS FOR THE ORTHODONTIC CLINICIAN
Rose D. Sheats, DMD, Guest Editor

Recent Issues

Vol 6 No 4 (December 2000)

PSYCHOLOGIC ISSUES RELATED TO ORTHODONTIC TREATMENT AND PATIENT COMPLIANCE
Pramod K. Sinha, DDS, BDS, MS, Ram S. Nanda, DDS, MS, PhD, and Roger B. Fillingim, PhD, Guest Editors
Vol 6 No 3 (September 2000)
BIOLOGY OF ORTHODONTIC TOOTH MOVEMENT: CLINICAL IMPLICATIONS
Bhavna Shroff, DDS, MDentSc, Guest Editor
Vol 6 No 2 (June 2000)
MOLAR DISTALIZATION
George J. Cisneros, DAID, MMSc, Guest Editor
Vol 6 No 1 (March 2000)
OBJECTIVES-DRIVEN ORTHODONTICS: EFFECTIVENESS OF MECHANOTHERAPY
Cyril Sadowsky, BDS, MS, Guest Editor
<<    
     Article
      >>
Seminars in Orthodontics
VOL 7, NO 1
Introduction
O n January 1, 2001, a new millennium offi-
cially began and orthodontics entered the
twenty-first century. How appropriate that Semi-
nars in Orthodontics would devote its first issue of
the millennium, as it did its first issue ever in
1995, to biomechanics, the very foundation of
orthodontic treatment!
Near the end of the nineteenth century, Ed-
ward Angle introduced the Angle system, the
first standardized orthodontic appliance system.
Angle's later invention, the edgewise appliance,
and Andrews' modification, the straight wire ap-
pliance, became the staples of orthodontic ther-
apy in the twentieth century. By the end of the
century, invisible braces were introduced and
popularized by a mass advertising campaign.
What does the twenty-first century have in
store for orthodontics? With all the changes in
appliances that have occurred during the past
100 years, the basic principles underlying how
we treat malocclusions remain the same: we ex-
ert forces to move teeth in the directions we
want. Physics has not changed. The same basic
physical principles are common to all orthodon-
tic appliance systems and techniques. Tooth
movement occurs in response to controlled
force systems placed on the teeth by educated
and skilled practitioners.
The subject of clinical biomechanics needs
little introduction for orthodontists reading Sem-
inars in Orthodontics. This issue is a compilation
of work that emerges from my own experience
with 2 dedicated icons of orthodontic education
Copyright © 2001 by W.B. Saunders Company
doi: 10.1053/sodo.2001.21052
Seminars in Orthodontics, Vol 7, No 1 (March), 2001: p l
Home | TOC |          
Index
MARCH 2001
and scientific inquiry: Dr Charles Burstone and
Dr Robert Isaacson, both of whom graciously
consented to write articles contained in this is-
sue. These 2 men have made enormous contri-
butions to our specialty in many areas, including
the field of biomechanics. It has been my privi-
lege to work with both of them, and it is an
honor for me to have the opportunity to dedi-
cate this issue to them.
The purpose of this issue is to present orth-
odontic biomechanics in a format that is directly
applicable to the clinical treatment of our pa-
tients. Requisite to clinical application is a thor-
ough knowledge of the basic information neces-
sary to understand the physical principles
common to all orthodontic appliances. The first
article is designed to provide this background
and prepare the reader for the clinical applica-
tions that follow. The remainder of the articles
describe how orthodontic biomechanical princi-
ples can be applied to several common compo-
nents and stages of orthodontic treatment.
The intent of the articles contained in this
issue of Seminars in Orthodontics is not to provide
a cookbook approach to orthodontic therapy, to
describe any particular treatment technique, or
to stifle creativity in any way. On the contrary, in
the spirit of educational progress promoted by
Drs. Burstone and Isaacson, the purpose is to
stimulate thought, encourage logical judgment,
and inspire orthodontic practitioners to develop
customized strategies for treating individual pa-
tients in the most efficient way possible.
Steven J. Lindauer, DMD, MDSc
Guest Editor
<<    
     Article
      >> Home | TOC |          
Index

The Basics of Orthodontic Mechanics

Steven J. Lindauer

The biologic cascade of events that ultimately results in bone remodeling

and orthodontic tooth movement begins with the mechanical activation of
an orthodontic appliance. The force systems produced by orthodontic ap-
pliances, consisting of both forces and moments, displace teeth in a manner
that is both predictable and controllable. By varying the ratio of moment to
force applied to teeth, the type of tooth movement experienced can be
regulated by the orthodontist. Orthodontic appliances obey the laws of
physics and can be activated to generate the desired force systems to
achieve predetermined treatment goals for individual patients. Likewise,
any orthodontic appliance can be analyzed to define the mechanical force
systems it produces. Understanding the biomechanical principles underly-
ing orthodontic appliance activations is essential for executing efficient and
successful orthodontic treatment. (Semin Orthod 2001;7:2-15.) Copyright©
2001 by W.B. Saunders Company

he physical concepts that form the founda-
T tion of orthodontic mechanics are the key
to understanding how orthodontic appliances
work and are critical for designing new appli-
ances. The principles are not unique to orth-
odontics but are basic to the science of static
mechanics. Physical laws of statics may be ap-
plied to explain the force systems developed by
orthodontic appliance activations. Simple me-
chanical principles can help deduce how teeth
will be displaced as a result of application of
these force systems. It is the biologic reaction to
these perturbations that ultimately results in
orthodontic tooth movement. To control tooth
movement with the objective of achieving pre-
dictable results based on predetermined treat-
ment goals, the basic mechanics underlying
orthodontic appliance activations must be thor-
oughly understood.
From the Department of Orthodontics, School of Dentistry, Vir-
ginia Commonwealth University, Richmond, VA.
Supported in part by the Medical College of Virginia Orthodontic
Education and Research Foundation.
Address correspondence to Steven J. Lindauer, DMD, MDSc,
Department of Orthodontics, School of Dentistry, Virginia Common-
wealth University, Richmond, VA 23298-0566.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0701-0002$35.00/0
doi:10.1053/sodo.2001.21053
Predicting How Teeth Will Move
in Response to Application of
Orthodontic Force Systems
Orthodontic appliances are used to produce
force systems that will displace teeth and initiate
a biologic cascade, allowing teeth to move. Al-
though many treatment modalities and philoso-
phies advocate different appliances, the force
systems they produce can be dissected into the
same basic physical components: forces and mo-
ments. Forces alone can be used to move teeth
and will often produce moments causing the
teeth to also rotate, tip, and torque. By using
appliances to control rotation, practitioners gain
more control over how teeth move. Varying the
ratio of moment to force applied allows the orth-
odontist to vary the type of tooth movement
effected.
Forces
Forces are vectors, having both direction and
magnitude. To move a tooth predictably, a force
needs to be applied in the desired direction,
with the desired magnitude, and at the correct
position on the tooth. Changing the direction,
magnitude, or point of force application will
affect the quality of the tooth displacement that
will occur. In other words, if mesial movement of
a tooth is indicated, a force to push or pull the

Seminars in Orthodontics, Vol 1, No 1 (March), 2001: pp 2-15

<<    
     Article
      >> Home | TOC |          
Index

Basics of Mechanics

tooth in a mesial direction must be applied. The

force can act anywhere along its line of action so
B
pushing is equivalent to pulling. Increasing the
magnitude of force will increase the amount of
tooth displacement initially. However, it is un-
clear how force magnitude is related to the rate
of tooth movement, which is a biologically con-
trolled phenomenon.1'2
Intuitively, the point of force application also
has an influence on the quality of tooth move-
ment. There is only one point on a tooth
through which a force can be applied that will
move the tooth in the direction of the force
without tipping or rotating it. This point is the Figure 2. The center of resistance in a tooth with full
center of resistance and a force acting through it periodontal support (A). The center of resistance is
more apical in a periodontally compromised tooth
will cause pure translation of the tooth as shown (B).
in Figure 1.
If a tooth were truly a free body floating in promised tooth with loss of attachment as shown
space, the center of resistance would be coinci- in Figure 2.4"0
dent with the tooth's center of mass or gravity. Forces, as vectors, can be combined or di-
However, teeth are restrained by surrounding vided mathematically. Two or more forces acting
tissues, most notably the periodontal ligament at a single point can be added using simple
(PDL). The location of the center of resistance, trigonometry or vector addition and repre-
therefore, depends on the size and shape of the sented as a single force at that point. For exam-
tooth as well as on the quality and level of the ple, separate distally and extrusively directed
supporting structures. In a healthy tooth with an forces can be combined into one distal-extrusive
intact PDL, the center of resistance is presumed force as shown in Figure 3. Similarly, a single
to be somewhere between Ys and Yz the distance distal-extrusive force can be resolved mathemat-
from the alveolar crest to the root apex.3 For a ically into its distal and extrusive components.
maxillary central incisor, this is approximately
10 mm apical to the level of placement of an Moments
orthodontic bracket. The center of resistance is
located more apically for a periodontally com- When a force is applied at any point other than
through the center of resistance, in addition to

Figure 1. Center of resistance, shown throughout as a

solid black dot. A force acting through the center of Figure 3. Forces are vectors and can be combined or
resistance results in pure translation of a tooth. resolved mathematically.
<<    
     Article
      >>
Steven J. Lindauer
moving the center of resistance in the direction
of the force, a moment is created. A moment is
defined as a tendency to rotate and may refer to
rotation, tipping, or torque in orthodontic ter-
minology. If a distal force is applied buccal to
the center of resistance, the center of resistance
of the tooth will move distally and the tooth will
rotate mesiobuccally (Fig 4A). If a distal force is
applied coronal to the center of resistance, as
when an elastic chain is stretched over the
bracket on a premolar, the center of resistance
will move distally and the crown of the tooth will
tip distally (Fig 4B). If an intrusive force is ap-
plied facial to the center of resistance, the center
of resistance will intrude and the crown of the
tooth will torque facially (Fig 4C).
A force applied directly through the center of
resistance will cause pure translation of the
tooth in the direction of the force with no rota-
tion. If the same force is applied away from the
center of resistance, toward the crown for exam-
ple, the tooth will move in the direction of the
force and there will be a moment created to tip
the crown in the direction of the force (Fig 5A).
Increasing the magnitude of the force (Fig 5B)
or applying the same force even further from
the center of resistance (Fig 5C) will increase the
tendency for rotation. Therefore, the magnitude
of a moment (M) is equal to the magnitude of
the applied force (F) times the distance (d) of
that force from the center of resistance, M = Fd.
The distance is always measured perpendicularly
from the line of action of the force to the center
of resistance.
Figure 4. A force applied at the bracket (black) will
result in both a force and a moment at the center of
resistance (gray). Occlusal view (A), buccal view (B),
mesial view (C). Applied forces and couples are
shown in black throughout. Equivalent force systems
(forces and moments) at the center of resistance are
shown in gray.
Home | TOC |          
Index
A 1,000 g-mm
1%
100g-
2,000 g-mm
•^\
100 g
100 g 100 g
Figure 5. The magnitude of a moment depends on
both the magnitude of the applied force and its per-
pendicular distance from the center of resistance,
M = Fd (A). The magnitude of the moment increases
as the force increases (B) or the distance increases
(C).
Couples
Pure rotation of a tooth without translation can
be accomplished by applying 2 equal and oppo-
site forces that are not acting along the same
line. Two equal and opposite, noncolinear
forces are called a couple. The 2 forces cancel
out any tendency for the center of resistance of
the tooth to move, but the moments created by
the 2 forces do not cancel each other. The tooth,
therefore, rotates about its center of resistance
regardless of the point of application of the
couple. If the 2 forces of the couple act on
opposite sides of the center of resistance, their
effect to create a moment is additive. If they are
on the same side of the center of resistance, they
are sub tractive. Either way, no net force is felt by
the tooth, only a tendency to rotate. In this way,
a couple applies a pure moment to a tooth.
The magnitude of the moment created by a
couple is dependent on both force magnitude
and distance. The moment of a couple is really
the sum of the moments created by each of the
2 forces that make up the couple:
M^Couple
( = M
Force 1 + MForce 2 Or M Couple
= Fjd! + F2d2.
F! and F2 are equal but opposite. Therefore, the
magnitude of a moment created by a couple is
F(dj + d 2 ) or F times the distance between the
2 forces, M = Fd.
A couple exerts no net force on the center of
resistance because the 2 forces that comprise it
are opposite in direction and cancel each other.
Therefore, a couple alone always acts to rotate,
tip, or torque the tooth around the center of
<<    
     Article
      >>
Basics of Mechanics
resistance. Likewise, the magnitude of the mo-
ment created by a couple depends only on the
magnitude of its forces and the distance between
them, not on the distance of the couple from the
center of resistance. Therefore, a couple acts the
same on a tooth regardless of the point at which
it is applied.
A conceptually simple example of a couple is
shown in Figure 6. A premolar is rotated by
stretching an elastic in one direction from the
buccal attachment and another elastic from the
lingual attachment in the opposite direction.
Thus, 2 equal and opposite forces are applied
and the tooth rotates around its center of resis-
tance without translation.
More commonly in orthodontics, couples are
applied by engaging a wire in an edgewise
bracket slot. To achieve a first-order couple, the
wire is angulated to produce equal magnitudes
of force at the mesial and distal aspects of the
bracket in opposite, buccal and lingual direc-
tions as shown in Figure 7A. To create a second-
order couple, the wire produces equal but op-
posite intrusive and extrusive forces at the mesial
and distal aspects as in Figure 7B. A twist or
torque in the wire will produce intrusive and
extrusive forces that are equal and opposite act-
Figure 6. A couple is applied to derotate a premolar.
Before (A) and after (B).
Home | TOC |          
Index
B
Figure 7. Couples are most often created in orth-
odontics by inserting an active wire into an orthodon-
tic bracket. The wire applies equal and opposite non-
colinear forces (black) resulting in a pure moment
(gray). Occlusal view (A), buccal view (B), mesial view
(C).
ing at the buccal and lingual aspects of the
bracket slot to produce a third-order couple as
shown in Figure 7C.
Equivalent Force Systems
Descriptions of orthodontic tooth movement of-
ten refer to movements of the crowns of teeth
that are easy to visualize clinically. However,
tooth movement is more fully described by tak-
ing into account both the translatory movement
of the tooth and the rotation, tip, and torque
experienced.
A comprehensive way of describing tooth
movement is to express the components of
movement experienced by the tooth at the cen-
ter of resistance, which include both translation
and rotation. For example, in Figure 4B, the
distal force applied at the bracket will cause the
tooth to move distally and the crown to tip dis-
tally. The force at the bracket is equivalent to a
force at the center of resistance plus a moment
that will cause the tooth to tip.
Moment-to-Force Ratios and Centers
of Rotation
The goal of orthodontic treatment is to move
teeth a prescribed distance in a predetermined
direction to enhance the esthetic and functional
aspects of occlusion and achieve a stable result.
One of the most common types of tooth move-
ment is that which occurs when closing an ex-
traction site. Space closure is cited as an example
<<    
     Article
      >>
Steven J. Lindauer
of typical tooth movement, but the principles
described are relevant to orthodontic tooth
movement for any purpose.
By varying the ratio of moment to force ap-
plied to teeth, the quality of tooth movement
can be changed among tipping, crown move-
ment, translation, and root movement.4'7'8
Whenever a force is applied at the crown of a
tooth, a tendency for the tooth to rotate, tip, or
torque (a moment) is also created. In addition
to the force applied, a couple may also be en-
gaged intentionally to partially correct, com-
pletely correct, or overcorrect this tendency. By
changing the ratio of the moment from the
applied couple to the force applied, the center
of rotation of tooth movement can be varied to
produce the type of tooth movement desired.
Tipping
During space closure, there is no practical, di-
rect way to apply a force directly through the
center of resistance of a tooth to achieve pure
translation without tipping. To move a tooth
through an extraction space, a force is applied at
the bracket to pull the tooth in the desired
direction. The force alone will cause the tooth to
move in the correct direction, but the crown will
also tip in that direction while the apex moves in
the opposite direction. In this case, no moment
has been applied to prevent the tipping that
occurs. Only a force has been applied (Fig 8A).
The moment-to-force ratio (M/F) applied is 0/F
or 0.
When only a force is applied at the bracket to
move a tooth, the equivalent force system at the
center of resistance is the force plus a moment
that will tip the crown in the direction of the
B to the bracket, a force alone will produce a
Figure 8. Tipping. The applied force system (A). The
equivalent force system at the center of resistance (B).
The predicted tooth movement with a center of rota-
tion, shown throughout as a gray dot, just apical to the
center of resistance (black dots) (C).
Home | TOC |          
Index
B
Figure 9. Crown movement. The applied force sys-
tem (A). The equivalent force system at the center of
resistance (B). The predicted tooth movement with a
center of rotation at the apex (C).
force (Fig 8B). If the center of resistance is 10
mm apical to the bracket, this moment is 10 mm
times the magnitude of the force. For example,
a distal force of 100 g at the bracket will create
an equivalent of 100 g of distal force at the
center of resistance plus a moment of 1,000
g-mm in the direction of distal crown tip.
Without a moment to counteract the ten-
dency of the tooth to tip in the direction of the
force, the center of resistance of the tooth moves
in the direction of the force, the crown moves
further than the center of resistance, and the
apex actually moves in a direction opposite to
the force. The tooth appears to have rotated
around a point just apical to its center of resis-
tance as illustrated in Figure 8C. Therefore, the
center of rotation when the moment to force
ratio is 0 is just apical to the center of resistance.
Crown Movement
Knowing that a force applied at the bracket to
move a tooth will also result in a tendency to tip,
a countermoment in the form of a couple may
also be applied intentionally to counteract tip-
ping. If the center of resistance is 10 mm apical
moment that is 10 mm times the magnitude of
the force. Applying a countermoment or couple
less than 10 mm times the magnitude of the
force will reduce the tendency of the tooth
crown to tip in the direction of the force but not
negate it completely (Fig 9A). An applied M/F
of about 7/1 will result in crown movement
while the apex of the root remains relatively
stationary.7
When a M/F of 7/1 is applied at the bracket,
the equivalent force system at the center of re-
<<    
     Article
      >> Home | TOC |          
Index

Basics of Mechanics

sistance is a force to move the tooth plus a small

net tendency for the crown to tip in the direc-
tion of the force (Fig 9B). For example, if a force
of 100 g is applied to move a tooth dis tally, there
is a tendency from that force for the tooth crown
to tip distally of 1,000 g-mm. A countermoment
or couple of 1,000 g-mm in the opposite direc-
tion also would need to be applied intentionally
to negate the tendency to tip completely. If a
couple of only 700 g-mm were applied at the Figure 11. Root movement. The applied force system
bracket, the tooth would have a net tendency for (A). The equivalent force system at the center of
the crown to tip distally of 300 g-mm. At the resistance (B). The predicted tooth movement with a
center of rotation at the crown (C).
center of resistance there would be a distal force
of 100 g plus a moment to tip the crown distally
of 300 g-mm. The moment (of the couple) to
would cause the tooth to move in the direction
force ratio (M/F) applied is 700/100 or 7/1.
of the force and the crown to tip in the same
With an applied M/F of 7/1, the tooth will
direction. The couple completely negates this
move in the direction of the force and the crown
tendency to tip, but the tooth still moves in the
will tip somewhat in the same direction. While
direction of the force. The M/F applied is 10/1,
the center of resistance is moving distally as a
and the tooth translates without tipping.
result of the applied force, the crown is tipping
When a M/F of 10/1 is applied at the bracket,
distally at a greater rate but the apex is moving
the equivalent force system at the center of re-
to a lesser extent or not at all. The tooth appears
sistance is a single force with no net moment
to have rotated around its apex, as illustrated in
(Fig 10B). For example, if a force of 100 g is
Figure 9C. Therefore, the center of rotation when
applied at the bracket to move a tooth distally,
the moment to force ratio is 7/1 is at the apex of the
the equivalent force system at the bracket is
tooth, and only crown movement occurs.
100 g of distal force plus a tendency for the
crown to tip in the direction of the force of 1,000
Pure Translation
g-mm. If a couple with a countermoment of
When a force to move a tooth is applied at a 1,000 g-mm tending to tip the crown in the
bracket that is 10 mm away from the center of direction opposite to the force were also applied
resistance, a tendency for the tooth to tip is intentionally, the net equivalent force system
created that is 10 mm times the magnitude of would be a single distal force of 100 g through
the force. To counteract the tendency for tip- the center of resistance. The M/F applied is
ping, a couple can be applied intentionally to 1,000/100 or 10/1.
produce a moment of equal magnitude in the With an applied M/F of 10/1, the tooth will
opposite direction (Fig 10A). The force alone translate in the direction of the force without
tipping. This is often referred to as pure trans-
lation and is shown in Figure IOC. In pure trans-
lation, the center of rotation is considered to be
at infinity because no rotation occurs.

Figure 10. Pure translation. The applied force system
(A). The equivalent force system at the center of
resistance (B). The predicted tooth movement (C). In
pure translation, the center of rotation is at infinity.
Root Movement
When the countermoment applied intentionally
at a bracket is more than 10 mm times the
magnitude of the force applied, the tooth moves
in the direction of the force but the crown tips in
the opposite direction (Fig 11 A). The force
alone would cause the tooth to move in the
direction of the force and the crown to tip in the
same direction. The couple applied more than
<<    
     Article
      >>
Steven J. Lindauer
negates this tendency to tip, but the center of
resistance still moves in the direction of the
force while the crown does not. An applied mo-
ment-to-force ratio of about 13/1 will result in
root movement while the crown of the tooth
remains relatively stationary.7
When a M/F of 13/1 is applied at the bracket,
the equivalent force system at the center of re-
sistance is a force to move the tooth plus a small
net tendency for the root to tip in the direction
of the force (Fig 11B). For example, if a force of
100 g is applied to move a tooth distally, there is
a tendency from that force for the tooth crown
to tip distally of 1,000 g-mm. A countermoment
or couple of 1,000 g-mm in the opposite direc-
tion would also need to be applied to negate the
tendency to tip completely. If a couple of 1,300
g-mm were applied, the tendency to tip would be
more than counteracted and there would be a
net tendency for the crown to tip mesially of 300
g-mm. The equivalent force system at the center
of resistance is a distal force of 100 g plus a
moment to tip the crown mesially of 300 g-mm.
The M/F applied at the bracket is 1,300/100 or
13/1.
With an applied M/F of 13/1, the tooth will
move in the direction of the force and the root
will tip in the same direction. While the center
of resistance is moving distally as a result of the
applied force, the root is tipping distally at a
greater rate but the crown is moving to a lesser
extent or not at all. The tooth appears to have
rotated around its crown as illustrated in Figure
11C. Therefore, the center of rotation when the
moment-to-force ratio is 13/1 is at the crown of
the tooth and only root movement occurs.
Pure Rotation
If only a couple, and no net force, is applied to
a tooth, the tooth will rotate around its center of
resistance and the tooth will not translate (Fig
12A). Because the action of a couple does not
depend on its point of application, a pure mo-
ment always acts at the center of resistance (Fig
12B). The forces of the couple cancel out any
tendency for the center of resistance of the
tooth to move, but the moment produced by the
couple causes the tooth to tip as shown in Figure
12C. The moment-to-force ratio is infinite and
the center of rotation is coincident with the
Home | TOC |          
Index
Figure 12. Pure rotation. The applied force system
(A). The equivalent force system at the center of
resistance (B). The predicted tooth movement with a
center of rotation at the center of resistance (C).
center of resistance. This is referred to as pure
rotation.
Predicting the Force Systems Created by
Orthodontic Appliance Activations
The objective of activating an orthodontic appli-
ance is to produce forces and moments to move
teeth in a predictable and controlled manner.
The appliance itself obeys the laws of physics. It
acts by effecting force systems at all points of
attachment. It is not possible to fully understand
the response to appliance activation by observ-
ing the displacement at one end of an appliance
without considering the effects at the other.
The force systems produced by orthodontic
appliance activations must be resolved separately
from the actual forces and moments that indi-
vidual teeth will experience at their respective
centers of resistance. Understanding the physics
that determine the force systems generated by
activating orthodontic appliances discloses the
forces and moments that are applied to teeth at
their points of attachment, usually at the brack-
ets. To deduce how each tooth will be displaced
as a result of the activation, the equivalent force
systems acting at the centers of resistance must
be assessed subsequently.
Static Equilibrium
When orthodontic appliances are activated and
inserted, tooth movement does not occur imme-
diately but proceeds slowly over an extended
period of time. For this reason, the physical laws
of statics are considered adequate to describe
the instantaneous force systems produced by
orthodontic appliances. These are the condi-
<<    
     Article
      >>
Basics of Mechanics
tions under which analysis of orthodontic force
systems occurs. The laws of statics cannot be
used to describe how the force systems will
change as a tooth moves and an appliance deac-
tivates and alters its configuration.
The physical laws of statics are governed by
Newton's third law, which may be summarized as
stating that for every action there must be an
equal and opposite reaction. The orthodontic
application is that for every appliance, but not
necessarily for every tooth to which it is attached,
the sum of the forces and the sum of the mo-
ments must be equal to zero.9 That is, because
the appliance itself does not move instanta-
neously once it is placed, the net force system
produced by the appliance as a whole must
be equal to zero. This condition must be met
by every orthodontic appliance regardless of
the treatment philosophy used. It is impossible
to design an appliance that defies the laws of
physics.
Equal and Opposite Forces
Perhaps the simplest orthodontic appliance to
analyze is the elastic band. An elastic band
stretched between two points of attachment will
produce a force of some magnitude at one end
and, by the laws of equilibrium, produce an
opposite force of the same magnitude at the
other end.
As far as the elastic band is concerned, it is in
equilibrium. The sum of the forces produced by
the elastic, equal and opposite, is zero. The elas-
tic itself produces no moments, so the sum of
the moments is also zero and the conditions of
static equilibrium are met.
One Couple Appliances—Statically
Determinate Systems
A 1-couple orthodontic appliance is inserted
into a bracket or tube at 1 end and is tied as a
point contact at the other.10 Because it is not
engaged into an orthodontic bracket, the end
that is tied as a point contact cannot produce a
couple but only a simple force at that site. The
other end, which is engaged in the bracket slot,
can produce both a force and a couple at that
attachment. The appliance is a 1-couple system
because a couple is generated only at the site of
full engagement. It is statically determinate be-
cause the magnitudes of the forces and mo-
Home | TOC |          
Index
ments produced can be determined clinically
after the appliance is inserted into the bracket.
This can be done by inserting the appliance into
the bracket and measuring the force required to
activate the wire to the site where it will be tied
as a point contact.
An example of a 1-couple orthodontic appli-
ance is a long arm or cantilever activated to
extrude a high maxillary buccal canine as dem-
onstrated in Figure ISA. The wire is inserted
into the molar auxiliary tube and bent to rest
coronal to the canine. It is activated by displac-
ing the wire apically and tying it to the canine
bracket to create an extrusive force as in Figure
14. In a 1-couple system, the direction of the
forces and couple exerted by the appliance are
intuitive and can be deduced in a number of
ways.
The most consistent way to derive the force
system produced by any orthodontic appliance
is to remove the activated wire from its at-
tachments and lay it passively over the attach-
ment sites. The angle formed by the wire and
the brackets will show the direction of the
couple produced at the site of engagement
where the angle between the wire and bracket
is largest.11'13
Because there is only one site of engagement
Figure 13. A long arm or cantilever to extrude a high
canine (A). The passive wire showing the angle be-
tween the molar bracket and the wire (B). The force
system exerted by the wire is in equilibrium with a
crown-mesial moment at the molar, and equal and
opposite extrusive and intrusive forces at the canine
and molar, respectively (C).
<<    
     Article
      >> Home | TOC |          
Index

10 Steven J. Lindauer

attachment sites. In this case, inserting the wire

into 1 attachment and using a gauge to measure
the force required to deflect the wire to the
other bracket will not necessarily give an accu-
rate assessment of the force produced by the
appliance. Because of the inability to measure
force systems produced by 2-couple appliances
clinically, they are referred to as being statically
indeterminate.
The force systems produced by 2-couple orth-
Figure 14. Clinical example of a wire tied as a point odontic appliances depend on both the wire
contact to extrude a high canine. geometry and bracket angulation relationships.
A rough idea of the directions of the forces and
moments exerted by a 2-couple appliance may
in a 1-couple system, the direction of the couple
be deduced by the method described above: the
at that site depends only on the angle formed
wire is passively placed over both attachment
between that bracket and the wire. As shown in
sites to determine the angle formed between the
Figure 13B, the molar bracket must rotate coun-
bracket slot and the wire at each end. If the
terclockwise to engage the wire. The couple pro-
angles formed at the 2 attachments are equal
duced by the wire at the molar will therefore be
and opposite, equal and opposite couples will be
in a direction to tip the molar crown mesially
generated and no force will be produced at ei-
and root distally. The laws of equilibrium dictate
ther site, as shown in Figure 15A. If the angles
that the sum of the moments exerted by the wire
are equal and in the same direction, then both
be equal to zero. With a counterclockwise mo-
sites will experience couples in the same direc-
ment at the molar, there must be a clockwise
tion of equal magnitude. The forces produced at
moment to maintain equilibrium. That moment
the attachment sites will be equal in magnitude
is produced by intrusive and extrusive forces of
equal magnitude exerted by the wire at the mo-
lar and canine, respectively, as shown in Figure
13C. B
To further illustrate the state of equilibrium
of the appliance, assume that a 50-g extrusive
force is exerted by the wire at the canine. This
can be measured using a force gauge after in-
serting the wire into the molar tube and before
tying it to the canine. An intrusive force of 50 g
must, therefore, be present at the molar to have
i i
the sum of the forces exerted by the appliance
equal to zero. If the molar and canine are 20
mm apart, a couple of 50 g times 20 mm or 1,000
g-mm is exerted by the appliance as a whole in a
clockwise direction. To have the sum of the mo-
ments equal to zero, a counterclockwise couple
%/ i
of 1,000 g-mm is exerted by the appliance at the Figure 15. Force systems from a 2-couple appliance
molar to tip its crown mesially and root distally, depend on wire-bracket geometry. Equal and oppo-
as shown in Figure 13C. site bracket-wire angle relationships result in equal
and opposite couples with no forces (A). Equal brack-
et-wire angle relationships in the same direction result
Two-Couple Appliances—Statically in equal couples in the same direction with large
Indeterminate Systems forces to maintain appliance equilibrium (B). If
bracket-wire angle relationships are unequal, the at-
A 2-couple appliance is one that is engaged into tachment with the largest angle will have the largest
attachments at both ends. A couple, therefore, couple and resultant forces will be in a direction
may be generated by the wire at either or both opposite this moment to maintain equilibrium (C).
<<    
     Article
      >>
Basics of Mechanics
and opposite in direction to each other. To-
gether, the forces will form a couple on the wire
to maintain equilibrium of the appliance as a
whole. That couple formed by the 2 forces will
be opposite in direction and equal in magnitude
to the sum of those couples produced at the
individual attachment sites, as shown in Figure
15B.
If the angles formed between the passively
placed wire and the 2 bracket slots are not equal
in magnitude, then the site with the greatest
angle can be determined. This will be the site at
which the greatest couple will be generated. The
direction of the moment produced at that tooth
will be that which will bring the bracket to the
wire. The forces at the 2 attachment sites will be
equal in magnitude and opposite in direction to
each other as always. Together, those forces will
form a couple on the wire to maintain equilib-
rium of the appliance as a whole. The couple
formed by the 2 forces will be opposite in direc-
tion to the couple exerted at the site of attach-
ment with the greatest bracket-wire angulation
as shown in Figure 15C. The magnitude of the
forces and the direction of the couple at the
other attachment site, however, may not be ap-
parent from clinical observation alone.
The relative moments and forces produced by
2-couple appliance activations are extremely sen-
sitive to clinical geometry. They have been de-
termined for both 2-dimensional14-16 and 3-di-
mensional17'18 conditions.
The forces and moments produced by a
straight segment of round wire inserted into 2
orthodontic brackets were first described by Bur-
stone and Koenig in 1974.14 When the 2 brackets
are equally but oppositely angled as shown in
Figure 16A, the resultant couples are mirror
images of each other (their mathematical sum is
zero) and no forces are produced. As the angu-
lation of the bracket on the right is varied while
the left bracket is held constant, a static analysis
can be used to determine the relative moments
and equilibrium forces that result. A nonlinear
reduction of the right moment occurs as the
angulation of the right bracket is decreased
slightly in Figure 16B. As the absolute sum of the
2 moments increases because of the change in
relative bracket angulations, proportional in-
creases in the forces are noted that maintain the
conditions of equilibrium (Fig 16B). When the
angle of the right bracket is half that of the left,
Home | TOC |          
Index
11
B/
/, x.
^/ NT /^
V u VI U
t
/^
/ ^ V /
V V
I
/,
/^ /r
U V
Figure 16. Force systems from a 2-couple appliance:
straight segment of wire in malaligned brackets. Equal
and oppositely angled brackets result in equal and
opposite couples (A). As 1 bracket angulation de-
creases, the magnitude of the couple at that bracket
decreases and forces result (B). When the angulation
of 1 bracket is half that of the other, no couple is
experienced at the bracket with the smaller angula-
tion and forces are consequently increased (C). As the
bracket angle continues to decrease at 1 end of the
appliance, the couple at the lesser angled bracket is in
the same direction as at the greater angled bracket
and forces are even greater (D). When both brackets
are equally angled in the same direction, couples at
the 2 brackets are equal and in the same direction
with forces at a maximum (E).
but still opposite in direction, no couple is
present at the right bracket, as illustrated in
Figure 16C. Moments at the right bracket in the
same direction as the left bracket couple in-
crease as the right bracket angle decreases to
zero and then increases to mimic the left bracket
angulation (Fig 16D). Finally, when both brack-
ets are equal in direction and angulation, cou-
ples are also equal (their mathematical sum is
maximal), and equilibrium forces are at a max-
imum (Fig 16E).
Analogously, the static force systems gener-
ated by placing wires with V- and step-bends into
aligned, coplanar brackets have been well docu-
mented.15 In a 2-dimensional model using 2
brackets, a symmetrically placed V-bend pro-
duces equal and oppositely directed couples, as
shown in Figure 17A. Asymmetric bends result in
various combinations of moments and forces.
Moving the bend slightly off center results in an
increase in the couple generated at the bracket
closer to the bend and a decrease at the bracket
<<    
     Article
      >>
12 Steven J. Lindauer
Figure 17. Force systems from a 2-couple appliance:
bent wire in aligned brackets. When the apex of the V
bend is half way between the brackets, the wire exerts
equal and opposite couples at the 2 attachments and
no forces (A). As the V bend is moved off center, the
couple nearer the bend increases and the couple
further from the bend decreases. Forces result to
maintain appliance equilibrium (B). When the V
bend is at Vs the distance between the brackets, a
couple is only present at the bracket nearer the bend.
No couple is experienced at the bracket further from
the bend, and forces result to maintain equilibrium
(C). When the V bend is very close to 1 bracket,
couples in the same direction are experienced at both
brackets, with the larger couple at the bracket closer
to the bend. Forces increase as the bend is moved
further off center (D). A step bend, regardless of
where it is placed, results in equal couples in the same
direction at both attachments. Forces are at a maxi-
mum (E).
further away, as shown in Figure 17B. The sum
of the moments from the 2 couples is no longer
zero, so forces are generated that produce a
counteracting couple on the wire as a whole to
maintain equilibrium conditions. When the
bend is located at Vs of the distance between 2
brackets, because of the deflection angle of the
activated wire, a couple results at only the
bracket nearer the bend (Fig 17C). Forces in-
crease to maintain equilibrium. Bends closer to
the bracket result in couples at both brackets in
the same direction with the greater moment
generated at the bracket closer to the bend (Fig
17D). The 2 couples are now additive, and even
greater forces result at the 2 attachments to
maintain equilibrium of the appliance. Step
bends are less sensitive than V bends to location
and result in moments of equal magnitude and
Home | TOC |          
Index
direction at both brackets independent of where
they are placed, as shown in Figure 17E. With
couples of equal magnitude produced at both
attachment sites in the same direction, forces
are increased further to maintain equilibrium
conditions.
The forces and moments shown in Figures 16
and 17 are correct for 2-couple appliances active
in any 1 dimension. The brackets, therefore, are
shown without teeth to emphasize that the force
systems may be acting in the occlusal, lateral, or
frontal planes. Relative sizes of the arrows and
curves reflect differences in force and moment
magnitudes, respectively.
Predicting How Teeth Will Move in
Response to Orthodontic Appliance
Activations
The first section of this article, "Predicting How
Teeth Will Move in Response to Application of
Orthodontic Force Systems," described how mo-
ments and forces displace individual teeth. The
second section, "Predicting the Force Systems
Created by Orthodontic Appliance Activations,"
discussed the way in which moments and forces
are generated by orthodontic appliances. This
final section shows how these two steps can be
used together to predict how teeth will move
when orthodontic appliances are activated. Con-
versely, the 2 steps can be used to design an
appliance that will move teeth in a predictable
way. It is important to distinguish between the 2
concepts: teeth move in response to forces and
moments applied at their brackets, and orth-
odontic appliances are activated to transfer
forces and moments to the brackets of teeth.
Predicting the Result of Appliance Activation
Using the laws of static mechanics, the force
systems generated by an orthodontic appliance
are calculated to discern the forces and mo-
ments transferred to teeth at their points of
attachment. Subsequently, the forces and mo-
ments applied at the brackets of teeth are used
to predict how the teeth will be displaced ini-
tially and eventually move as a result of bone
remodeling.
As an example of predicting how teeth will
move in response to appliance activation, an
orthodontic wire used to move a maxillary ca-
<<    
     Article
      >>
Basics of Mechanics
nine buccally, out of lingual crossbite, is illus-
trated in Figure 18. The appliance is activated by
making a mesial in-bend near the molar and
inserting the wire into the molar tube. The wire
is tied to the canine but not inserted into the
canine bracket.
Because the wire is engaged only at the molar
attachment, a couple is generated by the wire
only at the molar. The couple is in a direction
that will rotate the molar crown mesiolingually.
Equal and opposite lateral forces in a direction
to counteract the couple will be generated by
the wire to move the canine buccally and molar
lingually, as shown in Figure ISA. The buccal
force at the canine can be measured using a
force gauge once the wire is inserted into the
molar tube. If the force measures 50 g and the
distance from the molar to the canine is 20 mm,
the mesiolingual couple at the molar is 50 g X
20 mm or 1,000 g-mm in magnitude. The lingual
force at the molar bracket is 50 g, and the buccal
force at the canine bracket is 50 g.
The sum of the forces exerted by the wire and
the sum of the moments exerted by the wire
must be equal to zero to satisfy the conditions of
equilibrium. The forces, 50 g lingual at the mo-
lar and 50 g buccal at the canine, sum to zero.
The 2 forces create a couple exerted by the wire
of 50 g X 20 mm or 1,000 g-mm in a clockwise
direction, as shown in Figure ISA. The couple
generated at the molar must be equal and op-
posite, 1,000 g-mm counterclockwise, for the
sum of the moments to equal zero. The couple
at the molar is in a mesiolingual direction with a
magnitude of 1,000 g-mm.
Figure 18. Predicting the result of an appliance acti-
vation. A 1-couple appliance is used to move a canine
buccally, out of crossbite. The force system exerted by
the appliance in the occlusal view (A). Forces exerted
by the appliance at the brackets (black) and the equiv-
alent force systems at the centers of resistance (gray)
from a mesial aspect (B).
Home | TOC |          
Index
13
The second step in determining how teeth
will move is to discern the equivalent force sys-
tems exerted at the centers of resistance of the
teeth involved. These are shown in Figure 18B.
There is a lingual force of 50 g at the molar
bracket and a mesiolingual couple of 1,000
g-mm. If the center of resistance of the molar is
10 mm apical to the bracket, the equivalent
force system at the molar center of resistance is
50 g of lingual force plus a moment of 10 mm X
50 g or 500 g-mm, tending to tip the crown
lingually. In addition, there is a moment of 1,000
g-mm, tending to rotate the molar mesiolin-
gually.
At the canine bracket there is a buccal force
of 50 g. If the canine center of resistance is 10
mm apical to the canine bracket, the equivalent
force system at the canine center of resistance is
50 g of buccal force plus a moment of 10 mm X
50 g or 500 g-mm, tending to tip the crown
buccally. The molar will, therefore, tend to move
lingually, its crown will tip lingually, and the
tooth will rotate mesiolingually. The canine will
move buccally and its crown will tip buccally.
Designing an Orthodontic Appliance
The steps of force system analysis are reversed if
the objective is designing an appliance to move
teeth predictably. First, the desired force systems
at the centers of resistance are determined.
From this, the force systems required at the
brackets can be calculated and an appliance de-
signed to deliver the desired forces and mo-
ments.
As an example, an appliance designed to
close a premolar extraction site by molar trans-
lation and canine translation is illustrated in
Figure 19. If the magnitude of the space closing
force desired is 100 g, a mesial force at the molar
center of resistance of 100 g and a distal force of
100 g at the canine center of resistance will be
necessary, as shown in Figure 19A. This will pro-
duce molar translation mesially and canine
translation distally.
The force systems required at the brackets
(Fig 19B) that will result in these center-of-resis-
tance equivalents must then be determined. If
the molar center of resistance is 10 mm apical to
the bracket, a mesial force of 100 g at the molar
bracket would produce a force of 100 g at the
<<    
     Article
      >>
14 Steven J. Lindauer
; 100g 100g
-o c«--
Figure 19. Designing an orthodontic appliance. De-
sired force systems at the centers of resistance to
translate 2 teeth toward each other without tipping
(A). Force systems necessary at the brackets to achieve
the desired force systems (B). Closing loop designed
to deliver the necessary force systems at the attach-
ments of the 2 teeth (C). Reanalysis of the appliance's
effects shows that space closing forces placed at the
brackets (black) as seen from the occlusal view will
cause the teeth to move toward each other and rotate
(gray) (D).
center of resistance plus a tendency for the
crown to tip mesially of 10 mm X 100 g or 1,000
g-mm. A countermoment of 1,000 g-mm in a
direction to tip the molar crown distally would,
therefore, need to be applied at the bracket in
addition to 100 g of mesial force to negate this
tendency for tipping and result in pure transla-
tion of the molar.
At the canine center of resistance, a distal
force of 100 g is desired. A 100 g distally directed
force at the canine bracket would produce a
1,000 g-mm tendency for the canine crown to tip
distally if the canine center of resistance is 10
mm apical to the bracket. A countermoment of
1000 g-mm should be applied at the bracket to
tip the canine crown mesially in addition to the
distal force of 100 g.
Lastly, the appliance system should be reana-
lyzed to determine any side effects produced by
the design chosen. In the example, a closing
loop with mesial and distal forces of 100 g is
designed as shown in Figure 19C. A couple of
1,000 g-mm to produce pure translation of the
molar, and a couple of 1,000 g-mm to produce
pure translation of the canine, are applied by
forming preactivation bends. This can be accom-
plished using a bending template19 or by mea-
suring the moments and forces clinically using a
Home | TOC |          
Index
specially designed force-moment gauge as
shown in Figure 20 (Orthomeasurements,
Young Research and Development, Inc, Avon,
CT). Alternatively, the clinician may choose to
activate the appliance, monitor tooth movement
over time, and make adjustments accordingly.
The sum of the forces, 100 g mesial for the
molar and 100 g distal for the canine, is zero.
The sum of the applied moments, 1,000 g-mm
crown distal for the molar and 1,000 g-mm
crown mesial for the canine, is also zero, so the
appliance is in equilibrium and no vertical force
side effects are present. The molar is expected to
translate mesially, and the canine is expected to
translate distally.
Analysis of the space-closing appliance from
the occlusal view (Fig 19D) shows effects not
seen in the lateral view. The mesial force at the
molar will result in mesial molar movement plus
a tendency for the molar to rotate mesiolin-
gually. The distal force at the canine will result
in distal canine movement plus a tendency for
the canine to rotate distolingually. Additional
appliance adjustments would be required to ne-
gate these unwanted rotational tendencies.
Conclusion
Armed with the basic building blocks of mechan-
ics, the orthodontist devises an intricate plan of
appliance activations to achieve predetermined
treatment goals. Forces and couples are applied
to teeth to move them in the desired directions.
Tooth movement is monitored regularly to as-
sure that treatment proceeds smoothly and pos-
Figure 20. Measuring both forces and moments ap-
plied by an activated wire clinically is possible only
with a specially designed force-moment gauge.
<<    
     Article
      >>
Basics of Mechanics
itively. Unwanted effects are corrected by adjust-
ments along the way. The final result is achieved
by a series of well-planned mechanical interven-
tions that initiate and sustain a controlled bio-
logic reaction.
The components of comprehensive orth-
odontic treatment, preliminary alignment, over-
bite control, space closure, root paralleling, and
finishing, rely on a series of biomechanical pro-
cesses. The choice of appliances and techniques
used by practitioners varies radically among in-
dividuals, but the fundamental forces and mo-
ments they produce are universal. Appliances
will always act according to the laws of physics.
Understanding the basic biomechanical princi-
ples involved in effecting controlled tooth move-
ment makes achieving successful orthodontic
treatment outcomes more predictable and con-
sistent.
Acknowledgment
The author thanks Ms. Carol Wilkins for her help in prepar-
ing the illustrations for this article.
References
1. Quinn RS, Yoshikawa DK. A reassessment of force mag-
nitude in orthodontics. Am J Orthod 1985;88:252-260.
2. Lindauer SJ, Britto AD. Biological response to biome-
chanical signals: Orthodontic mechanics to control
tooth movement. Semin Orthod 2000;6:145-154.
3. Burstone CJ, Pryputniewicz RJ. Holographic determina-
tion of centers of rotation produced by orthodontic
forces. Am J Orthod 1980;77:396-409.
4. Smith RJ, Burstone CJ. Mechanics of tooth movement.
Am J Orthod 1984;85:294-307.
5. Meisen B. Adult orthodontics: Factors differentiating the
selection of biomechanics in growing and adult individ-
Home | TOC |          
Index
15
uals. Int J Adult Orthod Orthognath Surg 1988;3:167-
177.
6. Lindauer SJ, Rebellato J. Biomechanical considerations
for orthodontic treatment of adults. Dent Clin North
Am 1996;40:811-836.
7. Burstone CJ. Application of bioengineering to clinical
orthodontics, in Graber TM, Swain BF (eds): Orthodon-
tics. Current Principles and Techniques. St Louis, MO,
Mosby, 1985, pp 193-227.
8. Kusy RP, Tulloch JFC. Analysis of moment/force ratios
in the mechanics of tooth movement. Am J Orthod
Dentofac Orthop 1986;90:127-131.
9. Mulligan TF. Common Sense Mechanics in Everyday
Orthodontics. Phoenix, AZ, CSM Publishing, 1998, pp
36-52.
10. Lindauer SJ, Isaacson RJ. One-couple orthodontic appli-
ance systems. Semin Orthod 1995;!: 12-24.
11. Mulligan TF. Common Sense Mechanics in Everyday
Orthodontics. Phoenix, AZ, Publishing, 1998, pp 1-17.
12. Isaacson RJ, Lindauer SJ, Rubenstein LK. Activating a
2 X 4 appliance. Angle Orthod 1993;63:l7-24.
13. Demange C. Equilibrium situations in bend force sys-
tems. Am J Orthod Dentofac Orthop 1990;98:333-339.
14. Burstone CJ, Koenig HA. Force systems from an ideal
arch. Am J Orthod 1974;65:270-289.
15. Burstone CJ, Koenig HA. The force system from step
and V bends. Am J Orthod Dentofac Orthop 1988;93:
59-67.
16. Ronay F, Kleinert MW, Meisen B, et al. Force system
developed by V bends in an elastic orthodontic wire.
Am J Orthod Dentofac Orthop 1989;96:295-301.
17. Lindauer SJ, Isaacson Rf, Conley PA, et al. Force systems
from three-dimensional orthodontic archwires, in Lan-
grana NA, Friedman MH, Grood ES (eds): Proceedings
of the 1993 Bioengineering Conference, New York,
American Society of Mechanical Engineers, 1993;40:262-
265.
18. Isaacson RJ, Lindauer SJ, Conley P. Responses of 3-d
arch wires to vertical V bends. Semin Orthod 1995; 1:57-
63.
19. Burstone CJ, Hanley KJ. Modern Edgewise Mechanics
Segmented Arch Technique, USA, Ormco Corporation,
1985.
<<    
     Article
      >> Home | TOC |          
Index

Leveling and Aligning:

Challenges and Solutions
Bhavna Shroff and Steven J. Lindauer

Leveling and aligning is usually the first step in the mechanical execution of
an orthodontic treatment plan. Most often, this is achieved by inserting
wires of increasing stiffness into the brackets of malaligned teeth. The force
systems generated by placing straight wires into crooked brackets may or
may not result in favorable tooth movement depending on the geometric
relationships among the brackets and the outcome desired. Analysis of the
relationships between adjacent teeth will show whether the force systems
produced by insertion of a straight wire will be desirable or not. Alternative
treatment strategies, including the use of extraoral, interarch, or auxiliary
appliances, may be indicated when the anticipated side effects of straight
wire alignment are unfavorable. Evaluation of the force systems produced
during orthodontic leveling and aligning can improve treatment efficiency
and help avoid unexpected tooth movements. (Semin Orthod 2001;7:16-25.)
Copyright © 2001 by W.B. Saunders Company

reliminary alignment of the teeth within
P each arch is usually the first step in a treat-
ment sequence aimed at achieving full orth-
odontic correction. Depending on the individ-
ual treatment goals and the treatment
philosophy used, this step may involve leveling
and aligning all of the teeth or may initially
exclude some teeth to avoid round-tripping.
Early alignment of rotated or malposed teeth
allows these corrections to be maintained
through the treatment period, permitting bio-
logic adaptation and enhanced stability during
the retention phase. Lining up the brackets is
also important in any technique in which sliding
mechanics will be used to close spaces between
teeth.
Initial leveling and alignment of the teeth
has been simplified by the increased availabil-
From the Department of Orthodontics, University of Maryland
Dental School, Baltimore, MD, and the Department of Orthodontics,
School of Dentistry, Virginia Commonwealth University, Richmond,
VA.
Address correspondence to Steven J. Lindauer, DMD, MDSc,
Department of Orthodontics, School of Dentistry, Virginia Common-
wealth University, Richmond, VA 23298-0566.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0701-0003$35.00/0
doi:10.1053/sodo.2001.21054
ity and use of wires with low load-deflection
rates and shape memory characteristics. An
arch form of nickel titanium wire inserted into
malaligned brackets can accomplish what once
required intricate bending of loops into stain-
less steel wires. Preadjusted brackets of various
prescriptions allow a greater degree of tooth
alignment to be attained in this early stage of
treatment.
The convenience of flexible wires and pread-
justed brackets, however, should not serve as a
substitute for detailed diagnosis of the patient
and careful planning of mechanical interven-
tion. Indeed, the use of wires with low load-
deflection characteristics may actually increase
the possibility that the undesirable side effects of
poorly planned orthodontic mechanics will be
expressed to a greater extent before being de-
tected. Analysis of the force systems that will be
generated by insertion of straight wires into mal-
aligned brackets will show the unanticipated side
effects before they occur. Depending on the
individual situation, these side effects may be
desirable or not. If unfavorable side effects can
be anticipated, steps can be taken to control
them, or an alternate mechanics plan can be
developed to achieve the desired outcome in a
different way.

16 Seminars in Orthodontics, Vol 7, No 1 (March), 2001: pp 16-25

<<    
     Article
      >>
Leveling and Aligning
Leveling With Straight Wires
Use of the straight wire technique in contempo-
rary orthodontic therapy has become very pop-
ular since its introduction by L. F. Andrews in
the early 1970s.1 The fundamental concept was
developed based on the characteristics of ideal
occlusion, the ideal position of the teeth within
each arch, and the interdigitation of teeth be-
tween arches. Andrews described 6 keys to ideal
occlusion that included not only the molar rela-
tionship but also the crown angulations (mesio-
distally), the crown inclinations (labiolingually),
tooth rotations, presence of spacing, and the
anatomy of the occlusal plane. The appliance
design developed is a result of Andrews' obser-
vations. It includes precise amounts of first-, sec-
ond-, and third-order prescription to achieve
ideal tooth positioning when a straight wire is
tied into the brackets without placement of ad-
ditional bends in the wire. Proper positioning of
the brackets at specific heights on the buccal
contours of each tooth is critical for the correct
expression of the appliance prescription.
The popularity of the straight wire technique
is related to its ease of use and a projected
reduction in chairside time. Straight wire treat-
ment offers a simplified approach to the man-
agement of a specific category of malocclusion.
It has become apparent, however, that the
straight wire strategy is not suitable for the treat-
ment of all malocclusions and that inherent lim-
itations reduce successful treatment completion
in some clinical situations. The early recognition
of such situations as well as an understanding of
how to manage them are critical for achieving
consistently successful treatment outcomes.
Asymmetric buccal occlusions and unilateral ver-
tical discrepancies are among the malocclusion
Figure 1. Bracket geometries
I, IV, and VI with their respec-
tive force systems. (Adapted
and reprinted with permis-
sion from Burstone CJ, Koe-
nig HA. Force systems from
an ideal arch. Am J Orthod
1974;65:270-289.2)
Home | TOC |          
Index
17
types that may be difficult to manage with a
straight wire approach if not fully diagnosed and
analyzed before the initiation of therapy.
When all teeth in an arch are engaged into a
straight wire, it is important to recognize
whether the teeth are aligned both in the shape
of the wire and along the plane of occlusion. Are
there any undesirable side effects expressed that
may have been predicted and therefore con-
trolled? There is a systematic approach to ana-
lyzing these clinical situations. To understand
how tooth movement occurs when a straight
wire is placed between 2 teeth, the fundamental
principles of orthodontic biomechanics must be
applied.
Burstone and Koenig2 analyzed the force sys-
tems developed by the placement of a straight
wire between 2 brackets. The angulation of 1
bracket was increased while the other bracket
position remained stationary. A ratio of the an-
gulation between the 2 brackets was measured
and varied among 1.0, 0.5, 0, —0.5, —0.75, and
— 1.0. The 6 different bracket geometries were
analyzed, and the force system developed by
each was described. Among the 6 V geometries
described by Burstone and Koenig, 3 are of par-
ticular importance: geometries I, IV, and VI (Fig
I).3-5 Geometry I is a step geometry and involves
2 moments in the same direction with vertical
forces of equal amount and opposite direction.
Geometry IV is an asymmetric V with vertical
forces on both teeth but a single moment con-
centrated on 1 tooth. Geometry VI is a symmet-
ric V geometry and involves 2 equal and oppo-
site moments with no vertical forces.
The fundamental principles of biomechanics
explained are useful for analyzing the force sys-
tems resulting from the placement of a straight
IV VI
<<    
     Article
      >> Home | TOC |          
Index

18 Shroff and Lindauer

wire into adjacent teeth. The advantages and

disadvantages of inserting straight wires into ad-
jacent brackets during leveling and aligning can
be assessed using these principles.6

Side Effects of Straight Wire Mechanics

in the First Order
When planning a mechanics strategy and design-
ing an appliance to correct a malocclusion, ob-
servation and analysis of the initial geometric
relationships between teeth is critical. Analysis of
the force systems acting on the entire arch is
nearly impossible because of the complexity in-
volved. A simpler approach is to isolate 2 tooth
segments and, starting at the midline, observe
the relationship of each pair of teeth relative to
one another. Beginning with the 2 central inci-
sors, the geometric relationship between these
teeth is evaluated and the corresponding force
system is drawn. Then, the relationship between
the lateral and central incisors is studied using a
similar approach. Ultimately, all forces and mo-
ments within the arch are identified and
summed, and a final force diagram is obtained.
In the alignment of rotated teeth, the straight
wire approach is favorable in some situations,
whereas in other cases, a careful analysis of the
initial tooth geometric relationships would sup-
port a different approach to treatment. In the
mandibular arch shown in Figure 2A, the geo-
metric relationships present are a good illustra-
tion of when a straight wire approach would be
appropriate. The 2 central incisors are rotated
mesial in creating a symmetric V geometry. The
desired corrective force system involves 2 equal
and opposite moments as illustrated in Figure
2B. Placement of a straight wire into the brackets
of all the teeth in the arch results in a correction
of the malocclusion as shown in Figure 2C. In
this situation, the force system is called consis-
tent.
Figure 2. Occlusal view of a mandibular arch showing
A symmetric V geometry is not the only con- 2 central incisors rotated mesially inward (A). The
sistent geometry for the use of a straight wire. force system generated when a straight wire is placed
Figure 3A shows a series of step geometries. The into the brackets of the 4 anterior teeth (B). Occlusal
force system desired for correction involves la- view of the corrected malocclusion (C).
biolingual forces as well as moments on the in-
cisors to align them. The force system developed labial movement of the right central incisor (Fig
by inserting a straight wire into the brackets of 3B). Figure 3C shows the initial alignment of the
the 4 anterior teeth will create counterclockwise teeth using a straight wire.
moments on the 2 central incisors as well as Often, the initial geometry is not favorable for
lingual movement of the left central incisor and alignment using a straight wire. The mandibular
<<    
     Article
      >>
Leveling and Aligning
Figure 3. Occlusal view of a malocclusion with a se-
ries of step geometries (A). The force system on the 2
central incisors (B). Clinical view of the corrected
malocclusion using a straight wire approach (C).
Home | TOC |          
Index
19
malocclusion shown in Figure 4A shows a lin-
gually placed right lateral incisor. In this case,
the geometric relationship between the right
lateral and central incisors is a step geometry
and the placement of a straight wire into the
brackets of the 4 anterior teeth will align the
teeth and also shift the midline to the right side
(Figs 4B and 4C).
Rotated teeth may also display geometries
that will not be consistent with the placement of
a straight wire to align them. In the maxillary
arch shown in Figure 5A, the relationship be-
tween the central incisors is a step geometry and
an asymmetric V geometry is observed between
the central and lateral incisors on the right side.
Analysis of the force system shows that, although
correction of the 2 central incisors will occur as
a result of straight wire placement, the right
lateral incisor will be displaced labially, which is
an undesirable side effect (Fig 5B). Figure 5C
shows the clinical results of straight wire place-
ment into the malposed teeth with labial move-
ment of the right lateral incisor.
It is apparent that it is sometimes beneficial to
not engage a straight wire into all of the teeth in
an arch. Bypassing teeth that may experience
undesirable side effects is indicated in selected
situations after careful analysis of the force sys-
tem that would be generated by inserting an
arch wire. The force system generated by a
straight wire can, in some cases, worsen the ini-
tial malocclusion.
The maxillary arch shown in Figure 6A shows
a palatally positioned, small, right lateral incisor
rotated distally inward, and left central and lat-
eral incisors with a step relationship between
them. The relationship between the right lateral
and central incisors is recognized as an asymmet-
ric V geometry. Analysis of the force system
shows that, although the left lateral incisor will
be corrected by rotating mesial out and moving
labially, the right lateral incisor will move fur-
ther lingually (Fig 6B). It is therefore more ap-
propriate to bypass the right lateral incisor ini-
tially and only tie the wire into this tooth when
the rest of the arch is in better alignment. The
arch can then be joined together to provide
adequate anchorage for correcting the right lat-
eral incisor position without undesirable side
effects (FigGC).
Posterior teeth may also be malposed and
require alignment. First molar mesial in rota-
<<    
     Article
      >> Home | TOC |          
Index

20 Shroff and Lindauer

Midline Shift to the Right

Figure 4. Occlusal view of a malocclusion with a lin-

gually positioned mandibular right lateral incisor (A).
The force system generated by insertion of a straight
wire (B). Occlusal view of the corrected malocclusion
(C).
Figure 5. Occlusal view of a malocclusion with a step
geometry (A). Placement of a straight wire results in
an inconsistent force system (B). Placement of a
straight wire resulted in undesirable side effects at the
right lateral incisor (C).
<<    
     Article
      >> Home | TOC |          
Index

Leveling and Aligning 21

-c >-
Figure 7. Force system generated when a straight
wire is placed into bilaterally mesially inward rotated
maxillary first molars. Expansion of the molars is ex-
pected, as well as constriction in the premolar areas.

tions are common discrepancies that often re-

quire correction in the initial phase of treatment
of a Class II malocclusion. When a straight wire
is inserted into rotated molars, the relationship
between the brackets of the premolars and the
buccal attachment of the molar is an asymmetric
V geometry. The rotation of the molars will be
corrected as a result of the moment created.
Expansion of the molar width will also occur as
well as constriction of the premolar region as a
result of the transverse forces developed be-
tween the molars and premolars (Fig 7). It is
therefore advantageous to isolate the molars bi-
laterally and correct their rotations without con-
necting them to the rest of the arch. Use of a
transpalatal arch fabricated of 0.030-inch stain-
less steel or a precision palatal arch prefabri-

Figure 6. Occlusal view of a malocclusion with a com-

bination of step geometries and rotations of the inci-
sors (A). The force system generated by placement of
a straight wire indicates that the lingual position of
the right lateral incisor gets worse (B). The correction
obtained for the central incisors and the left lateral
incisor (C). Figure 8. The force system delivered by a palatal arch
is the one desired to correct bilaterally mesially in-
ward rotated maxillary first molars.
<<    
     Article
      >> Home | TOC |          
Index

22 Shroff and Lindauer

Figure 9. Occlusal view of a maxillary dental arch show-

ing rotated first molars bilaterally (A). The right (B) and
left (C) buccal relationships are slightly Class II. The
occlusal view (D) shows the aligned arch, and the right
(E) and left (F) buccal relationships have improved.

cated of 0.032 X 0.032-inch titanium molybde-
num alloy (TMA) permits correction of the
molar rotations without undesirable side effects
on the rest of the dental arch (Fig 8).7
Figure 9A shows a maxillary arch with bilat-
eral mesial in rotations of the first molars in a
patient with a mild Class II dental relationship
(Figs 9B and 9C). The maxillary anterior teeth
were aligned using a segment of straight wire.
Correction of the molar rotations bilaterally was
obtained using a palatal arch, as shown in Figure
9D. The Class II relationship of the molars im-
proved as a result of the mesial out rotations
(Figs9E and9F).
Control of molar width and rotation is also
critical during space closure. Typically, molars
will rotate mesially inward as they experience a
mesial force during space closure, and premo-
lars and/or canines will rotate dis tally inward as
they are retracted (Fig 10). These side effects
cannot be efficiently controlled in a straight wire
system, and the clinician usually relies on the
replacement of initial, light wires with progres-
sively heavier wires for the side effects to work
<<    
     Article
      >>
Leveling and Aligning
Figure 10. Occlusal view of the maxillary arch before
extraction of the second premolars (A). Schematic
representation of the force system generated during
space closure (B). Clinical side effects (C).
themselves out eventually. Placement of bends
or curvature in the arch wire to control this side
effect has also been advocated. In treatment
techniques using sliding mechanics, additional
friction is probably introduced by adding bends
or curves and may result in lengthening of the
overall treatment time. A more efficient way to
control molar rotation is to use a transpalatal
arch. A stainless steel 0.032 X 0.032-inch square
or 0.0324nch round transpalatal arch can be
Home | TOC |          
Index
23
used to provide enough rigidity to prevent un-
wanted molar rotation or width changes.
Side Effects of Straight Wire Mechanics
in the Second Order
During orthodontic therapy, control of the oc-
clusal plane is of particular importance. Steep-
ening of the occlusal plane is a common side
effect when placing a straight wire into the
bracket of a distally tipped canine. As the root of
the canine is moved distally, the anterior seg-
ment of teeth will extrude and the bite will
deepen.
Another example is during extrusion of a
high canine unilaterally. Figure 11A shows the
force system generated by the placement of a
straight wire through a high maxillary right ca-
nine. The canine will extrude as desired, but the
lateral incisor and first premolar on that side will
intrude and tip toward the canine space. An
open bite may result on that side of the arch,
and the anterior occlusal plane will be canted up
on the right side (Fig 11B). Clinically, the cant
of the anterior occlusal plane can be avoided by
using a rigid wire tied into the brackets of all the
teeth in the arch and bypassing the high canine.
A flexible auxiliary overlay wire of 0.014-inch or
0.016-inch nickel titanium can then be used to
extrude the canine against the stabilized arch
(FigllC).
Alternatively, it is possible to extrude a high
buccal canine using a cantilever arm extending
from an auxiliary tube on the molar (Fig 12).8'10
In this case, a heavy stainless steel arch wire is
engaged that bypasses the canine. A passive pal-
atal arch can be placed to connect the right and
left buccal segments of teeth. This helps to es-
tablish an appropriate anchorage unit to avoid
undesirable side effects as the canine is ex-
truded. The intrusive force experienced by the
posterior segment on that side is distributed to
several teeth, and therefore, its expression is
minimized.
Undesirable side effects may also be observed
clinically when canines located at different
heights are aligned with a straight wire. Figure
13 shows the development of a cant of the ante-
rior occlusal plane when a straight wire is placed
without prior analysis of the force system that
will be generated. In this case, use of cantilevers
from the molar auxiliary tubes with an archwire
<<    
     Article
      >> Home | TOC |          
Index

24 Shroff and Lindauer

Figure 12. Clinical example of a cantilever used to

erupt a canine in the maxillary arch.

bypassing the canines would have been recom-

mended to avoid the side effect observed.

Conclusion
Straight wire mechanics can often be used to
achieve the tooth movements desired during
orthodontic leveling and aligning. Flexible wires
that maintain their activation over long periods
of time, combined with preadjusted appliances
that reduce the need for intricate wire bending,
make use of this method of alignment conve-
nient and attractive. It is important, however, to
understand the mechanics involved and to rec-
ognize when straight wires will not achieve
adequate results. Analysis of tooth-to-tooth re-
lationships will aid in identifying bracket ge-
ometries resulting in consistent and inconsis-
tent force systems. In some cases, insertion of
straight wires may result in undesirable side
effects that could prolong overall treatment
time and/or compromise the final orthodon-
tic outcome achieved.

Figure 11. Schematic representation of the force sys-

tem resulting from insertion of a straight wire in a
high buccal canine on the right side of the arch (A).
Frontal view showing the development of a cant of the
anterior occlusal plane (B). Schematic representation
of a straight wire and a bypass arch wire used simul-
taneously to erupt a canine (C).
<<    
     Article
      >>
Leveling and Aligning
Figure 13. Clinical example of a malocclusion with 2
canines at different vertical positions (A). Placement
of a straight wire to correct this malocclusion results
in the development of a cant of the anterior occlusal
plane (B).
Home | TOC |          
Index
25
Acknowledgment
Special thanks are extended to Dr Charles J. Burstone for
inspiring this article and for his guidance in the selection of
the illustrations. Special thanks are extended to Mrs Barbara
Vallonga for preparing the manuscript and to Mrs Carol
Wilkins for her help with computer graphics.
References
1. Andrews LF. The six keys to normal occlusion. Am J
Orthod 1972;62:296-309.
2. Burstone CJ, Koenig HA. Force systems from an ideal
arch. Am J Orthod 1974;65:270-289.
3. Burstone CJ, Koenig HA. The force system from step and
V bends. Am J Orthod Dentofac Orthop 1988;93:59-67.
4. Isaacson RJ, Lindauer SJ, Rubenstein LK. Activating a
2 X 4 appliance. Angle Orthod 1993;63:l7-24.
5. Isaacson RJ, Lindauer SJ, Rubenstein LK. Moments with
the edgewise appliance: Incisor torque control. Am J
Orthod Dentofac Orthop 1993;103:428-438.
6. Smith RJ, Burstone CJ. Mechanics of tooth movement.
Am J Orthod 1984;85:294-307.
7. Burstone CJ. Precision lingual arches. Active applica-
tions. J Glin Orthod 1989;23:10M09.
8. Jacoby M. The "Ballista Spring" system for impacted
teeth. Am J Orthod 1979;74:143-151.
9. Shroff B. Canine impaction: Diagnosis, treatment plan-
ning and clinical management, in Nanda R: Biomechan-
ics in Clinical Orthodontics. Philadelphia, PA, Saunders,
1997, pp 99-108.
10. Lindauer SJ, Isaacson RJ. One-couple orthodontic appli-
ance systems. Semin Orthod 1995; 1:12-24.
<<    
     Article
      >> Home | TOC |          
Index

Biomechanics of Deep Overbite Correction

Charles J. Burstone

Correction of deep overbite can be accomplished in different ways depend-

ing on the treatment goals chosen for individual patients. The 2 primary
methods of correction are intrusion of anterior teeth or extrusion of poste-
rior teeth. Successful intrusion of the incisors depends on careful control of
the force system used. Low force magnitude, force constancy, a properly
selected single point of force application, and control of force direction are
all important factors to consider. The design of the intrusion arch may be
continuous, or a 3-piece intrusion arch may be selected depending on the
needs of the patient. Alternatively, extrusion of posterior teeth may be
indicated in patients who are still actively growing and who have short
vertical facial dimensions. (Semin Orthod 2001;7:26-33.) Copyright ©2001 by
W.B. Saunders Company

A common finding in many malocclusions is

the presence of deep overbite. Because
deep overbite is a symptom, it is not too sur-
prising that there are numerous etiologic fac-
tors that can lead to deep overbite and many
different treatment goals for its correction.
Patients that show long faces or a Class II point
A to point B relationship require control of
the vertical dimension with no rotation of the
mandible downward and backward during the
correction of the overbite. In these patients,
intrusion mechanics of the incisors is re-
quired. On the other hand, there are patients
with smaller vertical dimensions or individuals
showing sufficient vertical growth potential for
whom the treatment of choice is the extrusion
of posterior teeth.
Two patients with a 2-year growth prediction
are shown in Figure 1. In Figure 1A, typical
maxillary-mandibular differential growth not
only improves the Class II relationship, but also
increases the vertical dimension from anterior
nasal spine to men ton. In this patient it is per-
From the Department of Orthodontics, School of Dental Medi-
cine, University of Connecticut Health Center, Farmington, CT.
Address correspondence to Charles J. Burstone, DDS, MS, De-
partment of Orthodontics, School of Dental Medicine, University of
Connecticut Health Center, Farmington, CT 06030.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0701-0004$35.00/0
doi:10.1053/sodo.2001.21059
fectly permissible to extrude posterior teeth be-
cause the mandible would not be hinged open
during treatment. By contrast, Figure IB shows a
patient in whom minimal growth is expected
during treatment. To control the vertical dimen-
sion, it is necessary in this type of patient to
intrude the incisors.
The decision to intrude or extrude is based
on at least 3 factors: skeletal convexity, vertical
dimension, and the interocclusal (freeway) space.
The estimated amount of growth during treat-
ment helps to determine the amount that pos-
terior teeth can be extruded. In some malocclu-
sions it may be more convenient and efficient to
intrude anterior teeth initially, such as in a Class
II, Division 2 patient, even though the final plan
may not necessarily require intrusion.
Patients with flat mandibular planes and
small vertical dimensions present an entirely
different problem than do long-faced individ-
uals. It is desirable in many of these patients to
increase the vertical dimension. However, this
may not be practical from a point of view of
stability unless future growth will occur. Even
in these patients, it may be necessary to in-
trude incisors. A biomechanical alternative to
intrusion of anterior teeth in patients with
short vertical dimensions is to extrude poste-
rior teeth initially and maintain fixed arches in
place during treatment to allow time for adap-
tation to occur.

26 Seminars in Orthodontics, Vol 7, No 1 (March), 2001: pp 26-33

<<    
     Article
      >>
Biomechanics of Deep Overbite Correction
Figure 1. Growth influences the decision to intrude
incisors. Two-year growth prediction shows the over-
bite corrected by growth. Posterior teeth can be
erupted (A). Little growth in 2-year prediction. Inci-
sor intrusion is needed (B).
The biomechanics of 2 different types of deep
overbite correction are discussed separately in
this article. First, incisor intrusion, and second,
extrusion mechanics for posterior teeth.
Incisor Intrusion
For many years it was believed that it was impos-
sible to intrude teeth and that if intrusion was
attempted, undesirable sequellae such as devital-
Home | TOC |          
Index
27
ization would occur. Early studies of treated pa-
tients saw little intrusion of incisors because the
mechanics used tended to extrude posterior
teeth. It has been shown that the use of light
constant forces enables the intrusion of teeth
with minimal disruption of posterior anchor
units. It has also been shown that as the forces
for intrusion are increased, more root resorp-
tion but not necessarily a greater rate of intru-
sive movement may result.1 Figure 2 shows a
patient in whom intrusion was accomplished in
both the upper and lower arches using light
constant forces. The upper incisors commonly
must be intruded more than lower incisors to
maintain the original cant of the plane of occlu-
sion. This requires controlled mechanics be-
cause in the Class II patient, the application of
Class II elastics or cervical headgear and other
similar mechanisms can steepen the plane of
occlusion and negate any intrusion effects.
There are 2 basic designs to an intrusion arch:
(1) a continuous arch, and (2) a 3-piece intru-
sion mechanism.2'6 Both of these appliances are
described in this section. The application of
each is determined by the needs of the pa-
tient.7-8
The continuous intrusion arch is shown in
Figure 3. A relatively rigid anchorage unit con-
nects the teeth of the posterior segment. The
cuspid is bypassed by placing a small step in the
region of the cuspid or eliminating the cuspid
bracket entirely. Anterior teeth are connected
together with an incisor segment. A 0.017 X
0.025-inch or 0.016 X 0.022-inch titanium mo-
lybdenum alloy (TMA) intrusion arch from an
auxiliary tube places the intrusive force on the
incisors. As the wire is brought down to the
central incisors or the lateral incisors, only single
forces are directed in an intrusive direction.
The key to successful intrusion is control of
the force system. Specifically, force magnitude,
constancy, the use of only a single-point applica-
tion, control of the direction of force, and the
selection of a proper point for the force appli-
cation are carefully planned and delivered.
Force magnitude can be determined either
using tables or directly by a force gauge (Fig 4).
Sometimes the clinician will neglect to measure
the forces and only place a V bend posteriorly.
This can be dangerous because arches vary in
length and there is not a constant angulation for
a desirable activation. If too much force is ap-
<<    
     Article
      >> Home | TOC |          
Index

28 Charles J. Bur stone

plied, undesirable side effects, including steep-

ening of the occlusal plane or distal tipping of a
molar, can occur. The magnitude of force de-
pends on the number of teeth and their size. For
example, during intrusion of upper incisors,
about 60 g of force for 4 incisors are used. Figure
5 shows a patient with a continuous intrusion
arch before and after intrusion. The use of low
forces and a stable anchorage unit will not upset
posterior anchorage and should maintain the
original plane of occlusion.
The force-deflection rate of the intrusion
arch is very low, usually under 10 g/mm, be-
cause the distance is large between the auxiliary
tube of the molar and the incisor brackets.9 This
not only produces a large deflection, minimizing
the need for any reactivation, but also ensures
greater constancy of force. It also enhances the
accuracy of the appliance because any small er-
ror in activation produces a minimal change in
the delivered force.
A particularly important consideration in in-
trusion is to assure that the intrusion arch does
not fit into the brackets of the incisors. Instead,
a separate segment is placed. There are a num-
ber of reasons why it is not desirable to put
either a rectangular or a round intrusion arch
wire directly into an edgewise bracket anteriorly.
The intrusive arch can change shape, producing
mesial displacement of the roots of incisors.
Most importantly, any torque, labial or lingual,
can alter the intrusive force (Fig 6). If purposely
or accidentally placed lingual root torque is
present, it could completely eliminate any intru-
sive force. At the other extreme, labial root
torque may increase the intrusive force with a
concomitant increase of extrusive force and tip
back moment on the molar. Once an edgewise
intrusion arch wire is placed into the anterior
brackets, a precise mechanism is not present.
The clinician should carefully look at the an-
atomic arrangement of the teeth to determine
which teeth require intrusion. The Class II, Di-
vision 2 patient may only need intrusion of 2
central incisors. Many Class II, Division 1 pa-
tients require intrusion of 4 incisors. These an-

Figure 2. Maxillary and mandibular intrusion using a

continuous intrusion arch. Cranial base superimposi-
tion (A). Separate maxillary and mandibular superim-
positions (B).
<<    
     Article
      >> Home | TOC |          
Index

Biomechanics of Deep Overbite Correction 29

Figure 3. Passive and active continuous intrusion arches. Separate posterior and anterior segments are placed.
The canine is bypassed. Buccal view passive (A) and active (B). Frontal view passive (C) and active (D).

atomic discrepancies should be eliminated by

segmental intrusion rather than by indiscrimi-
nate leveling. If the patient initially has leveling
wires placed in a full-arch wire, it then almost
becomes impossible to produce effective intru-
sion of the incisors.
One of the key aspects of controlling the

Figure 4. The force system. Measuring the force with

a force gauge (A). The reactive force on the posterior
anchorage unit produces potential extrusion and Figure 5. Upper incisor intrusion. Before (A) and
steepening of the occlusal plane (B). after (B).
<<    
     Article
      >> Home | TOC |          
Index

30 Charles J. Burstone

Figure 8. Frontal view of a 3-piece intrusion arch with

hooks attached distal to the lateral incisors. Separate
right and left springs apply intrusive force distal to the
lateral incisors.
B
the long axis of the tooth. The incisor will
readily intrude and neither retract nor flare.
With a typical axial inclination, the force is labial
to the center of resistance so that the tooth will
intrude but also have a moment that would re-
tract the root provided the intrusive arch is tied
back. For Class II, Division 2 patients, some lin-
gual root movement may be desirable. However,
in patients with already flared incisors, placing
an intrusive force labial to the center of resis-
tance is more problematic. The root is probably
Figure 6. Placing an arch wire in the incisor brackets
alters the magnitude of the intrusive force. Lingual
root torque produces extrusion (A). Labial root
torque produces intrusion (B).

force system during intrusion is to direct the

force somewhat parallel to the long axis of the
tooth. In Figure 7, 3 different axial inclinations
of incisors are shown. With a vertical incisor, a
continuous intrusion arch can direct the force
close to the center of resistance and parallel to

Figure 7. An intrusive force labial to the incisors

produces different effects as axial inclinations vary. Figure 9. Three-piece intrusion arch with chain elas-
The intrusion force unfavorably moves the incisor tic (A) or spring (B) redirects the force parallel to the
root lingually in a flared incisor. long axis of the incisor.
<<    
     Article
      >>
Biomechanics of Deep Overbite Correction
Figure 10. Cantilever with eyelet. The direction of
the force is parallel to the ligature tie.
too far lingual to begin with, and furthermore,
the force is not directed along the long axis of
the tooth. Consequently, there is a large labial
component to the force. The tooth will not
readily intrude and can flare further. It is in this
type of patient that the 3-piece intrusion arch is
used.
The 3-piece intrusion arch is similar to the
continuous arch in that it requires a stable an-
chorage unit for the posterior teeth and a sepa-
rate anterior segment. Instead of a continuous
wire, separate tip back springs are applied on the
right and left sides (Fig 8). The bent hook shown
in Figure 8 delivers an intrusive force distal to
the brackets of the lateral incisors. When the
force is directed at 90° to the occlusal plane, its
point of attachment can then be placed through
the center of resistance of the incisors so that no
flaring of the teeth occurs.
In addition to altering the point of force ap-
plication, with flared incisors it may be necessary
to redirect the force. There are a number of
possible methods for changing the line of action
Figure 11. Angling the poste-
rior extension redirects the
force parallel to the incisor
long axis (A). Intrusive force
on posterior extension of the
anterior segment is 90° to the
occlusal plane (B).
Home | TOC |          
Index
31
Figure 12. Force can be positioned either anterior or
posterior to the center of resistance of the incisor
segment to produce intrusion-protrusion, pure intru-
sion, or intrusion-retraction.
of the force so that it is parallel to the long axes
of the incisors. The intrusive force can be sup-
plemented by a distal force from a chain elastic
or a coil spring. The resultant force can then
become parallel to the long axes of the incisors
(Fig 9).
Two other methods for redirecting the force
involve using separate cantilever intrusive springs.
The first is shown in Figure 10. The orientation
of the tie is parallel to the direction of force. By
shortening the arm, the force can be directed
more distally. The second very simple method
for redirecting the force is shown in Figure 11. A
posterior extension to the anterior segment is
angled so that the force is now directed along
the long axes of the teeth. This assumes no
friction along the arch wire so that the resulting
force only acts at 90° to the posterior section of
the anterior segment.
<<    
     Article
      >>
32 Charles J. Burstone
Figure 13. Extrusive mechanics. Upper bite plate on precision lingual arch (A). Bite plate attached to
the lower arch allows separated posterior teeth to be extruded with vertical elastics or allowed to
erupt (B).
By using either a continuous intrusion arch or
a 3-piece mechanism, the orthodontist can alter
not only the magnitude of the force, but also the
position of the force with respect to the center of
resistance (Fig 12).10 Furthermore, for optimal
results, it is necessary to orient the force so it
approaches parallelism to the long axes of the
incisors. The use of a single force leads to a
Figure 14. Vertical elastic applied to posterior teeth
separated by a bite plate. Individual tooth extrusion
(A). Segmental tooth extrusion (B).
Home | TOC |          
Index
greater accuracy than that achieved when an
arch wire is placed into the brackets of the inci-
sors with a continuous arch or 2 X 4 mecha-
nism.11-14
Key to anchorage control is the maintenance
of low-magnitude forces and the use of a rigid
posterior segment. This includes a lingual or
transpalatal arch to maintain posterior widths.
Backup with occipital headgear may be consid-
ered. A posteriorly and intrusively directed force
from the headgear acting anterior to the center
of resistance of the molar segment produces a
moment that minimizes any steepening of the
occlusal plane. Of course, headgear should not
be used to cover up mistakes in intrusion me-
chanics where force magnitudes are too great.
Extrusion of Posterior Segments
The extrusion of posterior teeth for the correc-
tion of deep overbite may be less demanding
than intrusive mechanics but must still be ac-
complished carefully to avoid canting of the oc-
clusal plane. Many continuous arches extrude
teeth. More efficiently, a 3-piece tip back mech-
anism with increased forces to a large anterior
segment can be used to tip back and extrude the
posterior teeth.15 To minimize any steepening of
the upper plane of occlusion with larger forces,
cervical headgear with a long and high outer
bow can produce a moment to bring the upper
plane of occlusion vertically without a change of
cant.
An upper bite plate attached to a precision
lingual arch is a useful adjunct for posterior
eruption with or without other mechanics (Fig
<<    
     Article
      >>
Biomechanics of Deep Overbite Correction
ISA). Unlike removable bite plates, the fixed
appliance is not under the control of the pa-
tient, which enhances its efficiency. A lower bite
plate from cuspid to cuspid can also be used to
separate the posterior teeth, allowing for vertical
extrusive mechanics to be expressed more easily
(Fig 13B). With posterior teeth separated by
either an upper or lower bite plate, vertical elas-
tics can be used either to an entire segment or to
individual teeth, because often not all teeth have
to be erupted equally (Fig 14). The position of
the force as well as the number of teeth in the
buccal segment can be controlled.
Conclusion
The correction of deep overbite requires careful
differential diagnosis and the determination of
which teeth must be intruded or extruded for
proper correction. Therefore, the mechanics for
treatment can differ radically from one patient
to another. The key to successful correction is
not only the proper treatment plan, but precise
mechanics to achieve the predetermined treat-
ment plan goals.
References
1. Bellinger EL. A histologic and cephalometric investiga-
tion of premolar intrusion in the Macaco, speciosa mon-
key. Am J Orthod 1967;53:325-355.
2. Burstone CJ. Rationale of the segmented arch. Am J
Orthod 1962;48:805-822.
Home | TOC |          
Index
33
3. Burstone CJ. Mechanics of the segmented arch tech-
nique. Angle Orthod 1966;36:99-120.
4. Burstone CJ, van Steenberg E, Hanley KJ. Modern Edge-
wise Mechanics and the Segmented Arch. Ormco Press,
1995, pp 32-48.
5. Burstone CJ. Biomechanics of the orthodontic appli-
ance, in Graber TM (ed): Current Orthodontic Con-
cepts and Techniques. Philadelphia, PA, Saunders, 1969,
pp 160-178.
6. Lindauer SJ, Isaacson RJ. One-couple orthodontic appli-
ance systems. Semin Orthod 1995;l:12-24.
7. Burstone CJ. Biomechanical rationale of orthodontic
therapy, in Meisen B (ed): Controversies in Orthodon-
tics. Berlin, Germany, Quintessence, 1991, pp 131-146.
8. Burstone CJ. Deep overbite correction by intrusion.
Am J Orthod 1977;72:l-22.
9. Burstone CJ, Baldwin JJ, Lawless DT. The application of
continuous forces to orthodontics. Angle Orthod 1961;
31:1-14.
10. Shroff B, Lindauer SJ, Burstone CJ, et al. Segmented
approach to simultaneous intrusion and space closure:
Biomechanics of the three-piece base arch appliance.
Am J Orthod Dentofac Orthop 1995;107:136-143.
11. Koenig HA, Burstone CJ. Force systems from an ideal
arch: Large deflection considerations. Angle Orthod
1989;59:11-16.
12. Ronay F, Kleinert MW, Meisen B, Burstone CJ. Force
system developed by V bends in an elastic orthodontic
wire. Am J Orthod Dentofac Orthop 1989;96:295-301.
13. Burstone CJ, Koenig HA. Creative wire bending: The
force system from step and V bends. Am J Orthod Dento-
fac Orthop 1988;93:59-67.
14. Burstone CJ, Koenig HA. Force systems from an ideal
arch. Am J Orthod 1974;65:270-289.
15. Romeo DA, Burstone CJ. Tip-back mechanics. Am J
Orthod 1977;72:414-421.
<<    
     Article
      >> Home | TOC |          
Index

Closing Anterior Open Bites:

The Extrusion Arch
Robert J. Isaacson and Steven J. Lindauer
The principles of mechanics can be adapted to the treatment of clinical
problems in many ways. Anterior open bites, long a troublesome problem in
clinical practice, can be addressed with arch wire mechanics using asym-
metrical V bends in the wire. The activation of the wire is the reverse of the
intrusion arch and will effectively work as an extrusion arch to close anterior
open bites without the use of anterior vertical elastics. The open bite closure
can involve both jaws or be limited to extruding the teeth in 1 jaw only. All
of the mechanics are opposite to those associated with a 1-couple intrusion
arch. The system can be designed so that the reciprocal forces and mo-
ments, acting at the molar, can be controlled. Strategies for control of
unwanted tooth movements require attention to all of the components of
the force system and not just the desired bite closing forces. (Semin Orthod
2001;7:34-41.) Copyright © 2001 by W.B. Saunders Company

T he treatment of malocclusion commonly

requires control of the deep bite. As a re-
sult, the intrusion arch and intrusion mechanics
have long been present in some form in most
appliance systems.
The remarkable fact is that the reverse version
of this problem, the open bite, has received far less
attention. This may be because open bites occur
less frequently. However, open bites are present in
all orthodontic practices and are problems in
which practitioners do not always enjoy predict-
able success. The need for a reliable biomechani-
cal technique for open bite closure that does not
require patient compliance has been obvious.
Anterior open bites may look very similar to
each other, but it is likely that they have various
factors contributing different amounts to their eti-
ology. As a result, it is not surprising that open bite
treatments involve a wide variety of treatment ap-
proaches. Some approaches focus on the associ-
From the Department of Orthodontics, School of Dentistry, Vir-
ginia Commonwealth University, Richmond, VA.
Supported in part by the Medical College of Virginia Orthodontic
Education and Research Foundation.
Address correspondence to Robert J. Isaacson, DDS, MSD, PhD,
Department of Orthodontics, School of Dentistry, Virginia Common-
wealth University, Richmond, VA 23298-0566.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0701-0005$35.00/0
doi:10.1053/sodo.200L21064
ated long-face skeletal problem and try to reduce
vertical facial height with surgery (LeFort surgery)
or intrusion of molars (vertical pull headgears,
splints, or repelling magnets). Other approaches
accept the existing skeletal morphology and focus
on local factors addressing treatment toward the
tongue (cribs or tongue reduction surgery) or the
facial musculature (functional appliance shields).
Often, however, the cause cannot be posi-
tively identified, and the open bite is treated
with dental compensations. Undoubtedly, the
most common approach has been the use of
vertical elastics to close the anterior open bite.
Almost all orthodontists have used this ap-
proach, and almost all orthodontists have expe-
rienced some degree of dissatisfaction with their
inability to close anterior open bites reliably,
mostly based on the requirement of patient com-
pliance to make the treatment succeed.
This article is devoted to the use of an auxil-
iary wire, placed over complete or segmented
arch wires, to produce tooth movement and
dental compensations for anterior dental open
bites with no patient compliance required.
The Extrusion Arch
The extrusion arch is a term that was coined to
describe the reverse action of the already exist-
ing and well-established intrusion arch. The

34 Seminars in Orthodontics, Vol 7, No 1 (March), 2001: pp 34-41

<<    
     Article
      >>
Closing Anterior Open Bites
term, extrusion arch, is probably somewhat mis-
leading because the action of the wire is not to
extrude the tooth from its attachment appara-
tus.
What does happen when a tooth is moved
vertically within the alveolar process? When the
open bite closes, does the tooth move with re-
spect to the alveolar process and leave the alve-
olar process behind with a longer clinical crown
resulting? All available evidence shows that,
whether the tooth is intruded or extruded, ver-
tical movement brings the entire attachment ap-
paratus, including the alveolar process and the
gingival tissues, with the tooth. In fact, some
work has even been reported describing treat-
ment procedures to try to prevent the attach-
ment from the normal process of following the
vertical movement of a tooth in those cases
where a treatment requires a longer clinical
crown.1
The extrusion arch is a new adaptation of the
biomechanical principle of an off-center bend,
or asymmetrical V, in an arch wire to develop a
specific set of biomechanical responses.2 Despite
the fact that many systems have used the princi-
ples of an intrusion arch to treat deep bites for
many decades, the concept of using the reverse
configuration of the wire to treat anterior open
bites was only recently reported.3
The principle of an extrusion arch has been
applied as a segmental wire for some time, pre-
dominantly to bring in impacted canines.3 The
application of this principle with a continuous
auxiliary arch wire to multitooth anterior open
bites emerged when teaching new residents the
principles involved in the use of intrusion
arches. When a new resident described the in-
trusion arch backward, the obvious application
to an open bite became apparent. When the
authors applied this theory clinically and used
an upside down intrusion arch in an open-bite
patient who was not willing to wear vertical elas-
tics, the open bite closed in a matter of several
weeks. This was indeed a very impressive new
application of an old principle.
The extrusion arch is a very efficient and
effective way to close anterior open bites, and
open bites are the nemesis of most mechanics.
The vertical elastic has been the most commonly
used tool in the past and, too often, vertical
elastics became a contest of wills between the
orthodontist and the patient—a contest often
Home | TOC |          
Index
35
won by the patient. The extrusion arch, how-
ever, gives the orthodontist the ability to close
anterior open bites without patient compliance,
and in addition, to decide whether the open bite
closure should come from just the maxillary
teeth moving down, just the mandibular teeth
moving up, or both.
The biomechanics of an extrusion arch are
fairly straightforward. As with most clinical prob-
lems, the first question is, Which teeth do I want
to move in what direction? With an anterior
open bite the answer is clear. I want the front
teeth to move vertically together. Now, however,
the question is more sophisticated: Do I want the
upper teeth, the lower teeth, or both to move
vertically?
Sometimes the anterior open bite is primarily
a skeletal growth problem.4 The disproportion-
ate bony facial growth results from relatively
more vertical growth at the alveolar process as
compared with the vertical growth occurring at
the ramus (Fig 1). This is a long-face problem
evolving and, in the most troublesome situa-
tions, a backward rotating facial growth pattern.
In these individuals, the anterior alveolar pro-
cess must grow vertically rapidly or the open bite
will get worse. If the clinical open bite extends
from molar to molar, the problem is likely to be
a skeletal problem with insufficient dental com-
pensations and is even more difficult to treat.
If the open bite is a local problem, and just
involves an anterior segment of teeth, the prog-
nosis is much better. This is especially true if a
cephalometric analysis shows a skeletal pattern
with relatively normal vertical development.
Sometimes the local causative factor, eg, a digit,
is no longer present, but the tongue, lips, and
function are maintaining the dental open bite.
This kind of open bite will be relatively indepen-
dent of vertical facial growth. Of course, the
possibility of a skeletal open bite existing in com-
bination with local factors adapted to the open
bite is quite possible.
When an open bite problem is addressed by
inserting a continuous arch wire into the brack-
ets on all the teeth, the results are rarely satis-
factory. Wiping reverse occlusal curve in the
maxillary wire and/or a large accentuated curve
in the lower wire simply is not effective. The
mechanics are slow to work, and the side effects
are often undesirable. When the wire is left in
place long enough, the result is often essentially
<<    
     Article
      >> Home | TOC |          
Index

36 Isaacson and Lindauer

a transfer of the open bite from the anterior

teeth to the premolars.

Action at the Molar

Figure 2 shows the simple 2-dimensional sche-
matic view of the actions of an extrusion arch.
Notice that it is the exact reverse of an intrusion
arch. When the anterior end of the extrusion
arch wire is brought up to attach to the incisors,
a second-order couple or tendency for rotation
is produced at the molar. This couple will always
rotate the molar crown mesial/root distal with a
center of rotation located exactly at the center of
resistance. No other kind of rotation is possible
with a couple regardless of where the bracket is
placed on the tooth.
Although this fundamental force system will
always act as shown, several additional actions
occur as a part of the force system in the same
wire. In biomechanical terms, the second-order
couple at the molar cannot exist without equi-
librium, ie, the need for the system to be in

Figure 1. Average facial growth pattern, in which the

vector of vertical growth component at the condyle
and fossa equals the sum of the vertical growth at the
alveolar processes and maxillary sutures (A). This re-
sults in no mandibular rotation. The direction of
mandibular displacement will be a translation in the
direction of the condylar growth. However, when the
mandible rotates, the rotation is a result of the ratio of
the vertical component of condylar growth to the
vertical component of alveolar and sutural growth.
The same amount of condylar growth as shown in
Figure 1A, but a lesser amount of vertical growth
occurring at the sutures and alveolar processes (B).
This results in a forward rotating mandibular growth
pattern with a concurrently shorter lower facial height
and characteristically deep labiomental fold. The den-
tition will most commonly show deep anterior over-
bite despite the occurrence of lesser amounts of ver-
tical alveolar growth. The lip-to-tooth distance is
usually reduced. The same amount of condylar
growth as shown in Figures 1A and IB, but a greater
amount of vertical growth occurring at the sutures
and alveolar processes (C). This results in a backward
rotating mandibular growth pattern with a concur-
rently longer lower facial height and an associated
characteristic mentalis strain and dimpled chin. Be-
cause the alveolar process must grow more in the
anterior region, any inability to dentally compensate
for the skeletal growth results in an anterior open
bite. The choice of dental compensation and an ex-
trusion arch as a treatment is based on the esthetics of
the lip-to-tooth distance, which is already commonly
increased in these patients.
<<    
     Article
      >> Home | TOC |          
Index

Closing Anterior Open Bites 37

±* •

Figure 2. Schematic view of the biomechanics of an
extrusion arch. Elevation of the anterior portion of
the wire creates a second-order couple at the molar
bracket, resulting in crown mesial/root distal rotation
around the center of resistance (arrows in bold). The
equilibrium of this couple is another couple com-
posed of the extrusive force at the incisor and an
intrusive force at the molar (shaded arrows).
t
Figure 3. Same as Figure 2, but showing the equilib-
rium forces (arrows in bold) and the second-order
couple at the molar (shaded arrows). The compo-
nents of the equilibrium shown and the second-order
couple in Figure 2 are inseparably related, and chang-
ing the magnitude or location of either one of them
will affect the other.

center of resistance of the molar intrusively and

balance. This balance requires that, because the
to rotate the molar around the center of resis-
molar will want to rotate in a counterclockwise
tance in a crown facial/root lingual direction.
direction, an equal tendency for the system to
rotate in a clockwise direction must also be This is a relatively minor component of the ex-
trusion arch force system.
present. Physics requires that the sum of the
moments in all planes must equal zero.
Timing
The equilibrium, or balance, is achieved be-
cause the anterior end of the wire wants to ex- None of the multiple undesirable actions at the
trude the incisor and the wire in the molar tube molar will be significant if the extrusion arch is
will want to intrude the molar (Fig 3). These 2 allowed to act for only a limited length of time.
forces are equal and opposite and define an- This is not an issue of differential forces, it is one
other couple tending to rotate the whole system of timing. When an extrusion arch is used to
clockwise in an amount equal and opposite to
the tendency of the couple at the molar bracket
to rotate the system counterclockwise. This equi-
librium is a balance, and changing any part of
the system will unavoidably change the other
parts also. If it is desired to counteract some
unwanted component of a system in equilib-
rium, it is reasonable to add additional force
systems on top of this system—this will not affect
the equilibrium. It is not reasonable to alter the
arch wire itself without expecting the other com-
ponents of the equilibrium to change also.
When viewing the extrusion arch wire from Figure 4. Frontal view of the intrusive force present at
the frontal plane as in Figure 4, it is apparent the molar when an extrusion arch is activated. Be-
that the intrusive force at the molar tube is cause the force is acting lateral to the center of resis-
tance, a moment is created for crown facial and root
acting lateral to the center of resistance. An lingual rotation around the center of resistance. This
intrusive force acting lateral to the center of moment acts to rotate the tooth simultaneously with
resistance will result in a tendency to move the the intrusive force present.
<<    
     Article
      >>
38 Isaacson and Lindauer
extrude anterior teeth, it is moving the conical
roots of the anterior teeth in a direction that
requires little or no bone resorption. These
teeth can and do move very rapidly. In most
cases, anterior teeth can easily move in an extru-
sive direction 1 to 2 mm per month. If the
extrusion arch is left in place longer than a
couple of months, the force systems acting on
the molar will begin to manifest. These molar
actions require substantial amounts of bone re-
sorption, but they can become evident if the
extrusion is left in place for a protracted period.
The most common reason an orthodontist
leaves an extrusion arch in place too long is
failure of the open bite to close clinically. The
extrusion arch is an overlay arch and it matters
what resistance is present as a result of the arch
wire in the brackets under the extrusion arch.
For the extrusion arch to be effective, it is nec-
essary for the teeth to move vertically in different
amounts with respect to each other. If an arch
wire is in place, the wire must yield between the
brackets. If this arch wire in the brackets is too
stiff, the forces of the extrusion arch wire cannot
manifest and are negated.
On the other hand, the extrusion arch wire is
capable of such rapid tooth movement that
there is a justifiable concern for keeping the
appliance under control. It is not advisable to
use this arch wire with a patient who has a high
risk of missing subsequent appointments. Be-
cause of controls, the authors have not had over-
treatment result in overextrusion of anterior
teeth. However, the authors have had overtreat-
ment result in overexpression of other compo-
nents of the system; such as exaggerated molar
responses associated with a patient who did not
return to the clinic for a protracted period.
Overextrusion has occurred when the extru-
sion arch has been used as a single-tooth seg-
ment, eg, to bring down a high facially located
canine. When used as a single-tooth appliance,
the extrusion arch is at greatest risk of overtreat-
ing the problem. Stopping the extrusive move-
ment and allowing the tooth to relapse, or re-
versing the action of the arch wire, best corrects
this. At the present time, the authors bring down
single, vertically unerupted teeth most often us-
ing nickel titanium overlay wires. Use is made of
segmental extrusion arches, primarily for palatal
canines, because they can be activated laterally
at the same time that they are activated verti-
Home | TOC |          
Index
cally. Nickel titanium overlay arch wires effi-
ciently move teeth toward the arch in a vertical
direction only. Segmental extrusion arches, how-
ever, are more effective when simultaneous
movements of teeth are required in a vertical as
well as a buccal or lingual direction.
Obviously, the best solution for overtreatment
is prevention, and it is advisable to see these
patients more frequently than might be the nor-
mal practice, until the clinician has gained con-
fidence in what to expect. The authors com-
monly use anterior open bite extrusion arch
wires concurrently with light nickel titanium
arch wire in place in the brackets of the entire
arch. This tends to keep the bracket heights
near each other and to keep the extrusion arch
wire system from getting out of control.
To allow the arch wire freedom to work and
still maintain the bracket relationships to each
other, it is advisable to use either a light wire in
the brackets under the extrusion arch or some
other form of control mechanism to prevent
overtreatment. When this control is flexible
enough to allow teeth to move vertically, it will
also begin to move adjacent teeth as the incisor
teeth move vertically. It should be noted that just
as the light wire allows the anterior teeth free-
dom to move, it will also allow the posterior
teeth freedom to move. Therefore, when treat-
ment is protracted, the effects at the molar will
become increasingly apparent. This is especially
true if the molar is banded alone with no sup-
port from the adjacent teeth.
An alternative to the use of nickel titanium
wires in all the brackets is the use of stiff wire in
the brackets of the teeth you do not wish to
intrude or rotate in the buccal segment (Fig 5).
This stiff segment under the extrusion arch will
stabilize the buccal segment, minimizing the
molar responses. Should any responses to the
force at the molar appear, they would have to
have their action on the entire segment of teeth
as if it were one big tooth. The tendency for the
whole segment of teeth to rotate can be further
countered by having the patient wear vertical
elastics in just the buccal segment. Generally,
better success has been achieved in getting pa-
tients to wear lateral vertical elastics as opposed
to getting them to wear anterior vertical elastics.
This greater resistance unit will reduce the
amount of response seen, but it will not change
the force system acting on the molar. Because
<<    
     Article
      >> Home | TOC |          
Index

Closing Anterior Open Bites 39

t
Figure 5. A segment of steel wire in the brackets of Figure 6. A segment of steel wire placed in the inci-
the posterior teeth to stabilize the molar and resist the sors to extrude the incisors as one big tooth. They will
mesial crown rotation resulting from the second-or- maintain their relationship to each other, but will
der couple. For the rotational forces to manifest, they change bracket heights relative to the remainder of
would have to rotate the entire segment of teeth, the arch as the extrusion arch works.
which would tend toward a lateral open bite. An
advantage of the segmented approach is that the an-
terior teeth are free to move while the posterior teeth
are stabilized. The disadvantage is that the bracket
heights between the anterior and posterior segments
tend to get malaligned as the open bite is closed. For
this reason it is preferable to use extrusion arches just
before appliance removal. Insertion of a straight arch
wire after bracket heights are malaligned with an
extrusion arch will likely result in recreating the an-
terior open bite just closed.

the heavy segment of wire does not include the

anterior teeth to be extruded, the anterior teeth
are free to move vertically.

Action at the Incisors

The extrusion arch is normally used to extrude
anterior teeth. Extrusion can involve single teeth
or groups of teeth. When a group of teeth is to
be extruded, a segment of heavy arch wire may
be used in the brackets of the anterior teeth, and
the teeth are extruded as if they were one big
tooth (Fig 6).
The question arises as to whether the extrusion
arch wire should be tied to a segment of wire in the
incisor brackets, tied to a continuous arch wire in
all of the brackets, or placed directly into the
brackets of the incisors. Any of these approaches
will probably be effective. The decision of which to
use is a matter of convenience and control. If the
extrusion arch is tied to a segment of wire in the
anterior brackets, the segment of wire moves the
teeth attached as one big tooth. This will move
t
Figure 7. Action of the extrusion arch at the incisors.
The biomechanics shown in Figures 2 and 3 are all
still present, but not shown in this figure. This Figure
shows the moment created as a result of where force
of the extrusion arch wire is applied at the incisors.
Because the wire is tied more anteriorly, the line of
extrusive force is further away from the center of
resistance. This results in a moment created by the
force equal to the force times the distance the force is
away from the center of resistance. This moment will
tend to tip the incisors lingually. Minimizing the dis-
tance the force acts in front of the center of resistance
reduces the moment and this tendency for lingual
rotation. This happens when the extrusion arch is tied
at the lateral incisors. The tendency for lingual tip-
ping can also be overcome with a stop on the extru-
sion arch in front of the molar tubes.
<<    
     Article
      >> Home | TOC |          
Index

40 Isaacson and Lindauer

Figure 8. Adult male patient with a chief complaint of a midline diastema (A). When told of the potential for
open bite closure without surgery, he consented to treatment (B). Anterior and posterior teeth treated as
segments, and extrusion aches begun in both upper and lower arches. Note the mesial molar crown tip because
of the second-order couple. Note also the intrusion and buccal tip of the molar resulting from the force acting
at the bracket lateral to the molar center of resistance (B). Open bite closure after 2 months of extrusion arch
mechanics (C). Vertical elastics have been worn in the buccal segments to resist and correct the molar tendency
to tip to the mesial. The incisors were rebracketed at a more gingival position to allow insertion of a straight arch
wire (C). Result 17 months after appliance removal (D). Retention used employed routine removable appli-
ances. Patient has had prosthetic restoration of anterior teeth for esthetic purposes, and the result continues to
be stable. Note molar position is the same as it was prior to treatment.

readily, but will move the incisor brackets to dif-
ferent heights than the rest of the teeth in the
arch. If the extrusion arch is tied to a continuous
nickel titanium wire, the bracket heights are better
maintained with respect to each other. The speed
of extrusion may be somewhat slowed down, but
the extrusion is kept under better control in terms
of overtreatment. If the extrusion arch wire is
placed into the incisor brackets, it must be able to
be seated, and then it will move the incisors as one
big tooth. This latter configuration is really a 2-cou-
ple system, and the third-order torque at the inci-
sors influences the forces of extrusion. This makes
it a more complex system without any special ad-
vantages. It is analogous to the relationship be-
tween a 1-couple intrusion arch (the reverse of the
extrusion arch) and the commonly used utility
arch.
Application of any extrusion force to anterior
teeth is effective just as the application of a
single force is effective anywhere else. If the
force is tied at the central incisors, it is probably
acting anterior to the center of resistance (Fig
7). Such a force, in addition to translating the
incisors vertically, will act anterior to the inci-
sors' center of resistance. Clinically, the incisors
will tend to tip lingually and upright, thereby
reducing arch perimeter. The best method to
avoid the latter is to try to apply the force more
posteriorly by tying the extrusion arch at the
lateral incisors.
The Wire
The magnitude of the extrusive force used is
around 100 g for 4 incisors. This is easily
achieved with a 90° bend in a 0.016 X 0.022-inch
stainless steel arch wire with a helix at the molar.
More commonly use is made of the same size of
titanium molybdenum alloy (TMA) wire without
a helix. This is more comfortable for the patient
and is easy to insert. The usual care must be
<<    
     Article
      >> Home | TOC |          
Index
Closing Anterior Open Bites 41

Figure 9. Adult female patient showing the occlusal pattern of dental compensation for a skeletal open bite
(date 2/93) (A). Following appliance placement, the dental open bite became more manifest (date 6/93) (B).
Extusion arches were placed at this time in the upper and lower arches (date 6/93) (B). After 1 month of
extrusion arch mechanics, also having placed a continuous light arch wire beneath the extrusion arches (date
7/93) (C). Following 2 months of extrusion arch mechanics the open bite was closed (date 8/93) (D). Because
a continuous light wire had been placed in the brackets beneath the extrusion arches; the vertical alignment of
the teeth relative to one another was not excessively altered.

taken to overbend this alloy to get the activation
desired.
Retention
The problem of retaining open bite corrections
is the same irrespective of the treatment that
closed the open bite. It is expected that LeFort
surgical open bite closure procedures will be
relatively stable, and these treatments actually
reduce the space for the tongue. Extrusion
arches probably have no more nor less ability to
be stable than any other treatment procedure.
The question of retainers is difficult because
the typical Hawley type retainer has little impact
on open bites. A removable retainer can keep
teeth from tipping to the facial, which, if occur-
ring, will reduce overbite. Removable retainers
cannot prevent actual translation of the center
of resistance in an intrusive direction. Results
achieved by the authors with extrusion arches
have been generally positive, as illustrated in
Figures 8 and 9.
Acknowledgment
The authors thank Ms. Carol Wilkins for her help in prepar-
ing the illustrations for this article.
References
1. Kozlovsky A, Lieberman M. Forced eruption combined
with gingival fiberotomy. A technique for clinical crown
lengthening. J Glin Periodontal 1988;15:534-538.
2. Isaacson RJ, Lindauer SJ, Davidovitch M: The ground
rules for arch wire design. Semin Orthod 1995;1:3-11.
3. Lindauer SJ, Isaacson RJ. One-couple orthodontic appli-
ance systems. Semin Orthod 1995;!: 12-24.
4. Isaacson JR, Isaacson RJ, Speidel TM, et al. Extreme vari-
ation in vertical facial growth and associated variation in
skeletal and dental relations. Angle Orthod 197l;41:219-
229.
<<    
     Article
      >> Home | TOC |          
Index

Space Closure and Anchorage Control

Andrew J. Kuhlberg and Derek N. Priebe

The ability to close extraction spaces preferentially is an essential skill

required during orthodontic treatment. Although many approaches to space
closure and anchorage control have been described, the biomechanical
principles defining the nature of the force systems applied show many
similarities between otherwise diverse techniques. The core concept of
anchorage control is the delivery of a differential force system to the anchor
teeth relative to the active teeth. Specifically, anchorage is determined by
applying unequal moment-to-force ratios (M/F ratios) to each unit. This
implies the use of orthodontic appliances that provide either unequal forces
or unequal moments. Unequal moment force systems or differential mo-
ment force systems are an excellent means of achieving anchorage control.
The fundamental concepts and clinical methods of anchorage control are
described. (Semin Orthod 2001;7:42-49.) Copyright© 2001 by W.B. Saunders
Company

o anchor is to secure firmly, to hold an The problem of anchorage control is rooted

T object against movement; anchorage is that
which provides the secure hold. Specifically,
orthodontic anchorage is the ability to prevent
tooth movement of one group of teeth while
moving another tooth or teeth. Controlling an-
chorage is one of the most critical elements of
orthodontic treatment.
Orthodontic tooth movement is the result of
the controlled application of mechanical forces
to the teeth and periodontium. The stimulus
that provokes the biologic activity leading to
tooth movement is the mechanical forces ex-
erted by orthodontic appliances. The response is
bone remodeling and repositioning of teeth.
From this perspective, orthodontic treatment
can be conceived of as a stimulus-response
model. Anchorage control involves the ability to
create appropriate force systems (stimulus) that
will provide the desired treatment effects (re-
sponse).
From the Department of Orthodontics, University of Connecticut,
School of Dental Medicine, Farmington, CT.
Address correspondence to Andrew J. Kuhlberg, DMD, MDS,
Department of Orthodontics, University of Connecticut, School of
Dental Medicine, Farmington, CT 06030.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0701-0006$35.00/0
doi:10.1053/sodo.2001.21073
in Newton's third law of motion, for every action
there is an equal and opposite reaction. Thus,
the distal forces acting to retract anterior teeth
must be opposed by equal forces acting on the
anchorage units in the mesial direction. The
mesial forces must be accounted for to avoid
anchorage loss. In light of this, orthodontists
have developed a variety of strategies and tech-
niques to maintain anchorage by applying many
methods to inhibit or prevent movement of the
anchor teeth. Historically, most techniques for
anchorage control were developed empirically,
yet their efficacy reflects the ingenuity of their
inventors.
Several anchorage control methods have
been developed over the last century.1'4 The con-
tributions of such icons as Angle, Case, Tweed,
Begg, and others have provided a foundation for
modern orthodontic mechanotherapy. Al-
though each of them espoused different meth-
ods and philosophies, a review of their individ-
ual works shows more similarities than
differences.
By 1907, E.H. Angle advocated 5 types of
anchorage control. Occipital anchorage de-
pended on the use of extraoral headgear. Inter-
maxillary anchorage included the use of elas-
tics.1 The 3 remaining methods were dental
anchorage techniques. Angle decribed simple,

42 Seminars in Orthodontics, Vol 7, No 1 (March), 2001: pp 42-49

<<    
     Article
      >>
Space Closure and Anchorage Control
reciprocal, and stationary methods for dental
anchorage. Both simple and reciprocal anchor-
age methods relied on competing support of the
dentition to effect tooth displacement. In con-
trast, Angle's stationary anchorage methods
were based on his view that firm support of the
anchorage units, through banding multiple
teeth, acted to resist tipping and thus promote
anchorage.
Calvin S. Case also advocated stationary an-
chorage methods despite his ideological depar-
ture from Angle's "New School."2 Although he
described the use of extraoral and intermaxillary
forces, he too recognized that resistance to tip-
ping movements was requisite for intraarch an-
chorage control. With a singular approach, Case
advocated the use of firm, soldered attachment
of the anchorage teeth to one another to main-
tain their upright positions. Case stated that,
with this strategy, "the applied force will be
equally distributed over the entire mesial or dis-
tal surfaces of the alveoli for all the roots, in-
creasing the stability of the anchorage to an
incalculable degree."2
Approximately 20 years later, Charles Tweed
advocated similar techniques. His method of an-
chorage preparation was aimed at maintaining
the anchorage teeth against unwanted tipping
and extrusive side effects.3'5'6 A series of tip back
bends acted to anchor the teeth like tent stakes
to resist vertical and anteroposterior displace-
ment during intermaxillary elastic traction. Al-
though Tweed reported that his methods were
more mechanical in nature than biologic, the tip
back bends were generally a further refinement
of Angle's and Case's stationary anchorage
methods.
Despite his adherence to the differential
force theory, P.R. Begg also used a similar pro-
cedure for anchorage control.7'9 With the use of
his light wire technique, Begg regularly used tip
back bends to help maintain the anteroposterior
position of the anchorage teeth to effect prefer-
ential tooth movement.4'10 Additionally, he pro-
posed tipping the anterior teeth during initial
retraction, followed by an uprighting phase.
All of these methods have proven to be gen-
erally effective and well-accepted approaches to
orthodontic mechanotherapy. Further advance-
ments in these techniques have been evolutions
rather than revolutions. The common denomi-
nator of these and subsequent techniques is that
Home | TOC |          
Index
43
each aimed at controlling the type of tooth
movement that occurred, ie, tipping versus
translation.
Fundamentally, advocates of many of the con-
temporary orthodontic techniques have adapted
their approaches to different hardware designs.
Understanding the conceptual basis of biome-
chanics in anchorage control permits greater
latitude in treatment delivery and transcends the
limits of any specific technique. Additionally, the
contemporary shift toward compliance-indepen-
dent orthodontic treatment further requires a
grasp of fundamental biomechanical principles.
Anchorage from a Biomechanical
Perspective
The basic techniques for anchorage control gen-
erally rely on 3 essential similarities: (1) ex-
traoral forces on the anchorage unit (headgear),
(2) intermaxillary elastics, (3) tipping move-
ments of the active teeth while simultaneously
discouraging tipping of the anchorage teeth.
Patient compliance is a mandatory requirement
for headgear and elastic wear. Without cooper-
ation, control of tooth movement is lost and
treatment outcome may be compromised.
The attempt to maintain anchorage by pro-
moting different types of tooth movement for
the active teeth versus the anchor units shows
the biomechanical essence of anchorage con-
trol. Understanding how this strategy works re-
quires an analysis of how the applied force sys-
tems determine the resulting type of tooth
movement. The relationship between mechani-
cal force systems and tooth movement has been
well described and illustrates that the nature of a
tooth's movement depends on the ratio of the
applied moment relative to the applied force
(M/F ratio) at the orthodontic bracket.11
The way a tooth moves is dependent on the
nature of the forces (ie, the force system) im-
posed on it. The force system includes the ap-
plied force and moments at the bracket (via
elastic, coil, loop, etc), and the actual force dis-
tribution about the periodontium (stress-strain
relationship). The force distribution is a func-
tion of the tooth's center of rotation.11'21 Con-
trolled tipping is tooth movement with the cen-
ter of rotation of the tooth at the root apex. The
resultant forces tend to be distributed at the
marginal portion of the periodontal ligament
<<    
     Article
      >> Home | TOC |          
Index

44 Kuhlberg and Priebe

(PDL). The M/F ratio for controlled tipping is

reported at approximately 7/1 for most teeth
with normal periodontal support. Translation or
bodily movement, on the other hand, maintains
the axial inclination of the tooth with the center
of rotation at an infinite distance from the apex.
The resultant force distribution tends to be
more equally distributed along the pressure side
of the alveolar structures. Translation requires a
M/F ratio of about 10/1. Lastly, root move-
ment— or displacement of the root apex while
holding the crown stationary—occurs with a
M/F ratio of 12/1. Here, the applied forces tend
to be concentrated along the apical Vs of the
root (Fig 1).
Why does this analysis show the biomechani-

Controlled
Tipping
M/F -7:1 Figure 2. The effect of a large M/F ratio on tooth
movement. A large M/F ratio produces root move-
ment (A). A pure moment would produce only rota-
tion, which would result in distal crown movement
(B).

cal essence of anchorage control? First, let us

Translation look at the effect of a high M/F ratio applied to
the anchor teeth. An applied force at the crown
M/F -10:1
produces uncontrolled tipping as a result of the
moment of the force. The applied moment (mo-
ment of the couple) counteracts the tipping ef-
fect of the force. The applied moment acts in
the opposite direction of the moment of the
force. It moves the root(s) toward the extraction
space. In addition, as the magnitude of the ap-
plied couple increases, the rotation of the tooth
would move the crown away from the space
Root (Fig 2).
Movement
Conversely, a low M/F ratio produces tipping.
M/F -12:1 With the apex remaining stationary, the crown
tips toward the extraction space. Geometrically,
the result is greater tooth movement at the oc-
clusal plane relative to a tooth undergoing trans-
lation. Figure 3 shows a comparison of tipping
versus translation, the center of resistance of the
tooth for each example is displaced equally. The
crown movement, however, is noticeably greater
Direction of Movement
for the tipped tooth. This shows how tipping
Figure 1. Tipping, translation, and root movement, movements can result in greater movements of
The type of tooth movement depends on the M/F teeth from a clinical perspective.
ratio. The theoretical effectiveness of differential
<<    
     Article
      >> Home | TOC |          
Index

Space Closure and Anchorage Control 45

example, increase the retraction force on the

Figure 3. Tipping produces more movement at the
crown or occlusal plane compared with translation.
For both teeth in this illustration, the center of resis-
tance of the tooth is displaced the same distance.
anterior teeth (M/Fposterior > M/Fanterior) (Fig
4B). Another means of increasing the retraction
force is the use of J-hook headgear applied to
the anterior teeth.
The applied moment is determined by the
wire-bracket relationship. In the case of a
straight wire, the magnitude of the moments on
the anterior and posterior teeth may be pre-
sumed to be equal (see Schlegel22 for a discus-
sion on the effect of bracket width on the mo-
ment expressed as frictional force). For both
headgear and elastics, the biomechanical effec-
tiveness is largely a result of the generation of
unequal forces applied to posterior and anterior
teeth. Unfortunately, this approach depends on
patient compliance for success. When this is the
only means of anchorage control, treatment re-
mains at the mercy of motivational tactics and
cooperative patients.

M/F ratios is readily apparent. The question is,

how can these force systems be produced clini-
cally? For the purpose of discussion, consider
the correction of a Class II malocclusion in
which maximum posterior anchorage is needed.
The objective is unequal applied M/F ratios:
high M/F for posterior teeth, low for anterior
teeth. If M/Fposterior > M/Fanterior, then there
must be either unequal forces or unequal mo-
ments. JHeadgear
Unequal forces cannot be simply produced by Force
a spring, loop, or chain elastic, because for every
action there is an equal and opposite reaction.
The retraction force a spring applies to the an-
terior teeth is reciprocally applied to the poste-
rior teeth. To deliver unequal forces, external or
extra-arch mechanisms must be included. Head-
gear and intermaxillary elastics are probably the
2 most common means of generating these ad-
ditional forces.
In its simplest form, headgear acts to produce
a distal force on the anchorage teeth. By acting
in opposition to the traction force from a spring
Intermaxillary
or chain elastic, the headgear reduces the net Elastic
force on the posterior teeth (M/Fposterior > Force
M/Fanterior). Although there may be additional
headgear effects, the aim conceptually is to re- Figure 4. The effect of changing the force magnitude
on the M/F ratio. Headgear is a means of decreasing
tard the mesial forces on the posterior teeth (Fig the mesial force to the posterior teeth (A). Intermax-
4A). illary elastics (Class II elastics) increase the distal force
Intermaxillary elastics, Class II elastics in this to the anterior teeth (B).
<<    
     Article
      >>
46 Kuhlberg and Priebe
The inequality, M/Fposterior > M/Fanterior, in-
dicates the need for an alternative approach.
Rather than varying the forces, unequal mo-
ments may be applied. Increasing the moment
on the posterior teeth and/or decreasing the
moment on the anterior teeth serves as another
option toward creating differential M/F ratios.
The horizontal force on the anterior teeth
equals the horizontal force on the posterior
teeth. The moments or couples created by the
bracket/wire-spring combination generate a
greater moment to the anchorage teeth. Simul-
taneously, a lower moment acts on the anterior
teeth.
For the Class II/upper anterior retraction
challenge, the M/F ratio on the posterior teeth
will produce translation or root movement,
while the low M/F ratio on the anterior teeth
will show controlled tipping. The large posterior
moments encourage anchorage preservation as
they resist tipping. Also, a very large posterior
moment would actually cause distal crown move-
ment, effectively increasing the size of the ex-
traction space!
The application of unequal moments must
also satisfy Newton's laws. Because the moments
on each end of the spring are unequal, the total
force system must have additional effects. Verti-
cal forces, intrusive to the anterior and extrusive
to the posterior, are also acting. The vertical
force magnitude depends on the difference in
the 2 moments and the distance between ante-
rior and posterior attachment points (Fig 5).
In addition to the potential side effects cre-
ated by the vertical forces, this approach to space
Figure 5. The force system from differential moment
orthodontic appliance designs for space closure.
Home | TOC |          
Index
closure frequently results in occlusal plane dis-
crepancies between the anterior and posterior
teeth. The posterior teeth may be positioned
with the crowns distally tipped and the roots
mesially oriented. The canines commonly have a
root-mesial axial inclination and the incisors are
excessively upright. This situation is a natural
consequence of the force system used but may
also be an advantage given appropriate maloc-
clusions (ie, anterior protrusion with excessive
dentoalveolar height and gingival display). An
appropriate stage of root correction after space
closure prepares the occlusion for orthodontic
finishing details.
In comparison with the use of elastics or
headgear, a differential moment approach to
anchorage control reduces the influence of
compliance on treatment outcome. Because the
force system is generated by the intraoral appli-
ance, elastics or headgear become less critical.
In extremely difficult cases, headgear or elastics
may be used to further supplement anchorage.
Several orthodontic springs, loops, and de-
vices have been designed using this approach to
anchorage control.23"26 The wide variety of de-
signs reflects the breadth of the options available
to the clinician for implementing this strategy
for anchorage control in patient care. The im-
portant issue is not the specific spring, it is the
force system the spring applies to the dentition.
Biologic Considerations
Another factor in anchorage control is the rela-
tive rates of tooth movement for tipping, trans-
lation, and root movement. The stress distribu-
tion within the periodontal support is different
for each type of tooth movement. The stresses
on the PDL are greatest at the cervix of the tooth
for controlled tipping and approach zero at the
apex. Conversely, the greatest stresses are at the
apex for root movement. Translation applies a
uniform stress along the root surface. The rates
of tooth movement for each of these stress-strain
relationships may also affect anchorage control.
Tooth displacement rates have often been
evaluated on the basis of force magnitude. Smith
and Storey7 reported that the manipulation of
force magnitudes has an impact on relative rates
of tooth displacement and thus anchorage con-
trol. Unfortunately their conclusions have not
been supported by others.27"32 It is suggested,
<<    
     Article
      >> Home | TOC |          
Index

Space Closure and Anchorage Control 47

however, that the stress distribution about the
periodontal ligament, rather than the absolute
magnitude of the force, has a greater impact on
rates of displacement.33 Histologie studies have
shown that tipping produces localized regions of
high stress, whereas translation results in a more
diffuse stress distribution.34"36 Thus, a simple
force applied at the bracket will be concentrated
at the apical and marginal regions of the PDL
and effectively increase the stress in these areas.
If force magnitude, specifically the stress magni-
tude within the PDL, determines the rate of
displacement,19'29'31 then tipping movements oc-
cur faster because of the higher localized
stresses. Storey reported that tipping movements
occurred more rapidly than translational move-
ments.37 Although there is still some question
regarding the effects of force magnitude on
rates of tooth displacement, the combination of
these biologic concepts with the geometric ad-
vantage of tipping movements over translation
(Fig 3) may help explain the effectiveness of
differential moment strategies for anchorage
control.
has a similar effect. Because wire stiffness is in-
versely related to the third power of the length,
an off-centered or asymmetrically positioned
spring will deliver greater moments to the teeth
that it approximates (Fig 6).39
Another method of anterior retraction that
uses a differential moment strategy for anchor-
age control is combined incisor intrusion and
retraction. This simple yet effective appliance
uses the tip back moment of the intrusion arch
for creating the large posterior M/F ratio.42'43
The retraction force is applied with either coil
springs or elastic chain (Fig 7). By carefully con-
trolling the intrusive and retraction forces, the
overbite and overjet can be simultaneously cor-
rected.
Careful monitoring is crucial for successful
anchorage control during space closure. A sys-

Clinical Techniques Using Differential

Moments for Anchorage Control
A number of springs have been designed that
use the differential moment strategy for anchor-
age control.23'26'38'39 The selection of one spring
or another depends largely on individual pref-
erences. The T-loop spring described by Burst-
one and subsequently refined or modified is a
simple yet effective device for controlled space
closure.23'38"40 Although most frequently pre-
sented as a segmented spring, it can also be
effective within a continuous wire.41 With cor-
rect application, however, most retraction
springs may be effective at closing spaces while
simultaneously providing anchorage control.
The core principle of loop design for all of
these springs is increased stiffness of the wire on
the anchorage side of the spring. All other fac-
tors being equal, an increase in wire stiffness has
the effect of establishing greater moments at the Figure 6. Anchorage control with a differential mo-
engaged teeth. Increases in stiffness may be ac- ment strategy through the use of a T-loop spring. A
complished by using composite springs with the T-loop positioned toward the posterior attachment
incorporation of wires showing different moduli increases the moment to the posterior teeth and de-
creases the moment to the anterior teeth (A). The
of elasticity, with the suffer section engaging the expected tooth movements, the anterior teeth are
anchorage units. Conversely, asymmetric posi- expected to tip distally while the posterior teeth show
tioning of the loop toward the anchorage teeth root correction (B).
<<    
     Article
      >>
48 Kuhlberg and Priebe
Figure 7. Combined anterior retraction and deep
overbite correction with posterior anchorage control.
An intrusion arch is used to create the moment on the
posterior segment with the concurrent intrusive force
on the anterior teeth and extrusive force on the pos-
terior teeth. A chain elastic or coil spring is used to
create the retraction force (A). The anticipated tooth
movements would be intrusion and retraction of the
anterior teeth following the line of action of the re-
sultant force and molar tip back which aids in anchor-
age preservation (B).
tematic evaluation of treatment progress identi-
fies the necessary adjustments for each patient
visit. The amount and type of tooth movement
of the active and anchor teeth need to be
assessed. Subsequent appliance adjustments
should be based on treatment progress. Specific
spring and/or wire activations can be made tai-
lored to the individual patient's treatment objec-
tives.
A frequently overlooked consideration in an-
chorage control is the first-order side effects of
space closure. The mesially directed, buccally
located force on the molar will tend to produce
a mesially inward rotation. This rotation gives
the appearance of anchorage loss when viewed
from the buccal perspective. However, distaliza-
tion of the molar may not be necessary, a mesi-
ally-outward first-order rotation may be all that is
needed for regaining the desired molar posi-
Home | TOC |          
Index
tion. A transpalatal arch provides an excellent
means for preventing this side effect or actively
correcting it.44'45
Few studies have investigated effectiveness of
differential moment strategies for anchorage
control. Hart et al46 found adequate anchorage
control with differential torque mechanics for
extraction space closure in 18 Class I malocclu-
sions and 12 Class II, Division 1 malocclusions.46
Rajcich and Sadowsky47 showed minimal anchor-
age loss with a differential moment approach for
anchorage control using intra-arch mechanics.
Well-controlled clinical studies of explicit orth-
odontic treatment strategies are difficult be-
cause of the great number of confounding vari-
ables associated with orthodontic treatment.
The differences among patients and the specific
objectives of their treatments complicate the
analysis of the effectiveness of particular treat-
ment mechanisms. However, the studies that
have been completed provide support for a dif-
ferential moment strategy for anchorage con-
trol.
References
1. Angle EH. Treatment of Malocclusion of the Teeth, ed
7. Philadelphia, PA, S.S. White Dental Manufacturing
Co., 1907.
2. Case CS. A Practical Treatise on the Technics and Prin-
ciples of Dental Orthopedia and Prosthetic Correction
of Cleft Palate, ed 2. Chicago, IL, C.S. Case, 1921, pp.
486.
3. Tweed CH. Clinical Othodontics, ed l (vol l). St Louis,
MO, Mosby, 1966, pp. 1-423.
4. Begg PR. Begg Orthodontic Theory and Technique.
Philadelphia, PA, Saunders, 1965.
5. Vaden JL, Dale JG, Klontz HA. The Tweed-Merrifield
edgewise appliance: philosophy, diagnosis, and treat-
ment, in Graber TM, Vanarsdall RL, (eds): Orthodon-
tics: Current Principles and Techniques. St. Louis, MO,
Mosby-Year Book, 1994, pp. 627-684.
6. Vaden JL. The Tweed-Merrifield philosophy. Semin
Orthod 1996;2:237-240.
7. Smith R, Storey E. The importance offeree in orthodon-
tics: The design of cuspid retraction springs. AustJ Dent
1952;56:291-304.
8. Begg PR. Differential force in orthodontic treatment.
Am J Orthod 1956;42:481-510.
9. Begg PR, Kesling PC. The differential force method of
orthodontic treatment. Am J Orthod 1977;7l:l-39.
10. Begg PR. The origin and progress of the light wire
differential force technique. Begg J Orthod Theory
Treat 1968;4:9-34.
11. Smith R, Burstone C. Mechanics of tooth movement.
Am J Orthod 1984;85:294-307.
12. Reitan K. Continuous bodily tooth movement and its
<<    
     Article
      >>
Space Closure and Anchorage Control
histological significance. Acta Odontol Scand 1947;7:
115-144.
13. Fortin J. Translation of premolars in the dog by control-
ling the moment-to-force ratio on the crown. Am J
Orthod 1971;59:541-551.
14. Brodsky JF, Caputo AA, Furstman LL. Root tipping: A
photoelastic-histopathologic correlation. Am J Orthod
1975;67:1-10.
15. Baeten LR. Canine retraction: A photoelastic study. Am J
Orthod 1975;67:11-22.
16. Nikolai RJ. On optimum orthodontic force theory as
applied to canine retraction. Am J Orthod 1975;68:290-
302.
17. Pryputniewicz RJ, Burstone CJ. The effect of time and
force magnitude on orthodontic tooth movement. J
Dent Res 1979;58:1754-1764.
18. Burstone CJ, Pryputniewicz RJ. Holographic determina-
tion of centers of rotation produced by orthodontic
forces. Am J Orthod 1980;77:396-409.
19. Quinn RS, Yoshikawa DK. A reassessment of force mag-
nitude in orthodontics. Am J Orthod 1985;88:252-260.
20. Tanne KM, Sakuda M, Burstone CJ. Three-dimensional
finite element analysis for stress in the periodontal tissue
by orthodontic forces. Am J Orthod Dentofacial Orthop
1987;92:499-505.
21. Tanne K, Koenig HA, Burstone CJ. Moment to force
ratios and the center of rotation. Am J Orthod Dentofa-
cial Orthop 1988;94:426-431.
22. Schlegel V. Relative friction minimization in fixed orth-
odontic bracket appliances. J Biomech 1996;29:483-491.
23. Burstone CJ, Koenig HA. Optimizing anterior and ca-
nine retraction. Am J Orthod 1976;70:1-19.
24. Gjessing P. Controlled retraction of maxillary incisors.
Am J Orthod Dentofacial Orthop 1992;101:120-131.
25. Siatkowski RE. Continuous archwire closing loop design,
optimization, and verification. Part II. Am J Orthod
Dentofac Orthop 1997;! 12:487-495.
26. Siatkowski RE. Wear and tear from sliding mechanics.
J Glin Orthod 1997;31:812-813.
27. Hixon EH, Atikian H, Callow GE, et al. Optimal force,
differential force, and anchorage. Am J Orthod 1969;55:
437-457.
28. Hixon EH, Aasen TO, Clark RA, et al. On force and
tooth movement. Am J Orthod 1970;57:476-489.
29. Boester CH, Johnston LE. A clinical investigation of the
concepts of differential and optimal force in canine
retraction. Angle Orthod 1974;44:113-119.
30. Andreasen GF, Zwanziger D. A clinical evaluation of the
differential force concept as applied to the edgewise
bracket. Am J Orthod 1980;78:25-40.
31. Owman-Moll P, Kurol J, Lundgren D. The effects of a
Home | TOC |          
Index
49
four-fold increased orthodontic force magnitude on
tooth movement and root resorptions. An intra-individ-
ual study in adolescents. Eur J Orthod 1996; 18:287-294.
32. Pilon JJ, Kuijpers-Jagtman AM, Maltha JC. Magnitude of
orthodontic forces and rate of bodily tooth movement.
An experimental study. Am J Orthod Dentofacial Or-
thop 1996;110:16-23.
33. Burstone C. Application of bioengineering to clinical
orthodontics, in Graber T, Vanarsdall R, (eds): Orth-
odontics: Current Principles and Techniques. St. Louis,
MO, Mosby, 2000.
34. Reitan K. Some factors determining the evaluation of
forces in orthodontics. Am J Orthod 1957;43:32-45.
35. Reitan K. Tissue behavior during orthodontic tooth
movement. Am J Orthod 1960;46:881-900.
36. Thilander B, Rygh P, Reitan K. Tissue reactions in orth-
odontics, in Graber T, Vanarsdall RL (eds): Orthodon-
tics: Current Principles and Techniques. St. Louis, MO,
Mosby, 2000, pp. 117-191.
37. Storey E. The nature of tooth movement. Am J Orthod
1973;63:292-314.
38. Burstone CJ. The segmented arch approach to space
closure. Am J Orthod 1982;82:361-378.
39. Kuhlberg AJ, Burstone CJ. T-loop position and anchor-
age control. Am J Orthod Dentofacial Orthop 1997; 112:
12-18.
40. Manhartsberger C, Morton JY, Burstone CJ. Space clo-
sure in adult patients using the segmented arch tech-
nique. Angle Orthod 1989;59:205-210.
41. Nanda R, Kuhlberg AJ. Biomechanics of extraction
space closure, in Nanda R (ed): Biomechanics in Clini-
cal Orthodontics. Philadelphia, PA, Saunders, 1997.
42. Shroff B, Lindauer SJ, Burstone CJ, et al. Segmented
approach to simultaneous intrusion and space closure:
Biomechanics of the three-piece base arch appliance.
Am J Orthod Dentofacial Orthop 1995;107:136-143.
43. Shroff B, Yoon WM, Lindauer SJ, et al. Simultaneous
intrusion and retraction using a three-piece base arch.
Angle Orthod 1997;67:455-461.
44. Burstone C, Manhartsberger C. Precision lingual arches.
Passive applications. J Glin Orthod 1988;22:444-451.
45. Burstone C. Precision lingual arches. Active applica-
tions. J Glin Orthod 1989;23:101-109.
46. Hart A, Taft L, Greenberg SN. The effectiveness of
differential moments in establishing and maintaining
anchorage. Am J Orthod Dentofacial Orthop 1992;102:
434-442.
47. Rajcich MM, Sadowsky C. Efficacy of intraarch mechan-
ics using differential moments for achieving anchorage
control in extraction cases. Am J Orthod Dentofacial
Orthop 1997;! 12:441-448.
<<    
     Article
      >> Home | TOC |          
Index

Root Correction During Orthodontic Therapy

Bhavna Shroff

During orthodontic therapy, control of root alignment is critical for achieving

optimal treatment results and to assure a good long-term prognosis for the
correction obtained. Root correction is an important step of treatment that
should not be overlooked. Careful evaluation of the position of the roots
after space closure in extraction cases is performed for anterior and poste-
rior teeth, and necessary correction should be implemented to obtain an
optimal occlusion and an adequate bone distribution between teeth in the
arch. Similarly, in nonextraction cases, root parallelism is achieved to pro-
mote a good periodontal prognosis and long-term maintenance of the cor-
rection obtained. Different treatment strategies may be used to achieve
anterior and posterior root correction, each having advantages and limita-
tions clinically. (Semin Orthod 2001;7:50-58.) Copyright © 2001 by W.B.
Saunders Company

ontrol of the axial inclinations of teeth
C during orthodontic therapy is critical for
achieving excellent results and ensuring long-
term stability after completion of treatment. The
careful evaluation of individual tooth axial incli-
nations is often carried out as a second stage of
space closure in extraction therapy or before
completion of treatment in nonextraction ther-
apy. Good axial inclinations and adequate root
parallelism with regular bone distribution be-
tween teeth helps to obtain and maintain a sta-
ble treatment result.
The evaluation of root axial inclinations is
also critical in patients with congenitally missing
teeth when the goal is to replace these teeth with
either implants or bridges. Parallelism of the
abutments' roots as well as adequate bone distri-
bution are important factors in the prognosis
and successful outcome of treatment.
Root correction, which may involve individual
teeth (separate root correction) or groups of
teeth (en masse root correction), is also instru-
From the Department of Orthodontics, University of Maryland
Dental School, Baltimore, MD.
Address correspondence to Bhavna Shroff, DDS, MDentSc, De-
partment of Orthodontics, University of Maryland Dental School,
666 W Baltimore St, Baltimore, MD 21201.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0701-0007$35.00/0
dot: 10.1053/sodo.2001.21074
mental in positioning teeth over basal bone to
achieve an ideal occlusal relationship in the
anterior and posterior portions of the dental
arches.1 For example, the retraction of canines
by tipping may result in an inadequate axial
inclination that does not allow for the correct
anteroposterior positioning of the anterior
teeth. Similarly, when anterior teeth are re-
tracted en masse and are too upright after space
closure is completed, it is difficult to achieve an
ideal posterior occlusion. The axial inclination
of premolars and canines after space closure
needs to be carefully evaluated to assure good
parallelism and adequate bone distribution im-
portant for long-term periodontal health.
Root Correction in a Continuous Arch
Wire System
In clinical practice using edgewise or straight
wire appliances, control of root angulation dur-
ing space closure and anterior root correction
are usually achieved by placing torque in a rect-
angular wire of appropriate cross section.2 Typ-
ically, after completion of space closure, clinical
observation and/or radiographic evaluation of
the axial inclinations of the anterior teeth help
to determine the need for anterior root correc-
tion. Arch wires of increasing cross section are
placed into the brackets. The arch wire is fully
engaged to fill the bracket slots and express the

50 Seminars in Orthodontics, Vol 7, No 1 (March), 2001: pp 50-58

<<    
     Article
      >>
Root Correction During Orthodontic Therapy
built-in third-order prescription of the attach-
ments (Fig 1). Additional lingual root torque,
achieved by twisting the arch wire, may be incor-
porated into the anterior portion of the arch to
increase the efficiency of the correction of the
root position of the anterior teeth. Side effects
commonly encountered include extrusion of the
anterior teeth and a loss of posterior anchorage
(Fig 2) .3 The overjet may increase because of the
flaring of the incisors as their roots are moved
lingually. This occurs if the arch wire is not
properly tied back and will result in reopening
of spaces in the dental arch.
It is difficult to analyze the force system and
not possible to determine the magnitudes of the
forces and moments when using this continuous
arch wire approach. Adequate root correction
usually takes longer than necessary and results in
higher concentrations of stress in the apical por-
tion of the roots. Root resorption of the incisors
may be observed because of the high levels of
stress in the periodontal ligament around the
apex and the considerable moments developed
by stainless steel rectangular wires.4
During the third stage of treatment in the
Begg technique, torquing auxiliaries are used to
correct the axial inclinations of the incisors,
which are usually severely tipped lingually dur-
ing space closure.5'7 Typically, torquing auxilia-
ries made of 0.016-inch Australian stainless steel
wire are overlaid on the main continuous arch-
wire. A moment is delivered to the anterior
teeth, moving their roots lingually and flaring
their crowns. Extrusion of the anterior teeth is a
common side effect. As a result of the high
moments delivered and the amount of root cor-
Figure 1. A full-size arch wire is placed into the
bracket slots to express the built-in third-order pre-
scription of the attachment.
Home | TOC |          
Index
51
Figure 2. When lingual root torque is applied to the
anterior teeth, a common side effect is extrusion of
the anterior teeth. The posterior teeth experience an
intrusive force, and the lingual root moment gener-
ated to correct the axial inclinations of the anterior
teeth will result in loss of posterior anchorage.
rection required, significant resorption of the
roots of the anterior teeth has also been reported.4
To adequately complete orthodontic therapy
and achieve a good buccal occlusion, teeth need
to be positioned over basal bone with specific
axial inclinations.1 This is critical to achieve a
good posterior occlusion and will ensure that
posterior teeth articulate optimally with their
antagonists.
In the straight wire technique, root correc-
tion of posterior teeth is generally achieved by
placing a continuous wire into the brackets of
teeth that need correction of their root axial
inclinations. This approach relies on the second-
order moment produced as a result of full wire
engagement. In such a system, it is difficult to
analyze the forces and moments generated by
the appliance, and side effects are often unpre-
dictable.8'9 A more predictable approach would
be to isolate the teeth that need root correction
from the main arch wire and use a spring de-
signed to deliver the force system required for
correction.
Diagnosis and Evaluation for Root
Correction
Root correction may be considered the second
phase of space closure, and most often comple-
tion of space closure is recommended before
evaluating for the potential need to correct root
axial inclinations. Clinical assessment of root po-
sitions during space closure is often very useful
and may be done by monitoring the inclinations
of the canine and anterior brackets.
Lateral cephalometric head films, radiographs
taken at 45°, and panoramic radiographs are com-
<<    
     Article
      >>
52 Bhavna Shroff
monly used to assess the need for root correc-
tion. Lateral head films primarily assist in evalu-
ating the axial inclinations of the anterior teeth
by comparing a film taken before initiation of
treatment and one taken after completion of
space closure. Radiographs taken at 45° indicate
the axial inclinations of canines, premolars, and
molars and are helpful for assessing proper root
parallelism, adequate bone distribution, and
bone levels. Despite the amount of deformation
inherent in panoramic radiographs, they remain
the most popular radiographs routinely used to
assess the axial inclinations of the posterior
teeth. This is primarily because panoramic ra-
diographs are easily available and comparison
with a pretreatment panoramic radiograph is
usually possible.
Incisor Root Correction
Incisors that need root correction or lingual
root torque after completion of space closure
require a counterclockwise moment applied to
them with a center of rotation at the brackets.
This results in lingual root movement of the
anterior teeth. The magnitude of the moment
necessary to correct the axial inclinations of 2
maxillary central incisors is about 1,500 g-mm or
less per side (3,000 g-mm total); 2,000-2,500
g-mm per side (4,000 to 5,000 g-mm total) is
suggested to correct the axial inclinations of the
4 maxillary incisors. Vertical forces are devel-
oped on the anterior teeth and on the posterior
teeth as a result of the moment applied to
achieve anterior root correction. The anterior
teeth are extruded while the posterior teeth ex-
perience an intrusive force. Anchorage require-
ments are critical during root correction of the
anterior teeth. A rowboat effect, moving the en-
tire maxillary dental arch forward and resulting
in a more Class II dental relationship, may be
observed as the roots of the anterior teeth are
moved lingually. The use of headgear to support
anchorage during anterior root correction may
help to minimize or eliminate this side effect.
The root spring used for anterior root correc-
tion may be fabricated using 0.022 X 0.016-inch
(ribbonwise) titanium molybdenum alloy (TMA),
or 0.021 X 0.025-inch (edgewise) TMA, to be
inserted into 0.022 X 0.028-inch edgewise brack-
ets. The root spring is placed into the brackets of
the anterior teeth, stepped up around the ca-
Home | TOC |          
Index
nines and premolars, and extended distally as a
cantilever with hooks mesial to the first molars
(Fig 3). The distal extension of the root spring
will be attached to a continuous bypass arch wire
that engages the buccal segments and is stepped
around the anterior teeth undergoing root cor-
rection. The bypass arch wire is typically made of
0.017 X 0.025-inch TMA or 0.018-inch stainless
steel. It is stepped occlusally around the brackets
of the anterior teeth to be corrected (Fig 4). All
teeth in the arch are tied together under the
wires with a figure-8 ligature to avoid opening
space between the teeth. The figure-8 ligature
wire also prevents incisor flaring and helps main-
tain a center of rotation of the anterior teeth at
the brackets of the incisors.
The distance from the incisors to the point of
attachment of the hook of the root spring mesial
to the molars is measured, and the amount of
force necessary to generate an adequate mo-
ment is calculated. For example, if a moment on
the incisors of 1,500 g-mm per side (3,000 g-mm
total) is desired and the distance between the
incisors and the point of attachment of the
spring on each side is 30 mm, an intrusive force
posteriorly of 50 g on each side is required.
Preactivation bends are placed at the gingival
position of the anterior step up and a gentle
curvature is incorporated bilaterally along the
posterior cantilever (Fig 5). The amount of
force is measured on the right and left sides and
trial activation is made on each side of the
spring.
Figure 3. Frontal view of a root correction spring in
place in the incisors and a bypass arch wire stepped
around the incisors and inserted into the brackets of
the posterior teeth.
<<    
     Article
      >> Home | TOC |          
Index

Root Correction During Orthodontic Therapy 53

rior root spring. The incisor bypass arch wire was

Figure 4. Sagittal view of the root spring hooked on
the bypass arch wire mesial to the first maxillary mo-
lars.
fabricated using 0.018-inch stainless steel. The
arch wire was inserted into the brackets of the
posterior teeth and bypassed the maxillary inci-
sor brackets occlusally (Fig 7).
By bending the cantilever gingivally, 70 g of
activation was placed on each side of the spring.
The patient was also given high-pull headgear to
help increase posterior anchorage. Evaluation of
the amount of anterior root correction obtained
was achieved by superimposing lateral cephalo-
metric films taken before and after root correc-
tion and by monitoring the axial inclinations of
the anterior teeth clinically (Fig 8).

Clinical Applications Case 2

Case 1 L.L. was a 13-year, 5-month-old female Cauca-
sian patient who presented for treatment be-
N.B. was a 15-year-old African American patient
cause her "front teeth were sticking out" (Fig 9).
who came to the orthodontic clinic at the Uni-
Her dental history included a thumb-sucking
versity of Maryland for treatment of his crowded
habit that was still active. The extraoral exami-
teeth (Fig 6). The patient's profile was convex
nation showed an oval face with good symmetry.
with excessive lip protrusion, and his lower facial
height was increased. At rest, the amount of
maxillary incisor shown was negative and the
interlabial gap was increased. The patient pre-
sented with an Angle Class II malocclusion in
the permanent dentition with 3 mm of over] e t
and an anterior openbite. The maxillary midline
was 2 mm to the right of the facial midline, and
the mandibular midline was coincident with the
facial midline. The patient presented with mod-
erate to severe maxillary and mandibular crowd-
ing. The lateral cephalometric analysis showed a
skeletal class II with an increased lower facial
height and flared maxillary and mandibular in-
cisors. The treatment plan included the extrac-
tion of 4 first premolars.
Treatment was initiated with derotation of
the maxillary first molars using a 0.030-inch
stainless steel transpalatal arch. Canines were
then segmentally retracted and incorporated
into the buccal segments of teeth. En masse
space closure was achieved using a continuous
0.016 X 0.022-inch TMA arch wire with bilateral
T-loops in the maxillary and mandibular arches.
After completion of en masse space closure, a
panoramic film and a lateral cephalometric film
were taken to evaluate the need for root correc-
t
Figure 5. Frontal view of an anterior root correction
tion. The maxillary anterior teeth were deter- spring with bilateral activations (A). Once activated,
mined to be too upright. Root correction of the the distal arms of the root spring will be pulled occlu-
4 maxillary incisors was initiated using an ante- sally and hooked on the bypass arch wire (B).
<<    
     Article
      >> Home | TOC |          
Index

54 Bhavna Shroff

L.L. presented with a Class II, Division 1 mal-

occlusion in the permanent dentition. Her right
and left molars were full cusp Class II. Her right
canine was Class II by 7 mm and the left canine
was Class II by 5 mm. She had 8 mm of overjet
and no overbite (Fig 9). There was spacing in
the anterior portion of the maxillary (8 mm)
and mandibular (3 mm) arches. The patient's

Figure 6. Frontal view of the patient's occlusion. The

overjet is 3 mm, and a significant open bite is present.
The maxilllary midline is 2 mm to the right of the
facial midline, and the mandibular midline is coinci-
dent with the facial midline (A). The right buccal
occlusion is Class I (B), and the left buccal occlusion
is slightly Class II with a crossbite of the second pre-
molar and first and second molars (C).

The maxillary dental midline was aligned with

the facial midline, and the mandibular midline
was 3 mm to the right of the maxillary midline.
At rest, there was a 4-mm interlabial gap, and 3
to 4 mm of maxillary incisor showed at rest. The
soft tissue profile was convex, and the lower
facial height was slightly increased. The patient's
mandibular plane angle was flat.
Figure 7. Frontal view of the patient's occlusion at
the initiation of anterior root correction. The root
spring and the bypass arch wire are in place (A). The
right (B) and the left (C) buccal occlusions are shown
with the distal arm of the spring hooked to the bypass
arch wire mesial to the first molars.
<<    
     Article
      >> Home | TOC |          
Index

Root Correction During Orthodontic Therapy 55

Treatment objectives included attainment of

ideal over] e t and overbite with a Class I canine
occlusion. Also planned was correction of the
midline discrepancy. The soft tissue objectives
were to decrease lip protrusion and control the
nasolabial angle.
The patient's treatment was started with the
placement of 0.022-inch Roth prescription
brackets on her maxillary and mandibular teeth
with the exception of the maxillary first premo-
lars, which were to be extracted for orthodontic
purposes. Bands were fitted and cemented on
the 4 first permanent molars, and initial align-

Figure 8. Frontal (A) and right (B) and left (C)

buccal views of the occlusion for evaluation before
debonding.

maxillary arch was V shaped and narrow anteri-

orly. Her maxillary molars were rotated mesially
inward. The maxillary lateral incisors were
smaller than average and had an atypical shape
on their distal aspect.
L.L.'s cephalometric analysis indicated a con-
vex skeletal profile primarily caused by a maxilla
that was positioned forward. Her maxillary inci-
sors were labially positioned but upright, and Figure 9. Frontal view of the patient's occlusion. The
patient presented with a Class II malocclusion with 8
her mandibular incisors were flared. The upper mm of overjet and no overbite (A). The right buccal
and lower lips were procumbent with respect to occlusion is Class II by 7 mm (B), and the left buccal
Sn-Pg. occlusion is Class II by 5 mm (C).
<<    
     Article
      >> Home | TOC |          
Index

56 Bhavna Shroff

ment was achieved with braided stainless steel

archwires. An active 0.030-inch stainless steel
transpalatal arch was fabricated to derotate the
maxillary first molars (Fig 10). At that time, the
maxillary arch wire was cut mesial to the molars
to allow for their rotation without resistance.
After the molars were derotated, the patient
was referred for extraction of the maxillary first
premolars. A 0.016-inch stainless steel arch wire
with stops mesial to the molars and slight bilat-
eral tip back was placed. Separate canine retrac-
tion was initiated bilaterally using chain elastics.
The patient was given high-pull headgear to
wear at night to control maxillary posterior an-
chorage and the vertical dimension. The canines
were then incorporated into the buccal seg-
ments of teeth. Segments of 0.017 X 0.025-inch
TMA wire were placed in the buccal segments.
En masse retraction of the maxillary incisors
was achieved using a 0.016 X 0.022-inch stainless
steel arch wire with bilateral T-loops tied into the
maxillary anterior teeth and extending to the
auxiliary tubes of the first molars. A tip back
activation was placed to help with anchorage
control and achieve differential space closure. In
the mandibular arch, a 0.016 X 0.022-inch stain-
less steel arch wire was placed.
Once the maxillary extraction spaces were
closed, the patient was reevaluated for anterior
root correction. A 0.019 X 0.025-inch TMA wire
was placed in the maxillary arch and replaced at
a subsequent visit with 0.021 X 0.025-inch TMA.
An anterior root spring was then inserted to
Figure 11. Frontal view of the patient's occlusion at
achieve anterior root correction. The root the initiation of anterior root correction. The root
spring was fabricated using 0.021 X 0.025-inch spring and bypass arch wire are in place (A). The
TMA. A 0.018-inch stainless steel arch wire right (B) and the left (C) buccal occlusions are shown
with the distal arm of the spring hooked to the bypass
arch wire mesial to the first molars.

was inserted into the posterior teeth and by-

Figure 10. A 0.030-inch stainless steel transpalatal
arch is placed to rotate the molars mesially outward
and control the molar width during treatment.
passed the incisors undergoing root correction
(Fig 11).
After anterior root correction was achieved, a
continuous 0.017 X 0.025-inch TMA finishing
wire was inserted. Residual spaces were closed
with light chain elastics. Spaces were kept open
distal to the maxillary lateral incisors because of
the existing tooth size discrepancy attributable
to the small size of these teeth (Fig 12). The
retention plan included maxillary and mandib-
ular Hawley wrap-around appliances.
<<    
     Article
      >>
Root Correction During Orthodontic Therapy
Figure 12. Frontal view of the patient's occlusion
immediately after debonding (A). Right (B) and left
(C) buccal occlusion at the completion of treatment.
Discussion and Conclusion
At the completion of en masse space closure, the
axial inclinations of the incisors, canines and
premolars should be evaluated before proceed-
ing to the finishing stages of treatment. En
masse root correction of the anterior segment of
teeth, including the canine as well as separate
canine root correction, may be indicated. The
force system desired needs to be determined to
obtain optimal tooth movement.
En masse root correction of the anterior
segment of teeth including canines may be
necessary when retraction of these teeth was
accomplished by a tipping movement. The
movement necessary to correct the anterior
teeth is often a rotation around the incisal edge
Home | TOC |          
Index
57
of the incisors. This tooth movement can be
achieved by using a root correction spring as
advocated by Burstone.10-11 The choice of the
root spring activation will depend on the rela-
tionship between the anterior and posterior seg-
ments of teeth at the completion of space clo-
sure.
Movement of the anterior and posterior seg-
ments of teeth can be accomplished in both the
sagittal and vertical directions to correct discrep-
ancies. In clinical situations in which 2 equal and
opposite moments are needed, no vertical forces
will be generated by the system. However, when
the anterior and posterior segments of teeth
display a step geometry or an asymmetric V ge-
ometry, vertical forces will be present and will
need to be considered as desirable or undesir-
able side effects of the treatment mechanics.
Root correction is a critical step of orthodon-
tic treatment before finishing. In extraction
therapy, evaluation of root axial inclinations is
usually performed after space closure to ensure
that adequate parallelism of the roots has been
achieved. As described, proper root alignment
and axial inclinations are key factors for the
attainment of a functional, stable, and estheti-
cally pleasing occlusion. Adequate root parallel-
ism and bone distribution will also be beneficial
to long-term periodontal health and are there-
fore important to ensure a good prognosis for
treatment.
Acknowledgment
The author thanks Mrs Barbara Vallonga for the preparation
of the manuscript and to Mrs Carol Wilkins for her assistance
with the computer graphics.
References
1. Andrews LF. The six keys to normal occlusion. Am J
Orthod 1972;62:296-309.
2. Tweed CM. Clinical Orthodontics, Volumes 1 and 2. St.
Louis, MO, Mosby, 1966.
3. Isaacson RJ, Lindauer SJ, Rubenstein LK. Moments with
the edgewise appliance: Incisor torque control. Am J
Orthod Dentofac Orthop 1993;103:428-438.
4. Reitan K. Initial tissue behavior during apical root re-
sorption. Angle Orthod 1974;44:68.
5. Begg PR. Differential force in orthodontic treatment.
Am J Orthod 1956;42:481-510.
6. Begg PR. Employing the principle of differential force.
Am J Orthod 1961;47:30-48.
<<    
     Article
      >>
58 Bhavna Shroff
7. Begg PR, Kesling PC. Begg Orthodontic Theory and
Technique. Philadelphia, PA: Saunders, 1977;203-214.
8. Burstone CJ, Baldwin JJ, Lawless DT. The application of con-
tinuous force to orthodontics. Angle Orthod 1961;31:1-14.
9. Smith RJ, Burstone CJ. Mechanics of tooth movement.
Am J Orthod 1984;85:294-307.
Home | TOC |          
Index
10. Burstone CJ. Mechanics of the segmented arch tech-
nique. Angle Orthod 1966;36:99-120.
11. Burstone CJ. Modern Edgewise Mechanics and the Seg-
mented Arch Technique: A Practical Application of Bi-
omechanics to Clinical Orthodontics. Glendora, CA:
Ormco, 1995;74-86.
<<    
     Article
      >> Home | TOC |          
Index

Dental Clinics

W
hether your practice is new or well-established, we know
how difficult it is to keep up with what's happening
in your field. Dental Clinics can help. This highly fo-
cused, clearly illustrated, topical, hardcover reference cuts to the core of
THE DENTAL the most important current information...presenting it to you for easy
CLINICS OF comprehension...ensuring you a quick return on your invested time!
NORTH AMERICA More valuable and more specifically attuned to your needs than tradi-
tional journals, this outstanding quarterly periodical keeps you abreast of
timely research, innovations, and advances in the discipline. First-hand
reviews from the field's leading specialists include news of exciting,
current, proven-successful developments in basic science and clinical
practice to help you provide optimal care.

The first information-packed issue of 2001 can be yours at absolutely

no risk! Subscribe now and you'll receive your first issue for a 30-day
trial. If you are not completely satisfied, write "cancel" on the invoice and
return it within 30 days at no further obligation.

The issue is yours to keep

Try it FREE for 30 Days! -

to Im
January New Techniques in Esthetic and Restorative Dentistry
(J. Brucia & G. Freedman)
April Forensic Dentistry
(R. Fixott)
July Women's Oral Health
(D. Studen-Pavlovich & D.N. Ranalli)
October Sleep Disorders
(R. Attanasio)

For more information or foreign prices, contact:

To order, call
Subscription Rates (4 issues):
toll-free Individual $127.00
WJB. SAUNDERS
Institution $176.00 Harcoiirt Health Sciences
1-800 The Curtis Center
Independence Square West
654- Philadelphia, PA 19106-3399
Attention: Periodicals Marketing
2452 Or visit our home page:
(7:30 am-7:00 Dm ET)
www.harcourthealth.com

©W.B. Saunders 2001. Offer valid in USA only. Please add the applicable sales tax for your area. Pric ISSN 0011-8532
<<    
     Article
      >> Home | TOC |          
Index

W.B. SAUNDERS

JOURNALS Essential Information for Today's Professionals from the Leading Health Care Publisher

ANESTHESIOLOGY American Journal of Kidney Diseases—The Official Journal RADIOLOGY

Journal of Cardiothoracic and Vascular Anesthesia Journal of Digital Imaging—The Official Journal of the Society
Journal of Pain—Official Journal of the American Pain Society Journal of Renal Nutrition—The Official Journal of The Council for Computer Applications in Radiology
Regional Anesthesia and Pain Medicine on Renal Nutrition of the National Kidney Foundation Seminars in Breast Disease
Official Journal of the American, Asian and Oceanic, Seminars in Nephrology Seminars in Nuclear Medicine
and Latin American Societies of Regional Anesthesia Seminars in Radiologie Technology
Seminars in Anesthesia NEUROLOGY Seminars in Roentgenology
Seminars in Cardiothoracic and Vascular Anesthesia Journal of Pain—Official Journal of the American Pain Society Seminars in Ultrasound, CT and MRI
Techniques in Regional Anesthesia and Pain Management Journal of Stroke and Cerebrovascular Diseases—Official Journal Techniques in Vascular and Interventional Radiology
of the National Stroke Association and theJapan Stroke Society
CARDIOVASCULAR DISEASES Seminars in Cerebrovascular Diseases and Stroke RHEUMATOLOGY
Progress in Cardiovascular Diseases Seminars in Pediatric Neurology Seminars in Arthritis and Rheumatism
CRITICAL CARE MEDICINE NURSING SURGERY
Journal of Critical Care Applied Nursing Research Journal of Pediatric Surgery—Official Journal of the Section on
Archives of Psychiatric Nursing—Official Journal of the SERPN Surgery of the American Academy of Pediatrics, British Association
DENTISTRY Division, International Society of Psychiatric-Mental Health Nurses ofPaediatric Surgeons, American Pediatric Surgical Association,
Journal of Oral and Maxillofacial Surgery—Official Journal of Journal of Pediatric Nursing—Nursing Care of Children and Families
Journal of Pediatric Oncology Nursing—Official Journal of the Association of Pediatric Surgeons
Journal of Prosthodontics—Official Journal of The American Association of Pediatric Oncology Nurses Operative Techniques in General Surgery
Journal of PeriAnesthesia Nursing—Official Journal of the American Operative Techniques in Gynecologic Surgery
Seminars in Orthodontics Operative Techniques in Neurosurgery
Journal of Professional Nursing—Official Journal of the American Operative Techniques in Plastic and Reconstructive Surgery
DERMATOLOGY Association of Colleges of Nursing Operative Techniques in Thoracic and Cardiovascular Surgery—
American Journal of Contact Dermatitis—The Official Journal Nurse Practitioner Forum An Official Publication of The American Association for
of the American Contact Dermatitis Society
Pain Management Nursing—Official Journal of the American Society
Seminars in Cutaneous Medicine and Surgery
Seminars in Colon and Rectal Surgery
EMERGENCY MEDICINE PeriAnesthesia and Ambulatory Surgery Nursing Update—Official Seminars in Laparoscopic Surgery
American Journal of Emergency Medicine Publication of the American Society of PeriAnesthesia Nurses Seminars in Pediatric Surgery
Clinical Pediatric Emergency Medicine Seminars for Nurse Managers Seminars in Spine Surgery
Seminars in Oncology Nursing Seminars in Thoracic and Cardiovascular Surgery—An Official
ENDOCRINOLOGY Seminars in Perioperative Nursing Publication of The American Association for Thoracic Surgery
Metabolism—Clinical and Experimental Seminars in Thoracic and Cardiovascular Surgery: Pediatric Cardiac
OBSTETRICS AND GYNECOLOGY Surgery Annual—An Official Publication of The American
GASTROENTEROLOGY/HEPATOLOGY Clinical Journal of Women's Health Association for Thoracic Surgery
Clinical Perspectives in Gastroenterology— The Official Clinical Operative Techniques in Gynecologic Surgery Seminars in Urologie Oncology
PracticeJournal of the American Gastroenterological Association Seminars in Vascular Surgery
Gastroenterology— Official Journal of the American ORTHOPEDICS
Arthroscopy: The Journal of Arthroscopic and Related Surgery— TRANSPLANTATION
Official Publication of the Arthroscopy Association of North America Liver Transplantation—4« Official Publication of the American
the Study of Liver Diseases and the International Society of Arthroscopy, Knee Surgery, and Association for the Study of Liver Diseases and the International
Liver Transplantation—4« Official Publication of the American Orthopaedic Sports Medicine Liver Transplantation Society
Association for the Study of Liver Diseases and The International Journal of the American Society for Surgery of the Hand—An Official Transplantation Reviews
Liver Transplantation Society Journal of the American Society for Surgery of the Hand
Seminars in Gastrointestinal Disease Journal of Hand Surgery—An Official Journal of the American UROLOGY
Techniques in Gastrointestinal Endoscopy Society for Surgery of the Hand Seminars in Urologie Oncology
Operative Techniques in Orthopaedics
HEMATOLOGY/ONCOLOGY Operative Techniques in Sports Medicine VETERINARY MEDICINE
Seminars in Hematology Seminars in Arthroplasty Advances in Small Animal Medicine and Surgery
Seminars in Oncology Seminars in Spine Surgery Clinical Techniques in Small Animal Practice
Seminars in Radiation Oncology Seminars in Avian and Exotic Pet Medicine
Transfusion Medicine Reviews OTORHINOLARYNGOLOGY Veterinary Surgery— The Official Journal of The American
American Journal of Otolaryngology
INFECTIOUS DISEASES Operative Techniques in Otolaryngology—Head and Neck Surgery of Veterinary Surgeons
Seminars in Infection Control
Seminars in Pediatric Infectious Diseases PATHOLOGY For more information about these journals,
Seminars in Respiratory Infections Annals of Diagnostic Pathology
Human Pathology please contact:
MEDICAL TRANSCRIPTION Seminars in Diagnostic Pathology Periodicals Marketing
The Latest Word
PHYSICAL MEDICINE WJB. SAUNDERS
NEONATAL/PERINATAL MEDICINE Archives of Physical Medicine and Rehabilitation—Official Journal Harcourt Health Sciences
Newborn and Infant Nursing Reviews of the American Congress of Rehabilitation Medicine and the
Seminars in Perinatology American Academy of Physical Medicine and Rehabilitation
The Curtis Center
Independence Square West
NEPHROLOGY PSYCHIATRY Philadelphia, PA 19106-3399
Advances in Renal Replacement Therapy—A Journal of Comprehensive Psychiatry—0^a'fl//0«raß/ of the American
The National Kidney Foundation
Phone (215) 238-5614
Seminars in Clinical Neuropsychiatry Or visit our homepage at:
©2001 W.B. SAUNDKRS www.wbsaunders.com
<<    
     Article
      >> HOME
| |          
Vol 7, No 2 June 2001

Seminars in

R Lionel Sadowsky, DMD

Editor

The Alexander Discipline

Richard G. Alexander, DOS, MSD
Guest Editor

W. B. Saunders Company • A Harcourt Health Sciences Company

<<    
     Article
      >> Home | TOC |          
Index

M Mosby
Harcourt Health Sciences

NOW AVAILABLE ON THE I N T E R N E T :

VISIT www.mosby.com/prosdent

ISSN 0022-3913
The most frequently cited
journal on prosthetic and
restorative dentistry
Inside U.S.A. Social and scientific forces are combining to make prosthetic and restorative den-
Individuals $145.00 tistry more important— and more challenging—than ever. Experts agree that
Institutions $299.00
Students/Residents* $ 75.00 the demand for prosthodontic services will continue to increase as we enter the
21st century. In this expanding and innovative field, no journal keeps you up-
Outside U.S.A.
Individuals $179.00
to-date like The Journal of Prosthetic Dentistry.
Institutions $333.00
Students/Residents* $109.00 Each issue of the Journal brings you original, peer-reviewed articles on the latest
*Please supply, on institution letterhead, your clinical techniques, new dental materials, recent research findings pertinent to
name, dates of internship/residency, and signature
of program director. Orders will be billed at the
treatment procedures, and helpful tips from fellow readers. Color photos and
individual rate until proof of status is received. illustrations make step-by-step procedures easy to follow.
Airmail rates are available upon request.

§ SUBSCRIPTION PRICES INCLUDE You can rely on the Journal for comprehensive coverage of the discipline and the
ACCESS TO FULL TEXT ONLINE. specialty, including these clinical areas:
To order, call toll-free: • fixed prosthodontics and restorative dentistry • removable prosthodontics
• maxillofacial prosthetics • dental implants • craniomandibular function
1-800-654-2452 and dysfunction • imaging techniques • dental technology
Outside U.S.A. and Canada:
1-407-345-4000 The Journal of Prosthetic Dentistry, now in its 50th year, is a trusted source for
Fax: clinical and professional information. According to the most recent Science
1-407-363-9661
Citation Index, the Journal is the most frequently cited prosthetic and restorative
E-mail:
periodical.service@mosby.com dentistry journal in the world. The Journal is the official publication for 31 U.S.
Visit: and international prosthodontic organizations. Start your subscription to The
www.mosby.com/prosdent Journal of Prosthetic Dentistry today!
Or contact: SPECIAL OFFER FOR SUBSCRIBERS!
M Mosby As part of your subscription to The Journal of Prosthetic Dentistry, you'll receive
FREE access to the online version of the journal. You'll have instant access to the
Customer Subscription Services
6277 Sea Harbor Drive full text of each issue as it publishes. One click of the mouse allows you to search
Orlando, FL
and easily pinpoint information by abstract, title or author. In addition, you'll
32887-4800 U.S.A.
have access to PubMed (MEDLINE) reference links. This offer is available only
©2001 Mosby. Prices subject to
change without notice. Add the to journal subscribers, so don't delay! Visit www.mosby.com/prosdent today for
applicable sales tax for your area.
full details!
<<    
     Article
      >>
Seminars in Orthodontics
EDITOR
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent
Professor and Chairman
Department of Orthodontics
University of Alabama
1919 Seventh Avenue South
Birmingham, AL 35294
Fax: (205) 975-7590
: Seminars in Orthodontics (ISSN 1073-8746) is published
quarterly by the W.B. Saunders Company. Months of issue are
March, June, September, and December. Corporate and
Editorial Offices: The Curtis Center, Independence Square
West, Philadelphia, PA 19106-3399. Accounting and Circulation
Offices: 6277 Sea Harbor Drive, Orlando, FL 32887-4800.
POSTMASTER: Send change of address to: Seminars in
Orthodontics, W.B. Saunders Company, Customer Service, 6277
Sea Harbor Drive, Orlando, FL 32887-4800.
Editorial correspondence should be addressed to:
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent, Editor,
Seminars in Orthodontics, Professor and Chairman, Department
of Orthodontics, University of Alabama, 1919 Seventh Avenue
South, Birmingham, AL 35294-0007; fax: (205) 975-7590.
Correspondence regarding subscriptions or change of
address should be directed to Seminars in Orthodontics, W.B.
Saunders Company, Periodicals Department, P.O. Box 628239,
Orlando, FL 32862-8239 or e-mail hhspcs@harcourt.com.
Change of address notices, including both the old and new
addresses of the subscriber and the mailing label, should be
sent at least 1 month in advance.
Customer Service: 1-800-654-2452
Yearly subscription rates: United States and possessions:
individual, $125.00; institution, $154.00; student and resident,
$72.00; single issue, $47.00. All other countries: individual
$156.00; institution, $186.00; student and resident, $94.00;
single issue, $47.00. For all areas outside the United States and
possessions, there is no additional charge for surface delivery.
For air mail delivery, add $16.00. To receive student/resident
rate, orders must be accompanied by name of affiliated
institution, date of term, and the signature of program/residency
coordinator on institution letterhead. Orders will be billed at
individual rate until proof of status is received.
Prices are subject to change without notice. Current prices
are in effect for back volumes and back issues. Single issues,
both current and back, exist in limited quantities and are
offered for sale subject to availability. Back issues sold in
conjunction with a subscription are on a prorated basis. Checks
should be made payable to W.B. Saunders Company and sent
to Seminars in Orthodontics, W.B. Saunders Company, Periodicals
Department, 6277 Sea Harbor Drive, Orlando, FL 32887-4800.
Copyright © 2001 by W.B. Saunders Company. All rights
reserved. No part of this publication may be reproduced or
transmitted in any form or by any means, electronic or
mechanical, including photocopy, recording, or any information
storage and retrieval system, without permission in writing
from the Publisher. Printed in the United States of America.
Correspondence regarding permission to reprint all or
part of any article published in this journal should be
W.B. SAUNDERS COMPANY
A Division of Harcourt Brace & Company
Home | TOC |          
Index
addressed to Journal Permissions Department, W.B. Saunders
Company, 6277 Sea Harbor Drive, Orlando, FL 32887-4800.
Telephone number: 1-407-345-2500.
The appearance of the code at the bottom of the first page
of an article in this journal indicates the copyright owner's
consent that copies of the article may be made for personal or
internal use, or for the personal or internal use of specific clients,
for those registered with the Copyright Clearance Center, Inc.
(222 Rosewood Drive, Danvers, MA 01923; (508) 750-8400;
www.copyright.com). This consent is given on the condition that
the copier pay the stated per-copy fee for that article through the
Copyright Clearance Center, Inc. for copying beyond that
permitted by Sections 107 or 108 of the US Copyright Law.
This consent does not extend to other kinds of copying, such
as copying for general distribution, for advertising or promotional
purposes, for creating new collective works, or for resale.
Absence of the code indicates that the material may not be
processed through the Copyright Clearance Center, Inc.
Advertising representative: MJ. Mrvica Associates, Inc,
2 West Taunton Ave, Berlin, NJ 08009. Telephone (609) 768-
9360. Fax (609) 753-0064.
Publication of an advertisement in Seminars in Orthodontics
does not imply endorsement of its claims by the Editor(s) or
Publisher of the journal.
The contributors have checked generic and trade names and
verified drug doses for accuracy according to the standards
accepted at the time of publication. The ultimate
responsibility, however, lies with the prescribing physician.
Please convey any errors to the Editor.
The ideas and opinions expressed in Seminars in
Orthodontics do not necessarily reflect those of the Editor or the
Publisher. Publication of an advertisement or other product
mention in Seminars in Orthodontics should not be construed as
an endorsement of the product or the manufacturer's claims.
Readers are encouraged to contact the manufacturer with any
questions about the features or limitations of the products
mentioned. Neither the Editor or Publisher assume any
responsibility for any injury and/or damage to persons or
property arising out of or related to any use of the material
contained in this periodical. The reader is advised to check the
appropriate medical literature and the product information
currently provided by the manufacturer of each drug to be
administered to verify the dosage, the method and duration of
administration or contraindications. It is the responsibility of
the treating physician or other health care professional, relying
on independent experience and knowledge of the patient, to
determine drug dosages and the best treatment for the patient.
Seminars in Orthodontics is indexed in the Cumulative
Index to Nursing and Allied Health Literature® print index
and the Cinahl® database.
<<    
     Article
      >>
Seminars in Orthodontics
EDITOR
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent
EDITORIAL BOARD
Richard G. Alexander, Arlington, TX
Rolf G. Behrents, Memphis, TN
Samir E. Bishara, Iowa City, IA
Robert Boyd, DBS, San Francisco, CA
Larry M. Bramble, Cypress, CA
John S. Casko, Iowa City, IA
Harry L. Dougherty, Van Nuys, CA
T.M. Graber, Evanston, IL
Robert J. Isaacson, Richmond, VA
Alexander Jacobson, Birmingham, AL
Lysle E.Johnston, Jr., Ann Arbor, MI
Gregory J. King, Seattle, WA
Vincent G. Kokich, Tacoma, WA
Steven J. Lindauer, Richmond, VA
INTERNATIONAL
Zeev Abraham, Herzliya, Israel
W.G. Evans, Johannesburg, South Africa
Roberto Justus, Mexico City, Mexico
Home | TOC |          
Index
James A. McNamara, Jr, Ann Arbor, MI
Robert N. Moore, Grand Island, NE
Ravindra Nanda, Farmington, CT
Perry M. Opin, Milford, CT
Sheldon Peck, Newton, MA
William R. Proffit, Chapel Hill, NC
Cyril Sadowsky, Chicago, IL
David M. Sarver, Birmingham, AL
T. Michael Speidel, Minneapolis, MN
William J. Thompson, Bradenton, FL
James L. Vaden, Cookeville, TN
Robert L. Vanarsdall, Jr., Philadelphia, PA
Katherine Vig, Columbus, OH
C.B. Preston, Buffalo, NY
Shinkichi Namura, Tokyo, Japan
George Skinazi, Paris, France
Björn U. Zachrisson, Oslo, Norway
<<    
     Article
      >> Home | TOC |          
Index

Seminars in Orthodontics
VOL 7, NO 2 JUNE 2001

The Alexander Discipline

Richard G. Alexander, DDS, MSD
Guest Editor
CONTENTS

Introduction 59
Richard G. Alexander

The Principles of the Alexander Discipline 62

Richard G. Alexander

Character Development: A Value-Added Concept 67

C. Moody Alexander

The Alexander Discipline Applicance Design and Construction 74

M. Alan Bagden

Face Bow Correction of Skeletal Class II Discrepancies in the

Alexander Discipline 80
Charles B. Alexander and J. Moody Alexander

The Orthodontic Management of Vertical Deficiencies in the

Alexander Discipline 85
Remo Benedetti

The Relationship Between the Curve of Spee, Relapse, and the

Alexander Discipline 90
Sal Carcara, C. Brian Preston, and Ossama Jureyda

An Extraction Approach to Borderline Tooth Size to Arch Length

Problems in Patients With Satisfactory Profiles 100
J.C. Boley

Treatment of Class III Malocclusions in the Alexander Discipline 107

Shinji Takagi and Yasuhiko Asai

Nonextraction Approach to Tooth Size Arch Length Discrepancies With

the Alexander Discipline 117
Peter H. Buschang, Sherri J. Horton-Reuland, Lee Legier,
and Christopher Nevant

Finishing and Retention Procedures in the Alexander Discipline 132

Tucker Haltom
<<    
     Article
      >> Home | TOC |          
Index

Seminars in Orthodontics
Future Issues
Vol 7 No 3 (September 2001)
THREE-DIMENSIONAL DIAGNOSIS AND TREATMENT IN ORTHODONTICS
Robert Boyd, DDS, MEd and Sheldon Baumrind, DDS, MS, Guest Editors
Vol 7 No 4 (December 2001)
BIOSTATISTICS FOR THE ORTHODONTIC CLINICIAN
Rose D. Sheats, DMD, Guest Editor

Recent Issues

Vol 7 No 1 (March 2001)

CLINICAL BIOMECHANICS
Steven J. Lindauer, DMD, MDSc, Guest Editor
Vol 6 No 4 (December 2000)
PSYCHOLOGIC ISSUES RELATED TO ORTHODONTIC TREATMENT AND PATIENT COMPLIANCE
Pramod K. Sinha, DDS, BDS, MS, Ram S. Nanda, DDS, MS, PhD, and Roger B. Fillingim, PhD, Guest Editors
Vol 6 No 3 (September 2000)
BIOLOGY OF ORTHODONTIC TOOTH MOVEMENT: CLINICAL IMPLICATIONS
Bhavna Shroff, DDS, MDentSc, Guest Editor
Vol 6 No 2 (June 2000)
MOLAR DISTALIZATION
George J. Cisneros, DMD, MMSc, Guest Editor
Vol 6 No 1 (March 2000)
OBJECTIVES-DRIVEN ORTHODONTICS: EFFECTIVENESS OF MECHANOTHERAPY
Cyril Sadowsky, BDS, MS, Guest Editor
<<    
     Article
      >>
Seminars in Orthodontics
VOL 7, NO 2
Introduction
"Nothing is really new. We only rediscover for
ourselves."
Socrates
What is it that separates the Alexander Dis-
cipline1 from other orthodontic tech-
niques? It is difficult to identify specific details
that can be attributed to the Alexander Disci-
pline. It grew out of the Tweed Technique, and
today maintains many of its principles. The
present technique incorporates ideas found
from other teachings and techniques, but much
of it was gained empirically, from trial and error.
Its originality has grown from many proven ideas
and concepts that have been put together in a
unique package.
The specifics that make this technique differ-
ent include a unique bracket selection with spe-
cific designs created for specific teeth. Increased
interbracket space is created from single brack-
ets to allow more flexibility with suffer arch
wires, resulting in easier engagement and fewer
arch wire changes, and rotational wings give con-
trolled guidance and direction to the teeth. In
addition, a unique arch form has been devel-
oped by the compilation of hand-bent arch wires
to provide an arch form that will fit most patients
within one standard deviation.2 The Alexander
Discipline, however, is much more than a
bracket system or arch form. The technique of
treatment incorporates specific mechanics that
were first created or popularized by this tech-
nique. They include: treat one arch at a time,
beginning in the upper arch; in extraction cases
treat the upper arch while allowing the crowded
mandibular arch to "drift" before placing appli-
ances (driftodontics).3 Use is made of a cervical
face bow to a tied-back arch wire to create an
orthopedic response in normal and low-angle
skeletal Class II cases.4'5 Control lower incisor
Copyright © 2001 by W.B. Saunaers Company
doi:10.1053/sodo.2001.23533
Seminars in Orthodontics, Vol 7, No 2 (June), 2001: pp 59-61
Home | TOC |          
Index
JUNE 2001
flaring by —5° torque in the incisor brackets and
placing an initial rectangular flexible arch
wire.4"6 Upright the lower first molars with —6°
tip.7 Spread lower anterior roots with specific
angulated brackets.7 Successfully level lower
arches by using a reverse curve in the arch wire
employing the specific prescription.6'8 Attach
Class II and Class III elastics on lateral incisors
rather than on cuspids to produce a more hor-
izontal vector of force on the arches.1 Place ball
hooks on the lateral brackets for elastic attach-
ment, retract upper cuspids on 0.016 stainless
steel arch wire with power chains.1 Specific arch
wire sectioning and elastic attachments finalize
posterior occlusion, and by using a unique max-
illary wrap-around retainer wire design, post-
treatment settling is controlled.
Having been privileged to teach in the Baylor
Department of Orthodontics for over 35 years, a
concerted effort was made to take beginning
and final diagnostic records on almost all cases
treated in my private office. Today, many of our
new patients are the offspring of patients treated
many years ago. This has allowed us to make
long-term posttreatment records on many pa-
tients. This accumulation of potential knowl-
edge has given opportunities for many graduate
students to investigate particular questions in
orthodontics. To date, over 30 research studies
have been performed by Baylor graduate stu-
dents, while other articles have been written by
students from the Universities of Texas, Tennes-
see, Alabama, Buffalo and others.
As a result of this, it may be that no technique
has been investigated as thoroughly as the Alex-
ander Discipline by using the authors' patients.
And the good news is that the results of these
studies change anecdotal clinical observations
into evidence-based facts. The unique prescrip-
tion design of the brackets makes it a superior
straight-wire appliance. In addition to the
unique bracket design, it includes —5° of torque
in the mandibular incisor bracket and —6° distal
tip built into the first molar brackets, which
59
<<    
     Article
      >>
60 Richard G. Alexander
allows for controlled and effective mandibular
arch leveling. The unique biomechanical princi-
ples of actively tying back a heat-treated, curved
rectangular arch wire contributes to successful
arch leveling.
If one believes that control of intercanine
width and lower incisor flaring is important, as
has been shown in the literature,3'5 maximum
efforts should be made to control this area. Pos-
sibly the most significant and important part of
the unique design of this bracket system is ex-
pressed in the lower anterior brackets. By using
single brackets with wings, an advantage that is
not possible with twin brackets is created. By
removing interfering wings during bracket
placement on crowded lower anterior teeth,
brackets can usually be placed on each tooth.
Because of the additional interbracket space cre-
ated by the single brackets, a flexible rectangular
wire can be placed into the —5° of torqued
bracket, thus controlling the flaring of these
teeth.
In this issue of Seminars in Orthodontics, a
group of talented clinicians and researchers
share their thoughts regarding the Alexander
Discipline. Beginning with my brother and men-
tor, C. Moody Alexander, emphasis is correctly
placed on the need and opportunity to motivate
patients. His positive attitude toward life is cer-
tainly reflected in the way he influences his pa-
tients, students, and fellow orthodontists.
Bagden details the specifics of the design and
construction of the appliance. He has been us-
ing and lecturing on the technique for more
than 20 years. Because most of our patients are
treated by nonextraction, the next three articles
discuss that subject. Chuck and J. Moody Alex-
ander detail the treatment of Class II skeletal
patterns with cervical headgear. One of the
greatest joys in this author's life has been having
two sons who have followed in their father's
footsteps. Without question, my greatest contri-
bution to our speciality will be their positive
influence on our profession.
Benedetti discuses the clinical details needed
to produce routinely quality finished results with
vertical deficiencies. To substantiate results of
treatment modalities Preston, Carcara, and
Jareyda present their findings on leveling the
mandibular curve of Spee in nonextraction pa-
tients.
Home | TOC |          
Index
Boley then discusses extraction therapy. Hav-
ing been in the same study club for more than
35 years with Dr. Boley, we still continually chal-
lenge each other on the best treatment plan for
borderline extraction patients. The long-term
results and stability of patients treated by Dr.
Boley are impressive.
Because Class III patients are much more
common in Asia, developing a technique with
our study club in Japan has been extremely ben-
eficial for us all. Drs. Asai and Shingi Takagi,
leaders in the Alexander Discipline Study Club
of Japan, provide information on Class III man-
agement.
Dr. Peter Bushang has contributed signifi-
cantly to the Department of Orthodontics at
Baylor. His interest in using my patients' records
in his students' research has been extremely
educational, and has changed many anecdotal
opinions into evidence-based information. Bus-
hang, Nevant, Leglar, and Horton present re-
search studies on the transverse dimension in
patients treated by using the Alexander Disci-
pline.
The final article on "Finishing" is written by
Dr. Tucker Haltom, a great clinician and the
first president of the Alexander Discipline Study
Club of America.
The Alexander Discipline was introduced to
orthodontists in a presentation to the American
Association of Orthodontists at its Convention in
Washington, DC in 1978. Since that time, as a
result of hundreds of lectures and courses, in-
terest in this technique has spread throughout
the world. It is with humility and honor that this
work is presented in this issue of Seminars in
Orthodontics. May it have a positive effect in the
world of orthodontics.
Richard G. "Wick" Alexander, DDS, MSD
Guest Editor
References
1. Alexander RG. The Alexander Discipline. In: Engel GA
(ed). Glendora, CA: Ormco, 1986.
2. McKelvain GD. An arch form designed for use with a
specific straight wire orthodontic appliance [master's
thesis]. Dallas, TX: Baylor University, Department of
Orthodontics, 1982.
3. Nevant CT, Buschang PH, Alexander RG, et al. Lip
bumper therapy for gaining arch length. Am J Orthod
1991;100:330-336.
<<    
     Article
      >>
Introduction
4. Glenn G, Sinclair PM, Alexander RG. Non-extraction
orthodontic therapy; post-treatment dental and skeletal
stability. Am J Orthod 1987;92:321-328.
5. Elms T. The long-term stability of class II, division 1,
nonextraction cervical face-bow therapy; Part 2, cepha-
lometric analysis. Am J Orthod 1996;109:386-392.
6. Carcara S. Leveling the curve of Spec with a continuous
archwire technique-a long-term study cast analysis. Un-
published Master's Thesis, State University of New York
at Buffalo, Buffalo, NY, 1998.
Postscript
Two giants in orthodontics in the Southwest have
recently left us. Both were founding members of the
Tweed Study Group of Texas and had immeasureable
influence upon the quality of orthodontics taught and
practiced in this part of the country.
Dr. Fred Schudy made contributions in growth and
development, diagnosis, and treatment mechanics that
have influenced every orthodontist in the world. His
teachings had a significant influence in the development
of the Alexander Discipline.
Dr. Bob Gaylord founded the orthodontic department
at Baylor College of Dentistry in Dallas. As the first univer-
sity-trained orthodontist in North Texas, he moved our
Dr. Fred Schudy Dr. Bob Gaylord
Home | TOC |          
Index
61
7. Williams R. Eliminating lower retention. J Glin Orthod
1985;19:345.
8. Bernstein R. Leveling the curve of Spec with a continu-
ous archwire technique-a long-term cephalometric anal-
ysis. Unpublished Master's Thesis, State University of
New York at Buffalo, Buffalo, NY, 1999.
9. Alexander RG. The Vari-Simplex Discipline. J Glin
Orthod 1983;18:9.
10. Alexander RG. Retention.. .a practical approach to that
critical last step to stability. Clin Impressions 1997;6:14-16.
specialty to a higher level. The face of orthodontics has
been forever changed as his students are continuing this
tradition throughout the world. My life was changed when
he offered me a teaching position in the department.
Along with Dr. AI Westfall, first chairman of the Uni-
versity of Texas Orthodontic Department, who set the
standard for quality education in orthodontics, these
gentleman were the bedrock of orthodontics . . . our
mentors, teachers and friends. They will be sorely missed.
The challenge they have left us is to continue the
heritage they so nobly began.
We dedicate this issue of the journal to these icons in
orthodontics.
Dr. AI Westfall
<<    
     Article
      >>
The Principles of the Alexander Discipline
Richard G. Alexander
The Alexander Discipline is based on the premise of a number of principles.
This article lists and briefly describes these principles and the reason each is
considered important in the management of the orthodontic patient in the
Alexander Discipline. (Semin Orthod 2001;7:62-66.) Copyright © 2001 by
W.B. Saunders Company
ny enduring principle must be built on a
A solid foundation, on certain beliefs that
have been tested and proven by time and expe-
rience. In the Alexander Discipline, a certain
number of principles are followed that give this
technique its uniqueness. The first three princi-
ples focus on the philosophic nature and the
attitudinal approach to the delivery of the Disci-
pline.
One of the original goals of the technique is
to make treatment easy and more comfortable
for the patient. For any technique in orthodon-
tics to be successful, the patient must be involved
in the procedures. Even though some appliances
are said to be noncompliant, the reality is that
no such thing is possible. Each patient must be
willing to keep their teeth clean, take care of the
appliances, watch what they eat, and be present
for their appointments. Allowing the patient to
become a partner in the treatment procedures
not only gives them some ownership in the pro-
cess, but it ensures that the results will reach a
higher level.
Patient compliance is critical to the success of
this technique. Too often, other techniques fo-
cus on the mechanics of treatment. Mechanics
are important, however, mechanics alone will
not produce the optimal result without patient
cooperation. In orthodontic education, perhaps
the forgotten skill is teaching the student moti-
vational techniques for successful results.1'2
From Arlington, TX.
Address correspondence to R.G. Wick Alexander, DDS, MSD,
840 West Mitchell, Arlington, TX 76013.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0702-0001$35.00/0
doi:10.1053/sodo.2001.23536
62 Seminars in Orthodontics, Vol 7, No 2 (June), 2001: pp 62-66
Home | TOC |          
Index
When the need for this skill is understood, the
clinician will accept the responsibility to learn
techniques that will enhance their ability to mo-
tivate their patients while producing high-quality
results.
Principle number 1 is taken from Allen's3
book As a Man Thinketh, "In all human affairs
there are efforts and there are results, and the
strength of the effort is the measure of the re-
sult." From this sentence comes the formula,
Effort = Results.
Principle number 2 is based on another
quote, "Sometimes when I consider what tre-
mendous consequences come from little things,
I am tempted to think, there are no little
things."4
Principle number 3 comes from World War II
and is used in many variations today, "keep it
simple stupid."3 Of course, the acronym is KISS.
Principle number 4 states that you should
plan your work. Accurate diagnosis and treat-
ment planning is critical. No matter what ceph-
alometric analysis (Fig 1) is used, three basic
questions must be answered from the cephalo-
metric tracing before a proper treatment plan
can be produced:
1. Sagittal skeletal pattern: Determining the
Class I, II, or III growth pattern will help
decide what type of orthopedic force is pre-
ferred.
2. Vertical skeletal pattern: Determining
whether the case has a high-, medium-, or
low-angle skeletal pattern will influence
treatment decisions.
3. Incisors position: (a) In most cases, in the
author's opinion, the best and most stable
position for lower incisors is the position in
which the patient presents. To keep lower
<<    
     Article
      >>
Alexander Discipline
POINTS OF MEASUREMENT
Figure 1. Cephalometric measurements used to determine sagital and vertical skeletal patterns and incisor
positions.
incisors in their original positions is often
our goal, (b) In extraction cases, lower inci-
sors are almost always uprighted. (c) Our
studies5'7 have shown that lower incisors can
be advanced up to 3° and remain stable.
Beyond that degree, instability is more
likely. The only time the lower incisors are
advanced beyond this degree is when they
are abnormally retroclined. The latter situa-
tion is commonly seen in Class II, Division 2,
and Class II, Division 1 deep-bite cases.
By maintaining good torque control of the
upper incisors, along with the lower incisors, a
balanced interincisal angle is created. This is
critical for long-term stability.8
Principle number 5 describes our goals for
stability. Objectives include mandibular incisors
that are balanced on basal bone with a good
interincisal angle, cuspids not expanded, proper
root artistic positioning, upright mandibular
molars, normal overbite and over]et, and a func-
tional occlusion in centric relation. These goals,
when achieved, have been found to create
healthy, aesthetically pleasing, and stable re-
sults.5'6'8'10
Home | TOC |          
Index
63
Principle number 6 describes specific brack-
ets designed for increased interbracket space;
wings for rotation and correction, then control;
precision pretorqued slots; and precision base
variation. Details of the bracket system are dis-
cussed by Bagden on page 74 in this issue of
Seminars in Orthodontics.
Principle number 7 recommends "building
treatment" into the bracket placement. In plac-
ing brackets, three dimensions are considered:
bracket height, bracket angulation, and mesio-
distal bracket position. This is also described
later.
Principle number 8 is to obtain predictable
orthopedic correction by using a face bow, face
mask, rapid palatal expansion, lip bumper, or
other auxiliary appliances such as the transpala-
tal arch, the Nance, lingual arch, magnets, and
distalizing mechanics.
Face bow treatment is discussed in another
article in this issue. In the Alexander Discipline,
a face bow and face mask are used primarily for
orthopedic forces. This means that these forces
are placed on consolidated, tied-back arch wires
in growing patients. If arch wires are not tied
<<    
     Article
      >> Home | TOC |          
Index

64 Richard G. Alexander

back, the facebow forces are changed to orth-

odontic forces, resulting in tooth movement.
ORMCO
Principle number 9 discusses the use of a
proven arch form design12 (Fig 2) and a contem-
porary arch wire force system.13 Most patients
are treated by using continuous arch wires be-
ginning with the maxillary arch. The initial arch
wire is round and flexible (.016 NiTi). The tran-
sitional arch wire has intermediate stiffness (.016
stainless steel or 17 X 25 titanium alloy). The
final wire is stiff, 17 X 25 stainless steel. The only
difference in the mandibular sequence is that
the initial arch wire is a flexible rectangular wire,
for initial torque control. The functions of the
arch wires include: elimination of rotations, de-
velopment of arch form, leveling the arches,
control of torque, and final arch form.
Principle number 10 is to consolidate
arches early in treatment. The purpose of clos-
ing spaces is to change 10 to 12 independent
force units (the teeth) into 1 unit. When this
has been accomplished, orthopedic forces,
such as a face bow or a face mask, can create
skeletal changes rather than dental changes.
Also, intraoral elastics, when attached to the
ball hooks on the brackets, will not move in- Part No 207-0060
dividual teeth or cause spaces to open between
the teeth. Consolidated arches are a goal of Figure 2. Most maxillary arch forms will fall
this treatment. within 1 SD of this template. Two mandibular arch
Principle number 11 is to obtain complete forms are needed to accomplish this. (Courtesy of
Ormco Corp, Glendora, CA.)
bracket engagement when placing arch wires,
ligating with steel ligatures, and maintaining
consolidation with omega loops "tied back."
One of the most important concepts of the dis- quirements are placed into the stainless steel
cipline is using tied-back arch wires. finishing arch wire: arch form, torque, curve,
Principle number 12 is to level arches and and omega loops. After this wire has been
open the bite with accentuated and reverse properly tied in (full-bracket engagement and
curves of Spec. Clinical experience and re- tied back with steel ligature wires), time is
search13'14 have substantiated that leveling the needed for the generated forces to have their
arches and opening the bite with the Alexander effects and to move the teeth into their final
Discipline is not only successful, but also stable positions. Often this wire will remain in place
(Fig 3). until fixed appliances are removed.
Principle number 13 advocates progressing Principle number 14 focuses on creating sym-
into finishing arch wires rapidly and allowing metry. Coordination of the arches is essential to
sufficient time for the arch wire to move the establish occlusal symmetry. The maxillary and
teeth to their desired position. By following mandibular arch forms have now been individ-
the previous principles and sequencing the ually finalized and the goal then is to get the
treatment plan, the finishing arch wire is usu- maxillary and mandibular arches coordinated.
ally placed in 6 to 9 months in nonextraction Coordination is accomplished by using pre-
patients. In extraction treatment procedures, formed arch wires in both arches as well as sym-
progressing into finishing arch wires may take metrically adjusting the inner bow of the face
9 to 12 months All of the final finishing re- bow and the lip bumper. Final symmetry is es-
<<    
     Article
      >>
Alexander Discipline
Figure 3. Mandibular heat-treated 17 x 25 ss arch wire with reverse curve of Spee tied in and tied back (A).
Six months later with both arches level (B).
tablished by specific elastics in finishing arch
wires.
Principle number 15 recommends that finish-
ing arch wires be in place before initiating elastic
wear. By establishing arch form and proper
torque controls before using intraoral elastics,
the elastic forces act more orthopedically, mov-
ing the entire arches without adversely affecting
the teeth. The exceptions to this rule include:
the use of cross-bite elastics when necessary;
Class III elastics may be used when the lower
arch is initially bonded to prevent flaring of the
lower incisors, and/or while closing lower ex-
traction spaces with a closing loop arch wire in
maximum anchorage situations; and Class II
elastics may be used when closing lower extrac-
tion spaces with a closing-loop arch wire to move
lower molars forward in minimum anchorage
situations.
Principle number 16, in nonextraction cases,16
recommends initiating treatment in the upper
arch and progressing into finishing arch wires as
soon as possible. Because the major goal in non-
extraction treatment is to control the position of
the lower anterior teeth, total focus can then be
placed on these teeth when the lower arch is
banded/bonded. The lower anterior teeth are
controlled by —5° torque in lower incisor brack-
ets, — 6° tip on lower first molars, the use of
initial flexible rectangular arch wire, slenderiz-
ing teeth if necessary, and Class III elastics if
necessary.
Principle number 17 recommends that, in
extraction cases, treatment be initiated in the
upper arch. The objective is to remove potential
bracket interferences by improving the overbite
with an accentuated curve of Spee and retract-
Home | TOC |          
Index
65
ing the cuspids before bonding/banding the
lower arch.
Upper cuspid teeth are retracted with power
chains on .016 stainless steel arch wire. This
procedure usually takes 6 to 8 months.
Principle number 18 recommends that, in
extraction cases,17 treatment is delayed in the
mandibular arch to allow time for dnftodontics
(Fig 4). This is the term the author coined to
describe the spontaneous unraveling of the
lower anterior teeth, making it much easier
to place brackets after 4 to 6 months. When
the upper cuspids have been retracted to a
Class I relationship, the lower arch should be
bonded/banded.
Principle number 19 advises the use of a spe-
cific retention plan18'36 incorporating retainer
design, time sequence, and resolution of third
molar teeth in an effort to ensure long-term
stability. The upper "wrap-around" retainer wire
is fabricated to a specific design and has proven
to be extremely effective according to the au-
thor. Also recommended is the fixed lower cus-
pid-to-cuspid retainer design using an .0215 Tri-
ple-Flex wire (Ormco, Glendora, CA) bonded to
each tooth. After bracket removal, the upper
retainer is worn only 8 to 10 hours per 24-hour
period, being placed after dinner and removed
the next morning. The patient is instructed not
to wear it out of their home. The resulting re-
duction of lost and broken retainers has been
remarkable.
Principle number 20 is "to work your plan."
Although every case is unique in some ways,
in many ways every case is also the same. The
general treatment plan in most cases as out-
lined in these principles is to treat the upper
<<    
     Article
      >>
66 Richard G. Alexander
Figure 4. Pretreatment mandibular occlusal view (A). Four months later, showing driftodontics (B).
arch first by using a specific series of arch
wires. If the case requires orthopedic correc-
tion, it is initiated on the maxillary arch with
an rapid palatal expander (RPE) and/or face
bow or facemask. Approximately 6 months af-
ter commencing maxillary arch treatment,
treatment is initiated in the lower arch. A
specific series of arch wires are used to posi-
tion the mandibular teeth. After the finishing
arch wires are in place, appropriate elastics are
used to coordinate the arches and finalize the
occlusion. Retainers are then placed.
Following these basic step-by-step procedures
allows the clinician to control treatment
progress. By being able to anticipate treatment
objectives of the next appointment, future
scheduling is simplified and treatment progress
can be easily monitored so that the treatment
can be completed on schedule.
The ultimate objective is a well-treated pa-
tient, completed in a timely fashion, with a sat-
isfied patient, parents, and doctor.
References
1. Alexander RG, Alexander CM, Alexander C, et al. Cre-
ating the compliant patient. J Glin Orthod 1996;30:493-
497.
2. Stroud J. The psychosocial effect of orthodontic treat-
ment [master's thesis]. Dallas, TX: Baylor College of
Dentistry, 1996.
3. Allen J. As a man thinketh. Classics of inspiration. Kansas
City, MO, Hallmark Cards, Inc, 1971, 57.
4. Covey S. First things first. New York, Simon and Schus-
ter, 1994, 287.
Home | TOC |          
Index
5. Glenn G, Sinclair PM, Alexander RG. Non-extraction
orthodontic therapy: Post-treatment dental and skeletal
stability. Am J Orthod 1987;92:321-328.
6. Elms T. The long-term stability of class II, division 1,
nonextraction cervical face-bow therapy: Part 1, model
analysis. Am J Glin Orthod 1996;109:271-276.
7. Elms T. The long-term stability of class II, division 1,
nonextraction cervical face-bow therapy: Part 2, cepha-
lometric analysis. Am J Glin Orthod 1996;109:386-392.
8. Nevant CT, Buschang PH, Alexander RG, et al. Lip
bumper therapy for gaining arch length. Am J Orthod
1991;100:330-336.
9. Alexander JM. A comparative study of orthodontic sta-
bility in class I extraction cases [master's thesis]. Dallas,
TX: Baylor College of Dentistry, 1995.
10. Alexander RG. Treatment and retention for long-term
stability. In: Retention and stability in orthodontics. Phil-
adelphia, W.B. Saunders, 1993.
11. Alexander RG. The quest for long-term stability. In:
Sachdeva R (ed). Orthodontics for the next millennium.
Glendora, CA: Ormco, 1997.
12. Alexander RG. A practical approach to arch form. Clin-
ical Impressions 1992;! :3-5.
13. Alexander RG. The Alexander Discipline. In: Engel GA
(ed). Glendora, CA: Ormco, 1986.
14. Bernstein R. Leveling the curve of Spec with a continu-
ous archwire technique-a long-term cephalometric anal-
ysis. Master's Thesis, State University of New York at
Buffalo, Buffalo, NY, January, 1999.
15. Alexander RG. The Alexander Discipline. In: Engel GA
(ed). Glendora, CA: Ormco, 1986, chap 7.
16. Alexander RG. The Alexander Discipline. In: Engel GA
(ed). Glendora, CA: Ormco, 1986, chap 9.
17. Alexander RG. The Alexander Discipline. In: Engel GA
(ed). Glendora, CA: Ormco, 1986, chap 10.
18. Alexander RG. The Alexander Discipline. In: Engel GA
(ed). Glendora, CA: Ormco, 1986, chap 14.
19. Alexander RG. The vari-simplex discipline-part 4 count-
down to retention. J Clin Orthod 1983;18:214-218.
<<    
     Article
      >> Home | TOC |          
Index

Character Development:
A Value-Added Concept
C. Moody Alexander

Orthodontists are constantly trying to improve. Technical advances in orth-

odontics have been a great asset to the clinician. Our specialty must not
forget, however, that this is a people business and in this "Age of Service/'
it behooves us to think in terms of a patient-centered practice. Orthodon-
tists have a unique opportunity to not only straighten teeth, but also to
teach character-building principles such as individual responsibility, delayed
gratification, self-discipline, patience, persistence, and overcoming discom-
fort during the course of orthodontic treatment. The use of these principles
is discussed, as well as how they are incorporated at various stages in
treatment. Helping each patient develop character for a better life is a new
challenge every day and it makes orthodontics fun. (Semin Orthod 2001;7:
67-73.) Copyright © 2001 by W.B. Saunders Company

he orthodontic profession, perhaps more
T than any other, is constantly trying to im-
prove, to do more, to move above and beyond,
and to broaden its horizons. The most powerful
drive in the ascent of man is his pleasure in his
own skill. He loves to do what he does well and,
having done it well, he loves to do it better.1
Scientific advances are now helping us treat the
whole patient, the face, the skeletal structures,
the teeth as well as the function. Although great
strides have been made in the technical sciences
that help us achieve quality results with improve-
ments such as heat-sensitive arch wires, better
bonding techniques, cephalometric growth stud-
ies, noncompliant appliances, and so forth, the
profession of orthodontics now has the oppor-
tunity to advance to another level and add to this
technical success by moving into the behavioral
sciences. Our specialty now has the opportunity
to help patients develop important character
traits and enhance the technical sciences by us-
ing behavioral science and people skills in our
From Dallas, TX.
Address correspondence to C. Moody Alexander, DDS, 5500
Preston Rd, Suite 360, Dallas, TX 75205.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0702-0002$35.00/0
doi:10.1053/sodo.2001.23539
clinical practices. Orthodontists are in the "peo-
ple business."
As orthodontists, we all think we are nice to
our patients and that we recognize the impor-
tance of the doctor-patient relationship. How-
ever, our space-age wires enable us to see our
patients at longer intervals and, if we are not
careful, the "noncompliant treatment" philoso-
phy can have us giving up on patients before
they even start their treatment. Ghafari2 dis-
cusses emerging paradigms in orthodontics and
warns that we should beware of an increasingly
impersonal relationship between the health pro-
vider and the patient. The Institute Of Medi-
cine,3 in looking at the challenges of dental
education, emphasizes that we should carefully
consider the patient. An orthodontist and chair-
man of one European orthodontic department
recently expressed such concern over the nega-
tive effect of the term noncompliant that he re-
quested a visiting lecturer to avoid using the
term during his presentation.
Now that we have stated the problem, what is
the solution? As orthodontists, we are in a
unique position to make a positive impact on the
lives of our patients and it happens everyday in
orthodontic offices all over the world. Dental
educators have stated that one of the main rea-
sons students apply to dental school is because
of the influence of their orthodontist. Orth-

Seminars in Orthodontics, Vol 7, No 2 (June), 2001: pp 67-73 67

<<    
     Article
      >>
68 C. Moody Alexander
odontists have a window of opportunity with
their adolescent patients. Through the course of
orthodontic treatment, patients can learn persis-
tence, self-motivation, impulse control, disci-
pline, acceptance of personal responsibility, and
delayed gratification. Orthodontic treatment
can also give patients the satisfaction of achiev-
ing a goal as well as teach patients how to attain
goals. These are important skills that will in-
crease an individual's quality of life and self-
concept while also building their character.
Because wearing braces is not easy, character
development to varying degrees is a natural by-
product of orthodontic treatment. Neither the
parents nor the orthodontist can accomplish the
task for the patient; the patient must accept
individual responsibility. There is no immediate
gratification; the patient must learn patience,
and persistence along with the importance of
teamwork. Each member of the team, the pa-
tient, the staff, the parents and the doctor all
have a role to play, and each must do their part
to achieve the quality result. It is important for
the patient to understand the treatment goals,
both long and short term. This participative
treatment concept will help the patient under-
stand the diagnosis and treatment plan tailored
to the time required to accomplish the goal. The
patient must own the process.
The patient understands that it is their effort
that produces the quality result. Statements such
as, "effort equals results," "as ye sow, so shall ye
reap," "what you put into it is what you get out of
it," are all principles of cause and effect that can
help in other aspects of a patient's life. Success is
no accident. The situation may be different; it
might be sports, career challenges, or personal
relationships, but the principles are the same;
set the goal, visualize the end result, plan the
work, work the plan, and never give up!
New Patient
Because the specific words used, the atmosphere
created, and the interaction between the doctor,
patient, and staff, are so critical, the new pa-
tient's first visit will be explained in great detail.
The doctor coming out to sit down in the recep-
tion room with the patient makes for an unusu-
ally warm and friendly welcome for the new
patient. Most people are slightly anxious in a
Home | TOC |          
Index
new situation and having the doctor briefly ex-
plain the office procedures helps them feel
more relaxed and comfortable.
The assistant brings the patient and parent
back into the treatment area where they see the
doctor and staff working on patients. At that
time, they are introduced to the staff. They see
the "Wall of Honor," which features photos of
patients taken the day their braces were re-
moved. It is emphasized that the "popcorn pop-
ping day of celebration" will come for them
sooner than they think, encouraging them to
identify with those happy smiles and to build
excitement and a positive attitude about this
wonderful experience of wearing braces. Begin
with the end in mind!4
The patient and parent are shown into the
special new patient room by the new patient
coordinator (NPC), where the coordinator takes
information while getting acquainted and bond-
ing with the patient. It is very important that
attention is directed more toward the patient
than toward the parent. The doctor completes
the examination while the NPC is taking notes.
The mission statement, "Healthy, happy smiles!"
that the patient and parent have just seen on the
"Wall of Honor", is discussed, followed by a short
demonstration on proper sulcular tooth brush-
ing, emphasizing the critical need for the pa-
tient's commitment to long-term oral health.
The doctor explains to the patient that the se-
cret is to get the bristle under the gum to re-
move the plaque. The patient is asked to repeat
the "secret," and when the patient responds cor-
rectly, the doctor congratulates the patient and
says, 'You just made an A+ on your pop quiz!"
and an "A+" is written on the toothbrush kit.
This positive emotional impact may seem trivial
but we are building a relationship based on
friendship, knowledge, trust, and fun!
The patient enjoys having a good time. It is
important to be very professional, but both pa-
tients and parents know that they can have a good
time at the office while developing good oral
health habits, getting their teeth straightened, and
building character. It is fun to learn and the more
you learn, the more fun you can have! The patient
can have fun and get the job accomplished!
It is important to be completely candid with
the patient and the parent concerning the dis-
comfort the patient will experience.
<<    
     Article
      >>
Character Development
To build confidence, the patient is taught:
Many things are difficult before they become easy. Re-
member when you first tried to ride a bicycle? You f ell off and
maybe even had to have training wheels. Is it easy to ride a
bike now ? Many things are difficult before they become easy,
whether it is riding a bike, doing braces, or doing brain
surgery. Does that make sense? The doctor, staff, and your
parents will all help you and you 'II learn fast. Everybody is
pulling for you!
After the treatment is discussed, the doctor
positions himself so that he and the patient
are facing each other squarely, eye to eye, as
he explains, "Now, Bobby (it is important to
use the patient's name often), we are talking
about this X number of dollars and that is a lot
of money." Orthodontic treatment is expen-
sive and the patient should know it is a sacri-
fice for his or her parents. "Now, to make that
worthwhile, it is going to take a great deal of
work on your part. Your mother would like to
do it for you and the doctor would like to do it
for you, but whose responsibility is it really?"
(Pause) It is effective to pause and let impor-
tant concepts sink in and it is gratifying to
watch the child think for a minute and then
point to themselves. This is a moment of truth,
a commitment. This is the verbal Individual
Responsibility Agreement (IRA). The doctor
turns to the parent and says, "It is so rewarding
to see these young people accept responsibility
and become accountable." Our fee includes
everything performed in the office, and the
only reason the fee would change is if the
treatment is prolonged because of poor coop-
eration. It would not be fair for the parents to
pay more, so if the treatment goes past time, a
lot of the patients put some of their own
money into it. The parents like hearing their
child agree to do their part. Accepting indi-
vidual responsibility is both a confidence
builder and a character builder for the pa-
tient. At a later appointment when we go over
the records and the consent form, we reem-
phasize this and ask the patient to sign the
agreement and take it home with him (Fig 1).
We keep a copy in the chart.
This "Character Development Methodol-
ogy" is the foundation on which the practice is
built. The basic principles include (1) build-
ing bonds of friendship and trust, (2) showing
the patient the treatment area and "Wall of
Home | TOC |          
Index
69
Honor" (3) promote "Beginning with the end
in mind," (4) introducing the concept, "Little
things do not mean a lot. . .they mean every-
thing," (5) relating oral hygiene tips for a
healthy, happy smile, (6} emphasizing partici-
pative treatment with the idea that most things
are difficult before they become easy, (7) un-
derscoring personal responsibility with the
IRA, and (8) making the commitment to have
fun! These points, which we consider to be a
method of character development, will be re-
peated and emphasized throughout the course
of the orthodontic treatment. Repetition and
application of these and other principles dur-
ing treatment will help imprint them in the
minds of our patients during treatment to the
extent that they become a part of their lives
even after the braces are removed.
Separation Agreement
Up to this point, it has been all words. The
initial discomfort of placing separators will
present a challenge. However, the soreness
can usually be mitigated by explaining every-
thing in detail; gently placing the separators
and praising the patient on how well he did,
even though it was a little uncomfortable.
Then the doctor says, "You are tough!" be-
cause it builds the patient's confidence. You
can almost see his chest swell with pride. Ex-
plaining that sensitive teeth will follow pre-
pares the patient further so that there will be
no surprises. "Inform before you perform," is a
cardinal principle in dealing with patients.
Banding and Bonding Appointment
After the patient is seated, a few minutes taken
to visit with the patient is a valuable investment
of time, explaining again the appointment's pur-
pose and congratulating him for doing so well
with the spacers. The doctor can do this before
the bands are fitted. The patient will feel com-
fortable and reassured that all are clear on the
treatment plan, type of appliance, and that the
patient, doctor, and staff will be working to-
gether as a team.
The appliances are placed and the patient is
dismissed after explaining what was accom-
plished to the parent. Spending time with the
parent is one of the most critical aspects of a
<<    
     Article
      >> Home | TOC |          
Index

70 C. Moody Alexander

^a/ie^ne^t
I realize that to undergo orthodontic treatment resulting
in a healthy, happy smile is a privilege, rather than a
right, for which my parents are sacrificing something else
to provide the treatment for me. Therefore, because I
appreciate this opportunity, I agree to accept personal
responsibility for the success of my treatment and to
contribute to it my time and efforts to the best of my
ability. I will cooperate to the fullest extent with Dr.
Alexander by following all instructions faithfully, wearing
elastics, headgear and/or other appliances as directed,
eating the approved types of food and meeting my
appointments promptly as scheduled.

Dr. Alexander hereby agrees to accept his responsibility

of implementing my treatment plan and, with my full
cooperation, ensuring the highest quality of orthodontic
result in the shortest length of time.

John Smith C. Moody Alexander,D.D.S.,M.S.

J. Clifton Alexander,D.D.S,M.S.

Dated Dated

Figure 1. The Individual Responsibility Agreement is signed by the patient and the doctors. It is framed to
take home to emphasize the importance of the commitment.

successful practice. Responding to a survey, one
mother said, "The doctor makes a point of
speaking to every parent individually and giving
each of them special attention when they have
questions. I've been in the office when it was
crowded and the doctor spoke to every parent
who had a child being seen. It makes you feel
comfortable and that 'you are not just another
patient.'"
It is best not to call the patients the day they
get their braces on, but to wait 24 hours and call
them on the evening of the second day. The
doctor speaks directly to the patient and says, "I
know they are sore and I called to see if you have
any questions or if there is any way I can help
you?" After talking to and reassuring the patient,
the doctor tells the patient that he is proud of
him or her, ending with 'You are over the worst
part and by tomorrow, they should begin feeling
a lot better." It is amazing how the power of
positive suggestion works. If the doctor tells the
patient he is going to get better, he usually does.
The patient and the parent both appreciate the
call.
<<    
     Article
      >>
Character Development
A Temporary Setback in Treatment
If a patient is having a problem (ie, poor hy-
giene, missed appointments, broken bands), we
encourage him to choose the attitude that it is
just a temporary setback. If one's favorite team
fumbles the ball, they don't give up. They get the
ball back and score a touchdown! Everybody has
problems. . .the difference is how we face the
problem, learn from it, and move on to success.
In the movie, Apollo 13, when it looked as if the
astronauts were going to die, the head of the
ground crew stated, "Failure is not an option."
His strength, leadership, and confidence stimu-
lated the rest of the team to come up with cre-
ative new ideas to save the mission. Of course, we
all fail at times but if we can transmit that type of
Apollo 73 winning attitude to our patients, we will
come closer to achieving our goals in orthodon-
tics and in life.
The Problem Patient
Speaking of failure, what happens at the end of
treatment when the patient is not wearing the
elastics as instructed and the teeth are not mov-
ing? There is a stalemate. Do we extract teeth, do
surgery, or what? No single approach works
100% of the time, but the following method can
be very effective.
The key to success with the problem patient is
the explanation and understanding of the IRA
by both patient and parent at the new patient
visit and again at the beginning of treatment.
Parents like their children to learn to be ac-
countable and to accept individual responsibil-
ity. They smile and agree as the patient signs the
IRA at the beginning of treatment. A great deal
of emphasis is placed on this "ceremony." The
certificate is on 8" X 10" bonded paper (Fig 1).
After the doctor and patient have signed, the
Agreement is put in a frame and given to the
patient and parent to take home and place on
the patient's desk or in some other conspicuous
spot in his room. In efforts to build the family,
the doctor can say 'You know, dads are real good
at contracts and things like that; so why don't
you go over this with your dad and write me a
letter about what he said?" Getting the father
involved is a vital part of the overall concept.
Patients are to wear the elastics all of the
time. . .eat in them, sleep in them, take them out
Home | TOC |          
Index
71
to brush well, then put them right back in. When
the teeth are not moving, it is obvious that the
elastics are not being worn as instructed. When
this situation arises, the patient is moved to the
consultation room and the parent is asked to sit
in. The doctor asks the patient, "Have you had to
miss some time wearing the elastics?" This ques-
tion and tone in which it is asked seems to be
more fact finding than accusatory. All orthodon-
tists want to build and enhance their relation-
ship with the patient and parent as well as building
respect for maintaining a disciplined form of treat-
ment. While struggling to achieve this balance, it is
helpful to remember the adage, "adversity is op-
portunity, and the difference is attitude."
Usually the patient will admit to having
missed some time. By being honest, they have
just won the George Washington Honesty
Award. "Do you remember the cherry tree and
how honest he was? Well, your parents and I
really appreciate you being honest. We all make
mistakes. . . of course, your mother has never
made a mistake (we laugh), but I've made plenty
of them and what do you do when you make a
mistake? (Pause and let the patient answer.)
'You fix it!" the patient answers. We all agree
and say, 'Yes, you fix it. . . but first you have to
have the courage to admit it and we're proud of
you for having that courage. So the best thing to
do is to admit it, just as you have done, learn
from it, and move on."
"Now you have three options. Number one is
that we can take the braces off and leave your
teeth crooked. Number two, you can pay an
extra $150 per month, some of which may be
your own money, and just keep the braces on as
long as it takes to straighten the teeth, wearing
the rubber bands only when you want to. Num-
ber three, you can wear those rubber bands
constantly, eat in them, sleep in them, and don't
ever take them off except to brush, and get your
braces off soon. Which option sounds best to
you?" It is amazing how many patients decide to
choose option number three. Actions produce
consequences.
If the patient fulfills their responsibility, the
teeth move and we make plans to remove the
braces. However, if the patient still misses time
wearing the elastics, a call to the father is very
effective. Remember, we got the father's input in
the letter from the patient early in treatment.
Experience shows that, for the most part, the
<<    
     Article
      >>
72 C. Moody Alexander
Figure 2. The Certificate of Achievement is framed and presented to the patient when appliances are
removed. The "thrill of victory!"
parents are very positive and supportive. The
groundwork was laid from the very beginning
and they know the doctor has performed every-
thing in their power to instruct and encourage
the patient. There are no surprises. "Inform be-
fore you perform" pays off again. The purpose is
to help the patient help themselves while striv-
ing to avoid animosity. When a patient accom-
plishes a difficult task, they always feel better
about themselves, another step in character
building. In closing the conversation with the
father, he is told that he will get a letter outlin-
ing the options and that I'm looking forward to
seeing Johnny at his next appointment. It is very
important to talk to the parent about this letter
before it is mailed to avoid misunderstanding
and negative reactions.
These problem situations must be handled
very carefully. Anyone can treat the cooperative
patient and achieve quality results. The chal-
Home | TOC |          
Index
lenge is the problem patient, and that is where
the behavioral science research can help us
learn how to turn the problem patient into a
quality result. Saying the right thing at the right
time and showing sincere concern for everyone
in the family (many times, two families!) can
turn a negative situation into a very rewarding
experience.
Yea! The Braces Are Coming Off!
One of the most devastating things that can
happen during treatment is when a patient
thinks he is going to get the braces off and he
does not. With proper planning, that will not
happen.
Usually, braces are removed on Thursday af-
ternoon and the staff pops popcorn, photo-
graphs are taken, and it is a very festive, fun, and
exciting time. Wearing braces is not easy and the
<<    
     Article
      >>
Character Development
patient deserves to enjoy this very special mo-
ment in his or her life! There is a great feeling of
accomplishment and it is important to recognize
this special event with a framed "Certificate of
Achievement" (Fig 2). The patient and parent
realize that this certificate was earned by the
patient and is awarded for "courageous and per-
severing dedication to improving his smile." It
does take courage to wear braces during the
uncomfortable times and it is not always conve-
nient to come for appointments, and peers may
ridicule patients. There is no immediate gratifi-
cation in wearing braces but dedication will
eventually be rewarded.
"Never forget the effort you put forth, as well
as the results you have achieved." Hopefully, this
positive experience will imprint on the patient's
mind so that they will always remember that they
put forth the effort. No one else did it for them.
They did it on their own and got results! The law
of cause and effect: effort = results! As you sow,
so you shall reap. It did not happen by accident,
the patient made it happen. "When you meet
new challenges, this experience and your new
smile will give you the confidence and the deter-
mination needed to reach your goals." Every day
is a new challenge. Parents know that, and when
their child meets new challenges, it can be very
empowering to remember this success.
This self-confidence and determination can
become a factor in helping patients reach their
goals. In the survey, an adult patient said that
wearing braces helps build character by teaching
a person how to set goals and how to "break up
a huge task into little steps that are easy to take.
With persistence, your goal is reached before
you know it." It is gratifying to affirm the patient
and tell them that they can do anything they
make up their mind to do. The situation may be
different, whether it is in school, career, or life,
but the principles are all the same. You set your
goal, visualize it in detail, make your plan, go for
it step-by-step, and, as Winston Churchill said,
"Never, never, never give up!"
Conclusion
In addition to improving smiles and occlusion,
orthodontists have a unique opportunity to con-
tribute to society through their special relation-
ship with the patient over a prolonged period of
time. No other medical or dental specialty pre-
Home | TOC |          
Index
73
sents the need for closely scheduled routine vis-
its by patients at their most impressionable age.
The patient works in tandem with the doctor to
achieve major goals, a healthy, happy smile, and
of equal or perhaps greater importance, strong
character traits. Implementation of this method-
ology has added a new dimension and excite-
ment to the author's practice. Goleman5 has
shown that students can learn emotional compe-
tence and attain a high quality of life. Reeder6
shows the relationship of malocclusion to self-
concept. Stroud7 has shown that orthodontic
treatment improves the psychologic functioning
and self-concept of patients, leading to a better
quality of life. In emphasizing the importance of
treating the whole patient, Starnes (Les O. Star-
nes, personal communication, 1997) asserts,
"Now I realize how providing an excellent result
falls way short of the overall potential impact I
can have on each patient's overall development.
We, as orthodontists, truly are in a unique posi-
tion to mold young people's lives. This once-in-
a-lifetime opportunity for character develop-
ment carries awesome responsibilities and,
unfortunately, most of us are not even aware of
the challenge."
Each patient is a new challenge. The degree
or the success varies and is dependent on the
commitment of both the patient and the doctor.
A quality result is our reason for being in orth-
odontics, and the application of the principles of
behavioral science and character development can
help us to encourage our patients to participate
more in their treatment, improving our results,
and helping the patients be the best they can be.
References
1. Bronowski A. The Ascent of Man. Boston, MA: Little
Brown, 1973, p 116.
2. Ghafari JG. Emerging paradigms in orthodontics-an es-
say. Am J Orthod Dentofacial Orthop 1997;! 11:573-580.
3. Institute of Medicine. Dental education at the crossroads-
challenges and changes. Washington, DC: National Acad-
emy Press, 1995.
4. Covey SR. Principle-centered leadership. New York:
Schribners, 1990.
5. Goleman D. Emotional intelligence. New York: Bantam
Books, 1995.
6. Reeder BK. The psychological impact of malocclusion
[master's thesis]. Dallas, TX: Baylor College of Dentistry,
1995.
7. Stroud JL. The psychological impact of orthodontic treat-
ment [master's thesis]. Dallas, TX: Baylor College of Den-
tistry, 1996.
<<    
     Article
      >> Home | TOC |          
Index

The Alexander Discipline Appliance Design

and Construction
M. Alan Bagden

Appliance design and construction is one of the most important aspects of

producing a successful orthodontic result. The Alexander Discipline has
developed a unique appliance prescription that incorporates particular ad-
vantages of a multitude of designs and combines them into a practical,
efficient, and comfortable system. By using the Discipline, and understand-
ing how it addresses individual case needs, the practitioner is afforded an
opportunity to deliver results of the highest quality to all patients in a
minimum of treatment time. (Semin Orthod 2001;7:74-79.) Copyright© 2001
by W.B. Saunders Company

T he orthodontic force delivery system, better

known as brackets and bands, is the defin-
ing characteristic of any technical discipline.
Various tips, torques, angulations, ins and outs,
geometry, and actual design is what gives each
technique its own particular personality. Appli-
ance design, with the advent of the straight-wire
concept of delivery, has progressed significantly
since the early days of the standard edgewise
system. Heretofore it was the wire, and the prac-
titioners ability to manipulate it, that gave each
case its own particular stamp of individuality.
Now it is possible to treat patients with repro-
ducible results by effectively understanding the
principles of a technique and conscientiously
constructing each case. Once an appliance has
been placed in its optimal position on the teeth,
the simple placement of these straight wires al-
lows each case to progress to completion with a
high degree of predictability.
The Alexander design maximizes the concept
of straight wire appliances. This is a Discipline
that not only uses a force delivery system that has
been well conceived and tested, it also has a
system of Principles that guides the practitioners
through each case with a level of conformity,
From the Springfield Doctors Center, Springfield, VA.
Address correspondence to M. Alan Bagden, DMD, Springfield
Doctors Center, 6120 Brandon Ave, Suite 104, Springfield, VA
22150.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0702-0003$35.00/0
doi:10.1053/sodo.2001.23544
ensuring predictable final results. Once a case is
well constructed with the Alexander system, the
Principles serve as a guide throughout the treat-
ment of the case.
This was the intent of Dr. Alexander when he
first introduced his "Vari-Simplex" bracket sys-
tem in 1978. "Vari" referred to the variety of
bracket types used and "Simplex" related to the
concept of keeping all aspects of the Discipline
as simple as possible. Arch wire fabrication and
the incorporation of many aspects of treatment
options into the brackets (ie, elastics hooks and
rotational wings on the brackets) added up to
the "simplex" concept. "Discipline" rather than
"appliance" was chosen to reflect that the orth-
odontist must be knowledgeable in all aspects of
edgewise mechanics and must play an active role
in the application and follow-up treatment of
each patient.
As previously mentioned, the Vari-Simplex
Discipline was developed as a conglomeration of
other brackets designs. The initial goal of devel-
oping a simple, philosophically nonextraction
technique, which would produce reproducible
superior results in a consistent fashion, while
being convenient to the patient, was the driving
force behind the evolution of Dr. Alexander's
Discipline. Reduction of stress from doctor, to
staff, to patient, and to the patient's family was,
and still is, one of the goals of the Discipline.
The Discipline has evolved over the years
through the "Mini-Wick" (second-generation)
Discipline, to the current design, which is the

74 Seminars in Orthodontics, Vol 7, No 2 (June), 2001: pp 74-79

<<    
     Article
      >>
Alexander Appliance Design and Construction
third generation of the Discipline, the "Alex-
ander Signature" design. As this issue of Seminars
in Orthodontics is being developed, work contin-
ues to develop the fourth generation of the Dis-
cipline.
The most important factor in determining
the original Vari-Simplex (Ormco Corp, Glen-
dora, CA). Discipline was the tooth location and
the size and shape of the teeth, especially the
mesiodistal width and curvature. These factors
influenced the interbracket width, which af-
fected the ability to rotate teeth and level the
arches. So, in some instances, the optimal
bracket design was a single bracket with wings
and, in other situations, a twin bracket design
was most advantageous. Likewise, in the case of
the single brackets, some were of Lewis (Ormco
Corp) design and others were of Lang design
(Ormco Corp). What is most important to real-
ize, however, is that the intentional different
designs of particular brackets provide distinct
advantages over other systems that use identical
bracket architecture for each tooth.
Particular advantages of the Alexander Disci-
pline bracket system include:
1. Bracket selection (Figs 1 and 2). The first,
and most important, advantage of the Alex-
ander Discipline is that the system is com-
posed of a number of bracket designs. The
security of the system, and its mechanics,
allows for twin brackets on anterior maxil-
lary teeth, single-wing Lang brackets on all
four cuspids, and single-wing Lewis brackets
on premolars and lower incisors. By creating
a variation (hence Vari-) in types of brackets
selected, the advantages of each design are
Figure 1. Frontal view showing bracket selection.
Home | TOC |          
Index
75
used in a single-slot (0.018" X 0.025") de-
sign. Although other systems use brackets of
varying slot size, the Alexander Discipline
uses varying brackets of identical slot size. In
situations in which mesial and distal wings
are necessary for rotational control, they are
incorporated. In those areas where flat-sur-
faced teeth require twin brackets, they are
used as well. The basic premise is that if twin
brackets are not required on all teeth, why
use them? And, if single-wing brackets are
appropriate for the cuspid and bicuspid ar-
eas, why not only use them there? This Vari-
ation leads to a SIMPLEX Discipline.
2. Interbracket space (Figs 3 and 4). Using
single brackets with wings in the lower ante-
rior and buccal segments allows maximal
interbracket distance. The new metals avail-
able allow the practitioner to engage suffer
(larger) wires faster with such a bracket de-
sign. This allows for faster leveling, less dis-
comfort, and improved torque control. This
also allows the orthodontist to get into their
final arch wires faster.
3. Rotational control. Rotation wings on cus-
pids, bicuspids, and lower anteriors provide
for improved rotational control and individ-
ual activation of particularly involved teeth.
In those situations in which a single tooth
does not respond to conventional mechan-
ics, individual forces can be applied by acti-
vating, deactivating, or removing individual
wings.
4. Torque. Each bracket has a 0.018 X 0.025
inch wire slot. Slot sizes do not vary from
anterior to posterior brackets and, realizing
Figure 2. Lateral view showing bracket selection.
<<    
     Article
      >>
76 M. Alan Bagden
Figure 3. Maxillary occlusal view showing inter-
bracket space and rotational wings.
that 5° of torque is lost for each 0.001-inch
"play" in the slot, final ideal wires (0.017" X
0.025") are constructed to fill the slot as
much as possible.
5. Lower incisor torque. Contrary to many
bracket prescriptions, —5° torque is incor-
porated into lower incisor brackets. This al-
lows for more efficient control of these teeth
during the leveling process and actually sets
up anterior anchorage in those situations
where the mandibular posterior teeth are to
be protracted in the correction of Class II
malocclusions. The -5° torque also aids in
ideally maintaining the position of these
teeth over the mandibular basal bone. The
use of a flexible rectangular arch wire in the
lower arch is recommended as soon as pos-
sible to optimally control torque in this crit-
ical area.
6. Lower first molar tip. The mandibular first
molar is also constructed to have a —6° tip
incorporated into its design (Fig 5). This,
being a throwback to the Tweed technique,
is essential in establishing posterior anchor-
age in Alexander cases. By creating this sit-
uation, the basic construction of a case al-
lows the mesial aspect of mandibular molars
to be uprighted, which, in turn, incorpo-
rates leveling mechanics with attention to
anchorage demands. The —6° tip of the mo-
lar bands also positively contributes to a
nonextraction philosophy in that it allows
distal movement of the molar crowns, which
Home | TOC |          
Index
Figure 4. Mandibular occlusal view showing inter-
bracket space and rotational wings.
can create additional arch length where
needed. Band placement is critical on the
first molar. For a typical case the band must
be placed, as always, with the occlusal mar-
gin of the band parallel with the occlusal
surface of the molar at the marginal ridges.
In open bite situations, care must be given
to tip the distal aspect of the band gingivally
so that the mesial cusp is not supererupted
and the distal aspect is supported, which
minimizes the bite opening effect of the —6°
tip of the bracket placement.
Bracket Selection
The following is a summary of the specific
brackets that are most effective for each tooth in
the arch.
Twin Brackets
Twin (Diamond) brackets (Ormco Corp) are
used on large, flat-surfaced teeth (namely, max-
illary central and lateral incisors). The flat sur-
faces of these teeth permit full arch wire engage-
ment in the twin brackets. Ball hooks for elastic
placement are usually placed on lateral incisor
brackets. There is little trouble tying the wire
into these brackets because of their ease of ac-
cessibility, and the brackets allow for 5 to 6 mm
of interbracket width, which is sufficient for flex-
ibility, rotational control, and torquing. These
brackets are smooth and minimize irritation on
labial tissues.
<<    
     Article
      >> Home | TOC |          
Index

Alexander Appliance Design and Construction 77

so severe that the bracket cannot otherwise be

placed in its ideal position. The offending wing
can be clipped or ground off, leaving the oppo-
site wing to create the desired rotational move-
ment. Where twin brackets are used in situations
where teeth are severely rotated, ideal bracket
position is not possible. The latter situation
would require rebonding at a later time in treat-
ment when space becomes available. This re-
bonding often requires an additional appoint-
ment that can be avoided with the use of Lewis
and/or Lang brackets.

Figure 5. Mandibular brackets with bands on first Molar Bands

and second molars.
Twin brackets with convertible sheaths are used
on the first molars. Headgear tubes are used on
Lang Brackets
the maxillary molars and are manufactured to
These brackets, originally developed by Dr. be on the occlusal aspect of the band. The latter
Howard Lang, are used on cuspids, which are allows for superior hygiene and accessibly for
large, round-surfaced teeth at the corners of the headgear where indicated. The mandibular first
arches. The contoured pad fits beautifully on molar bands can be constructed with convertible
the surface of the tooth and the straight wing arch wire tubes and lip bumper tubes (if neces-
eliminates interference with complete arch wire sary) placed on the gingival aspect of the
engagement. Thus, the bracket is easily ligated bracket. This allows the convertibility of the
and interbracket width is maximized. Twin tubes as well as allowing for the placement of lip
brackets on cuspids are not the brackets of bumpers in indicated situations. Single buccal
choice because they can interfere with opposing tubes are used on both mandibular and maxil-
cusps on occlusion (actually often causing cusp lary second molar teeth. Elastic hooks are lo-
attrition) and it is often impossible to get full- cated on all first and second molar brackets, and
bracket engagement on these teeth early in also as distal offsets used for tying back arch
treatment. wires. Lingual elastilugs are placed on all molar
bands.
Lewis Brackets
Redesigned Lewis brackets are used on round- Specifications of the Appliance
surfaced teeth not located at the corners of the
Bracket height in this Discipline, as in any other
arches (maxillary and mandibular bicuspids) as
technique, is extremely important in the con-
well as small, flat-surfaced teeth (mandibular
incisors) (Fig 6). The Lewis bracket is a fixed-
wing single bracket that again contributes posi-
tively to the concept of increased interbracket
width. The wings provide a distinct advantage in
having a built-in auxiliary for rotational control,
much in the same fashion as those on the Lang
brackets. By activating these wings, additional
rotational force can be exerted if necessary. No
additional wedges or particular ties are neces-
sary. These wings allow for fast, efficient, safe (ie,
little chance for bracket debonding during acti-
vation), and predictable action. It is also com-
mon to remove the wing on either side of the
main bracket in situations in which rotations are Figure 6. Bracket angulation on lower anteriors.
<<    
     Article
      >> Home | TOC |          
Index

78 M. A lan Bagden

struction of the appliance. The Discipline has
strict guidelines concerning bracket heights and
positions and are shown in Table 1. It must be
kept in mind that each bracket must be parallel
to the long axis of each tooth, regardless of the
bracket and tooth. Guide markings are milled
into each bracket to assist in correct long-axis
placement.
Special Considerations in Appliance
Construction
Deep-Bite Cases
The true Alexander Discipline dictates that the
maxillary arch have appliances placed first, with
the mandibular arch having appliances placed
when an adequate bite opening has been
achieved in order to prevent bracket interfer-
ence. By using wires with curves of Spee in the
maxillary arch, enough bite opening should be
obtained to allow timely placement of the man-
dibular appliances. However, in some instances,
particularly in adult patients, reverse curve wires
alone are not sufficient to adequately open the
bite. In these situations, the use of a maxillary
bite plate is strongly recommended. The bite
plate allows immediate placement of mandibu-
lar appliances and also hastens bite opening by
allowing simultaneous molar-bicuspid eruption
along with incisor intrusion. A bite plate can also
be used on those patients in whom early initial
treatment of the mandibular arch is desired.
in these situations. By preparing the case with
gingivally positioned brackets, extrusion of the
incisors facilitates closure of an open bite. Addi-
tional placement of vertical elastics also contrib-
utes to open-bite closure. Mandibular first mo-
lars should be placed with the distal aspect
seated more gingivally to offset the —6° tip in-
corporated into the band. This prevents the me-
sial cusp from supererupting, which would be
counterproductive in an attempt to close the
bite.
Extraction Cases
The Discipline has been developed to allow all
cases to be treated with the same bracket system.
Separate extraction and nonextraction bracket
series are not needed. It is recommended, how-
ever, that the bicuspid brackets adjacent to the
extraction sites be tipped so that the wing adja-
cent to the extraction site is angled toward the
extraction and therefore bicuspids are posi-
tioned with the mesial bracket angled toward the
extraction site. By doing so, the roots of the
teeth are uprighted toward the extraction area
allowing for improved parallelism with resulting
easier retraction of the cuspids. In molar pro-
traction situations the —6° tip of the molar band
is extremely advantageous during the process
in that the mesial aspect of the tooth is not
"dumped" in a mesial fashion during protrac-
tion; hence, ideal uprighting can be facilitated.

Open-Bite Cases
Bracket Angulation
Special bracket placement of anterior brackets
in an exaggeratedly gingival fashion is indicated To allow the roots to be properly positioned at
the end of the treatment, care is taken during
Table 1. Bracket Height the bracket placement to ensure that the brack-
Maxillary arch
ets are placed parallel to the long axis of the
Centrals X clinical crowns. The Alexander prescription was
Laterals X — 0.5 mm the first to advocate spreading the roots of the
Cuspids X + 0.5 mm lower anterior teeth.5
First bicuspids X
Second bicuspids X - 0.5 mm
First molars X — 0.5 mm
Second molars X — 1.0 mm Mesiodistal Position
Mandibular arch
Centrals X - 0.5 mm On flat-surfaced teeth, the bracket should be
Laterals X — 0.5 mm placed in the center of the clinical crown. The
Cuspids X + 0.5 mm
First bicuspids X
bracket is placed at the height of the contour on
Second bicuspids X - 0.5 mm all round-surfaced teeth. The molar tubes are
First molars X — 0.5 mm placed so that the mesial end of the tube is
Second molars X - 0.5 mm
placed parallel to the mesiobuccal cup of the
NOTE. X usually equals 4.5 mm. molar (Fig 7).
<<    
     Article
      >> Home | TOC |          
Index

Alexander Appliance Design and Construction 79

Concluding Observations ability to provide the practitioner with excellent

clinical results. Aspects of appliance have under-
Having used the Alexander Discipline in our
gone research and have been carefully evalu-
practice for more than 20 years, it is the opinion
ated, and also have been kept current with ad-
of this author that it is a technique that has the
vances in orthodontic technology. Careful
clinical application and the desire to produce a
superior final result must be the intent of the
practitioner from the inception of treatment.

Figure 7. Proper maxillary cuspid bracket mesiodistal
position.
References
1. Alexander RG. The Alexander Discipline. In: Engel GA
(ed). Ormco, Glendora, CA, 1986, chap 5.
2. Alexander RG. The Alexander Discipline. In: Engel GA
(ed). Ormco, Glendora, CA, 1986, chap 9.
3. Alexander RG. The role of occlusal forces in open-bite
treatment. J Glin Orthod 2000;34-38.
4. Alexander RG. The Alexander Discipline. In: Engel GA
(ed). Ormco, Glendora, CA, 1986, chap 10.
5. Williams R. Eliminating lower retention. J Glin Orthod
1985:342-349.
<<    
     Article
      >> Home | TOC |          
Index

Face Bow Correction of Skeletal Class II

Discrepancies in the Alexander Discipline
Charles D. Alexander and J. Moody Alexander

A brief history in the development of the Alexander Discipline incorporating

the face bow is described. The current use of this orthopedic appliance is
discussed showing the force vectors needed to address sagittal, vertical,
and transverse skeletal discrepancies. Appliance adjustment, applied force,
time worn, and modification of growth patterns are presented. Research
studies prove the successful results and long-term stability of the face bow.
(Semin Orthod 2001;7:80-84.) Copyright © 2001 by W.B. Saunders Company

In a study on the effects of the Milwaukee Effects On the Three Dimensions

Brace on scoliosis patients, Alexander re-
ported that the maxillofacial growth pattern is
affected by Milwaukee brace therapy.1 This find-
ing on orthopedic effects encouraged the au-
thor to evaluate more practical forces that could
affect Class II skeletal patterns.
During this same time, the Kloehnn headgear
was gaining popularity in distalizing maxillary
first molars. One of the negative side effects of
the Kloehnn headgear was the tipping and ex-
trusion of the molars, causing an opening of the
mandible plane angle. In an attempt to prevent
this undesirable effect, Alexander advocated a
continuous upper arch wire to prevent molar
tipping while adding tied-back omega loops to
reduce their extrusion and keep the arch con-
solidated (Fig 1). Although this approach pre-
vented the distal movement of the maxillary first
molars, another effect was observed. Results
from patients wearing the cervical face bow with
the tied-back arch wires indicated that very little
maxillary distal movement took place, however,
the Class II skeletal problem was being corrected
by the forward movement or growth of the man-
dible. This effect has been widely recognized
and used in the treatment of patients
From Montrose, CO; and Arlington, TX.
Address correspondence to Charles D. Alexander, DDS, MSD,
1228 E. Main, Montrose, CO 81401.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0702-0004$35.00/0
doi:10.1053/sodo.2001.23547
When used in the appropriate situations, the
face bow can affect all three dimensions, sagittal,
vertical, and transverse.2 Because the facebow is
an extraoral device and can affect or control all
three planes of space, it is a unique appliance for
skeletal correction.
Sagittal Dimension
Modifying maxillary skeletal growth by inhibit-
ing maxillary development anteriorly allowing
normal mandibular growth is the goal of the
cervical face bow. The Class II sagittal discrep-
ancy can be positively affected by the cervical
face bow (Fig 2). In a growing patient requiring
a Class II skeletal correction, the face bow can be
used to modify the skeletal development by in-
hibiting anteriorly directed maxillary growth.
The result is an expression of the genetic poten-
tial for mandibular growth and skeletal correc-
tion of the Class II skeletal discrepancy. Cepha-
lometric tracings of excellent response to
cervical headgear is shown in Figure 3.
Vertical Dimension
The goal of the combination (Fig 4) and high-
pull face bow (Fig 5) is to maintain the vertical
relationship of the maxillary posterior teeth and
modify maxillary skeletal growth by inhibiting
vertical maxillary development. The vertical
relationship can often be difficult to control
during orthodontic tooth movement. In the do-
licephalic face, management of the vertical di-
mension is critical to achieving a successful re-

80 Seminars in Orthodontics, Vol 7, No 2 (June), 2001: pp 80-84

<<    
     Article
      >>
Skeletal Class II Discrepancies
Figure 1. .016SS upper arch wire with curve of Spee
and omega loops.
suit. In such a pattern, the high-pull or
combination face bow can be used to inhibit or
control vertical development of the face. With
the multiple factors that influence anterior
open-bite correction, it is imperative that the
posterior molars not be extruded. High-pull face
bow, along with proper band and bracket place-
ment, can be effective in maintaining vertical
control in the maxillary posterior segments.
When the mandibular plane angle, Sella Nasion
to Mandibular Plane (SN-MP), is 36° to 41° then
a combination headgear is used, but when
SN-MP is greater than 42°, a high-pull facebow is
Figure 2. Cervical face bow.
Home | TOC |          
Index
81
Figure 3. Results of cervical facebow inhibiting max-
illary growth while allowing the mandible to reach its
genetic potential.
recommended to control maxillary molar verti-
cal position.
Transverse Dimension
Developing or maintaining the maxillary trans-
verse dimension is accomplished with the inner
bow of the face bow. Use of the inner bow of the
face bow to maintain or develop the transverse
Figure 4. Combination face bow.
<<    
     Article
      >> Home | TOC |          
Index

82 Alexander and Alexander

tionally used intraoral mandibular advancing or

functional devices, such as the Herbst and the
Jasper Jumper (Ormco, Orange County, CA),
can negatively affect maxillary and mandibular
incisor torque, a side effect not observed with
the face bow. The face bow is cost effective and
is easy to fit and adjust. Because the face bow is
removable, it does not adversely affect speech.
The authors also believe that there is no relapse
with successful face bow therapy because it does
not posture the mandible forward, the latter
which may result in relapse resulting from the
muscular action. Correction is accomplished by
the forward growth of the mandible, when the
headgear is appropriately used, and favorable
growth occurs.
One of the most often heard complaints
about the use of the face bow is the need for
Figure 5. High-pull face bow with special adjustment
to outerbows. patient motivation and the risk of noncompli-
ance. There are multiple reasons why patients
will not wear their face bows, many of which can
dimension is a method that is not often consid- be proactively addressed and prevented. It is
ered. The inner bow is routinely expanded 3 to imperative for the orthodontist to believe in the
4 mm (Fig 6) when a cervical or combination effectiveness of the appliance. When educating
headgear is being used for Class II correction. the patients and parents,3 the point must be
When also expanding the maxillary arch wire, a made that when compared with every other or-
permanent expansion of 2 to 4 mm of intermo- thopedic device, this is the best appliance to use
lar width can be achieved. Because of the ability when dealing with Class II skeletal corrections,
of the inner bow to maintain the expansion, vertical management, and/or requirements for
transpalatal arches (TPA) are rarely necessary. maximum anchorage. As the professional, our
Headgear is not the appliance of choice for belief in and recommendation for the appliance
posterior crossbite correction, but once a cross- can help motivate a large majority of the patients
bite has been corrected, the inner bow of the
to cooperate. Those patients who choose not to
face bow can be used to maintain the proper
wear the face bow can be treated with the so-
buccal over]et.
called noncompliance appliances.
Anchorage control. The face bow can also be
used to maintain anchorage of maxillary poste-
rior teeth in the Class I malocclusion. When
anchorage requirements exist, either in extrac-
tion or nonextraction cases, the face bow can be
used to prevent mesial molar movement. Even in
nongrowing individuals, the face bow can be
used to maintain molar position and assist in
molar rotation.

Advantages of Face Bow Therapy

The greatest and most obvious advantage of face
bow use is that it places only a distal force on the
maxilla. No undesired mesial effects occur. The
result is the prevention of undesirable tipping of
the maxillary and mandibular teeth. Conven- Figure 6. Innerbow expansion.
<<    
     Article
      >>
Skeletal Class II Discrepancies
Face Bow Adjustment
After a diagnosis has determined the specific
force vectors necessary to treat the skeletal prob-
lems, proper adjustment of the face bow is es-
sential. In many instances, at the start of treat-
ment, the maxillary first molars are rotated
mesiolingualy. For this reason, the authors ad-
vocate that the innerbow be adjusted to allow
the face bow to be seated with minimal derotat-
ing forces. These adjustments need to be re-
peated monthly for the first 6 months as the
molars are being derotated mesiodistally. The
innerbow is expanded 3 to 4 mm beyond the
normal molar width to help expansion in this
area (Fig 7). In the cervical or combination face
bow, the innerbow and outerbow are adjusted to
be parallel to the occlusal plane (Fig 8). This
important adjustment allows the forces to be
effective sagittally while not causing undesirable
vertical forces to the molars. When the high-pull
face bow is considered necessary in the treat-
ment of the patient, the outerbow is bent in such
a fashion as to direct the forces in a more vertical
fashion (eg, 45° to the occlusal plane). The crit-
ical factor is the relationship of the resultant
force to the center of resistance of the tooth or
the maxilla depending on the effect desired on
the maxilla.
The most critical factor in successful face bow
treatment is patient compliance. Experience has
shown that if the face bow is adjusted with ap-
proximately 16 oz of force per side and the
patient will sleep in it 8 to 9 hours every night,
consistently successful Class II skeletal correc-
tion can be achieved. It is suggested that the
patient place the face bow on 1 hour before
Figure 7. Adjusting innerbow.
Home | TOC |          
Index
83
Figure 8. Outerbow parallel to innerbow, both paral-
lel to occlusal plane.
going to bed, to become accustomed to it, then
it will be more likely that the patient will not
remove the headgear during the night.
An anecdotal observation of the authors that
helps explain the apparent stimulation of man-
dibular growth is the fact that the outerbows of
the face bow prevent the patient from sleeping
on the side of his face. By sleeping on the back
of his head, the patient's mandible is "free" to
grow in a symmetric pattern. Other intraoral
orthopedic appliances do not offer this benefit.
Treatment Time
Depending on growth, patients should be pre-
pared to sleep in their face bow over a period of
12 to 18 months. If growth and compliance oc-
cur simultaneously, this time could be reduced
to as little as 6 months. Giving the patient spe-
cific instructions as to when to wear the face bow
can be helpful. An example may be to "wear the
face bow from 9 PM until 7 AM every night for the
12 months."
Research Reports
A number of studies performed by graduate stu-
dents in the Department of Orthodontics of Bay-
lor College of Dentistry have shown the effective-
ness of orthopedic correction of skeletal Class II
malocclusions by using cervical face bows. Two
studies4-5 show success in the mixed dentition
and one study reports on positive results in the
early permanent dentition.6 Three articles7-9 ver-
<<    
     Article
      >>
84 Alexander and Alexander
ify the long-term stability of Class II correction
by using the cervical face bow.
Keys to Optimal Face Bow Results
Face bow therapy has been shown to be effec-
tive, however, a successful outcome requires
cooperation, growth, and a tied-back arch
wire.
Cooperation. The face bow should be worn
consistently. Eight to 10 hours every night is
usually adequate. In extreme anteroposterior
and vertical discrepancies, more wear can be
beneficial.
Growth. If the patient is not growing, no skel-
etal changes will occur.
Tie back on continuous arch wire. If the upper
arch wire is not consolidated into one unit, the
face bow will individually tip molars distally,
resulting in the loss of effective anterior
growth expression of the mandible and possi-
ble extrusion of upper molars. In addition to
maintaining the space closure by tying back
the arch wire, the wire in the molar tube keeps
the molars upright, helping prevent their ex-
trusion.
Conclusion
When used in conjunction with three require-
ments (cooperation, growth, and tie-back), face
Home | TOC |          
Index
bow therapy in the Alexander Discipline is a
highly effective, efficient, and comfortable appli-
ance for the clinician and the patient to correct
Class II skeletal problems.
References
1. Alexander RG. The effects of tooth position and maxillo-
facial vertical growth during treatment of scoliosis with
the Milwaukee brace. Am J Orthod 1965.
2. Alexander RG. The Alexander discipline. In: Engel GA
(ed). Ormco, 1986, chap 6.
3. Alexander RG, Alexander CM, Alexander CD, et al. Cre-
ating the compliant patient. J Glin Orthod 1996;30:493-
497.
4. Plunk MD. A cephalometric evaluation of the effects of
early headgear therapy [master's thesis]. Baylor College
of Dentistry, Dallas, TX: 1985.
5. Guymon M. A cephalometric evaluation of two phase
treatment of class II, division 1 malocclusion. [master's
thesis]. Dallas, TX: Baylor College of Dentistry, 1990.
6. Romine L. A cephalometric evaluation of the effects of
cervical facebow on the craniofacial complex, [master's
thesis]. Dallas, TX: Baylor College of Dentistry, 1982.
7. Glenn G, Sinclair PM, Alexander RG. Non-extraction
orthodontic therapy: Post treatment dental and skeletal
stability. Am J Orthod 1987;92:321-328.
8. Elms T. The long-term stability of class II, division 1,
nonextraction cervical face-bow therapy: Part 1, model
analysis. Am J Orthod 1996;109:27l-276.
9. Elms T. The long-term stability of class II, division 1,
nonextraction cervical face-bow therapy: Part 2, cephalo-
metric analysis. Am J Orthod 1996;109:386-392.
<<    
     Article
      >> Home | TOC |          
Index

The Orthodontic Management of Vertical

Deficiencies in the Alexander Discipline
Remo Benedetti

Although there are several different approaches to treating vertical deficien-

cies, the Alexander Discipline is an efficient and effective technique to
manage this group of malocclusions. Patient compliance is important be-
cause most of these treatments will require orthopedic appliances. Appro-
priate bracket selection and placement for maxillary arch development is
essential. Specific arch wire designs incorporating a curve of Spee are used.
The mandibular arch is then treated, focusing on torque control of the lower
incisors while using a reverse curve of Spee in the tied-back arch wires and
a bite plate if necessary. The ideal arches are then coordinated with various
elastics as needed. Retention is then instituted. (Semin Orthod 2001;7:
85-89.) Copyright © 2001 by W.B. Saunders Company

ower anterior vertical facial deficiencies are
L often accompanied by overeruption of an-
terior teeth and undereruption of posterior
teeth. The result is an excessive curve of Spee in
the mandibular arch and a reverse curve in the
maxillary arch. This presents as an abnormally
increased overbite. The freeway space in such
cases is often excessive.
Skeletal discrepancies in the sagittal dimen-
sion can accompany vertical deficiencies. In
growing children, Class II skeletal patterns may
be treated orthopedically with headgear while
simultaneously treating the orthodontic prob-
lems. Most deep-bite cases have low-angle skele-
tal patterns and therefore a cervical headgear is
the appliance of choice in Class II patients.
Class III patterns may be treated orthopedi-
cally by using a face mask. In nongrowing pa-
tients, vertical deficiencies can be successfully
treated with appropriate orthognathic surgery.
Principles in the Treatment of Vertical
Deficiencies
Vertical deficiencies are most often corrected by
intruding the anterior teeth, extruding the pos-
Address correspondence to Remo Benedetti, MD, DDS, Via
Brigata Liguria 3/58, Genova 16121, Italy.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0702-0005$35.00/0
doi:10.1053/sodo.2001.23549
terior teeth, or a combination of the two. Vari-
ous orthodontic approaches have been advo-
cated for the management of patients exhibiting
vertical facial deficiency. The goal of the Alex-
ander Discipline was to find an efficient and
effective technique that offered as few negative
side effects as possible. After a detailed evalua-
tion, a diagnosis is made and a treatment plan is
formulated.
Factors of special importance in this philoso-
phy include the final position of the lower inci-
sors. It is considered most important by advo-
cates of this orthodontic approach to avoid the
advancement of the lower anteriors. The one
exception to this rule, however, is in the deep-
bite patient where the incisors are excessively
upright. Increasing anterior torque in both
arches is necessary to achieve a normal interin-
cisal angle.
Most deep-bite cases can be treated without
extracting teeth. In cases with severe curve
of Spee in the mandibular arch, it may be
unwise to extract second bicuspid teeth. In
cases where moderate crowding is a concern,
interproximal enamel reduction is consid-
ered. For minor crowding in Class II patients,
extraction of maxillary bicuspid teeth only
may be appropriate. Extraction of a single
mandibular incisor in a severe, lower arch
length, discrepancy situation could also be a
consideration.

Seminars in Orthodontics, Vol 7, No 2 (June), 2001: pp 85-89 85

<<    
     Article
      >>
86 Remo Benedetti
Maxillary Arch Development
Developing the maxillary arch is accomplished
by eliminating rotations, closing spaces, accen-
tuating the curve of Spee, and establishing
proper torque in the anterior teeth. The maxil-
lary arch is developed by using precision-de-
signed, preadjusted brackets that allow treat-
ment to progress efficiently and effectively (Fig
1). The system of brackets provides adequate
interbracket space, excellent rotational control
(including 15° offset on the upper first molars),
and preadjusted slots. When placing the brack-
ets on the teeth, proper height, angulation, and
mesiodistal position are of great importance.
Maxillary Bracket Height
The normal position for the maxillary bracket is
measured from the incisal edge or cusp tip to
the center of the bracket slot. In some cases, the
maxillary six anterior brackets are placed
0.5-mm more incisally and the posterior brackets
are placed 0.5-mm more gingivally.
Figure 1. Pretreatment; overbite is 6 mm (A). After 4 months, 0.016 ss heat-treated arch wire with accentuated
curve and tied back (B). Overcorrected in 17 X 25 ss finishing arch wires (C). Three months after appliances
were removed (D).
Home | TOC |          
Index
Curve of Spee
After the initial arch wire, an accentuated curve
of Spee is placed to open the bite (Fig 1). Proper
placement of the curve of Spee in the arch wire
is critical (Fig 2). The curve should be placed in
the arch wire from mesial to the Omega loop
forward to the cuspid area and not beyond. In
the flexible wires (0.016 stainless steel [ss], tita-
nium molybdenum alloy) excessive curve can be
placed to encourage bite opening. The face bow
"stabilizes" the molars while the arch wire in-
trudes or "holds" the anterior teeth as the face
grows. Care should be taken when placing a
curve in a rectangular wire because this will in-
creases the amount of torque on the upper in-
cisors. The more torque needed, the more curve
can be placed in the arch wire. Caution should
be taken when placing a curve in the finishing
0.017 X .0 25 ss arch wire because this wire
delivers a heavy force to the teeth.
When determining the amount of curve to
place in the arch wire, it is important to look at
<<    
     Article
      >>
Vertical Deficiencies
justed brackets with adequate interbracket space
Figure 2. Proper reverse curve of Spee in the man-
dibular arch wire to level arch.
the patient's "smile line." If the incision-sto
mion measurement does not show a full clinical
crown, then great care must be taken with the
amount of curve placed in the arch wire. When
gingival tissue is exposed when smiling, more
curve can be placed in the arch wire.
This technique of arch leveling is so effective
that if excessive curve is placed and not moni-
tored closely, deep bites can turn into open
bites. When this occurs, the excessive curve in
the upper arch should be removed and the arch
wire should be flattened.
The arch wire is "toed in" slightly distal to the
omega loop to help rotate and control the first
molars. All ss wires are tempered (heat-treated)
before inserting. After the initial wire, all arch
wires are tied back by using omega loops.
Bite Plate
If the bite has not opened adequately after a few
months of treatment in the finishing arch wires, a
bite plate is placed. It is not placed until the max-
illary arch form is close to completion, usually the
month before the lower brackets are placed. By
delaying bite plate placement, fewer bite plate ad-
justments are needed. The bite plate is adjusted so
that the upper teeth do not touch the lower brack-
ets on closure. An example of a bite plate in an
adult patient is shown in Figure 3.
In some cases, special lingual brackets can be
bonded to upper incisors to achieve the same
bite opening result.
Mandibular Arch Development
Treatment of the mandibular arch is initiated
approximately 6 months after the maxillary
Home | TOC |          
Index
87
brackets are placed. Precision-designed, pread-
and rotational control that will eliminate rota-
tions and close spaces while establishing torque
control in the anterior teeth are used. First mo-
lars will be uprighted and the arch leveled. Sec-
ond molars should be banded. When placing
brackets on the teeth, attention must be directed
at their proper height, angulation, and mesio-
distal position. Lower anterior brackets must not
be placed more incisally than is usual because
this would result in premature contact with the
maxillary incisors when occluding.
In the mandibular arch, if torque needs to be
controlled, the initial arch wire must be rectan-
gular. Torque in the incisor brackets is —5°. The
first molars have —6° tip in the brackets to up-
right them. After the initial arch wire, all wires
are tied back. A reverse curve of Spee is placed
to level the arch.
Coordination of the Arches
After developing both arches, they must be co-
ordinated. Both the maxillary and mandibular
arch forms are established by using the Alex-
ander Archform Template (ORMCO, 1717 W.
Collins Ave, Orange, CA). The maxillary first
molars have been derotated and mandibular sec-
ond molars have been constricted. Curves of
Spee have been placed in the arch wires to level
the arches.
Since fewer arch wires are needed because of
the interbracket space, each wire can remain in
the patient's mouth for longer periods of time. It is
important to get into the finishing arch wires
quickly and allow time for the arch wire to deliver
their forces (Alexander Discipline Principle #13).
The action of the curve in the arch wire takes time
to be effective. If the overbite is not opening ade-
quately, the arch wire may be removed after 2 to 4
months for recontouring and/or increasing the
amount of curve in it.
Elastics
Elastics are used to further coordinate the
arches. It is important to remember that no
elastics should be used until finishing arch wires
are in place (with some exceptions). To help
level the mandibular arch, box elastics can be
used in the bicuspid area. Class II and midline
elastics are used after the overbite approximates
<<    
     Article
      >>
88 Remo Benedetti
normal if the headgear has not resolved the
Class II condition.
Proper interincisal angle should be established
with the normal overjet and an overcorrected
overbite. Finishing elastics2 are used to finalize
the posterior occlusion for long-term stability
Retention
Retention for vertically deficient patients is sim-
ilar to that of other patients except that a bite
plate is placed on the maxillary retainer and is
adjusted so that the posterior teeth are just out
of occlusion. The patient sleeps in the retainer
for 2 to 3 years. The mandibular cuspid-to-cus-
pid bonded 0.0215 multistranded wire can be
worn indefinitely.
Stability
The most important aspect is stability of the
treated malocclusion. Long-term studies per-
formed on patients treated by Alexander re-
ported that, "overbite and overjet were reduced
significantly with treatment and were seen to be
stable following orthodontic treatment."3 Elms4
stated that, "overall, the treatment effects re-
mained stable 6.5 years following retention and
9 years following treatment."
A study focusing exclusively on the leveling
Home | TOC |          
Index
Figure 3. An example of use of a bite plate in an adult
patient. Pretreatment (A), during treatment with bite
plate in place (B), after treatment (C).
of the mandibular arch in patients who had an
excessive curve of Spee was carried out.5 Car-
cara5 concluded that the Alexander Discipline
is an effective continuous arch wire technique
for leveling the curve of Spee in Class II, Divi-
sion I deep-bite cases treated by nonextraction
in which the initial curve of Spee is 2 to 4 mm.
Conclusion
Precision control of intraoral and extraoral
forces makes this system work efficiently. The
entire arch is banded/bonded simultaneously,
eliminating the need for sectional mechanics
and excessive arch wire changes. The bracket
design allows larger and suffer wires with a
curve to be placed earlier. The stored-up en-
ergy of the arch wire in the interbracket spaces
allows it to be active over a longer period of
time. Maxillary molars are controlled with 15°
rotational offset, and slight toeing in of the
arch wire eliminates the need for a transpala-
tal arch. Tying back of the arch wires prevents
flaring and spacing of the maxillary anterior
teeth and maintains the arch length. When
using rectangular arch wires, it also allows the
maxillary incisor roots to tip lingually while
some bodily intrusion takes place, thereby
opening the bite.
Leveling the maxillary arch first provides
<<    
     Article
      >>
Vertical Deficiencies
easier bracket placement later on in the man-
dibular arch. The —5° torque of the mandib-
ular incisors and —6° tip of the mandibular
first molars are effective in controlling the
incisor position and leveling the mandibular
arch. Fewer arch wire changes and longer in-
tervals between appointments make this tech-
nique very efficient.
Final results show correction of overbite,
torque control of the incisors, good interincisal
angle, upright mandibular molars, a level man-
dibular arch, and maintenance of the mandibu-
lar plane angle.
Home | TOC |          
Index
89
References
1. Dake ML. A comparison of the Ricketts and Tweed-type
arch leveling techniques. Am J Orthod 1989;95:72-78.
2. Alexander RG. The Vary Simplex Discipline-Part 4 count-
down to retention. J Glin Orthod 1983;18.
3. Glenn G. Nonextraction orthodontic therapy: Posttreat-
ment dental and skeletal stability. Am J Glin Orthod
1987;92:321-328.
4. Elms TN. Long-term stability of Class II, Division I, non-
extraction cervical face-bow therapy: II. Cephalometric
analysis. Am J Orthod 1996;109:386-392.
5. Carcara SJ. Leveling the curve of Spec with a continuous
archwire technique. A long-term study cast analysis [mas-
ter's thesis]. Buffalo, NY: State University of New York,
1998.
<<    
     Article
      >> Home | TOC |          
Index

The Relationship Between the Curve of Spee,

Relapse, and The Alexander Discipline
Sal Carcara, C. Brian Preston, and Ossama Jureyda

Exaggerated curves of Spee are frequently observed in dental malocclusions

that present with deep vertical overbites. During orthodontic treatment
such excessive curves of Spee are usually leveled and, in most instances,
this leveling will result in a reduction of the anterior overbite. The Alexander
Discipline provides a good example of modern straight-wire orthodontic
techniques that purport an ability to treat abnormal variations in the depth
of the occlusal plane. The records of 31 randomly selected patients treated
by nonextraction with the Alexander Discipline were studied. The results
show that the Alexander Discipline levels the curve of Spee in Class II,
Division I deep-bite cases and that when relapse occurs, the curve of Spee
returns to a lesser extent than was present before orthodontic treatment.
With the Alexander Discipline, a pretreatment curve of Spee that is not
completely level posttreatment has a slightly higher incidence and magni-
tude of relapse than a pretreatment curve of Spee that is completely level
posttreatment. This study indicated that, based on the pretreatment curve
of Spee, there is no ability to predict relapse in mandibular intercanine
width, overbite, overjet, mandibular incisor irregularity, and arch length in
Class II, Division I deep-bite cases treated with the Alexander Discipline.
(Semin Orthod 2001;7:90-99.) Copyright © 2001 by W.B. Saunders Company

Exaggerated curves of Spee1'2 are frequently
observed in dental malocclusions that
present with deep vertical overbites. As a part of
orthodontic treatment, such excessive curves of
Spee are usually leveled during orthodontic
treatment, and, in most instances, this leveling
will, in turn, result in a reduction of, if present,
deep anterior overbites. Clinicians who adhere
to the Tweed1 philosophy of orthodontic treat-
ment use continuous arch wires that incorporate
reverse curves of Spee to produce flat occlusal
planes. Accordingly, arch leveling occurs mostly
by an extrusion of the lower premolar teeth in
conjunction with a minimal intrusion of the
mandibular incisor teeth. In contrast to the ear-
From the Department of Orthodontics, State University of New
York at Buffalo, Buffalo, NY; and Private practice, New York, NY.
Address correspondence to C Brian Preston, BDS, Dip Orth, M
Dent, PhD, Department of Orthodontics, School of Dental Medicine,
Squire Hall, 3435 Main St, Buffalo, NY 14214-3008.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0702-0006$35.00/0
doi:10.1053/sodo.2001.23550
lier approach, advocates of sectional arch orth-
odontic mechanics2'3 treat deep curves of Spee
by intrusion of mandibular incisors while, usu-
ally, allowing the lower premolars to erupt into
occlusion.
A review of the literature reveals that there is
disagreement among the proponents of the var-
ious orthodontic techniques that are used to
level deep curves of Spee.4-8 The discussion re-
volves around which leveling technique pro-
duces the most effective overbite correction as
well as the most stable long-term treatment out-
comes. Those orthodontists who primarily use
sectional arches to produce flat occlusal planes
believe that leveling with continuous arch wires
tends to extrude the posterior teeth, which, in
most instances, will cause an increase in the
lower facial height. They further believe that, in
individuals with strong muscles of mastication,
the orthodontically extruded buccal segments
will tend to relapse after the orthodontic treat-
ment.4'5'9 This relapse would lead to the recur-
rence of anterior deep bites. When a reverse

90 Seminars in Orthodontics, Vol 7, No 2 (June), 2001: pp 90-99

<<    
     Article
      >>
The Curve of Spee, Relapse, and the Alexander Discipline
curve of Spec is placed in a continuous arch wire
for the purpose of arch leveling, this results in
an almost automatic tendency for the mandibu-
lar incisors to flare labially.10'11 Contrary to this
viewpoint, Ferguson12 states that a reverse curve
of Spee in an arch wire does not in itself cause
the lower incisor teeth to flare unless the arch is
allowed to act beyond the stage at which the
occlusal plane is flat. Orthodontists who use
Tweed's leveling technique6'13'15 argue that the
extrusion of premolars and molars provides a
stable change while, on the other hand, the
intrusion of the lower incisors often relapses to
produce an increased overbite.
Radiographic cephalometric studies showed
that both the Ricketts and modified Tweed tech-
niques can successfully correct deep dental over-
bites.16'17 These studies concentrated on over-
bite correction only and neither analyzed study
models to evaluate how effectively the curves of
Spee were leveled, nor did they evaluate the
long-term stability of the results that were pro-
duced.
The present article reflects the findings of a
study that was designed to evaluate the long-
term outcomes of a representative sample of
orthodontic patients who were treated accord-
ing to the Alexander Discipline. Irrespective of
the philosophy and mechanical principles of the
orthodontic technique used, one of the primary
objectives of orthodontic treatment is to obtain a
level occlusal plane.18 In this article, leveling will
be defined as the process of bringing the incisal
edges of the anterior teeth and the buccal cusp
tips of the posterior teeth into the same horizon-
tal plane.19
The anatomic definition of the anteroposte-
rior curve of occlusion is generally accepted by
orthodontists as describing the curve of
Spee.20"24 Some studies in the orthodontic liter-
ature propose other ways to define and measure
the curve of Spee on orthodontic study mod-
els.25"27 Three-dimensional digitizers25'26 have
been used to calculate the depth of the mandib-
ular curve of Spee mathematically. Koyama,27 in
a more practical approach to the problem, used
a caliper to measure the curvature of the occlu-
sal plane in both jaws and found the greatest
pretreatment depth of the curvature to be lo-
cated in the bicuspid region.
In a mechanical sense, the presence of a
curve of Spee may make it possible for a denti-
Home | TOC |          
Index
91
tion to resist the forces of occlusion during mas-
tication.28"33 Although several theories have
been proposed to explain the presence of a
curve of Spee in natural dentitions, its role dur-
ing normal mandibular function has been ques-
tioned.29-34'35 It has been proposed that an im-
balance between the anterior and the posterior
components of occlusal force can cause the
lower incisors to overerupt, the premolars to
infraerupt, and the lower molars to be mesially
inclined.36'37 According to Root28 and Fidler et
al,38 when a skeletal open bite is not present, the
curve of Spee in Class II malocclusions is deeper
than in other malocclusions. Although an exag-
gerated curve of Spee is often observed in Class
II, Division I relationships, it is not unique to this
type of malocclusion.39
Andrews18 noted that the occlusal planes in
120 nonorthodontically treated and ostensibly
normal occlusions varied from being generally
flat to having a slight curve of Spee. This finding
led him to believe that the presence of a curve of
Spee could be associated with postorthodontic
treatment relapse. Andrews concluded, "even
though not all of the orthodontic normals had
flat planes of occlusion, I believe that a flat plane
should be a treatment goal as a form of over-
treatment."18 A deep curve of Spee may make it
almost impossible to achieve a Class I canine
relationship18'28 though it may also result in oc-
clusal interferences that will manifest during
mandibular function.32-34
To date, there are little or no data that quan-
tify the amount of arch leveling that occurs with
orthodontic treatment, or the long-term, pos-
torthodontic treatment relapse of the curve of
Spee. It is perhaps worthwhile noting that very
little research has been undertaken to deter-
mine the most effective, and stable, method of
leveling a deep curve of Spee.
Numerous studies have been performed to
quantify the amount and type of postretention
relapse that occurs after orthodontic treat-
ment.6'15"17'38'42"52 In general, these studies have
noted posttreatment increases in overjet, over-
bite, mandibular incisor crowding, along with
decreases in arch length and arch width. Inves-
tigations have also been undertaken to deter-
mine whether untreated normal occlusions un-
dergo the same changes that are observed in
treated cases.50-51 At the same time, very little
research has been performed to evaluate the
<<    
     Article
      >>
92 Carcara, Preston, andjureyda
long-term stability of leveling the curve of Spee,
and few, if any, studies have attempted to corre-
late the pretreatment curve of Spee with postre-
tention changes in other aspects of the occlu-
sion.
The primary purpose of the present investi-
gation was to determine the effectiveness of the
Alexander continuous arch wire technique in
leveling the curve of Spee in Class II, Division I
deep bite cases. A second purpose of the study
was to determine the long-term stability of the
leveling of the curve of Spee achieved with the
Alexander Discipline. A third objective of the
research was to determine whether a relation-
ship exists between the presence of a deep curve
of Spee before orthodontic treatment and the
relapse that takes place in a number of occlusal
traits. The traits studied included the mandibu-
lar intercanine width, overbite, overjet, mandib-
ular incisor irregularity, and arch length.
The sample for this retrospective study con-
sisted of 31 patients, 22 female and 9 male,
randomly selected from the records of orth-
odontic patients treated in the private practice
of Dr. R.G. "Wick" Alexander, in Arlington,
Texas. The average age of the patients at the
start of treatment was 12 years and 6 months.
The average treatment time for the sample was 2
years and 1 month whereas the average time
from Tl to T2 record taking was 2 years and 5
months. Each case was treated by nonextraction
and met specific criteria for inclusion in the
study. These selection criteria included the pres-
ence of a Class II skeletal (ANB > 4°) and at
least a half-cusp Class II molar relationship, an
overbite of 50% or greater as measured from the
initial (Tl) study models, and a curve of Spee
measuring 2 mm or more.37 Only cases with
complete records were selected for this study.
These records consisted of dental casts taken
pretreatment (Tl), post-treatment (T2), and
postretention (T3). The posttreatment (T2)
records were taken 2 months after debonding at
a mean age of 14 years and 11 months. The final
(T3) records were taken at an average of 7 years
and 5 months after the removal of the fixed
retainer, which was at an average of 11 years and
5 months after the debonding of the patient. All
31 patients were treated by a single operator, Dr.
R.G. "Wick" Alexander, who used a fully pread-
justed fixed orthodontic appliance with a 0.018"
slot size according to the Alexander Discipline.
Home | TOC |          
Index
Dr. Alexander's patients were selected for this
study because he is the recognized authority for
this technique, a goal of his treatment is to level
any curve of Spee that is present in the mandib-
ular arch, and complete long-term records were
available for the present study.
The Alexander technique was also selected
for this study, over other preadjusted appliance
techniques, because of its unique prescription,
and its biomechanical principles that assist with
mandibular incisor control during arch leveling.
The unique features of the prescription include
a —5° torque built into the mandibular incisor
bracket base to maintain the lower incisors up-
right over the basal bone. In addition, a —6°
distal tip is incorporated into the mandibular
first molar buccal tube to facilitate molar up-
righting,1 and to create arch length to help re-
duce lower incisor flaring. The early use of rect-
angular wire, as is required in this system, makes
it easier, than is the case with some other orth-
odontic techniques, to control the position of
the lower incisors from the outset of treatment.
After the initial leveling phase of treatment
the upper and lower first arch wires are replaced
with "working arch wires" constructed from
0.016 X 0.022 inches or 0.017 X 0.025 inches
stainless steel. The maxillary arch wire has an
accentuated curve of Spee, and the mandibular
arch wire has a reverse curve of Spee, placed into
it to facilitate arch leveling. Other than the ini-
tial arch wires, all remaining arch wires include
omega loops placed 1 to 2 mm anterior to the
first or second molar tubes. These omega loops
allow all of the arch wires, after the initial arch
wires, to be actively tied back with 0.014-inch
stainless steel ligatures. The finishing arch wires
in both arches are constructed from 0.017 X
0.025 inch stainless steel wires. The upper and
lower arch wires are bent to incorporate an ac-
centuated or a reverse curve of Spee respec-
tively. A goal of the Alexander technique is to
have the 0.017 X 0.025 inch stainless steel fin-
ishing arch wire placed in both arches as early as
possible during treatment. The early placement
of this relatively heavy lower arch wire makes it
possible for the curve of Spee to be flat during
most of the active treatment. Each stainless steel
arch wire is heat-treated before insertion to in-
crease the stiffness of the wire.53 At the end of
treatment the bands are removed and retention
appliances are inserted. In all of the 31 patients
<<    
     Article
      >>
The Curve of Spee, Relapse, and the Alexander Discipline
selected for this study the mandibular canine-to
canine fixed retainer was removed after the
third molars were either extracted or had
erupted normally into occlusion. This occurred
at a mean time of 3 years and 4 months after
appliance removal. At the time of the removal of
the fixed retainer, selective interproximal strip-
ping was performed on each patient to decrease
the tendency for relapse of lower incisor crowd-
ing.42
Three sets of study casts (Tl, T2, and T3)
were collected for each of the 31 randomly se-
lected patients. The 93 sets of study models were
each assigned a random number that made it
possible for a single investigator to measure each
set in a random blind fashion. The curve of Spee
in this study was measured in the mandibular
buccal occlusion between the center of the in-
cisal edge of the central incisor anteriorly and
the distobuccal cusp tip of the first molar poste-
riorly.27 By using a standard palatometer (GPM,
Switzerland), the depth of the curve of Spee was
measured on each side of the mandibular arch
as being the vertical distance from the buccal
cusp tip of the most infraoccluded premolar, to
the occlusal plane previously described.27
The curves of Spee were measured on both
the left, and the right, sides of each of the 93
mandibular models included in this study. The
resulting sets of 93 left and 93 right measure-
ments were compared statistically by means of a
paired t test. The results indicated that there
were no significant statistical differences (P >
.05) between these pairs of measurements, curve
of Spee on the right side versus curve of Spee on
the left side, for each of the 31 patients at Tl,
T2, and T3. The average of the right and left
curves of Spee for each patient at the three
different time intervals was therefore used for
further definitive statistical analysis and compar-
ison.
The following measurements were made by a
single operator in a random blind fashion and
directly on study casts for each patient at three
time intervals (Tl, T2, T3): mandibular interca-
nine width,46 overbite,46 overjet,46 mandibular
incisor irregularity index,43 and mandibular
arch length.44
To test whether the curve of Spee remained
unchanged from Tl to T2, and from T2 to T3,
paired t tests were calculated. To compare the
incidence of relapse (T2-T3) of the curve of
Home | TOC |          
Index
93
Spee in the patients that were completely level at
T2 with those that were not completely level at
T2, a two-sample t test was calculated to compare
the proportion of relapse occurrence. To com-
pare the magnitude of relapse (T2-T3) of the
curve of Spee in the patients that were com-
pletely level at T2 with those that were not com-
pletely level at T2, two independent samples' t
test was calculated.
The treatment effects (Tl vs. T2) and relapse
(T2 vs. T3) of five variables (mandibular inter-
canine width, overbite, overjet, mandibular inci-
sor irregularity, and arch length), were calcu-
lated with paired t tests. A Pearson correlation
coefficient and regression analysis was then per-
formed to determine the predictive power of the
pretreatment curve of Spee (Tl) on the relapse
of the five variables studied (T2-T3).
The mean pretreatment (Tl) curve of Spee
for the 31 patients included in this study was
2.41 mm with a standard deviation of ± 0.48 mm
and a range of 2.00 to 3.75 mm. The mean
posttreatment (T2) curve of Spee for this sample
was 0.11 mm with a standard deviation of ± 0.19
mm and a range of 0.00 to 0.50 mm. The differ-
ences between the pretreatment (Tl) and post-
treatment (T2) curves of Spee were highly
statistically significant (P< .0001). It was con-
cluded that in this sample of patients a mean-
ingful degree of arch leveling was achieved with
the Alexander Discipline.
The mean treatment-induced reduction in
the curve of Spee was 2.30 mm with a standard
deviation of ± 0.47 mm. The range of reduction
of the depth of the curve of Spee from Tl to T2
was 1.50 to 3.75 mm. This corresponds to a
95.43% average reduction in the curve of Spee
during treatment. Twenty-two of the 31 patients
studied (approximately 71%) were completely
(100%) level after treatment (T2), whereas 9
patients (approximately 29%) had a residual
curve of Spee at the end of the orthodontic
treatment.
The mean posttreatment (T2) curve of Spee
for the 31 patients treated with the Alexander
Discipline was 0.11 mm with a standard devia-
tion of ± 0.19 mm and a range of 0.00 to 0.50
mm. The mean postretention (T3) curve of
Spee for this sample was 0.48 mm with a stan-
dard deviation of ± 0.50 mm and a range of 0.00
to 1.75 mm. The mean increase in the curve of
Spee from T2 to T3 was 0.37 mm with a standard
<<    
     Article
      >> Home | TOC |          
Index

94 Carcara, Preston, andjureyda

deviation of ± 0.40 mm and a range of 0.13 to
1.25 mm. The differences between the posttreat-
ment (T2) and postretention (T3) curves of
Spec, though small, were statistically significant
(P< .0001).
The posttreatment (T2) curve of Spee data
for the sample (N = 31) revealed two subpopu-
lations. Twenty-two patients at T2 had curves of
Spee that were completely leveled whereas nine
patients had residual curves of Spee at this time.
A comparison of the occurrence of relapse in
the curves of Spee in these two subpopulations
was calculated by using a two-sample t test. The
results of this test revealed that there was a sta-
tistically significant difference (P < .05) in the
occurrence of relapse of the curve of Spee in
these two subpopulations. A statistically greater
occurrence of relapse (88.9% vs. 50%, P< .05)
was seen between those patients that were com-
pletely leveled at T2 and those that were not
A comparison of the magnitude of relapse in
the curve of Spee that takes place in these two
groups between posttreatment and postreten-
tion was calculated by using two independent
samples' t test. The results of this test revealed a
statistically significant difference (P < .0001) in
the amount of relapse of the curve of Spee in
these two subpopulations (P< .0001). Eleven of
22 patients that were completely level at T2 sub-
sequently relapsed an average of 0.28 mm at T3,
which is equal to a relapse of 11.68% of the Tl
curve of Spee. By comparison, eight of the nine
cases that were not completely leveled at T2
relapsed an average of 0.39 mm at T3, which is
equal to 22.46% of the Tl curve of Spee.
The overall mean period of the time that
elapsed from taking the initial records (Tl) to
taking the final records (T3) was 14 years and 4
months with a range of 7 to 28 years, 8 months.
Over this period (T1-T3) the overall effect on
the curve of Spee was an average reduction of
-1.93 mm, which represents a mean 80.62%
reduction in the original depth of this curve.
The means and standard deviations for each
of the five variables measured on the study casts
(mandibular intercanine width, overbite, over-
jet, mandibular incisor irregularity, and arch
length) at Tl, T2, and T3 are reported in Table
1. The means and standard deviations for treat-
ment changes (T2-T1), posttreatment changes
(T3-T2), and overall changes (T1-T3) are
shown in Table 2.
Mandibular Intercanine Width
A total of 77.5% of the cases showed statistically
significant increases in the mandibular interca-
nine width during treatment (x = +1.37 mm,
P = .0002). The same 24 cases (77.5%) in which
intercanine widths were increased during treat-
ment showed a marginally significant postreten-
tion reduction (x = —0.62 mm, P = .0505) in
their intercanine widths. It should be noted that
when the mandibular fixed cuspid-to-cuspid re-
tainer was removed, interproximal enamel re-
duction was performed.
Overbite
In all 31 patients, the overbite was reduced sig-
nificantly during treatment (x = —2.67 mm, P<
.0001). In 74% of the cases the overbite in-
creased significantly postretention (x = +0.75
mm, P < .0001). The posttreatment mean over-
bite was 2.09 mm, and the postretention mean
overbite was 2.84 mm.
Overjet
In all 31 cases the overjet was reduced signifi-
cantly during treatment (x = —4.09 mm, P <
.0001). In 87.1% of the cases the overjet in-
creased significantly postretention (x = +1.09

Table 1. Pretreatment (Tl), Posttreatment (T2), and Postretention (T3) Model Measurements
Pretreatment (Tl) Posttreatment (T2) Postretention (T3)
Measure (mm) Mean SD Mean SD Mean SD
Mandibular width intercanine 25.75 2.1 26.11 1.4 25.5 2.36
Overbite 4.76 0.95 2.09 0.65 2.84 0.85
Overjet 6.27 2.97 2.18 0.56 3.27 0.93
Mandibular incisor irregularity 3.97 3.35 0.31 0.46 1.28 1.35
Arch length 62.22 4.64 64.01 3.17 61.85 3.41
Abbreviation: SD, standard deviation.
<<    
     Article
      >>
The Curve of Spee, Relapse, and the Alexander Discipline
Table 2. Treatment, Posttreatment, and Total Changes in Model Measurements
Treatment Changes
(T2-T1)
Measure (mm) Mean
Mandibular intercanine width 1.37
Overbite -2.67
Overjet -4.09
Mandibular incisor irregularity -3.66
Arch length 1.79
Abbreviation: SD, standard deviation.
mm, P < .0001). The posttreatment mean over-
jet was 2.18 mm and the postreten tion mean
over] e t was 3.27 mm.
Irregularity Index
The mean pretreatment incisor irregularity was
3.97 mm; 54.5% of cases had minimal irregular-
ity52 before treatment (<3.5 mm), 35.5% had
moderate incisor irregularity (3.5-6.5 mm), and
9.0% had severe incisor irregularity (>6.5 mm).
Treatment produced a significant decrease in
the incisor irregularity (x = -3.66 mm, P <
.0001). Incisor irregularity increased signifi-
cantly posttreatment (x = +0.98 mm, P <
.0001). However, 90% of cases at T3 had mini-
mal incisor irregularity, and 10% had moderate
irregularity. All 31 cases showed a net improve-
ment in incisor irregularity from Tl to T3.
Arch Length
A total of 64.5% of the cases showed a slightly
significant increase in arch length because of
treatment (x = +1.79 mm, P = .04) whereas
87.1% of the cases showed a significant decrease
in arch length postretention (x = —2.16, P <
.0001).
The Pearson correlation coefficient was cal-
culated by comparing the Tl curve of Spee with
the posttreatment changes (T3-T2) observed
for each of five variables (mandibular interca-
nine distance, overbite, overjet, mandibular in-
cisor irregularity, and arch length) and revealed
no statistical correlation (P > .05). Follow-up
regression analyses revealed no ability to predict
relapse in any of the five factors mentioned ear-
lier based on the Tl curve of Spee (P > .05).
Discussion
The important contribution that leveling the
curve of Spee makes toward the success of orth-
Home | TOC |          
Index
95
Posttreatment Total Changes
Changes (T3-T2) (T3-T1)
SD Mean SD Mean SD
1.85 -0.62 1.69 0.75 2.38
1.05 0.75 0.89 -1.92 1.06
2.96 1.09 0.84 -3.00 2.93
3.25 0.98 1.19 -2.69 2.94
4.57 -2.16 2.11 -0.37 4.42
odontic treatment has been well documented in
the literature.18'19'25-28-32'34'40 There is, however,
no general agreement as to the most appropri-
ate biomechanical principles that should be
used to accomplish stable long-term arch level-
ing. Two important studies have been per-
formed to compare the use of sectional versus
continuous arch leveling mechanics in the treat-
ment of deep-bite cases.16'17 Dake and Sinclair16
in a comparison of Ricketts' and Schudy's treat-
ments of adolescent Class II deep-bite low-angle
nonextraction cases, concluded that both oper-
ators' techniques were effective in overbite cor-
rection, and that these changes remained stable
after an average posttreatment period of 4 years
and 6 months.
Weiland et al,17 in a study of 50 adult low-
angle deep-bite cases, concluded that in adult
patients the Burstone45 segmental arch tech-
nique is superior to conventional continuous
arch wire techniques when arch leveling by inci-
sor intrusion is indicated. The earlier-men-
tioned studies16'17 compared the effectiveness of
overbite correction as measured on cephalomet-
ric radiographs. Neither study used study models
to measure the curve of Spee nor to measure the
effectiveness or long-term stability of leveling the
curve of Spee. The present study was prompted
by the recognition of a need for a long-term
study-model analysis of the effectiveness and sta-
bility of leveling the curve of Spee.
Findings reported in the literature dealing
with the stability of orthodontic treatment are
often contradictory, in large part, because of the
fact that investigators group malocclusions that
require different treatment strategies together.
Further, the orthodontic records that are used
in outcomes studies often belong to patients
who were treated by both experienced and inex-
perienced operators. It is also an unfortunate
fact that detailed outcomes goals are not regu-
<<    
     Article
      >>
96 Carcara, Preston, andjureyda
larly established for orthodontic patients before
the start of their treatment. Lastly, assessments
of relapse are often qualitative and do not allow
for quantitative comparison. By defining strict
guidelines for the selection of cases treated by a
single experienced operator with clearly defined
goals, the present study attempted to overcome
at least some of the earlier shortcomings.
The effectiveness of arch leveling achieved
with the Alexander Discipline was determined
by comparing Tl and T2 curve of Spee data by
using a paired t test. Results of the paired t test
indicated a statistically significant change (P <
.0001) in the curve of Spee during treatment. It
was concluded that the Alexander Discipline is
an effective preadjusted continuous arch wire
technique for leveling a curve of Spee in Class II,
Division I nonextraction deep-bite cases in
which the initial curve of Spee was in the range
of 2 to 4 mm. Seventy-one percent of the cases
studied were leveled completely, whereas 29%
had a slight residual curve of Spee at T2. For the
latter cases the mean curve of Spee remaining at
the end of treatment was 0.11 mm. A residual
curve of Spee of 0.11 mm is probably clinically
insignificant based on the qualitative observa-
tions of the posttreatment study models. The T2
models all exhibited Class I molar and canine
relationships with properly finished buccal oc-
clusions, and normal overjets and overbites.18
A question that cannot be answered by this
study is how the curve of Spee was leveled. Sev-
eral investigators4'5'9'10'11'16'17 have reported on
the negative effects of continuous arch wire me-
chanics. These effects include a flaring of the
lower incisors, an extrusion of the mandibular
molars, and an opening of the occlusal mandib-
ular plane. Some features of the Alexander Dis-
cipline, including the —5° of torque in the lower
incisors and the — 6° of distal tip in the mandib-
ular molars, are specific and probably unique
among the preadjusted appliance prescriptions.
These unique features, along with biomechani-
cal principles such as the use of heat-treated
arch wires with omega stops tied back to the
molar tubes, could play a role in preventing the
untoward side effects seen with some other
straight-wire techniques.
The long-term stability of arch leveling
achieved with the Alexander Discipline was de-
termined by comparing the T2 and T3 curve of
Spee data by using a paired t test. A statistically
Home | TOC |          
Index
significant change (P < .0001) was seen in the
curves of Spee after the removal of the mandib-
ular retention appliances. The curves of Spee
increased from a mean of 0.11 mm posttreat-
ment to a mean of 0.48 mm postretention. In
other words, the curve of Spee relapsed on av-
erage 0.37 mm over a period of 7 years and 5
months after the fixed lingual canine-to-canine
mandibular retainer was removed. Although the
relapse in the curve of Spee may be statistically
significant, it has been explained, in a clinical
sense, by several investigators as being a normal
physiologic process.18-27'31'32 It was concluded
that the Alexander Discipline efficiently "over
treats" Class II, Division I deep-bite malocclu-
sions so that when the relapse occurs the curve
of Spee returns to a lesser extent than was ini-
tially present. The overall long-term (T1-T3)
effect of orthodontic treatment with the Alex-
ander Discipline is an average of 80.62% reduc-
tion in the pre treatment curve of Spee. Twelve
of the 31 cases studied remained 100% level over
a time span of 5 to 25 years after the conclusion
of orthodontic treatment. This study shows that
in this sample the observed relapse of the curve
of Spee (x — 0.48 mm) was minimal and that it
occurred slowly over an extended period of
time. The effects of this degree of relapse of the
curve of Spee are probably clinically insignifi-
cant with regard to proper mandibular function,
esthetics, and occlusion.
The results of a two-sample t test used to
compare the proportion of relapse that took
place revealed a significant difference in the
incidence of relapse that occurred in the 22
cases that were completely leveled at the end of
treatment (T2) and the 9 cases that were not
(P < .05). In addition, the results of the two
independent samples' t tests also revealed a sig-
nificant difference in the magnitude of relapse
that occurred in the 22 cases that were com-
pletely leveled and the 9 cases that were not (P <
.0001). Half of the 22 cases that were completely
leveled at the end of treatment showed some
relapse at T3. The amount of this relapse was
11.68% of the original curve of Spee (Tl) or
0.28 mm. In contrast, eight of nine (88.9%) of
the cases that were not completely leveled at T2
relapsed, and the amount of relapse was 22.46%
(0.39 mm) of the original curve of Spee. It was
concluded that in those cases treated with the
Alexander Discipline that were not completely
<<    
     Article
      >>
The Curve of Spee, Relapse, and the Alexander Discipline
leveled posttreatment, there is a slightly higher
incidence and magnitude of relapse than in
those cases that were completely leveled.
To establish whether significant treatment
and posttreatment changes had taken place in
mandibular intercanine width, overbite, overjet,
mandibular incisor irregularity, and arch length,
preliminary statistical analyses were performed.
Paired t tests were calculated to compare the
pretreatment and posttreatment data and the
posttreatment and postretention data.
For each of the five variables measured from
the study casts, statistically significant changes
occurred during treatment with the Alexander
Discipline (P< .05). An evaluation of the effects
of treatment on these five variables was not the
primary goal of this research project. The find-
ings did, however, detect that in association with
the treatment there was a general decrease in
overbite, overjet, and incisor irregularity, and an
increase in mandibular intercanine width and
arch length. With one exception, arch length,
these results are similar to those reported by
Elms et al.46 The increase in the arch length
during orthodontic treatment that was observed
in the present study was not statistically signifi-
cant in the Elms et al46 study. In the present
study, four of the five variables (overbite, overjet,
incisor irregularity, and arch length) showed sta-
tistically significant (P < .05) posttreatment
changes. In the present study, the mandibular
intercanine width showed marginally significant
(P = .0505) posttreatment changes. Although it
was not a major goal of this study to investigate
the relapse of mandibular occlusal traits, signif-
icant posttreatment changes were detected for
all five variables studied. Although these results
are similar to those found by Elms et al,46 the
posttreatment changes noted for overbite, over-
jet, and the irregularity index were marginally
greater in the present study than are those re-
ported by Elms et al.46
Most of the posttreatment changes noted in
the mandibular intercanine width and arch
length were small and probably reflect normal
physiologic changes that occur with increasing
age, as reported in the literature.44'50'51 It must,
however, not be overlooked that overexpansion
of the intercanine arch width in the mandible is
a potential source of relapse after orthodontic
treatment. Although a statistically significant
posttreatment increase in incisor irregularity was
Home | TOC |          
Index
97
observed, it is a fact that 90% of the cases at T 3
had minimal incisor irregularity (<3.5 mm), 52
and all 31 cases showed a net improvement in
mandibular incisor crowding from Tl to T3.
The increase in the posttreatment overbite
may be attributed to a physiologic gradual re-
turn of the curve of Spee over time, as well as to
other factors such as attrition and overeruption
of the maxillary incisors. The latter parameters
were not investigated in this study and, further-
more, it should be emphasized that the changes
in overbite noted in this study were less than
previously reported.27
The posttreatment changes in the overjet that
were noted in this study were not much different
than those reported previously for Class II, Divi-
sion I malocclusions.16'17'47 It is important to
emphasize the fact that very few studies dealing
with posttreatment orthodontic changes have
used postretention records that could match this
sample in the length of time covered (x = 11
years and 5 months; range: 7 years to 28 years
and 8 months). In this respect the longer pos-
tretention time span of the cases included in this
study provided more time for posttreatment re-
lapse to take place.
Because it was shown that relapse had oc-
curred in the five variables previously men-
tioned, a Pearson correlation coefficient was cal-
culated to compare the pretreatment curve of
Spee with the posttreatment changes observed
for each of the five variables studied. The results
of this test revealed that no statistical correlation
existed between the original curve of Spee and
each of the five factors of relapse (P > .05).
Follow-up regression analyses revealed no ability
to predict relapse in mandibular intercanine
width, overbite, overjet, mandibular incisor ir-
regularity, and arch length based on the depth
of the pretreatment curve of Spee. It should be
noted that in each of these cases, interproximal
enamel reduction was performed on the man-
dibular anterior teeth. The variable with the
highest correlation was overjet r = -0.268), yet
only 7.2% of the variability seen in the overjet
change can be accounted for by the pretreat-
ment curve of Spee (r2 = 0.072). It is possible
that if a sample with larger pretreatment curves
of Spee were studied, a positive correlation
could be seen between the larger pretreatment
curves of Spee, and the relapse in other aspects
of the occlusion posttreatment.
<<    
     Article
      >>
98 Carcara, Preston, andjureyda
Although this study has shown the clinical
effectiveness of using continuous arch wire me-
chanics to level the curve of Spee, it must be
kept in mind that not every straight-wire appli-
ance has the unique prescription that is part of
the Alexander Discipline, namely the —5°
torque in the mandibular incisor and the —6°
distal tip built into the molar tubes. These
unique appliance features may play a large role
in allowing for an effective, and controlled, man-
dibular arch leveling as shown in this study. In
addition, the mechanical principles of actively
tying back a heat-treated curved arch wire may
contribute to the success of the arch leveling
achieved with the Alexander Discipline. It is un-
wise to assume that every straight-wire appliance,
using continuous arch wire mechanics to level
the curve of Spee, will be as successful as the one
studied here. Furthermore, this study investi-
gated the cases of not only an experienced cli-
nician but also the authority on the Alexander
Discipline.
Because only study models were evaluated,
this investigation was unable to ascertain the
exact process by which the curve of Spee is lev-
eled with the continuous arch wire mechanics of
the Alexander Discipline. Also, the exact process
by which the slight relapse of the curve of Spee,
noted in this study, occurred was not ascer-
tained. A comprehensive cephalometric ap-
praisal of the mechanism of arch leveling and
relapse of the curve of Spee in this sample has
been undertaken by Bernstein.54 Additionally,
study model and cephalometric investigations of
the curve of Spee leveling process by using inci-
sor intrusion mechanics should also be per-
formed. If the sample of such a study is carefully
matched to the present one, valid comparisons
could be made to ultimately determine the most
effective biomechanics necessary to level the
curve of Spee and to maintain it level in the long
term.
Conclusions
1. The Alexander Discipline is an effective con-
tinuous arch wire technique for leveling the
curve of Spee in Class II Division I deep-bite
cases treated by nonextraction in which the
initial curve of Spee is 2 to 4 mm.
2. The Alexander Discipline efficiently over-
treats a pretreatment curve of Spee of 2 to 4
Home | TOC |          
Index
mm in Class II Division I deep-bite cases
such that when relapse occurs, the curve of
Spee returns to a lesser extent than was
present before orthodontic treatment.
3. Postreten tion changes in overbite, overjet,
and irregularity index were small and
showed net improvement.
4. With the Alexander Discipline, a pretreat-
ment curve of Spee of 2 to 4 mm that is not
completely level posttreatment has a slightly
higher incidence and magnitude of relapse
than a pretreatment curve of Spee that is
completely level posttreatment.
5. There is no ability to predict relapse in man-
dibular intercanine width, overbite, overjet,
mandibular incisor irregularity, and arch
length in Class II Division I deep-bite cases
treated with the Alexander Discipline based
on the pretreatment curve of Spee.
References
1. Tweed CH. Clinical orthodontics. St. Louis: CV Mosby,
1966, pp 84-180.
2. Ricketts RM. Bioprogressive therapy as an answer to
orthodontic needs. Part I. Am J Orthod 1969;70:241-268.
3. Ricketts RM. Facial and denture changes during orth-
odontic treatment as analyzed from the temperoman-
dibular joint. Am J Orthod 1955;41:163-167.
4. Wylie WL. Overbite and vertical facial dimensions in
terms of muscle balance. Angle Orthod 1944;14:13-17.
5. Bench RW, Gugino CF, HilgersJJ. Bioprogressive ther-
apy. Part 2. J Glin Orthod 1977;ll:661-682.
6. Merritt J. A cephalometric study of the treatment and
retention of deep overbite cases [master's thesis]. Hous-
ton, TX: University of Texas, 1964.
7. Schudy FF. The association of anatomical entities as
applied to clinical orthodontics. Angle Orthod 1966;36:
190-203.
8. Graber TM. Orthodontics: Principles and practice. Phil-
adelphia: W.B. Saunders, 1969.
9. Otto RL, Anholm JM, Engel GA. A comparative analysis
of intrusion of incisor teeth achieved in adults and chil-
dren according to facial types. Am J Orthod 1980;77:437-
446.
10. Berman MS. Straight wire myths-BJO Interview. Br J
Orthod 1988;151:57-61.
11. Woods M. A reassessment of space requirements for
lower arch leveling. J Glin Orthod 1986;20:770-778.
12. Ferguson JW. Lower incisor torque-the effects of rectan-
gular archwires with a reverse curve of Spee. Br J Orthod
1990;17:311-315.
13. Schudy FF. Cant of the occlusal plane and axial inclina-
tion of teeth. Angle Orthod 1963;23:69-82.
14. Schudy FF. Vertical growth versus antero-posterior
growth as related to function. Angle Orthod 1964;34:
756-793.
15. Lett RL. Overbite correction and relapse as analyzed by
<<    
     Article
      >>
The Curve of Spee, Relapse, and the Alexander Discipline
some cephalometric and treatment related variables
[master's thesis]. Minneapolis, MN: University of Min-
nesota, 1969.
16. Dake ML, Sinclair PM. A comparison of the Ricketts and
Tweed-type arch leveling techniques. Am J Orthod 1989;
95:72-78.
17. Weiland FJ, Bartleon HP, Droschl H. Evaluation of con-
tinuous arch and segmented arch leveling techniques in
adult patients: A clinical study. Am J Orthod 1996;! 10:
647-652.
18. Andrews LF. The six keys to normal occlusion. Am J
Orthod 1972;9:296-309.
19. Baldridge DW. Leveling the curve of Spee: Its effect on
mandibular archlength. J Glin Orthod 1969;64:26-41.
20. Spee FG. The gliding path of the mandible along the
skull. J Am Dent Assoc 1980;100:670-675.
21. Gysi A. The problem of articulation. Dental Cosmos
1910;52:1-19, 148-169.
22. Christensen C. The problem of the bite. Dental Cosmos
1905;47:1184-1195.
23. Orthlieb J. The curve of Spee: Understanding the sagit-
tal organization of mandibular teeth. J Craniomandib
Pract 1997;15:333-340.
24. The Academy of Prosthodontics. Glossary of prosth-
odontic terms. J Prosthet Dent 1994;7l:50-112.
25. Germane N, Staggers JA, Rubenstein L, et al. Arch
length consideration due to the curve of Spee: A math-
ematical model. Am J Orthod 1992;102:251-255.
26. Braun S, Hnat WP, Johnson BE. The curve of Spee
revisited. Am J Orthod 1996;! 10:206-210.
27. Koyama T. A comparative analysis of the curve of Spee
(lateral aspect) before and after orthodontic treatment-
with particular reference to overbite patients. J Nihon
Univ Sch Dent 1979;21:25-34.
28. Root T. Level anchorage. Monrovia, CA: Unitek Corp,
1988.
29. Sicher H. Oral anatomy. St. Louis: CV Mosby, 1949.
30. Hemley S. Orthodontic theory and practice (ed. 2). New
York: Grune and Stratton, 1953.
31. Wheeler RC. A textbook of dental anatomy and physiol-
ogy (ed. 2). Philadelphia: W.B. Saunders, 1950.
32. Ash MM. Wheeler's dental anatomy, physiology and oc-
clusion (ed. 6). Philadelphia: W.B. Saunders, 1984.
33. OsbornJW. Orientation of the masseter muscle and the
curve of Spee in relation to crushing forces on the molar
teeth of Primates. Am J Phys Anthropol 1993;92:99-106.
34. Dawson P. Evaluation, diagnosis and treatment of occlu-
sal problems. St. Louis: CV Mosby, 1974.
35. Diamond M. Dental anatomy (ed. 3). New York: McMil-
lan, 1952.
36. Strang RH. A textbook of orthodontia (ed. 3). Philadel-
phia: Lea and Feibiger, 1950.
37. Gresham H. A manual of orthodontics. Christ Church,
New Zealand: N.M. Peryer, 1957.
Home | TOC |          
Index
99
38. Fidler BC, Artun J, Joondeph DR, et al. Long-term sta-
bility of angle class II, Division I malocclusions with
successful occlusal results at the end of active treatment.
Am J Orthod 1995;107:276-285.
39. Braun ML, Schmidt WG. A cephalometric appraisal of
the curve of Spee in class I and class II division I occlu-
sion for males and females. Am J Orthod 1956;42:255-
278.
40. Hellsing E. Increased overbite and craniomandibular
disorders-a clinical approach. Am J Orthod 1990;98:516-
522.
41. McNamara JA, Seligman DA, Okeson JP. Occlusion,
orthodontic treatment, and temporomandibular disor-
ders: A review. J Orofac Pain 1995;9:73-90.
42. Williams R. Eliminating lower retention. J Glin Orthod
1985;22:342-349.
43. Little RM. The irregularity index: A quantitative score of
mandibular anterior teeth. Am J Orthod 1975;68:554-
563.
44. Bishara SE, Jakobsen JR, Treder JE, et al. Changes in the
maxillary and mandibular tooth-size-archlength rela-
tionship from early adolescence to early adulthood.
Am J Orthod 1989;l:46-59.
45. Burstone CJ. The mechanics of the segmental arch tech-
nique. Angle Orthod 1966;36:99-120.
46. Elms TN, Buschang PH, Alexander RG. Long-term sta-
bility of class II division I nonextraction cervical face-bow
therapy: I. Model analysis. Am J Orthod 1996;109:271-
276.
47. Glenn, G, Sinclair PM, Alexander RG. Nonextraction
orthodontic therapy: Postreatment dental and skeletal
stability. Am J Orthod 1987;92:321-328.
48. Little RM, Reidel RA, Artun J. An evaluation of changes
in mandibular anterior alignment from 10 to 20 years
post-retention. Am J Orthod 1988;5:423-428.
49. Puneky PJ, Sadowsky C, BeGole EA. Tooth morphology
and lower incisor alignment many years after orthodon-
tic therapy. Am J Orthod 1984;10:299-305.
50. Sinclair PM. Little RM. Maturation of untreated normal
occlusion. Am J Orthod 1983;2:114-123.
51. DeKock WH. Dental arch depth and width studied lon-
gitudinally from 12 years of age to adulthood. Am J
Orthod 1972;62:56-66.
52. Little RM, Wallen TR, Reidel RA. Stability and relapse of
mandibular anterior alignment-first premolar cases
treated by traditional edgewise orthodontics. Am J
Orthod 1981;80:349-364.
53. Alexander RG. The Alexander Discipline, contemporary
concepts and philosophies. Glendora, CA: Ormco, 1986.
54. Bernstein: Leveling the curve of Spee with a continuous
archwire technique-A long-term cephalometric analysis
[master's thesis]. Buffalo, NY: University of Buffalo,
1999.
<<    
     Article
      >> Home | TOC |          
Index

An Extraction Approach to Borderline Tooth

Size to Arch Length Problems in Patients
With Satisfactory Profiles
J.C. Boley

Patients with mild to moderate tooth size to arch length discrepancies

(TSALD), and profiles on the full side of the satisfactory range ("borderline"
patients), can be treated with the extraction of premolars without a detri-
mental effect on the face. Pre- and posttreatment facial photographs of 51
consecutively treated four second premolar extraction patients were judged
by 95 laypersons. Their assessment was that the "mouth area" of these
patients was improved or not adversely affected 92% of the time. The
stability of borderline patients treated with extractions of premolars was
determined to be well within clinically accepted standards (<3.5 mm, Little's
irregularity index [II]) 85% of the time. The 23 patients studied were found to
have a mean II of 2.83 mm 12-years postretention. Various treatment tech-
niques used in these types of problems are discussed. Examples and the
results achieved with various approaches are shown. (Semin Orthod 2001;7:
100-106.) Copyright © 2001 by W.B. Saunders Company

tudies have shown that the Alexander Disci-
S pline is an effective technique in treating
nonextraction patients.1"3 One long-term study4
has shown excellent stability in extraction pa-
tients. The author's philosophy of treatment is
similar to the Alexander Discipline, but being
more Tweed-oriented, a higher percentage of
extraction cases are treated. There is still consid-
erable debate as to whether to extract or not to
extract teeth. This article describes an alterna-
tive treatment for borderline extraction patients.
One of the many perplexing problems in
orthodontics is how best to treat patients who
have mild to moderate tooth size to arch length
discrepancy (TSALD) and a satisfactory facial
profile. A major concern is whether a nonextrac-
tion approach (ie, an increase in arch perime-
ter), will contribute to unsatisfactory long-term
postretention stability or whether an extraction
From Baylor College of Dentistry, an Institution of the Texas
A&M University, System Health Science Center, Richardson, TX.
Address correspondence to J.C. Boley, DDS, MS, 400 S. Cotton-
wood Dr, Richardson, TX 75080.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0702-0007$35.00/0
doi:10.1053/sodo.2001.23551
solution will produce an unsatisfactory face
and/or smile. Another consequence of a nonex-
traction approach may be the proclination of
anterior teeth to an extent that strain and full-
ness of the lips will result.
This article describes how patients with mild
(3 to 5 mm) of TSALD and profiles on the full
side of the satisfactory range can be treated with
premolar extraction. The patients whose profiles
fall into this category can usually have their man-
dibular incisors retracted 1 or 2 mm, usually to
cephaltometric norms, without a detrimental ef-
fect on their face.
Four second premolars are usually the extrac-
tions of choice in this anchorage-losing situa-
tion. This extraction pattern has been discussed
often and well.5'14
One of the more recent and extensive studies
of borderline patients was by Paquette et al.15
They studied similar borderline Class II, Division
1 patients treated with extractions of premolars
and without any extractions. At recall, 14.5-years
posttreatment, half of the nonextraction pa-
tients and three quarters of the extraction pa-
tients exhibited satisfactory (<3.5 mm) mandib-
ular incisor irregularity with mean values of 3.4

100 Seminars in Orthodontics, Vol 7, No 2 (June), 2001: pp 100-106

<<    
     Article
      >>
Extraction Approach
mm and 2.9 mm, respectively. The extraction
patients cephalometric readings approximated
the Steiner ideals. The nonextraction patients'
profiles were 2 mm fuller, yet their appearance
was rated no more highly than the extraction
subjects. These findings enhance the option of
extraction treatment for the borderline patients.
To determine if extracting four second pre-
molars has a negative effect on the face, 51
consecutively treated four second premolar ex-
traction patients were studied.16 Pretreatment
and posttreatment facial photographs, as de-
picted in Fig 1, were judged by 95 laypersons.
The judges were asked which mouth area they
liked best. The findings indicated that facial es-
thetics were improved or not negatively effected
for 92% of the patients. This study supports
findings that indicated that extraction treatment
is not detrimental to facial esthetics.17"31 The
laypersons' evaluations of the patient in Fig 1 are
presented in Table 1.
Another factor of significance is the stability
of borderline patients treated with extractions.
The irregularity index (II)32 is the measurement
Figure 1. Example from Laypersons Facial Prefer-
ence Survey. Patient had 3 mm of crowding re-
solved by extracting four second premolars with-
out a detrimental effect on her facial features,
according to the judges. Pretreatment (A), postreat-
ment (B).
Home | TOC |          
Index
101
Table 1. Laypersons Facial Preference
Pretreatment 16.7%
Posttreatment 37.5%
No preference 45.8%
Posttreatment or no preference 83.3%
NOTE. The laypersons evaluation of the patient in Fig. 1
were as follows: 16.7% preferred the pretreatment face;
37.5% preferred the posttreatment face; 45.8% had no pref-
erence (ie, they perceived no significant improvement or no
significant negative effect from treatment). Therefore,
83.3% (37.5% + 45.8%) of the laypersons gave this patient
a favorable (preferred the posttreatment or no preference)
evaluation. She is one of the 92% of patients judged favor-
ably by the laypersons.
system most commonly used in studies evaluat-
ing relapse and stability. It is the sum of the
distance of the contact points adjacent to each
other, measured from the mesial of one canine
to the mesial of the other. It is a quantitative
method of measuring the amount of irregularity
in the anterior segment. It is not the same as
TSALD.
A subsample of 20 borderline extraction pa-
tients (Class I occlusion with TSALD of less than
6 mm and satisfactory faces) from Franklin's
thesis33 were found to have an II of 2.83 mm
(standard deviation [SD] 2.0) approximately 12-
years postretention. An II of 3.5 mm is consid-
ered to be satisfactory. A total of 85% fell into
the satisfactory category of less than 3.5 mm and
none were in the severe category of more than
6.5 mm. Figure 2 depicts a patient from this
stability study. These findings were similar to
those of Paquette et al.15
In a borderline case, if an extraction ap-
proach is chosen, losing posterior anchorage is a
priority. An evaluation of which teeth to extract,
the mechanics used, and the monitoring of the
progress is as critical as that of maximum an-
chorage problems. Similar principles are used in
all anchorage evaluations. There are degrees of
anchorage-loss problems just as there are de-
grees of anchorage-conservation problems. A to-
tal space analysis34 is a way to analytically decide
on a treatment approach. This analysis takes into
account the amount of space required to resolve
TSALD, correctly positioning the mandibular in-
cisors for best esthetics while also being compat-
ible with stability and leveling of the curve of
Spee. Embracing the concept of treating to ac-
cepted cephalometric norms for the mandibular
incisor (Frankfort mandibular incisor angle
[FMIA], lower incisor to point A-Pogonion line
<<    
     Article
      >>
102 /.C. Boley
[L1APO], lower incisor to Nasion-point B line
[LlNB]) is, in most instances, critical to this
extraction procedure. The exceptions are those
instances in which clinical judgment overrides
the guidelines of incisor position. A realization
that retracting the mandibular incisors 1 or 2
mm in slightly full profiles will not flatten the
profile to an objectionable extent permits ex-
traction in patients with mild TSALD.
Once the total discrepancy (as determined by
the total space analysis performed as indicated
earlier) is established, a decision must then be
made on how best to resolve the problem. Par-
amount is how to gain the space required to
resolve the discrepancy when using a nonextrac-
tion approach, or how to eliminate the excess
space when an extraction approach is selected.
The teeth of choice for extraction in the min-
imal anchorage patient are most often the four
second premolars. In some instances, upper first
premolars may be chosen. The extractions may
be performed in the permanent dentition, late
mixed dentition, or as the termination of a serial
extraction procedure.
Biomechanical techniques that can be used in
various situations include:
1. Sectional arches to close the extraction sites
completely or only sufficient space closure
for alignment of the anterior teeth.
2. Placing a closing-loop arch wire pitting the
first molar against the teeth anterior to the
extraction site.
3. Not banding or bonding second molars or
waiting until the end of treatment to do so.
4. Closing extraction space in one arch at a
time.
5. The use of intra-arch elastics.
6. Extraoral anchorage-reverse facial mask.
Home | TOC |          
Index
7. Extra distal root tip in first premolars and
canines.
8. Delay extracting the upper second premo-
lars until the lower spaces are closed.
The following two case reports show some of
the more commonly used techniques and when
to use them. The appliance used was an 0.022 X
0.028 set up, but similar in other respects to the
Alexander Discipline prescription.
Patient 1
A typical patient who represents those with slight
crowding (4 mm) and slight protrusion (1-2
mm) of mandibular incisors (illustrated in Figs
3-10 and Table 2). These patients typically have
a total discrepancy of 5 to 7 mm. They have
profiles that will be satisfactory with the mandib-
ular incisors left in their original position or
uprighted and retracted up to 2 mm after the
TSALD is resolved. The mechanics are very sim-
ple. Extract the four second premolars then
align, level, and close spaces with closing-loop
arch wires. Arch wires used in an 0.022 edgewise
appliance are maxillary and mandibular 0.016
NiTi or 0.016 stainless steel (ss); 0.020 ss; man-
dibular closing loop 0.019 X 0.026 ss and max-
illary closing loop 0.021 X 0.025 ss; mandibular
ideal arch 0.021 X 0.025 ss. Finishing in the
maxillary arch can be accomplished with the
closing-loop arch wire. Often in this type of pa-
tient the only teeth initially banded after the
extraction of the second premolars are the max-
illary and mandibular first molars and first pre-
molars. The extraction spaces are closed com-
pletely or nearly so by using an 0.017 X 0.025
sectional arch wires. These sectionals can be a
closing loop or a continuous segment using
Figure 2. Pretreatment
and 8-year postretention
lower occlusal casts from
stability study. This pa-
tient had an II of 1.74 mm
8 years after the termina-
tion of retention. Note
the similar arch forms in
1977 (pretreatment) (A)
and 1990 (postretention),
(B).
<<    
     Article
      >> Home | TOC |          
Index

Extraction Approach 103

Figure 3. Patient #1: Pretreatment facial photo-

graphs showing slightly full satisfactory profile. Figure 4. Patient #1: Pretreatment mandibular oc-
clusal model showing a -4 mm TSALD.

Table 2. Total Space Analysis-Patient #1

Model discrepancy -4.0 mm
Head film discrepancy -2.0 mm
Curve of Spec —0.5 mm
Total discrepancy — 6.5 mm
NOTE. The amount of space needed to resolve the crowd-
ing, level the curve of Spec, and position the mandibular
incisors for facial balance and stability. Model discrepancy
equals the mandibular arch perimeter minus the mesial-
distal width of the teeth (TSALD). Head film discrepancy
equals the amount of arch length used when the mandibular
incisors are uprighted. For this patient, the mandibular in-
cisors are to be uprighted 1 mm or 2.5°.
Figure 5. Patient #1: Pretreatment cephalometric
tracing showing that mandibular incisors can be
uprighted slightly (1 mm).

Figure 6. Patient #1: Posttreatment facial photo- Figure 7. Patient #1: Posttreatment occlusal cast
graphs showing satisfactory facial esthetics. shows maintenance of original arch form.
<<    
     Article
      >>
104 J. C. Boley
Figure 8. Patient #1: Superimposition of pre- and
posttreatment cephalograms showing minimal re-
traction of anterior teeth.
power chains buccally and lingually. The re-
maining teeth are bonded for alignment, level-
ing, and finishing. Approximately 8 oz of Class II
elastics are worn as needed, usually 8 to 12 hours
per day or more.
Patient 2
This patient shows a serial extraction approach
when minimal movement of the mandibular in-
Figure 9. Patient #1: Occlusion at 1-year 4-months
postreatment (A and B).
Home | TOC |          
Index
Figure 10. Patient #2: Pretreatment facial photo-
graph reveals a profile on the full side of the satis-
factory range.
cisor is desired (Figs 10-16). In such cases, a
serial extraction procedure is started with the
extraction of all four deciduous canines. In the
late mixed dentition, all four second premolars
are enucliated, or maxillary first premolars are
extracted and the mandibular second premolars
are enucliated. The remaining teeth are allowed
to fully erupt. Usually few irregularities or spaces
remain. Alignment, leveling, and detailing is ac-
complished with maxillary and mandibular
0.016 NiTi or 0.016 ss, 0.020 ss, and 0.021 X
0.025 ss ideal arch wires. Elastics are worn as
needed, though, most often, little elastic wear is
required.
Conclusion
With proper diagnosis and mechanics, all but
the most minimal borderline patients can be
treated with extraction of four second premolars
without detrimental effects on the face. Such a
strategy eliminates the risk to stability and facial
Figure 11. Patient #2: Posttreatment facial photo-
graphs document the good facial balance.
<<    
     Article
      >> Home | TOC |          
Index

Extraction Approach 105

esthetics that increasing mandibular arch length

may cause.
The concern the public and our specialty
should have is not that of extracting in border-
line patients, but of treating the more severe
borderline and/or true extraction patients by
using a nonextraction approach. The possibility
of relapse in these patients, treated by a nonex-
traction procedure, may be greatly increased. An
additional concern when using a nonextraction
approach in these patients is the creation of a
bimaxillary protrusion. Our goal should be to
give our patients a beautiful smile and a healthy,
Figure 12. Patient #2: The mandibular occlusal cast
stable dentition that will last a lifetime without a shows crowding in the incisors but no TSALD.
lifetime of retention, whether treated by the
extraction or nonextraction approach.

Figure 13. Patient #2: Panoramic radiograph at

band-bond of maxillary arch reveals the space clo-
sure after serial extraction. Figure 14. Patient #2: Superimposition of pre- and
posttreatment cephalometric tracings show virtu-
ally no movement in the mandibular incisors.

Figure 15. Patient #2: Posttreatment occlusal cast Figure 16. Patient #2: Occlusion 3-years postreten-
shows maintenance of original arch form. tion.
<<    
     Article
      >>
106
References
1. Glenn G, Sinclair PM, Alexander RG. Nonextraction
orthodontic therapy: Posttreatment dental and skeletal
stability. Am J Orthod 1989;92:321-328.
2. Elms T, Buschang PH, Alexander RG. Long term stabil-
ity of Class II Division l, nonextraction cervical-pull
facebow therapy: Part I Model analysis. Part II Cephalo-
metric analysis. Am J Orthod 1996;109:271-279; 109:386-
392.
3. Verser S. The transverse stability of combined rapid
palatal expansion and lip bumper therapy following
comprehensive orthodontic treatment [master's thesis].
Dallas, TX: Baylor University College of Dentistry; 1996.
4. Alexander JM. A comparative study of orthodontic sta-
bility in Class I extraction cases [master's thesis]. Dallas,
TX: Baylor University College of Dentistry; 1995.
5. Nance H. The removal of second premolars in orth-
odontic treatment. Am J Orthod 1949;35:685-696.
6. Dewel BF. Second premolar extraction in orthodontics:
Principles, procedures, and case analysis. Am J Orthod
1951;41:107-120.
7. Schwab DT. Extraction effects on the dental profile in
borderline cases. Angle Orthod 1963;33:120-122.
8. Schwab DT. The borderline patient and tooth removal.
Am J Orthod 197l;59:126-145.
9. Schoppe RJ. An analysis of second premolar extraction
procedures. Angle Orthod 1964;34:292-302.
10. De Castro N. Second-premolar extraction in clinical
practice. Am J Orthod 1974;65:115-137.
11. Schudy FF. The bimetric system. In: Schudy FF (ed). The
occlusal plane and the vertical dimension. Houston: D.
Armstrong, 1992, pp 275-326.
12. Joondeph DR. Second premolar serial extraction. Am J
Orthod 1976;69:169-184.
13. Logan L. Second premolar extraction in Class I and
Class II. Am J Orthod 1973;63:115-147.
14. Garlington M, Logan L. Vertical changes in high man-
dibular plane cases following enucleation of second pre-
molars. Angle Orthod 1990;60:263-268.
15. Paquette DE, Beattie JR, Johnston LE. A long term com-
parison of nonextraction and premolar extractions
edgewise therapy in "borderline" Class II patients. Am J
Orthod 1992;102:1-14.
16. Boley J. An extraction approach for borderline patients.
The Edward H. Angle Society of Orthodontists, South-
west Component Meeting. Phoenix, AZ, September
2000.
17. Drobocky O, Smith R. Changes in facial profile during
orthodontic treatment with extraction of four first pre-
molars. Am J Orthod 1989;95:220-230.
18. Young T, Smith R. Effects of orthodontics on facial
profile: A comparison of changes during nonextraction
Home | TOC |          
Index
J. C. Boley
and four premolar extraction treatment. Am J Orthod
1993;103:452-458.
19. Johnson D, Smith R. Smile esthetics after orthodontic
treatment with and without extraction of four first pre-
molars. Am J Orthod 1995;108:162-167.
20. Luppanapornlarp S, Johnston L. The effects of premo-
lar-extraction: A long-term comparison of outcomes in
"clear-cut" extraction and nonextraction Class II pa-
tients. Angle Orthod 1993;63:257-272.
21. Rushing SE, Silberman S, Meydrech E, et al. How den-
tists perceive the effects of orthodontic extraction on
facial appearance. J Dent Assoc 1995;126:769-772.
22. Mackley R. An evaluation of smiles before and after
orthodontic treatment. Angle Orthod 1993;63:183-190.
23. Conlin R. Finished cases and their faces. J Glin Orthod
1989;23:751-754
24. Staggers J. A comparison of results of second molar and
first premolar-extraction treatment. Am J Orthod 1990;
98:430-436.
25. Stromboni Y. Facial aesthetics in orthodontic treatment
with and without extractions. Eur J Orthod 1979;!:201-
206.
26. Bishara S, Cummins D, Jakobsen J, et al. Dentofacial and
soft tissue changes in Class II Division I cases treated with
and without extractions. Am J Orthod Dentofacial Or-
thop 1995;107:28-37.
27. Bishara S, Cummins D, Zäher A. Treatment and Post-
treatment changes in patients with Class II Division I
malocclusion after extraction and nonextraction treat-
ment. AmJ Orthod Dentofacial Orthop 1997;lll:18-27.
28. James RD. A comparative study of facial profiles in ex-
traction and nonextraction treatment. Am J Orthod
1998;! 14:265-276.
29. Boley J, Pontier J, Smith S, et al. Facial changes in
extraction and nonextraction patients. Angle Orthod
1998;68:539-546.
30. Bowman J, Johnston L. The esthetic impact of extraction
and nonextraction treatments on Caucasian patients.
Angle Orthod 2000;70:3-10.
31. Zierhut EC, Joondeph DR, Artun J, et al. Long term
profile changes associated with successfully treated ex-
traction and nonextraction Class II Division I malocclu-
sions. Angle Orthod 2000;70:208-219.
32. Little RM. The irregularity index: A quantitative score of
mandibular anterior alignment. Am J Orthod 1975;68:
554-563.
33. Franklin S. A longitudinal study of dental and skeletal
parameters associated with stability of orthodontic treat-
ment (thesis). Toronto: University of Toronto, Faculty of
Dentistry, 1995.
34. Merrifield LL. Differential diagnosis with total space
analysis. J Charles H Tweed Int Found 1978;6:10.
<<    
     Article
      >> Home | TOC |          
Index

Treatment of Class III Malocelusions in the

Alexander Discipline
Shinji Takagi and Yasuhiko Asai

In the diagnosis and treatment planning of Class III malocclusions, a distinc-

tion must be made between pseudo- and true Class III skeletal patterns. The
optimal time to initiate treatment is an important consideration. The Alex-
ander Discipline treatment mechanics includes the face mask, chin cap.
Class III elastics, and/or lip bumper and rapid palatal expansion. In the
nongrowing patient, surgical options are used. The clinical treatment of two
patients are presented. (Semin Orthod 2001;7:107-116.) Copyright© 2001 by
W.B. Saunders Company

n excellent treatment result is most difficult populations, reported to be approximately be-

A to achieve in Class III malocclusions of skel-
etal origin. A Class III skeletal pattern can be the
tween 4% to 13%.1

result of three possible growth patterns, maxil-

lary deficiency, mandibular excess, or a combi-
nation of both.
In many Caucasian Class III malocclusions,
the maxilla is deficient in the sagittal dimension.
In addition, the maxilla may also have a vertical
excess (VME) or a vertical maxillary deficiency
(VMD). The Class III VME is among the most
difficult orthodontic malocclusions to treat.
Most clinicians believe that mandibular growth
cannot be altered orthopedically. In the authors'
opinion, the most successful approach in the
nonsurgical treatment of Class III malocclusions
is to advance and/or lengthen the maxilla.
Although the treatment plan for Caucasian
and Asian patients is generally the same, certain
differences must be appreciated. The incidence
of Class III malocclusions is greater in Asian
From Smile Orthodontic Clinic, Hokuyoh-Ekimae, Chuoh-ku,
Sapporo, Japan; and Gifu, Japan.
Address correspondence to Shinji Takagi, DDS, Smile Orthodon-
tic Clinic, Hokuyoh-Ekimae, Bldg 9F, N4W3, Chuoh-ku, Sapporo,
060-0004, Japan.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0702-0008$35.00/0
doi:10.1053/sodo.2001.23555
Diagnosis and Treatment Planning
Before treatment, an accurate diagnosis is essen-
tial. Discussion with parents can assist in the
determination of any genetic skeletal patterns. A
distinction must be made between a pseudo- and
true Class III skeletal pattern. Cephalometric
evaluation by using measurements such as the
ANB angle, the angle of convexity (NPo), and
the WITS reading, will assist in this differentia-
tion. In some instances, however, it may be dif-
ficult to determine which is the offending jaw.
The soft-tissue profile may assist in the differen-
tial diagnosis.
Anterior crossbites may be the result of the
mandible sliding forward into a centric occlu-
sion relationship. Clinically, a useful test is to
manipulate the mandible to be sure that the
patient is closing into a centric relation bite. If
the mandible can be manipulated to allow the
anterior teeth to touch "end-on" (Figs 1 and 2),
it is more likely that a pseudo-Class III maloc-
clusion is present. Pseudo-Class III malocclu-
sions respond well to face mask therapy.
Treatment Timing
To control or alter the skeletal pattern nonsur-
gically, the patient must have growth remaining.

Seminars in Orthodontics, Vol 7, No 2 (June), 2001: pp 107-116 107

<<    
     Article
      >>
108 Takagi and Asai
Figure 1. Patient in centric occlusion showing an
anterior crossbite.
Class III malocclusions of mandibular origin of-
ten continue to grow over a prolonged period of
time and beyond that normally anticipated for
craniofacial growth. It is important to inform the
patient and/or parent that, regardless of the
mechanotherapy used, if growth is unfavorable,
a surgical treatment may become necessary.
In a study on the timing of Class III treatment,
Kassisieh2 evaluated the skeletal response to
maxillary protraction therapy on 52 patients.
These patients were divided into three age
Figure 3. VME patient with horizontal elastic force.
Home | TOC |          
Index
Figure 2. "End-on" bite in centric relation of pa-
tient in Figure 1.
groups, less than 7.5 years of age, 7.5 to 9.5 years
of age, and greater than 9.5 years of age.
In comparing these results with a control
group, the protraction group showed 1.5- to
2.0-mm of anterior maxillary displacement. Age-
related differences in response to protraction
therapy were not significant for maxillary or
mandibular horizontal movements. Significant
differences were observed for vertical move-
ments, with the youngest age group showing the
Figure 4. VMD patient with vertical elastic force.
<<    
     Article
      >> Home | TOC |          
Index

Class III Malocclusion 109

Figure 5. Lingual arch (LA) in upper arch (A). Lip bumper (LB) in lower arch (B). Initial lateral intraoral view
with anterior crossbite (C). Crossbite correction by LA, LB, and Class III elastics (D). .016 x .022 stainless
steel arch wire (4 months later) (E).

Figure 6. Case 1: pretreatment facial and intraoral photographs.

<<    
     Article
      >> Home | TOC |          
Index

110 Takagi and Asai

Table 1. Case 1: Arch Wire Sequence, Individual

Forces, and Retainer
Archwire Sequence

Upper Lower
016 NiTi 2 mo None 7 mo
016 X 016 ss 3 mo 014 NiTi 2 mo
016 X 022 ss 11 mo 016 X 0.16 NiTi 4 mo
017 X 025 finishing 8 mo 016 X 022 ss 6 mo
017 X 025 5 mo
finishing
Individual forces Retainer
Protractor 24 mo Wraparound in
upper
Chin cap 24 mo 3 X 3f i x e di n
lower
Elastics: up and down 4 mo Chin cap

emphasized that the Class III growth pattern can

Figure 7. Case 1: Pretreatment cephalometric trac-
ing.
greatest maxillary inferior displacement, and
subsequent mandibular downward and back-
ward rotation.
Based on these findings, the earlier a patient
begins treatment the better the response to the
face mask will be. In most situations, the best
time to treat Class III patients is when they first
see the orthodontist. However, when consider-
ing treating Asian patients in the primary denti-
tion, it should be noted that it may be difficult to
predict growth. Often an anterior crossbite in
the primary dentition, will self-correct as the
permanent anterior teeth erupt. It must be re-
be very unpredictable.3'7
Face Mask Therapy
It may be prudent to encourage growing pa-
tients to attempt face mask therapy when advis-
able. A surgical treatment option may, however,
become necessary. An assessment of vertical re-
lationships is important to ensure appropriate
direction of face mask elastic force application.
The Alexander Discipline dictates that to ob-
tain orthopedic and dentoalveolar changes, the
elastic forces from the face mask should be at-
tached to a consolidated, tied-back arch wire.
The elastic attachment from the face mask is
usually to the ball hooks on the maxillary lateral
incisors. The direction of force is determined by
cephalometric analysis.8'11 VME cases should

Figure 8. Case 1: Treat-

ment sequence. Lingual
B arch .016 NiTi and .016 x
.022 NiTi in maxillary
arch (A). .016 x .022
stainless steel in maxil-
lary arch, .014 NiTi
in mandibular arch (B).
.017 x .025 stainless steel
in maxillary arch, .016 x
.022 stainless steel in
mandibular arch (C).
<<    
     Article
      >> Home | TOC |          
Index

Class III Malocclusion Ill

have the elastic vector as parallel to the occlusal
plane as possible (Fig 3). VMD cases should have
a vector of 45° in relation to the occlusal plane
(Fig 4).
The amount of elastic force begins with 150
g/elastic per side, this increases for the next two
appointments until it reaches approximately
500 g. This force is then held constant. Because
a dentoalveolar movement as well as orthopedic
effect is taking place during this therapy, the
patient is instructed to wear the appliance as
much as possible. A minimum of 14 hours per
day is needed. The goal is to create a positive
overjet of approximately 5 mm, and then slowly
reduce the hours of wear per day, and then the
number of days the appliance is worn.
As in any orthopedic correction, each patient
varies in response to treatment, however, gener-
ally the patient can expect to wear the face mask
for at least 6 to 12 months.
The Chin Cap
Used for many years in Asia, a chin cap is less
effective than the face mask. Today it is used
during the maintenance phase of a two-phase
treatment or to help "hold" the mandible during
retention after full treatment has been com-
pleted.
Class III Elastics
The use of Class III elastics can be effective in
dentoalveolar compensation by tipping the an-
terior teeth. To a lesser degree the authors be-
lieve that if used in conjunction with 0.017 X
0.025 stainless steel with a tied-back arch wire in

Figure 9. Case 1: Posttreatment facial and intraoral photographs.

<<    
     Article
      >> Home | TOC |          
Index

112 Takagi and Asai

the 0.018 slot, elastics can produce some ortho- cant discrepancies, a possible solution is the ex-
pedic correction. traction of upper second bicuspid and lower first
bicuspid teeth. Generous use of Class III elastics
The Lip Bumper while closing spaces will help slide the upper
Lower molars can be uprighted and distalized molars mesially while tipping the lower anteriors
slightly by attaching Class III elastics to a lip lingually. Through dental compensation, the fi-
bumper.12'13 The result is an improvement in the nal occlusion will have a Class I cuspids and
molar relationship as well as gaining 3 to 4 mm molar relationship. If the maxillary arch has less
of arch length (Fig 5). crowding, an appropriate decision may be to
The Alexander Discipline bracket prescrip- extract teeth only in the mandibular arch.
tion,14 specifically the -5° torque in the lower Class III elastics will tip the lower anteriors
incisors and the -6° tip in the lower first molars, lingually and possibly flare the upper anteriors.
when supported with Class III elastics, is very The final occlusion will have a Class I cuspid
effective in tipping the mandibular teeth poste- relationship, but maintain a Class III molar re-
riorly. lationship. The major concern with this occlu-
sion is that, if no lower third molars are present,
Rapid Palatal Expansion and the Face Mask the upper second molars could be out of occlu-
sion. In the latter situation, to prevent the extru-
Use of a rapid palatal expansion (RPE) with a
sion of the upper second molar teeth, care must
face mask will enhance the effectiveness of the
be taken to allow the mesial cusps of the upper
protraction. Although there may be some virtue
second molars to occlude with the distal cusps of
in such treatment, it is difficult to place an RPE
the lower second molar teeth.
on a patient with normal transverse dimensions,
This dental compensation, tipping the upper
one that has no crowding, and an intermolar
anteriors labially and lower anteriors lingually,
width of 35 mm or more. The authors recom-
can produce an acceptable, though compro-
mend using the RPE if needed to improve the
mised, occlusion. The patient must be informed
transverse dimension, otherwise the face mask
that this alternative treatment may result in a less
alone can resolve the problem.
Alternative Treatment for Nongrowing
Patients
Anterior crossbites (pseudo-Class III) and skel-
etal Class III malocclusions can sometimes be
treated by the extraction of teeth. Although the
results will be less than optimal, acceptable func-
tional occlusion can be achieved by dental com-
pensation when extracting upper second bicus-
pid and lower first bicuspid teeth.
Anterior crossbites in some cases can be re-
solved by extracting one lower incisor. This
asymmetric extraction pattern works best when
the upper lateral incisors are smaller than nor-
mal and the molar relationship is closer to a
"super" Class I occlusion. Additional interproxi-
mal enamel reduction on the upper anterior
teeth can also help balance the resulting arch
length discrepancy.
True Class III (Skeletal) Malocclusions
Two choices are available for treating these pa- Figure 10. Case 1: Posttreatment cephalometric
tients nonsurgically. If both arches have signifi- tracing.
<<    
     Article
      >>
Class III Malocclusion
than optimal occlusion with possible compro-
mising consequences.
Case Report 1
The patient was a 9-year, 6-month-old girl at
her initial visit. Her chief concerns were cross-
bite and prognathism in the mandible. Al-
though she presented with an anterior cross-
bite and a skeletal Class III malocclusion, she
could protrude her mandible so that her inci-
sors could contact in an edge-to-edge relation-
ship. Her facial profile was a concave pattern
with retrusive middle face and a protrusive
chin (Fig 6). Cephalometric analysis con-
firmed a skeletal Class III pattern, maxillary
deficiency, a large gonial angle, mandibular
excess, and a likely counter-clockwise rotation.
Significant cephalometric readings were: SNA
Figure 11. Case 2: Pretreatment facial and intraoral photographs.
Home | TOC |          
Index
113
80.5°, SNB 84.0°, ANB -3.5°, FMA 26.5°,
FMIA 81.5°, IMPA 72.0°, Ll-Apo 4 mm, Ul-FH
111.5° (Fig 7).
Diagnosis and Treatment Plan
The patient was diagnosed as a skeletal Class
III malocclusion with an anterior crossbite
caused by maxillary deficiency and progna-
thism of the mandible. The treatment plan was
to initially attempt orthodontic treatment
without extracting teeth, apart from the third
molars, to correct the crossbite by upper-arch
expansion and maxillary protraction. Control-
ling the mandibular growth was also an objec-
tive. The establishment of a functional occlu-
sion and improvement of the soft-tissue profile
was the final objective.
<<    
     Article
      >> Home | TOC |          
Index

114 Takagi and Asai

Figure 12. Case 2: Pretreatment cephalometric Figure 14. Case 2: Posttreatment cephalometric
tracing. tracing.

Treatment Progress
continued with a chin cap and a retainer dur-
A lingual upper arch and face mask with a chin
ing the retention period and the mandibular
cap were placed. Crossbite correction was per-
third molar teeth were extracted. The patient
formed while expanding the upper arch. Not-
at 2 years after active treatment is shown in
ing progress of the maxillary protrusion and
Figure 9.
mandibular clockwise rotation and confirm-
ing, with a hand wrist radiograph, that fusion
Cephalometric Changes
of the radius bone had commenced, and also
noting eruption of the second molars, upper Maxillary forward displacement was observed
and lower arches were banded and bonded (Fig 10), the SNA angle increased to 83°, and
(Fig 8). Total treatment time was 24 months the soft-tissue profile was improved. The mandi-
(Table 1). Mandibular growth control efforts ble also grew in size, however, its growth direc-

Figure 13. Case 2: Treat-

ment sequence. Mandibu-
lar teeth banded/bond first,
.016 NiTi and .016 x .022
stainless steel in maxillary
arch. .016 NiTi, .016 x
.022 NiTi and .016 x .022
B stainless steel closing wire
in mandibular arch (A).
.016 x .022 stainless steel
in maxillary arch. .016 x
.022 stainless steel closing
wire in mandibular arch
(B). .017 x .025 stainless
steel finishing wire in both
arches (C).
<<    
     Article
      >> Home | TOC |          
Index

Class III Malocclusion 115

Table 2. Case 2: Arch Wire Sequence, Individual Forces, and Retainer

Arch Wire Sequence

Upper Lower
None 3 mo 016 X NiTi 2 mo
016 NiTi 2 mo 016 X 016 ss 4 mo
016 X 016 ss 4 mo 016 X 022 closing 3 mo
016 X 022 ss 2 mo 017 X 025 finishing 10 mo
017 X 025 finishing 8 mo
Individual forces Retainer
Elastics Wraparound in upper
Class III 6 mo 3 X 3 fixed in lower
Boxed 5 mo
Finishing 5 mo

tion became more "downward," decreasing the
SNB angle to 81°. As a result, the ANB angle
increased to 2°, becoming a total of 5.5°. The
FMA angle increased by 4.5° to 31° because of
backward rotation of the mandible. The upper
(Ul) and lower (LI) incisors were both tipped
labially, and Ul- FH (upper incisor to Frankfort
horizontal angle) and the Ul-IMPA (upper inci-
sor to mandibular plane angle) increased to
117.5° and 78.5°, respectively.

Figure 15. Case 2: Posttreatment facial and intraoral photographs.

<<    
     Article
      >>
116 Takagi and Asai
Case 2
The patient was a 14-year, 4-month-old girl at
her initial visit. Her chief concerns were crowd-
ing of her lower anterior segment and protrusive
lips. There was moderate crowding in the lower
anterior region and mild crowding in the upper
anterior region with a Class III occlusal relation-
ship in the posterior segments of the arches. She
also had a tongue habit. Protrusive lips and chin
were observed in the facial profile (Fig 11).
Cephalometric analysis indicated a skeletal Class
III tendency, a large gonial angle and body
length of mandible. Lower incisors appeared
more proclined, however, the IMPA angle was
smaller than reported mean values because of
the dental compensations present. Significant
cephalometric values were: SNA 78.5°, SNB
77.5°, ANB 1.0°, FMA 30.5° , FMIA 65.5°, IMPA
84.0°, Ll-Apo 8 mm, and Ul-FH 118.5° (Fig 12).
Diagnosis and Treatment
The patient was diagnosed as a Class III maloc-
clusion resulting from mandibular prognathism
with crowding in the lower incisors and a tongue
habit. The treatment plan was to extract the
upper second bicuspid and lower first bicuspid
teeth and to improve the soft-tissue profile and
functional occlusion by retracting her upper and
lower incisors. The patient was also to undergo
myofunctional therapy.
Treatment Progress
After extracting the bicuspid teeth, the lower
arch was banded and bonded first to retract the
lower incisors. The upper arch was bonded and
banded 3 months later. The upper arch was then
leveled. A closing loop arch wire was used for
retracting the lower incisors and power chains
were used in the upper arch for space closure.
Class III elastics, (boxed and M with tail-finish-
ing), were also used during treatment (Fig 13,
Table 2).
An excellent occlusion was established with
uprighted mandibular molars and retroclined
mandibular incisors. There was minimal growth
Home | TOC |          
Index
of the mandible during treatment. Total treat-
ment time was 19 months. The lower third mo-
lars were extracted during retention.
Cephalometric Changes
Minimal growth of the mandible was observed
and the SNA and SNB angles increased by 1°,
however, the ANB angle did not change. The
soft-tissue profile (protrusive lips) was improved
because the upper and lower incisors were
tipped lingually (Fig 14). Posttreatment results
are shown in Figure 15.
References
1. Susami R, Nakago T. Cross bite. In: Susarni R (ed). The
prevalence of cross bite. Tokyo: Ishiyaku Publish-
ers,1976, pp 8-19.
2. Kassisieh S. Age differences in the response to maxillary
protraction therapy [master's thesis]. Dallas, TX: Baylor
University, 1996.
3. Bjork A, Helm S. Prediction of the age of maximum
puberal growth in body height. Angle Orthod 1967;37:
134-143.
4. Chapman SM. Ossification of the adductor sesamoid and the
adolescent growth spurt. Angle Orthod 1972;42:236-244.
5. Grave KG, Brown T. Skeletal ossification and the adoles-
cent growth spurt. Am J Orthod 1976;69:611-619.
6. Hagg U, Taranger J. Maturation indicators and the pu-
bertal growth spurt. Am J Orthod 1982;82:299-309.
7. Fishman LS. Radiographic evaluation of skeletal matu-
ration-a clinically oriented method based on hand-wrist
films. Angle Orthod 1982;52:88-112.
8. Nanda R. Protraction of maxilla in rhesus monkeys by
controlled extraoral forces. Am J Orthod 1978;74:121-141.
9. Nanda R. Biomechanical and clinical considerations of a
modified protraction headgear. Am J Orthod 1980;78:
125-139.
10. Ishii H, Morita S, Takeuchi Y, et al. Treatment effect of
combined maxillary protraction and chincap appliance
in severe skeletal Class III cases. Am J Orthod Dentofa-
cial Orthop 1987;92:304-312.
11. Tanne K, Hiraga J Sakuda M. Effects of directions of
maxillary protraction forces on biomechanical changes
in craniofacial complex. Eur J Orthod 1989;! 1:382-391.
12. Nevant CT, Buschang PH, Alexander RG, et al. Lip
bumper therapy for gaining arch length. Am J Orthod
1991;100:330-336.
13. Alexander RG. The lip bumper alternative. Clin Impress
1992;l:6-8.
14. Alexander RG. The Alexander Discipline. Glendora:
Ormco, 1986.
<<    
     Article
      >> Home | TOC |          
Index

Nonextraction Approach to Tooth Size Arch

Length Discrepancies With the
Alexander Discipline
Peter H. Buschang, Sherri J. Horton-Reuland, Lee Legier, Christopher Nevant

Crowded dentitions can be treated by using extraction, interproximal reduc-

tion, or nonextraction approaches. The extraction/reduction approaches
provide additional space by removing tooth structure; the nonextraction
approach increases the available space by expanding arch widths and in-
creasing arch lengths. Although the severity of crowding and the soft-tissue
profile are the important determinants of the appropriate approach, stabil-
ity, timing of treatment, and different treatment approaches must also be
considered. Since the 1960s the use of maxillary and mandibular expansion
appliances has increased significantly. Studies have shown that the basal
portions of both arches normally expand during growth, albeit considerably
more so for the maxilla than the mandible. Both jaw increases have been
shown to be age related, with younger individuals having greater potential
for expansion. Arch widths are clearly adaptable; active maxillary expansion
alone has been shown to spontaneously produce mandibular expansion that
was maintained for up to two years postretention. These width changes
indicate an adaptive system operating. If the teeth are able to maintain their
equilibrium between the cheeks and the tongue while the system is nor-
mally expanding or when the maxilla is being actively expanded, which the
teeth apparently do, then there is good reason to expect at least partial
stability of the mandibular teeth after active expansion. (Semin Orthod 2001;
7:117-131.) Copyright© 2001 by W.B. Saunders Company

T his article reviews three distinct and inde-

pendent research studies performed at Bay-
lor College of Dentistry, each evaluating differ-
ent aspects of mandibular expansion. The first
study was among one of the earliest to fully
describe the clinical effects of mandibular lip
bumpers (LBs)1'2; it was performed when we
were still undecided on the best type of bumpers
to use. The second study3 evaluated different
approaches to expansion by comparing the ef-
fects of removable expansion appliances and LB
therapy on arch length deficiencies during the
mixed dentition. The third and most recent
study4 addresses perhaps the most important re-
maining question pertaining to active mandibu-
lar expansion: will it remain stable? This prelim-
inary study evaluates the short-term stability of
LB therapy.

Study #1. The Effects of LB Therapy on

From the Department of Orthodontics, Baylor College of Den-
tistry, The Texas A&M University System Health Science Center,
Deficient Mandibular Arch Length
Dallas, TX. Background
Address correspondence to Peter H. Buschang, PhD, Department
of Orthodontics, Baylor College of Dentistry, The Texas A&M Before 1989, little was known concerning the
University System Health Science Center, 3302 Gaston Ave, Dallas, therapeutic effects of LB therapy, even though
TX 75246.
Copyright © 2001 by W.B. Saunders Company
bumpers had been used as an alternative to
1073-8746/01/0702-0009$35.00/0 extraction therapy since the 1960s. In one of the
doi:10.1053/sodo.2001.23558 earliest published studies, Subtelny and Sakuda5

Seminars in Orthodontics, Vol 7, No 2 (June), 2001: pp 117-131 117

<<    
     Article
      >>
118 Buschang et al
reported that most patients treated with LBs
displayed varying amounts of distal movement
or uprighting of the mandibular molars. By us-
ing a larger sample of LB cases, Bergersen6 con-
firmed distal uprighting of the mandibular mo-
lars and further reported anterior movements of
the lower incisors. Relying on a small sample
(N = 11) of treatment patients, Bjerregaard et
al7 reported a 6-mm increase in arch circumfer-
ence, a 3-mm increase in intermolar width, 8° of
molar uprighting, and 5° of incisor proclination.
Cetlin and Ten Hoeve8 showed almost twice as
much increase in intermolar width and gradient
of arch width increases with LBs, from 2.5 mm at
the canines, 4 mm at the first premolars, and 5.5
mm at the first molars. The variation reported
between studies suggests a treatment effect that
may be related to, among other things, the type
of bumper used.
The following study more fully describes the
effects of LB therapy. It compares alternative LB
treatment approaches (different types of LBs
and different clinical manipulations) by using
two samples of consecutively treated cases.
Materials and Methods
Samples and Treatment
LB therapy was evaluated in 40 patients treated
for mandibular arch length discrepancy. The
sample consisted of 20 consecutively treated LB
cases from the private practices of Dr. J. Michael
Steffen, Edmund, Oklahoma and Dr. Richard G.
Alexander, Arlington, Texas. The following se-
lection criteria were used
1. Caucasians.
2. Mandibular arch length deficiency.
3. Treated by means of a LB appliance only.
4. Good cooperators, as determined before
record collection from progress notes on
the clinical chart.
The patients in group 1 were treated with a
LB fabricated from 0.045-inch stainless steel
round wire covered with a layer of plastic shrink
tubing (1.5-mm round). The LB was reactivated
at the adjustment loops every 2 to 3 months.
Treatment started at approximately 11 years of
age and continued for 1.4 years.
The group 2 patients were treated with a com-
mercially available, prefabricated LB (GAG In-
Home | TOC |          
Index
ternational Inc, Central Islip, NY). This LB had
a shield of acrylic from canine to canine that was
5.7 mm in occlusal-gingival dimension and 2.7
mm thick. The shield was individually contoured
to reduce the incisal plastic by 2 mm and reduce
the thickness on the lingual side by less than 1
mm. Treatment for group 2 started at an average
age of 12.1 years and continued for approxi-
mately 1 year. The average placement of the LBs
was 2 to 3 mm in front of the lower incisors at
the level of the gingiva. It was placed 4 to 5 mm
from the buccal segments and activated 2 mm at
the molar tubes.
Controls
Selected dental and cephalometric measures for
each patient in the sample were compared with
age- and sex-matched control values. Dental de-
velopment was compared with standards com-
piled by Moyers et al.9 Cephalometric measure-
ments were first adjusted for magnification and
then compared with standards compiled by
Riolo et al.10
Z or standard scores were computed for each
subject on an age- and sex-specific basis. Z scores
permit the data to be collapsed into a single
sample and provide information pertaining to
the growth status of the treated sample relative
to the reference standards. Significant differ-
ences in z scores indicated treatment effects.
Group differences were evaluated by using an
analysis of variance. Changes in Z-scores over the
treatment period were calculated by using
paired t tests.
Methodology
Cephalometric analyses were performed to eval-
uate anteroposterior tooth movements. An oc-
clusal plane was constructed on the preoperative
tracing through the mesiobuccal cusp tip of the
mandibular first molar and the incisal edge of
the mandibular central incisor. Arbitrary ante-
rior and posterior reference points were drawn
on the constructed occlusal plane. The post-
treatment cephalometric tracing was superim-
posed on the pretreatment tracing by using the
cortices, the internal structure of the mandibu-
lar symphysis, and the mandibular canal, struc-
tures that have been verified by implant studies
to remain stable mandibular landmarks.11 The
pretreatment occlusal plane and anterior and
<<    
     Article
      >> Home | TOC |          
Index

Nonextraction Approach to TSALD 119

1.42 5. Total arch length13—the sum of the right

and left distances from the mesial anatomic
contact points of the first permanent molars
to the contact point of the central incisors.
6. Arch depth—the distance from a line bisect-
ing mesial anatomic contact points of the
first permanent molars to the contact point
of the central incisors.
0.04

Figure 1. Yearly changes (mm/yr) in incisal position
for groups 1 and 2.
posterior reference point were then transferred
to the posttreatment tracing.
Dental model analysis was performed by using
electronic dial calipers and the following mea-
surements were recorded:
1. Intercanine width—the distance between
cusp tips.
2. Interfirst premolar width-the distance be-
tween the center of the occlusal develop-
mental grooves.
3. First molar width—the distance between the
central pits.
4. Irregularity index12—the sum of the dis-
placement of the contact points of the six
anterior teeth.
Results
Anteroposterior Dental Changes
The superimpositions more clearly showed the
treatment changes. Lower incisor angulation
showed no significant group difference (Ll/MP
increased 2.9° ± 5.0°/yr; LI/OP decreased 3.8°
± 5.3°/yr). Although the horizontal position of
the lower incisor root apex did not change sig-
nificantly relative to the anterior reference
point, the lower incisal edge moved anteriorly
1.4 ± 1.7 mm for both groups (Fig 1).
In contrast, the molars showed significant
group differences (Fig 2). The molar cusp tips in
group 1 remained stationary whereas the root
apices moved anteriorly (1.2 ± 2.2 mm/yr). In
group 2, the molar cusp tip moved posteriorly
(1.5 ± 1.9 mm/yr) whereas the root apices
moved anteriorly (1.2 mm/yr). The lower molar
angle to occlusal plane decreased 2.8° ± 5.0°/yr
for group 1 and 8.0° ± 8.4°/yr for group 2.
Total arch length increased 2.7 ± 2.6 mm/yr
for group 1, and 7.4 ± 4.2 mm/yr for group 2.
The Z scores suggest that the treatment changes
were significant and cannot be explained by nor-
mal growth and development alone.

1.51
0.02 B
-8.0

Figure 2. Yearly changes (mm/yr) in molar position for group 1 (A) and group 2 (B).
<<    
     Article
      >> Home | TOC |          
Index

120 Buschang et al

Figure 3. Yearly changes (mm/yr) in arch widths and depth for group 1 (A) and group 2 (B).

Transverse Dental Relationships 3. Regardless of the type of LB and the method

of clinical manipulation, the mandibular in-
All of the transverse dimensions showed signifi-
cantly greater increases in group 2 than group 1 cisor crowns moved labially and the apices
(Fig 3). Intercanine width increased 1.4 ± 0.8 remained stationary. Simply removing the
and 2.8 ±2.1 mm/yr in groups 1 and 2, respec- pressure of the lip from the lower canines,
tively. Interfirst premolar width increased 2.1 ± regardless of the means, appears to produce
1.0 mm/yr in group 1 and 4.2 ± 2.4 mm/yr in similar effects
group 2. Group 1 showed a 0.8 ± 1.5 mm/yr 4. Irregularity showed similar amounts of im-
increase in interfirst molar width and group 2 provement regardless of the type of bumper
showed an increase of 4.2 ± 3.8 mm/yr. used, indicating that observed differences in
The pretreatment irregularity index was posterior arch width had little or no influ-
8.9 ± 2.5 mm and 9.6 ± 4.0 for groups 1 and 2, ence on the resolution of crowding.
respectively. Irregularity decreased significantly
(2.2 ± 2.6 mm/yr) and ranged from 4.1 mm to
— 9.1 mm, with no significant group differences
(Fig 4). Again, the Z scores indicate that the
treatment changes were significantly larger than
those that would be expected from growth
alone.

Conclusions
1. LBs, regardless of type, produce treatment
effects that cannot be explained by growth
alone.
2. The larger prefabricated LB covered with
acrylic shields from canine to canine and
activated every 4 to 5 weeks produced signif-
icantly greater amounts of molar uprighting,
molar distalization, arch length increases,
and arch width increases than the stainless
steel bumpers covered with shrink tubing
and activated every 2 to 3 months. Presum-
ably, the larger bumper produces a greater
force to displace the buccal musculature lat- Figure 4. Yearly decreases (mm/yr) in incisor irreg-
erally and the mandibular molars distally. ularity for groups 1 and 2.
<<    
     Article
      >>
Nonextraction Approach to TSALD
Study #2. The Effects of Removable
Expansion Appliances on the
Mandibular Arch
Background
Delaying treatment until the permanent denti-
tion has fully erupted may limit treatment op-
portunities for maintaining and gaining space or
compromise future stability. When planning
treatment for arch length inadequacies, normal
skeletal and dental development should be
taken into consideration. Because dentoalveolar
bone develops coincident with the eruption of
the permanent teeth, delaying treatment until
the permanent teeth have fully erupted may
limit treatment alternatives or compromise treat-
ment results. The dental arch develops consid-
erably during the eruption of the permanent
canines and premolars.9'14'15 It also has been
shown that the mandibular skeletal base in-
creases in width, and that the width changes are
age related.16'17 Assuming that biologic systems
are best able to adapt developmentally during
periods of maximum change, treatments during
the mixed dentition phase of development may
hold greater potential for physiologically stable
results than treatment during the permanent
dentition.
To evaluate the effects of different basic ex-
pansion appliance designs, the LB and remov-
able expansion (REA) appliances were com-
pared. Both appliance systems have been
commonly used during the mixed dentition to
gain space in the mandibular arch. Theoreti-
cally, both appliances could create space by in-
creasing or maintaining existing arch length,
increasing arch width, or a combination of the
two. The purpose of this study was to evaluate
and compare the effects of the LB and REA
appliance systems to determine their modes of
action, rates of response, and indications for
clinical application.
Materials and Methods
Pretreatment and posttreatment cephalograms
and dental models were compared. The REA
sample consisted of 20 consecutively treated
cases evaluated at 9.2 ± 1.1 years of age and
again at 10.9 ±1.1 years. The LB sample in-
cluded 20 consecutively treated cases that began
treatment at 8.7 ±1.2 years and finished at 9.8 ±
Home | TOC |          
Index
121
1.2 years. All patients were Caucasians with arch
length deficiency whose records indicated good
cooperation. REA and LB were the only forms of
treatment rendered.
The patients in the REA group were treated
with a removable mandibular expansion appli-
ance with an expansion screw embedded in the
acrylic and located at the midline symphyseal
region of the mandible. The appliance was fab-
ricated from acrylic on the mandibular model.
The acrylic extended bilaterally 5 mm below the
gingival crest on the lingual surface of the alve-
olus and posteriorly to the distal of the first
molars. The lingual plates extended occlusally to
cover the entire occlusal surface of the posterior
teeth. Patients were instructed to turn the screw
once every 4 days.
The LB patients were treated with a commer-
cially available LB that had an acrylic shield
5.7-mm occlusogingivally extending from canine
to canine. The LB was placed 2 to 3 mm anterior
to the lower incisors at the level of the gingiva,
and 4 to 5 mm from the buccal segments with an
activation of 2 mm at the molar tubes. The LB
was activated at 3- to 4-week intervals.
Pre- and posttreatment cephalograms were
traced in random order by one investigator. An
occlusal plane passing through the mesiobuccal
cusp tip of the mandibular first molar and the
contact point of the deciduous first and second
molars was constructed on the pretreatment
tracing. The mandibular tracings were superim-
posed according to Björk and Skieller,11 and the
pretreatment occlusal plane was transferred to
the posttreatment tracing for orientation and
registration. The horizontal and vertical move-
ments of the mandibular incisors and molars
were evaluated relative to the pretreatment oc-
clusal plane. Cephalometric measurement er-
rors, based on the method error statistic,18
ranged from 0.4 to 1.1 mm and from 0.4° to 1.3°.
An occlusogram camera and Polaroid film
(Polaroid Corp, Cambridge, MA) was used to
photograph the occlusal surfaces at 1:1 magnifi-
cation. A total of 44 points were digitized on
each model, including the mesial and distal con-
tacts points, the buccal and lingual contact
points of the canines, deciduous molars and first
molars, and three reference points.
Selected measures were compared with age-
and sex-specific control values. Models mea-
surements were compared with reference data
<<    
     Article
      >>
122 Buschang et al
published by Moyers et al9; cephalometric mea-
surement were compared with reference data
published by Riolo et al.10 Z scores were calcu-
lated for each subject; significant changes in z
scores indicated treatment effects.
Results
Pretreatment incisor relationships showed no
significant differences between the REA and LB
groups (Fig 5). During treatment the lower in-
cisor of the LB group flared relative to the man-
dibular plane (2.2° ± 4.2°) and N-B (2.6° ±
4.1°). No incisor flaring was evident for the REA
group. The lower incisor tip moved anteriorly
(1.2 ± 1.4 mm) relative to the horizontal refer-
ence line for the LB group; no incisor flaring or
anterior movement was evident for the REA
group.
Vertical incisor positions showed no signifi-
cant pre- or posttreatment group differences.
Based on the changes in z scores, the incisors
tended to extrude slightly in both groups.
During treatment the molar root apex moved
anteriorly 1.6 ± 1.5 mm and 0.3 ± 2.2 mm for
the LB and REA groups, respectively (Fig 6).
Although the difference were not statistically sig-
nificant, the molar cusp tip moved anteriorly
0.2 ±1.9 mm for the LB group and posteriorly
0.7 mm
Figure 5. Treatment changes in incisor position and orientation for LBs (A) and REAs (B).
Home | TOC |          
Index
0.8 ± 2.0 mm for the REA group. Although the
LB group molars tended to show greater supe-
rior changes than the REA molars, the differ-
ences were not significant.
Arch depths (Fig 7) increased significantly
(P = .005) more with the LB than the REA.
Canine depth increased 1.8 ± 1.4 mm and 0.2 ±
1.9 mm with the LB and REA, respectively. Arch
depth at the premolars showed no group differ-
ences and more limited increases (0.9 ±1.9 mm
for the LB and 0.1 ± 1.4 mm for the REA). The
Z scores indicted that both groups had signifi-
cantly short mandibular arches before treat-
ment; the means represented arches approxi-
mately two standard deviations smaller than
average. Except for intercanine depth increases
with the LB, none of the other depth changes
were significantly different from control changes.
Arch widths showed significant increases at all
levels with different patterns for the LB and REA
groups (Fig 8). Intercanine width increased sig-
nificantly more with the REA (3.1 ± 1.8 mm)
than the LB (1.3 ± 1.9 mm). Although first and
second premolar expansion were not signifi-
cantly different, the REA group showed greater
increases at the first premolars and the LB group
showed greater width increases at the second
premolars. Intermolar arch width increased sig-
B 1.2mm
<<    
     Article
      >> Home | TOC |          
Index

Nonextraction Approach to TSALD 123

1.2mm B 0.6 mm

0.2mm

mm

1.6mm

Figure 6. Treatment changes in molar position and orientation for LBs (A) and REAs (B).

nificantly (P = .005) more with the LB group Conclusions

(5.3 ± 2.3 mm) than the REA (2.1 ± 2.0 mm).
Z scores showed that both groups had narrow
arches, with the LB group having narrower
arches than the REA group. Compared with age-
and sex-matched untreated controls, both
groups displayed arch width increases beyond
those expected for untreated children. Postex-
pansion intercanine width for the LB group ap-
proached, but was still narrower than, average
(ie, they were not wider than the average un-
treated arch). Although the REA tends to over-
expand anteriorly (widths larger than the aver-
age control values). The widths produced with
the LB more closely approximated untreated
control values.
1. LBs are indicated for malocclusion when
pretreatment incisors are in an upright po-
sition because flaring of incisors is a consis-
tent treatment response.
2. LBs produce relative extrusion of the molars
and flaring of the incisors.
3. Because LB tip molars distally, molars
should be mesially inclined before treat-
ment. This appliance may be ideal for reliev-
ing crowding in the buccal segments or pre-
serving leeway space after exfoliation of the
deciduous molars. An additional molar re-
sponse is buccal tipping of the molars.
4. The original arch form becomes tapered

1.8mm 0.2mm
Figure 7. Treatment changes in arch depth for LBs (A) and REAs (B).
<<    
     Article
      >>
124 Buschang et al
Figure 8. Treatment changes in arch width for LBs (A) and REAs (B).
with LB therapy owing to progressively
larger increases in posterior arch widths.
5. The REA is ideally suited for malocclusion
with mild to moderate crowding anteriorly.
Pretreatment incisors may be flared or pro-
clined because space is created by increasing
intercanine width without concomitant inci-
sor flaring.
6. The REA appliance may be suited for pa-
tients with open-bite tendencies because its
posterior bite plate effect minimizes the
eruption of the posterior segment and per-
mits passive eruption of the incisors.
7. The REA is not the appliance of choice for
posterior crowding or maintaining leeway
space.
8. The REA appliance produces broad or
square arch forms.
Study #3. The Transverse Stability of
Combined Rapid Palatal Expansion and
LB Therapy After Comprehensive
Orthodontic Treatment
Stability has long been held as the standard by
which orthodontic treatment is ultimately
judged.19'21 It has been established that certain
forms of expansion are highly unstable.22'26 For
example, expansion of the canines, especially in
adults, might be expected to be unstable.
However, the potential for stability of the
mandibular arch after active expansion might be
greater for younger individuals. Width changes
in both the dental and basal aspects of the man-
dibular arch have been reported during child-
Home | TOC |          
Index
hood and adolescence. Longitudinal studies
show that arch widths expand considerably dur-
ing the eruption of the permanent teeth.14'27'28
Implant studies have shown that the expansion
of mandibular basal structures is quite common
and appears to be age related.16'17 Changes that
normally occur in untreated subjects set up the
possibility for stability, for at least some growing
children, after active expansion therapy during
growth.
Werner et al29 evaluated skeletal and dental
changes in adolescents treated with mandibular
LBs. The nine patients that they followed up 2
years posttreatment showed decreases in arch
depth and partial stability of arch width.
The following study begins to address some of
the stability issues associated with mandibular
expansion. Two groups of LB patients were fol-
lowed up to evaluate the effects of retention;
patients wearing lower fixed and upper remov-
able retainers were compared with patients who
had been without any form of retention for at
least 1 year. All of the patients had been out of
treatment for at least 1 year. One year was cho-
sen because most relapses might be expected to
occur within a relatively brief time period.30-31
Materials and Methods
The stability of combined LB and RPE therapy
was evaluated by comparing pretreatment, post-
treatment, and postretention records of 33 pa-
tients (12 male and 21 female) treated for max-
illary and mandibular arch length discrepancy.
Sixty-eight patients were contacted, 36 patients
<<    
     Article
      >>
Nonextraction Approach to TSALD
were scheduled for record appointments (32
patients had moved or could not conveniently
make the appointment), and 3 scheduled pa-
tients did not present for their appointments.
Records included clinical charts, standard ceph-
alometric radiographs, and plaster models of the
maxillary and mandibular dental arch. The sam-
ple consisted of treated LB and RPE cases se-
lected by the primary investigator from the pri-
vate practices of Dr. Wick Alexander of
Arlington, Texas and Dr. Mike Scott of Long-
view, Texas. The following patient selection cri-
teria were used:
1. Class I or Class II cases with lower arch
length deficiency.
2. All cases were treated by nonextraction with
full comprehensive orthodontic treatment
including the use of LB and RPE appliances.
3. The patients were growing at time of treat-
ment.
4. Records had to be complete, including Tl,
T2, and T3, and they had to be of acceptable
quality.
The patients were grouped according to their
stage of retention. To be sure that the posttreat-
ment changes were independent of retention, a
retained group was compared with a nonre-
tained group. The retained group (n = 14) of
patients was still in active retention, consisting of
a lower fixed 3 X 3 retainer and an upper re-
movable Hawley retainer. The nonretained (n =
19) group included patients no longer in active
retention of the lower arch for at least 1 year, but
still possibly wearing an upper removable Haw-
ley retainer. In other words, their lower 3 X 3
retainers had been removed.
Patients in the retention group started treat-
ment at 10.4 years of age, they were treated for
2.3 years and postretention records were taken
3.5 years later, at an average age of 16.2 years.
The nonretained group started treatment at 11.
5 years, treatment lasted for 2.4 years, and the
posttreatment period was 5 years. The average
patient in the nonretained group was in lower
arch retention for 3 years, therefore, the postre-
tention time was approximately 2 years.
Patients in both groups were treated by using
a commercially available, prefabricated LB. The
LBs had an acrylic shield, 5.6-mm occlusogingi-
vally, extending from canine to canine. The LB
was placed 2.0 to 3.0 mm anterior to the lower
Home | TOC |          
Index
125
incisors at the level of the gingiva and 4.0 to 5.0
mm from the buccal segments, with activation to
produce 2.0 mm of expansion at the molar
tubes. The LB was activated by expansion at 3- to
4-week intervals and was used for approximately
12 months.
Simultaneously, fixed rapid palatal expansion
appliances were fabricated by using the Hyrax
design. The expansion screw was placed as deep
into the palate as possible at the level of the first
molars. The patients were asked to turn the
expansion screw once every day for 4 weeks;
therefore, the activation rate was 0.25 mm per
day for a total expansion of approximately 7.0
mm. The patients were checked after the first 2
weeks of expansion and were asked to continue
for another 2 weeks on average. The appliance
was left in place for 6 months for retention. After
LB and RPE therapy, full fixed appliances were
placed until the case was completed. When the
retainers were removed, interproximal reduc-
tion of the anterior teeth, amounting to approx-
imately 0.25 mm per surface from the mesial of
the canine to the mesial of the other canine, was
performed on all patients.
Methodology
Records were taken and the alginate impressions
were immediately poured in vacuum-mixed plas-
ter and appropriately trimmed for model analy-
sis. Dental model analysis was performed by us-
ing a Microscribe 3DX digitizer (Immersion
Corp, San Jose, CA). A total of 85 points were
identified according to definitions given by Mov-
ers et al,9 marked with a pencil and then digi-
tized in three dimensions (3D) by using a Mi-
croscribe 3DX. Based on the 3D coordinates the
following measurements were calculated:
1. Maxillary and mandibular arch width for the
canines, premolars, and first molar mea-
sured at the level of the cusps.
2. Maxillary and mandibular arch width for the
canines, premolars, and first molars at the
level of the gingival margin. The gingival
margin was defined as a point at the mesial
distal centroid on the lingual surface of the
tooth, at a level where the gingiva and tooth
meet.
3. Maxillary and mandibular arch perimeter,
defined as the sum of the distances from the
mesial contact point of the first molars to
<<    
     Article
      >>
126 Buschang et al
the distal contact point of the canines, plus
the mesiodistal widths of the canines, lateral,
and central incisors.
4. Maxillary and mandibular arch depth at the
level of the laterals, canines, and first mo-
lars, with the distances measured along the
midline, perpendicular to a line drawn from
the distal of the laterals, distal to the canines
and mesial to the first molars.
5. Mandibular irregularity index: the sum of
the linear displacement measurement of the
mandibular anterior incisors as suggested by
Little.12
Results
There were significant treatment width
changes at the occlusal level for all teeth (Figs 9
and 10). The canines were expanded less than
the premolars and molars. The maxillary arch of
the retained group showed greater increases at
the second premolar than the first molars; both
arches of the nonretained group showed greater
increase at the second premolars. The treatment
changes in arch width showed no significant
Figure 9. Treatment (A) and posttreatment (B) changes in arch widths for the retained (lower 3 X 3) LB group.
Home | TOC |          
Index
group differences. None of the posttreatment
changes for the retained group were statistically
significant. After treatment maxillary and man-
dibular second premolar and mandibular ca-
nines of the nonretained group showed small
but significant width decreases; none of the
other posttreatifiént changes were statistically
significant. Posttreatment group differences
were evident at the mandibular canines, with the
retained group remaining stable and the nonre-
tained group decreasing arch width slightly
( — 0.6 ± 0.6 mm). The decrease in mandibular
intercanine width may have been caused by the
consolidation of space produced by the inter-
proximal reduction performed after retention.
Figures 11 and 12 show that there were also
significant width changes at the level of the gin-
giva. For the retained group all widths except for
the maxillary canines showed statistically signifi-
cant increases during treatment; for the nonre-
tained group all widths except those at the max-
illary and mandibular canines increased during
treatment. Posttreatment changes were small
and none were statistically significant, either for
the retained or nonretained groups. There were
<<    
     Article
      >> Home | TOC |          
Index

Nonextraction Approach to TSALD 127

Figure 10. Treatment (A) and posttreatment (B) changes in arch widths for the nonretained LB group.

Figure 11. Treatment (A) and posttreatment (B) changes in gingival arch widths for the retained (lower 3 X 3 )
LB group.
<<    
     Article
      >>
128 Buschang et al
Figure 12. Treatment (A) and posttreatment (B) changes in gingival arch width for the nonretained LB group.
no significant group differences during treat-
ment or posttreatment.
Maxillary and mandibular arch depths
showed similar changes (Figs 13 and 14). The
arch depths at the lateral incisors and molars
tended to decrease during treatment. Maxillary
depth at the canines increased slightly for the
retained group and decreased for the nonre-
tained group; depths at the mandibular canines
increased slightly in both groups. There were no
significant group differences in arch depth
change during treatment. Posttreatment changes
in arch depth were small. For the retained group
mandibular arch depth tended to increase
whereas maxillary arch depth tended to de-
crease. For the nonretained group both arches
showed small decreases; only the decrease at the
mandibular first molars (0.9 ± 0.6 mm) was
statistically significant. Posttreatment changes in
mandibular arch depth were significant, with the
retained group increasing and the nonretained
group decreasing arch depth.
Incisor irregularity decreased significantly
during treatment (Fig 15). For the retained
group, irregularity decreased from 9.0 mm pre-
Home | TOC |          
Index
treatment to 1.2 mm at the end of treatment; it
decreased from 9.6 mm pretreatment to 1.0 mm
posttreatment in the nonretained group. Treat-
ment changes of incisor irregularity showed no
group differences. The 0.2-mm posttreatment
irregularity decrease seen in the retained group
was not statistically significant. Posttreatment in-
cisor irregularity increased 0.7 mm in the non-
retained group, which was significantly greater
than the changes observed for the nonretained
group.
Conclusions
This investigation was designed to determine the
relapse and short-term stability of LB and RPE
therapy. The sample was divided into a retained
group, who wore lower 3 X 3 retainers, and a
nonretained group, who had been out of lower
arch retention for at least 1 year.
1. During treatment the maxillary and mandib-
ular arches showed generalized increases in
arch perimeter associated with arch width
increases.
<<    
     Article
      >> Home | TOC |          
Index

Nonextraction Approach to TSALD 129

B
-1.0mm * t t 0.1 mm r^iCOn> $ t t
0.4mm m. ^ ^7 k_x7N-
T^L I -0.2mm .0H^HE £2L
-0.3 mm -0.3 mm IU_3

-0.1 mm 0.1 mm

0.4mm V^-^ 0.4mm \^^ ä5

-0.5 mm
^fa:^y *"
0.4mm
üijy i^, „
Figure 13. Treatment (A) and posttreatment (B) changes in arch depths for the retained (lower 3 X 3) LR
group.

B
-1.4mm
v& ty ^^j-^\ 3 ^ t -0.1 mm $ t t
-0.7 mm £
fQ <-^ -0.2mm £1 ^7 "*=7

^
\
V^x7V

-1.8 am (?S -0.5 mm VU^

0.1 mm -0.9mm

0.8mm T^
^^ x<J9/ -0.6 mm V^
-0.1 mm c :-./n.-..-. p^/'y
^ -0.4mm ',.M.,.,..p\. s
T -^
"^jy[L^L>^" ^J1J^^L>^ ^JJ
Figure 14. Treatment (A) and posttreatment (B) changes in arch depths for the nonretained LB group.
<<    
     Article
      >>
130 Buschang et al
Retained Group
-7.8 ± 2.6 mm
Non-Retained Group
-8.7 ±3.9 mm
Figure 15. Treatment (A) and posttreatment (B) changes in arch width for the retained (lower 3 X 3 ) and
nonretained LB groups.
2. With the exception of arch depths, which
decreased slightly in the maxilla and in-
creased slightly in the mandible, the re-
tained group remained stable over the post-
treatment period.
3. The net expansion achieved for RPE and LB
therapy, followed by full fixed appliances,
remains relatively stable over the short term.
The lack of significant mandibular arch re-
lapse after treatment may be attributed to
the new environment created by maxillary
skeletal expansion and the concomitant de-
velopmental changes.
4. There were relatively small amounts of relapse
for mandibular intercanine width in the non-
retained group. With the exception of the
canines, which relapsed 50% of the 1.2 mm
that they were expanded, approximately 90%
of the premolar and molar widths increases
(ranging from 3.1-3.6 mm and 4.0-5.2 mm in
the mandible and maxilla, respectively) re-
mained stable posttreatment.
Home | TOC |          
Index
B
-0.2 ± 0.9 mm
0.7 ± 1.2 mm
5. There was very little relapse of the maxillary
canines, even though they were expanded
approximately 2.5 mm, which was probably
associated with the normal width changes
that occur during the eruption of the per-
manent canines.
6. Differences in transverse changes between
the arch width and gingival arch widths
showed that the mandibular crowns were
tipped buccally approximately 1 mm. This
represents most of the intercanine width in-
creases but only a fraction of the posterior
width increase. The tipping could easily ac-
count for all of the posttreatment width de-
creases observed for either the retained or
nonretained groups.
Clinical Conclusions
The transverse dimension, once thought to be
unchangeable, can definitely be increased in
young patients who initially have constricted
<<    
     Article
      >>
Nonextraction Approach to TSALD
lower arches. The LB can gain or maintain 6 to
7 mm of space without substantially flaring the
lower incisors. The space was produced by a
combination of molar uprighting, molar expan-
sion, incisor tipping, and maintenance of leeway
space. In combination with rapid palatal expan-
sion and full orthodontic treatment to establish
better axial inclinations, relatively small amounts
of relapse were observed after retention was re-
moved.
Acknowledgments
These studies could not have been possible without the cases
graciously provided by Dr. R.G. Alexander, M. Collins, M.
Scott, andJ.M. Steffen.
References
1. Nevant CT. The effects of lip bumper therapy on defi-
cient mandibular arch length. Master's thesis submitted
to Baylor University, Baylor College of Dentistry, Dallas,
Texas, 1989.
2. Nevant CT, Buschang PH, Alexander RG, et al. Lip
bumper therapy for gaining arch length. Am J Orthod
1991;100:330-336.
3. Legier LR. The effects of removable expansion appli-
ances on the mandibular arch. Master's thesis submitted
to Baylor University, Baylor College of Dentistry, Dallas,
Texas, 1991.
4. Horton SJ. The transverse stability of combined rapid
palatal expansion and lip bumper therapy following
comprehensive orthodontic treatment. Master's thesis
submitted to The Texas A&M University System, Baylor
College of Dentistry, Dallas, Texas, 1997.
5. SubtelnyJD, Sakuda N. Muscle function, oral malforma-
tion, and growth changes. Am J Orthod 1966;52:495-517.
6. Bergersen EO. A cephalometric study of the clinical use
of the mandibular lip bumper. Am J Orthod 1972;61:
578-602.
7. Bjerregaard J, Bundgaard A, Meisen B. The effect of the
mandibular lip bumper and maxillary bite plane on
tooth movements, occlusion and space conditions in the
lower dental arch. Eur J Orthod 1980;2:257-265.
8. Cetlin NM, Ten Hoeve AJ. Nonextraction treatment.
J Glin Orthod 1983;17:396-413.
9. Moyers RE, Van der Linden F, Riolo M, et al. Standards
of human occlusal development. Monograph 5. Cranio-
facial Growth Series, Ann Arbor: Center for Human
Growth and Development, University of Michigan, 1976.
10. Riolo M, Moyers R, McNamara J, et al. An atlas of
craniofacial growth. Monograph 2. Craniofacial Growth
Series, Ann Arbor: Center for Human Growth and De-
velopment, University of Michigan, 1974.
11. Björk A, Skieller V. Normal and abnormal growth of the
Home | TOC |          
Index
131
mandible. A synthesis of longitudinal cephalometric im-
plant studies over a period of 25 years. Eur J Orthod
1983;5:l-46.
12. Little RM. The irregularity index: A quantitative score of
mandibular anterior alignment. Am J Orthod 1975;68:
554-563.
13. Nance HN. The limitation of orthodontic treatment:
Diagnosis and treatment in the permanent dentition.
Am J Orthod Oral Surg 1947;33:225-301.
14. Moorrees CF. Normal variation in dental development
determined with reference to tooth eruption status. J
Dent Res 1965;44:161-173.
15. Moorrees CFA, Gron AM, Lebret LM, et al. Growth
studies of the dentition: A review. Am J Orthod 1969;55:
600-616.
16. Gandini LG, Buschang PH. Maxillary and mandibular
width changes studied using metallic implants. Am J
Orthod Dentofacial Orthop 2000; 117:75-80.
17. Korn EL, Baumrind S. Transverse development of the
human jaws between the ages of 8.5 and 15.5 years,
studied longitudinally with use of implants. J Dent Res
1990;69:1298-1306.
18. Dahlberg G. Statistical methods for medical and biolog-
ical students. London: George Allen & Unwin, 1940.
19. Angle EH. Treatment of the malocclusion of teeth (ed.
7). Philadelphia: SS White Dental Manufacturing, 1907.
20. Kinglsley NA. Letter to the alumni society. Angle School
of Orthodontia, St. Louis MO, 1908.
21. Oppenheim A. A practical suggestion. IntJ Orthod Dent
Child 1934;20:894-985.
22. Tweed CH. Indications for the extraction of teeth in
orthodontic procedure. Am J Orthod Oral Surg 1944;
30:405-428.
23. Bishara SE, ChadhaJ, Potter R. Stability of intercanine
width, overbite, and overjet correction. Am J Orthod
1973;65:588-595.
24. Shapiro PA. Mandibular dental form and dimension.
Am J Orthod 1974;66:58-70.
25. Uhde MP, Sadowsky C, Begole E. Long-term stability of
dental relationships after orthodontic treatment. Angle
Orthod 1983;53:240-252.
26. Little R, Riedel R, Artun J. An evaluation of changes in
mandibular anterior alignment from 10-20 years post-
retention. Am J Orthod 1988;93:423-428.
27. Cohen JT. Growth and development of the dental arches
in children. J Am Dent Assoc 1940;27:1250-1260.
28. Barrow GV, White JR. Developmental changes of the
maxillary and mandibular arches. Angle Orthod 1952;
22:41-46.
29. Werner SP, Shivapuja PK, Harris EF. Skeletodental
changes in the adolescent accruing from use of the lip
bumper. Angle Orthod 1994;64:13-20.
30. Weinstein S, Haack D, Morris L, et al. On an equilib-
rium theory of tooth position. Angle Orthod 1963;33:
1-26.
31. Mew J. Relapse following maxillary expansion. Am J
Orthod 1983;83:56-61.
<<    
     Article
      >> Home | TOC |          
Index

Finishing and Retention Procedures in the

Alexander Discipline
Tucker Haltom

Carefully transitioning from orthodontic treatment into the retention phase

of orthodontics requires planning and preparation throughout treatment.
Precision finishing is critical for excellent results. By achieving established
goals and following specific steps in retention, the patient can have excel-
lent long-term stability. This article highlights some of the factors consid-
ered important in planning and performing retention according to the Alex-
ander Discipline. (Semin Orthod 2001;7:132-137.) Copyright © 2001 by W.B.
Saunders Company

The problem of retention must be solved during treatment or
it will not be solved at all.
Dr. Fred Schudy
reatment goals are the same today as they
T were when Tweed1 wrote them in 1955.
1. Pleasing balance and harmony of facial
lines: no lip strain should be present after
treatment. Often lip strain is the determin-
ing factor in an extraction decision. Facial
maturation, facial growth, and treatment
changes in nonextraction treatment can cor-
rect lip strain, and, of course, are consid-
ered.
2. Correct occlusion.
3. Healthy tissues.
4. Long-term stability.
In the Alexander Discipline the ultimate ob-
jective is to produce quality results and treat-
ment stability, nonextraction treatment when-
ever possible within the treatment goals, and
teeth placed in positions so that life-time reten-
tion is not necessary.
It is very difficult to align teeth with an im-
properly fitted appliance. Great care is taken
with bracket and band placement because the
precision of this early procedure contributes
From Albuquerque, NM.
Address correspondence to Tucker Haltom, DDS, MS, 10433
Lagrima de Oro NE, Albuquerque, NM 87111.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0702-0010$35.00/0
doi:10.1053/sodo.2001.23559
greatly to ideal finishing. Brackets are placed
exactly flat on the teeth, centered and angulated
correctly, and carefully measured with a height
gauge (Fig 1). Because root positioning is
considered to be of significant importance,
midtreatment panoramic radiographs are taken
to evaluate root positioning. Full thickness
0.017 X 0.025-inch arch wires are then adjusted
or brackets repositioned as indicated for ideal
root positioning. A primary goal of the Alex-
ander Discipline is to spread out the roots of the
lower incisors because it is thought that this adds
to long-term stability (Fig 2). 2
In addition, during treatment any undesir-
able interdental papilla spaces may be closed by
using air rotor slenderizing. Ideal gingival line
disharmonies are corrected with vertical posi-
tioning of incisors, and less often by using sur-
gical recontouring of the gingiva.
Certain criteria must be met before the patient
is ready for retention.3 These criteria include
• Ideal occlusion.
• Cuspid protected, with centric occlusion and
centric relation coincident.
• Normal overbite and overjet.
• Proper artistic positioning.
• Spread out incisor roots, especially the lower
incisor roots.
• Correct torque of the upper incisors to allow
for a good interincisal angle.
• Lower incisors balanced over basal bone
within 3° of their original position. When pro-
clined excessively, the lower incisors tend to
upright over time.

132 Seminars in Orthodontics, Vol 7, No 2 (June), 2001: pp 132-137

<<    
     Article
      >>
Alexander Discipline-Finishing and Retention
Figure 1. Measuring bracket height with gauge
aligned evenly with slot torque on all teeth except the
lower incisors. Measurement is made to slot opening
on these teeth.
• Original lower intercuspid width must be
maintained. Expanded lower cuspids typically
constrict after removal of retention appli-
ances.
• Lower first molars should be upright to main-
tain a leveled mandibular arch and overbite
correction.
• Habits should have been eliminated.
• Midlines should be coincident and correct.
• Correct arch form.
• Correct curve of Spee and curve of Wilson
should be optimal.
In addition, a circumferential supracrestal fi-
berotomy is performed on all adults with se-
verely rotated teeth 2 months before fixed appli-
ance removal. Removal of hyperplastic tissue in
the maxillary central incisor area is also per-
formed where heavy diastemas are present, es-
pecially if they are considered to be familial
traits.
The Countdown to Retention
When all the goals of the optimally treated pa-
tient are met and fixed appliance removal time
is approaching, four appointments are made
with specific objectives for each appointment.
Appointment 1: Sectioning of wires and finish-
ing elastics.
Appointment 2 (3 weeks later): Occlusal check
and final adjustments, and possible sectioning
Home | TOC |          
Index
133
of the opposing arch wire and removal of
molar bands.
Appointment 3 (3 weeks later): Fixed appliances
removal.
Appointment 4 (2 days later): Seating of the
retainers.
These last 6 weeks of treatment are devoted to
finalizing the posterior occlusion and the ante-
rior overbite. This is accomplished by arch wire
sectioning and the wearing of specifically at-
tached elastics: (3/4-in 2-oz Ostrich; Ormco,
Glendora, CA) in the posterior section of the
arches, and, if necessary, placement of an ante-
rior box elastic, (3/16-in 6-oz Impala; Ormco).
First Appointment
Before the procedures of this appointment be-
gin the patient is given specific instructions and
motivated to follow the instructions. The patient
is told that they can chew sugarless gum and the
braces will be removed in 6 weeks. They are also
informed that elastics are difficult to wear but
must be worn 18 to 20 hours a day
Arch wire sectioning and elastic configura-
tion is determined by the patient's original mal-
occlusion. If the beginning overbite was deep,
the lower arch wire is sectioned distal to the
cuspids and the posterior arch wires are re-
moved. With open-bite problems, the upper
arch wire is sectioned in a similar manner. If the
original overbite was close to normal, either or
both arch wires may be sectioned. A distal end
cutting instrument with no distal end holder can
be used to section the wires in the mouth or the
wires can be removed, sectioned, and the ends
rolled in for smoothness. For easy placement
and good retention of elastics, the wires must be
Figure 2. Panoramic radiograph showing ideal root
positioning after appliances removed.
<<    
     Article
      >>
134
Figure 3. Finishing elastics with Class II vector.
tied with steel ligatures or Kobayashi hooks
(American Orthodontics, Sheboygan, WI). The
upper incisors may be ligated together by using
a 0.007 ligature wire when indicated. Other ar-
eas susceptible to spacing can also be ligated
together.
The intermaxillary elastics are attached to
three upper teeth and three lower teeth in an up
and down fashion with specific angulations.4 If
the original malocclusion was Class I or Class II
then the elastics are worn with a Class II vector
(Fig 3). The same process is followed in Class
III occlusions placing the elastics as shown
(Fig 4).
Second Appointment (3 Weeks Later)
At this time the patient is very close to comple-
tion. Maxillary molar bands are now removed.
After checking the occlusion, minor final repo-
sitioning bends may be performed. Patients are
asked to chew and squeeze sugarless gum. At this
appointment, instructions for elastic wear at
nighttime only is often given. Tooth shaping
Figure 5. Results after polishing enamel. Lateral (A), frontal (B), and lateral (C).
Home | TOC |          
Index
Tucker Haitom
Figure 4. Finishing elastics with Class III vector.
may also be performed. The appointment for
band removal is made.
Third Appointment (3 Weeks Later)
All remaining bands and brackets are removed.
The teeth are polished and cleaned. Campbell's
polishing sequences are used to produce a beau-
tiful enamel finish (Fig 5).5 Interproximal con-
tact points are now polished by using the Dome
Interproximal Tooth Stripper (Dome, Inc, Tar-
zana, CA) (Fig 6). This creates a small amount of
space for these teeth to settle in the arch. It also
smooths and lightly flattens the contact areas for
added precision in interproximal contacts and
creates a broader contact area to reduce contact
slippage. The Dome wide abrasive strip is used
so it may reach through the circumferential su-
pracrestal fibers performing a slight fiberotomy
as indicated by rotations and where age or peri-
odontal condition do not contraindicate the
procedure. Only the contact areas are stripped if
there are contraindications to a fiberotomy.
<<    
     Article
      >>
Alexander Discipline-Finishing and Retention
Figure 6. Interproximal enamel reduction with Dome
stripper.
The four treatment goals of the Alexander
Discipline in the lower cuspid to cuspid area that
lead to long-term stability are (Fig 7)
1. Maintain the cuspid-to-cuspid width close to
the original dimension.
2. Lower incisors upright within 3° of original
angulation.
3. Roots of lower incisors spread out properly.
4. Interproximal enamel reduction done.
Impressions for working models and final
models are taken and the posttreatment review
is conducted. One of the joys in orthodontics is
to celebrate with the patient and parents after
appliances are removed. Showing the changes
achieved during treatment reinforces the need
to follow instructions during retention. The
third molar teeth are also discussed.
Fourth Appointment
Two days after the appliances are removed, the
retainers are seated.6
The Maxillary Retainer
A wraparound retainer design is constructed
with the facial bow soldered to C-clasps around
the terminal molar (usually second molars). A
preformed retainer wire (Fig 8) has been de-
signed to eliminate the tendency in previous
designs for the anterior portion of the wire to
slip gingivally. The advantages of this preformed
wire include
1. Flat surface against the anterior teeth for
stability.
Home | TOC |          
Index
135
Figure 7. Finishing goals for lower anteriors.
2. Round surface against the lips for comfort.
3. Increased wire stiffness that resists slipping
gingivally.
4. Lateral incisor offset bends.
5. Smaller adjustment loops positioned more
posteriorly.
6. Arch form conforms to Alexander/Orthos
design.
This preformed retainer wire allows much
faster adaptation in the laboratory so that re-
tainer construction is more efficient. Also, the
appliance is much more "patient friendly" be-
cause of the wire's stiffness and the unique an-
terior wire-and-loop design.
Special attention should be given to the up-
per second molars. In many cases, these teeth
have not fully erupted when the retainer is con-
structed and therefore the acrylic on the lingual
and the retainer wire on the distal should be
contoured to allow the teeth to continue to
erupt. This is accomplished by placing a C-clasp
around the maxillary second molar. The clasp is
Figure 8. Preformed wraparound retainer wire.
<<    
     Article
      >>
136 Tucker Haitom
Figure 9. UC" clasp not touching distolingual cusp of
second molar.
designed so that it does not touch the distolin-
gual cusps (Fig 9). The labial bow retainer wire
is soldered to the C-clasp in the distobuccal cusp
area, leaving enough space to adjust the C-clasp
for greater retention. When preparing the max-
illary retainer for delivery, care is taken to recon-
tour the acrylic to prevent it touching the lingual
surfaces of the teeth (Fig 10). This enables the
posterior teeth to continue settling after appli-
ance removal. If desired, the bite plate is ad-
justed anteriorly to allow the teeth to occlude
without touching any acrylic, so that when the
patient closes, only teeth are occluding with
teeth.
Figure 11. Dental floss holding 0.0215 multistranded
wire.
Home | TOC |          
Index
Figure 10. Maxillary retainer ready for delivery.
The Mandibular Retainer
In recent years, the bonded multistranded man-
dibular cuspid to cuspid has become very popu-
lar, mainly because of its ease of placement and
its effectiveness in preventing relapse. A 0.0215
multistranded wire (Triple-Flex; Ormco, Glen-
dora, CA) is contoured directly or indirectly on
the lingual surface of the anteriors from the
cuspid to the opposite cuspid. In extraction
cases, the wire can be extended to the mesial
groove of the bicuspids. To place the retainers
the preformed wire is held in place with dental
floss or elastics (Fig 11). The wire is bonded to
each of the anterior teeth with a low-viscosity
light-cured bonding agent. If slight lower incisor
malalignments are present, a 90° utility plier
(Fig 12) can be used to position the contacts
Figure 12. Utility plier adjusting contact points be-
fore light curing.
<<    
     Article
      >>
Alexander Discipline-Finishing and Retention
properly by gently squeezing the teeth as shown.
Instruction for Retention
The patient is instructed to wear the maxillary
retainer for only 10 to 12 hours from the begin-
ning, putting it on after the evening meal and
wearing it all night long. This procedure greatly
reduces the loss or breakage of retainers.
Retention Appointments
The patient is seen in 8 weeks for final records
and retainer adjustment. Another appointment
is made in another 8 weeks to adjust the re-
tainer. At this time the patient may wear the
retainer only when they sleep.
The patient is then scheduled to return in 12
months. The second year the maxillary retainer
is worn three times a week, and during the third
year, retainer wear is reduced to once a week.
After a decision has been made relative to the
third molars, the lower cuspid-to-cuspid fixed
retainer may be removed, unless the patient pre-
fers that it remain in place. The patient is ad-
vised to "Be your own orthodontist" and period-
Home | TOC |          
Index
137
ically place the upper retainer to see that it still
fits. At this time the patient is released from
active treatment, with the knowledge that their
records are kept on file if needed.
Conclusion
Careful attention to retention problems during
treatment, precision and artistic finishing, im-
proved retainer design, and a more reasonable
schedule of retainer wear all contribute to
achieving a beautiful occlusion and long-term
stability.
References
1. Tweed CH. Clinical orthodontics. St. Louis: CV Mosby,
1966.
2. Williams R. Elimination lower retention. J Glin Orthod
1985;22:342-349.
3. Alexander RG. The Alexander Discipline. Glendora, CA:
Ormco, 1986.
4. Steffen MJ. Five cent tooth positioners. J Glin Orthod
August, 1987:524-529.
5. Campbell P. Enamel polishing. Angle Orthod 1995;65:
103-110.
6. Alexander RG. Retention-a practical approach to that
critical last step to stability. In: Clinical Impressions. Glen-
dale, CA: Ormco, 1997, 14-17.
<<    
     Article
      >> Home | TOC |          
Index

tililiNCountless
älfi i*»:psÄ, j •••
hours
«i
pof fading with...
The 2001 Year Book of Dentistry®
EDITOR-IN CHIEF: Kenneth L. Zakariasen, DDS, PhD
ASSOCIATE EDITORS: Douglas N. Dederich, DDS, PhD;
Allan Boghosian, DDS; Bruce Horswell, MD, DDS, MS;
Fred Mclntyre, DDS, MS; and David Hatcher, DDS, MSC

on't miss out on valuable information you can use in your

D practice. Order your 2001 Year Book of Dentistry® today!
The Year Book is a unique collection of article abstracts and
commentaries on significant new developments in your field. Each year,
a distinguished editorial board reviews more than 500 journals world-
wide and selects only the most pertinent material for inclusion.
The comprehensive and easy-to-read abstracts are followed by personal
commentaries from the editors. These experts analyze the clinical
significance of each selection and discuss other studies of relevance.
You get the material you need without needing to sift through a library
of literature.
Subscribe to this time-saving annual today and get caught up on the vital
information you need to enhance your practice and improve patient
Month of Publication: August
care.
PRICES:
US $85.00 This year's hot topics include:
International $91.00
' dental adhesive systems temporomandibular
When you subscribe to the Year Book, we'll send you advance notice
of future volumes about two months before publication. To receive ' glass ionomers disorders
the new edition, you need do nothing—we'll send you the new vol-
ume as soon as it's available. (Postage, handling, and applicable
' preventive dentistry endodontics
sales tax are added to each shipment.) If you decide you no longer
want to subscribe, the advance notice makes it easy for you to let us
know. • infection control

ISSN 0084-3717

^f To order call toll-free 1 -800-654-2452

Outside the U.S. and Canada: 407-345-4000 • Fax: 407-363-9661
E-mail: periodicaLservice@mosby.com • Visit: www.mosby.com/periodicals
Or contact:
Subscription Services, Mosby, 6277 Sea Harbor Drive, Orlando, FL 32887-4800 U.S.A.

MMosby Harcourt Health Sciences

© 2001 Mosby. Prices are subject to change without notice.
<<    
     Article
      >> Home | TOC |          
Index

M Mosby
Harcourt Health Sciences

ISSN 0011-8486
Stay on top of
developments in
Inside U.S.A.
effective 11/1/2000
dentistry
Individuals $ 60.00
Institutions $121.00
Students/Residents* $ 39.00 Editor: Lawrence H. Meskin, DDS, PhD
Outside U.S.A.
Individuals $ 79.00
You may regularly read your favorite journals in your specialty, but you proba-
Institutions $141.00
Students/Residents* $ 57.00 bly have little extra time to explore general dental topics or other dental spe-
*Please supply, on institution letterhead, your cialties. At the same time you don't want to miss out on valuable information
name, dates of internship/residency, and signature
of program director. Orders will be billed at the you could use in your practice.
individual rate until proof of status is received.
Airmail rates are available upon request.
Each issue of Dental Abstracts presents approximately 60 abstracts of articles,
To order, call toll-free: covering a variety of dental topics and specialties. Editors of Dental Abstracts
1-800-654-2452 survey some 60 journals on a continuous basis to bring you the most news-
Outside U.S.A. and Canada: worthy material in an easy-to-read format. You'll learn about the latest
1-407-345-4000 advances in materials and techniques, infection control, dental practice man-
Fax:
1-407-363-9661
agement, and more. Articles are short summaries, providing you only the
E-mail: details you really need.
periodical.service@mosby.com
Visit: Dental Abstracts helps you stay informed of developments and advances in
www.harcourthealth.com
general dentistry and its specialties. This time-saving publication covers vital
Or contact: topics in practice management, endodontics, periodontics, orthodontics, oral

MMosby
Customer Subscription Services
surgery, esthetic dentistry, and more. Plus, the graphs, tables, and figures that
appeared in the original articles are carefully reproduced.
6277 Sea Harbor Drive
Orlando, FL
Catch up on your reading—order your subscription today!
32887-4800 U.S.A.
©2001 Mosby. Prices subject to
change without notice. Add the
applicable sales tax for your area.
<<    
     Article
      >> Home | TOC |          
Index

rmco
(800)854-1741

Getting From Here To There.^and Staying There

For information about Alexander Discipline courses, contact Ami Motsenbocker (817) 275 3233.
<<    
     Article
      >> HOME
<<    
     Article
      >> Home | TOC |          
Index

'-sfmerican Journal of
ORTHODONTICS
K *A Mosby
rl HarcourtHe
Harcourt Health Sciences

DENTOFACIAL
ORTHOPEDICS
=:—":;:;:„ -
Asrsssi
NOW AVAILABLE ON THE INTERNE!!
~S™ '—— -
Sffw^lS. ' VISIT www.mosby.com/ajodo
iiiis:r:-™^,„.™
. ""^»""^'^"^n^Hio-.

5B)^5-~: --
II ISSN 0889-5406

Discover the best-read

Inside U.S.A.
journal in orthodontics!
Individuals $147.00
Institutions $311.00 For complete diagnostic and clinical coverage of orthodontics, more
Students/Residents* $ 75.00 orthodontists read and refer to the American Journal of Orthodontics and
Outside U.S.A. Dentofacial Orthopedics than any other journal in the field.
Individuals $176.00
Institutions $340.00 As the official publication of the American Association of Orthodontists (AAO),
Students/Residents* $104.00
the Journal brings you outstanding peer-reviewed articles examining all phases
*Please supply, on institution letterhead, your
name, dates of internship/residency, and signature of orthodontic treatment. Illustrations, tables, and photos aid you in analyzing
of program director. Orders will be billed at the
individual rate until proof of status is received. clinical case studies and statistical data.
Airmail rates are available upon request.

SUBSCRIPTION PRICES INCLUDE In addition to clinical articles, the Journal's sections include:
ACCESS TO FULL TEXT ONLINE. • Continuing Education—Now you can get continuing education credits
quickly and conveniently.
To order, call toll-free: • Short Communications—Shorter articles that bring you quick delivery
1-800-654-2452 of time-sensitive information.
Outside U.S.A. and Canada: • Techno Bytes—You get information on computers and computer programs
1-407-345-4000 to enhance your diagnostic skills and practice management.
Fax: • Litigation and Legislation Update—Keeps you abreast of risk-management
1-407-363-9661 strategies and relevant court cases.
E-mail:
periodical. service@mosby. com Turn to the journal your colleagues have trusted for 85 years.
Visit:
www.mosby.com/ajodo SPECIAL OFFER FOR SUBSCRIBERS!
Or contact: As part of your subscription to American Journal of Orthodontics and Dentofacial
Orthopedics, you'll receive FREE access to the online version of the journal. You'll
M Mosby have instant access to the full text of each issue as it publishes. One click of the
Customer Subscription Services
6277 Sea Harbor Drive mouse allows you to search and easily pinpoint information by abstract, title or
Orlando, FL author. In addition, you'll have access to PubMed (MEDLINE) reference links.
32887-4800 U.S.A.
This offer is available only to journal subscribers, so don't delay! Visit
©2001 Mosby. Prices subject to
change without notice. Add the
applicable sales tax for your area.
www.mosby.com/ajodo today for full details!
<<    
     Article
      >>
Seminars in Orthodontics
EDITOR
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent
Professor and Chairman
Department of Orthodontics
University of Alabama
1919 Seventh Avenue South
Birmingham, AL 35294
Fax: (205) 975-7590
Seminars in Orthodontics (ISSN 1073-8746) is published
quarterly by the W.B. Saunders Company. Months of issue are
March, June, September, and December. Corporate and
Editorial Offices: The Curtis Center, Independence Square
West, Philadelphia, PA 19106-3399. Accounting and Circulation
Offices: 6277 Sea Harbor Drive, Orlando, FL 32887-4800.
POSTMASTER: Send change of address to: Seminars in~
Orthodontics, W.B. Saunders Company, Customer Service, 6277
Sea Harbor Drive, Orlando, FL 32887-4800.
Editorial correspondence should be addressed to:
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent, Editor,
Seminars in Orthodontics, Professor and Chairman, Department
of Orthodontics, University of Alabama, 1919 Seventh Avenue
South, Birmingham, AL 35294-0007; fax: (205) 975-7590.
Correspondence regarding subscriptions or change of
address should be directed to Seminars in Orthodontics, W.B.
Saunders Company, Periodicals Department, P.O. Box 628239,
Orlando, FL 32862-8239 or e-mail hhspcs@harcourt.com.
Change of address notices, including both the old and new
addresses of the subscriber and the mailing label, should be
sent at least 1 month in advance.
Customer Service: 1-800-654-2452
Yearly subscription rates: United States and possessions:
individual, $125.00; institution, $154.00; student and resident,
$72.00; single issue, $47.00. All other countries: individual
$156.00; institution, $186.00; student and resident, $94.00;
single issue, $47.00. For all areas outside the United States and
possessions, there is no additional charge for surface delivery.
For air mail delivery, add $16.00. To receive student/resident
rate, orders must be accompanied by name of affiliated
institution, date of term, and the signature of program/residency
coordinator on institution letterhead. Orders will be billed at
individual rate until proof of status is received.
Prices are subject to change without notice. Current prices
are in effect for back volumes and back issues. Single issues,
both current and back, exist in limited quantities and are
offered for sale subject to availability. Back issues sold in
conjunction with a subscription are on a prorated basis. Checks
should be made payable to W.B. Saunders Company and sent
to Seminars in Orthodontics, W.B. Saunders Company, Periodicals
Department, 6277 Sea Harbor Drive, Orlando, FL 32887-4800.
Copyright © 2001 by W.B. Saunders Company. All rights
reserved. No part of this publication may be reproduced or
transmitted in any form or by any means, electronic or
mechanical, including photocopy, recording, or any information
storage and retrieval system, without permission in writing
from the Publisher. Printed in the United States of America.
Correspondence regarding permission to reprint all or
part of any article published in this journal should be
W.B. SAUNDERS COMPANY
A Division of Harcourt Brace & Company
Home | TOC |          
Index
addressed to Journal Permissions Department, W.B. Saunders
Company, 6277 Sea Harbor Drive, Orlando, FL 32887-4800.
Telephone number: 1-407-345-2500.
The appearance of the code at the bottom of the first page
of an article in this journal indicates the copyright owner's
consent that copies of the article may be made for personal or
internal use, or for the personal or internal use of specific clients,
for those registered with the Copyright Clearance Center, Inc.
(222 Rosewood Drive, Danvers, MA 01923; (508) 750-8400;
www.copyright.com). This consent is given on the condition that
the copier pay the stated per-copy fee for that article through the
Copyright Clearance Center, Inc. for copying beyond that
permitted by Sections 107 or 108 of the US Copyright Law.
This consent does not extend to other kinds of copying, such
as copying for general distribution, for advertising or promotional
purposes, for creating new collective works, or for resale.
Absence of the code indicates that the material may not be
processed through the Copyright Clearance Center, Inc.
Advertising representative: MJ. Mrvica Associates, Inc,
2 West Taunton Ave, Berlin, NJ 08009. Telephone (609) 768-
9360. Fax (609) 753-0064.
Publication of an advertisement in Seminars in Orthodontics
does not imply endorsement of its claims by the Editor(s) or
Publisher of the journal.
The contributors have checked generic and trade names and
verified drug doses for accuracy according to the standards
accepted at the time of publication. The ultimate
responsibility, however, lies with the prescribing physician.
Please convey any errors to the Editor.
The ideas and opinions expressed in Seminars in
Orthodontics do not necessarily reflect those of the Editor or the
Publisher. Publication of an advertisement or other product
mention in Seminars in Orthodontics should not be construed as
an endorsement of the product or the manufacturer's claims.
Readers are encouraged to contact the manufacturer with any
questions about the features or limitations of the products
mentioned. Neither the Editor or Publisher assume any
responsibility for any injury and/or damage to persons or
property arising out of or related to any use of the material
contained in this periodical. The reader is advised to check the
appropriate medical literature and the product information
currently provided by the manufacturer of each drug to be
administered to verify the dosage, the method and duration of
administration or contraindications. It is the responsibility of
the treating physician or other health care professional, relying
on independent experience and knowledge of the patient, to
determine drug dosages and the best treatment for the patient.
Seminars in Orthodontics is indexed in the Cumulative
Index to Nursing and Allied Health Literature® print index
and the Cinahl® database.
<<    
     Article
      >> Home | TOC |          
Index

Mosby
M Harcourt Health Sciences

NOW AVAILABLE ON THE INTERNET!

VISIT www.mosby.com/tripleo
ORAL RADIOLOGY,

and
ENDODONTICS

ISSN 1079-2104

No other journal brings you

Inside U.S.A.
Individuals $141.00
such complete coverage
Institutions $307.00 Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics
Students/Residents* $ 69.00 offers comprehensive coverage of diagnostic methods, pathologic problems and
Outside U.S.A. medical-surgical treatments as they relate to developments in five branches of
Individuals $170.00 dentistry. It is the only major dental publication that gives readers such a prac-
Institutions $336.00
Students/Residents* $ 98.00
tical and complete overview.
*Please supply, on institution letterhead, your
name, dates of internship/residency, and signature
An aggressive editorial policy has enabled Oral Surgery, Oral Medicine, Oral
of program director. Orders will be billed at the Pathology, Oral Radiology, and Endodontics to keep pace with changing trends
individual rate until proof of status is received.
Airmail rates are available upon request. and developments in dentistry. Attuned to the needs of today's practitioners,
the journal features:
SUBSCRIPTION PRICES INCLUDE
ACCESS TO FULL TEXT ONLINE. • monthly editorials by the journal's section editors that address the
To order, call toll-free: most important current issues in each branch of dentistry
• review papers that bring you state-of-the-art information and serve
1-800-654-2452
as a ready reference
Outside U.S.A. and Canada: • Clinicopathologic Conference (CPC) articles that challenge you to
1-407-345-4000
test and improve your clinical diagnostic skills
Fax:
1-407-363-9661
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics
E-mail:
is recommended for initial purchase in the Brandon-Hill study, Selected List of
periodical.service@mosby.com
Books and Journals for the Small Medical Library (1999/2000 Edition). Start your
Visit:
www.mosby.com/tripleo subscription to the journal today!
Or contact: SPECIAL OFFER FOR SUBSCRIBERS!
As part of your subscription to Oral Surgery, Oral Medicine, Oral Pathology, Oral
M Mosby Radiology, and Endodontics, you'll receive FREE access to the online version of
Customer Subscription Services
6277 Sea Harbor Drive the journal. You'll have instant access to the full text of each issue as it publishes.
Orlando, FL One click of the mouse allows you to search and easily pinpoint information by
32887-4800 U.S.A.
abstract, title or author. In addition, you'll have access to PubMed (MEDLINE)
©2001 Mosby. Prices subject to
change without notice. Add the reference links. This offer is available only to journal subscribers, so don't delay!
applicable sales tax f or your area.
Visit www.mosby.com/tripleo today for full details!
<<    
     Article
      >>
Seminars in Orthodontics
EDITOR
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent
EDITORIAL BOARD
Richard G. Alexander, Arlington, TX
Rolf G. Behrents, Memphis, TN
Samir E. Bishara, Iowa City, IA
Robert Boyd, DDS, San Francisco, CA
Larry M. Bramble, Cypress, CA
John S. Casko, Iowa City, IA
Harry L. Dougherty, Van Nuys, CA
T.M. Graber, Evanston, IL
Robert J. Isaacson, Richmond, VA
Alexander Jacobson, Birmingham, AL
Lysle E.Johnston, Jr., Ann Arbor, Ail
Gregory J. King, Seattle, WA
Vincent G. Kokich, Tacoma, WA
Steven J. Lindauer, Richmond, VA
INTERNATIONAL
Zeev Abraham, Herzliya, Israel
W.G. Evans, Johannesburg, South Africa
Roberto Justus, Mexico City, Mexico
Home | TOC |          
Index
James A. McNamara, Jr, Ann Arbor, MI
Robert N. Moore, Grand Island, NE
Ravindra Nanda, Farmington, CT
Perry M. Opin, Milford, CT
Sheldon Peck, Newton, MA
William R. Proffit, Chapel Hill, NC
Cyril Sadowsky, Chicago, IL
David M. Sarver, Birmingham, AL
T. Michael Speidel, Minneapolis, MN
William J. Thompson, Bradenton, FL
James L. Vaden, Cookeville, TN
Robert L. Vanarsdall, Jr., Philadelphia, PA
Katherine Vig, Columbus, OH
C.B. Preston, Buffalo, NY
Shinkichi Namura, Tokyo, Japan
George Skinazi, Paris, France
Björn U. Zachrisson, Oslo, Norway
<<    
     Article
      >> Home | TOC |          
Index

The 2001 Year Book of Dentistry'

EDITOR-IN-CHIEF: Kenneth L. Zakariasen, DBS, PhD
ASSOCIATE EDITORS: Douglas N. Dederich, DDS, PhD; Allan Boghosian, DDS; Bruce Horswell, MD, DDS, MS;
Fred Mclntyre, DDS, MS; and David Hatcher, DDS, MSC

Dtoday!
on't miss out on valuable information you can use in your
practice. Order your 2001 Year Booh of Dentistry® This year's hot topics include:
dental adhesive systems endodontics
The Year Book is a unique collection of article abstracts and glass ionomers periodontics
commentaries on significant new developments in your field. Each temporomandibular
year, a distinguished editorial board reviews more than 500 disorders
journals worldwide and selects only the most pertinent material for
inclusion.
MONTH OF PUBLICATION: September
The comprehensive and easy-to read abstracts are followed by PRICES:
personal commentaries from the editors.These experts analyze the US $85.00 International $91.00
clinical significance of each selection and discuss other studies of When you subscribe to the Year Book, we'll send you advance notice of future volumes about two
months before publication. To receive the new edition, you need do nothing—we'll send you the new
relevance. You get the material you need without needing to sift volume as soon as it's available. (Postage, handling, and applicable sales tax are added to each ship-
through a library of literature. ment.) If you decide you no longer want to subscribe, the advance notice makes it easy for you to let
us know

ISSN 0084-3717

^T To order call toll-free 1 -800-654-2452

Outside the U.S. and Canada: 407-345-4000 • Fax: 407-363-9661 IM Mosby
E-mail: periodical.service@mosby.com • Visit: www.mosby.com/periodicals ilfl HorcourtHe
irt Health Sciences

Or contact: Subscription Services, Mosby, 6277 Sea Harbor Drive, Orlando, FL 32887-4800 U.S.A.
©2001 Mosby. F
<<    
     Article
      >> Home | TOC |          
Index

Seminars in Orthodontics
VOL 7, NO 3 SEPTEMBER 2001

Topics in Biomechanics
Stanley Braun, DDS, ME
Guest Editor
CONTENTS

Introduction 139
Stanley Braun

En Masse Space Closure With Precise Anchorage Control 141

Raymond E. Siatkowski

Cantilever Springs: Force System and Clinical Applications 150

Andrew J. Kuhlberg

Orthodontic Planning and Biomechanics for Transverse

Distraction Osteogenesis 160
Harry L. Legan

Cephalometric Changes After Long-Term Early Treatment With Face Mask

and Maxillary Intraoral Appliance Therapy 169
Prinda Lertpitayakun, Kuniaki Miyajima, Ryuzo Kanomi,
and Pramod K. Sinha

Commentary: Biomechanical Considerations in Maxillary Protraction

Therapy 180
Stanley Braun

The Biomechanics of Canine Retraction With Arch Wire Guidance 182

Robert J. Nikolai

The Mechanical Plan of the Segmented Arch Technique 191

Michael R. Marcotte

Three-Dimensional Force Systems from Activated Orthodontic Appliances 207

Steven J. Lindauer, Robert J. Isaacson, and A. Denis Britto

An Examination of the Effects of Leveling With Nickel Titanium

Rectangular Arch Wires Combined With Torqued Incisor Brackets 215
Stanley Braun
<<    
     Article
      >> Home | TOC |          
Index

Seminars in Orthodontics
Future Issues

Vol 7 No 4 (December 2001)

THREE-DIMENSIONAL DIAGNOSIS AND TREATMENT IN ORTHODONTICS
Robert Boyd, DDS, MEd and Sheldon Baumrind, DDS, MS, Guest Editors
Vol 8 No 1 (March 2002)
CLINICAL UPDATE ON TECHNOLOGICAL ADVANCES IN ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS
Gregory King, DMD, DMSc
Vol 8 No 2 (June 2002)
B10STATISTICS FOR THE ORTHODONTIC CLINICIAN
Rose D. Sheats, DMD, Guest Editor

Recent Issues

Vol l No 2 (June 2001)

The Alexander Discipline
KG. Alexander, DDS, MSD, Guest Editor
Vol 7 No 1 (March 2001)
CLINICAL BIOMECHANICS
Steven J. Lindauer, DMD, MDSc, Guest Editor
Vol 6 No 4 (December 2000)
PSYCHOLOGIC ISSUES RELATED TO ORTHODONTIC TREATMENT AND PATIENT COMPLIANCE
Pramod K. Sinha, DDS, BDS, MS, Ram S. Nanda, DDS, MS, PhD, and Roger B. Fillingim, PhD, Guest Editors
Vol 6 No 3 (September 2000)
BIOLOGY OF ORTHODONTIC TOOTH MOVEMENT: CLINICAL IMPLICATIONS
Bhavna Shroff, DDS, MDentSc, Guest Editor
Vol 6 No 2 (June 2000)
MOLAR DISTALIZATION
George J. Cisneros, DMD, MMSc, Guest Editor
Vol 6 No 1 (March 2000)
OBJECTIVES-DRIVEN ORTHODONTICS: EFFECTIVENESS OF MECHANOTHERAPY
Cyril Sadowsky, BDS, MS, Guest Editor
<<    
     Article
      >>
Seminars in Orthodontics
VOL 7, NO 3
Introduction
A t the heart of orthodontic therapy, whether it
involves moving teeth through bone, altering
the growth of osseous structures, or distraction
procedures, the application of sound biomechani-
cal principles is mandatory. By so doing, the clini-
cian assures a forecastable outcome in an efficient,
tissue-kind manner. Absent the application of
sound biomechanics, the results are no longer
forecastable, and, in reality, the outcome is not
controlled by the orthodontist. Accordingly, this
issue of Seminars in Orthodontics is devoted to the
application of biomechanics and to understanding
and addressing a variety of clinical problems.
In the first article, Dr. Siatkowski presents an
interesting and thought-provoking approach
for the controlled closure of extraction sites
through the use of the Opus loop. This loop
configuration delivers inherent moment-to-force
ratios for en masse space closure via translation.
Various types of anchorage are explained by a
theoretical model that is based on the control of
root tissue stress levels.
Dr. Kuhlberg, in the second article, explains a
wide variety of uses of cantilever springs. He shows
the important advantage of the cantilever in that it
can produce predictable force systems, allowing
the clinician to forecast the movement of the ac-
tive teeth while controlling the force systems expe-
rienced by the reactive or anchor teeth.
In the third article, the biomechanics of dis-
traction osteogenesis in the transverse plane is
reviewed by Dr. Legan. He begins with case se-
lection, diagnosis, and treatment planning. This
is followed by appliance placement consider-
ations and the mechanics involved in distrac-
tion. Postdistraction orthodontic procedures are
then addressed.
Dr. Lertpitayakun et al, in the fourth article,
report the findings related to one common type
of protraction face mask therapy combined with
Copyright © 2001 by W.B. Saunders Company
doi:10.1053/sodo.2001.26699
Seminars in Orthodontics, Vol 7, No 3 (September), 2001: pp 139-140
Home | TOC |          
Index
SEPTEMBER 2001
the use of a maxillary removable appliance in
the early treatment of Class III Japanese chil-
dren. In an attached commentary, the biome-
chanical principles of the protraction face mask
used in the study are reviewed, as well as that of
an improved design that permits better control
of the maxilla's movement.
The biomechanics of canine retraction on an
arch wire is modeled in a very interesting and
enlightening manner by Dr. Nikolai in the fifth
article. The interaction between the force sys-
tems generated at the bracket slot/wire interface
with those of the periodontium resulting from
the application of a distal driving force is exam-
ined in detail. The analysis is sequential from
initial canine tipping onward.
Dr. Marcotte presents an example of a pretreat-
ment, in-depth sequential mechanics plan related
to the therapy of a patient, using the segmented
arch technique. This plan acts as a road map to
achieve a predictable treatment outcome. He
shows how the treatment objective is achieved in
three-dimensional space with surety and efficiency.
The forecasted anteroposterior position of the
dentition, the occlusal plane, and the arch form
are under the clinician's control throughout ther-
apy because the force systems and related tooth
movements are entirely predictable.
In the seventh article, Dr. Lindauer et al, uses
various forms of a cantilever to show the impor-
tant fact that we exist in a three-dimensional
environment. Too often the clinician, while con-
centrating on the active and reactive force sys-
tems in unidimensional space, overlooks the
third dimension, deriving unplanned dental
movements. The authors refresh our collective
memories with several clinical examples.
Finally, I present the findings of a clinical
study that evaluates mandibular arch leveling by
using a Niti rectangular arch wire in combina-
tion with torqued incisor brackets. Some clini-
cians believe this prevents incisor flaring. The
study reveals that incisor flaring is not pre-
vented. It is often masked clinically because the
139
<<    
     Article
      >> Home | TOC |          
Index

140 Stanley Braun

intercanine widths are characteristically greater migrate apically. This may actually place the la-
in the preformed Niti arch wires compared with bial bone at greater risk than leveling with round
the natural human arch form. An examination wire,
of the biomechanics reveals that the moment-
to-force ratio resulting from the use of Niti arch
wires, combined with the torqued incisor brack- Stanley Braun, DDS, MME
ets, causes the incisors' center of rotation to Guest Editor
<<    
     Article
      >> Home | TOC |          
Index

En Masse Space Closure With Precise

Anchorage Control
Raymond E. Siatkowski

The Opus loop was designed to deliver inherent moment-to-force (M/F)

ratios sufficient for en masse space closure via translation for teeth of
average dimensions absent marginal bone loss. Because the loop's inherent
M/F is high enough, no activation bends or bends in the formed loop need
be added before insertion. Because of the lack of activation bends, the loop's
neutral position is precisely and accurately defined, it being merely the
loop's passive position as it sits before insertion. Because the loop's neutral
position is easily and accurately determined by the clinician, simple cinch-
back activations after insertion can take advantage of tooth movement
thresholds to meet anchorage treatment objectives. One of the three an-
chorage objectives in clinical practice predetermined by the patient's treat-
ment plan is achieved simply and easily. This article presents the theoretical
basis that explains the loop's use of tooth movement thresholds for precise
anchorage control. The simple loop activations needed to achieve the de-
sired anchorage outcomes are presented for various arch wire alloys and
sizes. A bialloy closing loop arch wire is presented that takes advantage of
alloy performance for clinical use: infrequent reactivations, ease of comfort
bending, and incisor axial inclination control. (Semin Orthod 2001;7:
141-149.) Copyright © 2001 by W.B. Saunders Company

he Opus Loop arch wire1'2 was designed
T and optimized to provide an inherent mo-
ment-to-force (M/F) ratio of 8.0 to 9.1 mm, the
range necessary to translate groups of teeth of
average dimension.3'4 This M/F is achieved with-
out the addition of activation bends in the arch
wire or within the loop itself. Therefore, its neu-
tral position, the position of the loop when it is
tied-in is the same as that of the unactivated loop
before it is tied into the brackets.5 Having the
loop's neutral position precisely known allows
accurately known force systems to be applied to
the teeth via simple cinch-back activations.
A schematic drawing of the arch wire in posi-
tion to retract maxillary incisors is shown in
Figure 1. The apical horizontal leg is 10 mm
From Picton, New Zealand.
Address correspondence to Raymond E. Siatkowski, BEE, ME,
DMD, PO Box 287, Picton, New Zealand.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0703-0001$35.00/0
doi: 10.1053/sodo. 2001.26686
long, the ascending legs are at an angle of 70° to
the plane of the brackets, the apical helix is on
the leg ascending from the anterior teeth, that
ascent must begin within 1.5 mm posterior to
the most distal bracket of the anterior segment
being retracted, and the spacing between the
ascending legs and especially the apical loop legs
must be 1 mm or less. All these dimensions are
critical to the performance of the arch wire;
dimensional deviations degrade its perfor-
mance. Clinically practical comfort bends are
not critical.
Cinch-back activations for the arch wire for
each of the three anchorage situations encoun-
tered in clinical practice are shown in Figures 2A
and 2B for clinically useful sizes of arch wires in
stainless steel and TMA (Ormco/"A" Co, Or-
ange, CA). The large activations possible in
0.017" X 0.025" TMA arch wires should be
noted: appointment intervals can be extended
and appointments involve mere monitoring dur-
ing this stage of treatment with this arch wire.
Unfortunately, a full arch wire with sufficient

Seminars in Orthodontics, Vol 7, No 3 (September), 2001: pp 141-149 141

<<    
     Article
      >> Home | TOC |          
Index

142 Raymond E. Siatkowski

10 mm Loop Height and Length
Figure 1. Schematic drawing of Opus Loop Arch wire
in place for retraction of maxillary incisors after sep-
arate canine retraction. *4.5 mm for mandibular lat-
eral incisors and canines based on mean dimensions
from Wheeler6 and usual bracket heights.
anterior lingual twist is extremely difficult to
bend by hand in TMA. A jig to do that for this
alloy has been successfully developed. A further
improvement is shown in Appendix A.
The Wire-Bracket Play numbers, seen in Fig
2C, refer to commonly available wires and brack-
ets from U.S. vendors.7 Those from European
manufacturers can have far greater values.8 It is
important that sufficient lingual twist exists in
the arch wire, engaging the incisors so that the
bracket-arch wire play is reduced for axial con-
trol of the incisors.9
In Group C anchorage cases (posterior pro-
traction required) the use of intermaxillary
elastics to deliver an additional 150 gm/side
presupposes that the opposing arch has a stiff
rectangular stainless steel arch wire in place.
Instead, a TP 256 torquing auxiliary (kit #241-
200, 0.012" auxiliary torquing wire on 0.020"
arch wire; TP Orthodontics, Inc, LaPorte, IN)
can be overlaid over the closing loop arch wire
to provide additional protraction force to the
posterior teeth (Fig 3).10 The use of a TP 256
overlay to provide the additional protraction
force to the posteriors has several advantages:
(1) the clinician is free to perform other treat-
ment steps in the opposing arch; (2) undesired
vertical forces from intermaxillary elastics are
not a factor; and (3) posterior arch width in-
creases from intermaxillary elastics are not a
factor when using TMA arch wires. Clinical ap-
plications of the arch wire have been shown in
previous publications.1'2'10

A Maximum Anchorage ^^ Minimal Anchorage

Incisor retraction +/- after canines retracted Posterior protraction

Force: 100- 150 gm/side Force: 75 gm/side + Cl III elastics (150 gm/side)
or, preferably, TP 256 auxiliary

^3L - - ^
Maximum activation (mm)
Maximum activation (mm) Stainless Steel TMA -
.016 X.022 .018 X.025 .017 X.025 .019 X.025 .021 X .025
Stainless Steel TMA •
.016X.022 .018X.025 .017X.025 .019X.025 .021 X.025 1.0 1.0* 2.5 2.0 1.0
2.0 1.0 4.0 3.0 2.0 * crossed legs:

C3 Moderate Anchorage
3 • £ -tzr
Approximate Wire-Bracket Play, after Sebanc et al (7)
Anterior retraction and posterior protraction [variations occur amongst manufacturers]
Stainless Steel TMA >
Force: 150 - 200 gm/side .016 X.022 .018 X.025 .017 X.025 .019 X.025 .021 X .025
slot size .018 .022 .022
Play, degrees 13 ° 18° -8°

Maximum activation (mm)

Stainless Steel TMA •
.016 X.022 .018 X.025 .017 X .025 .019 X .025 .021 X .025

3.0 2.0 6.0 4.0 3.0

Figure 2. Initial (maximum) activations of the Opus Loop arch wire for the three groups of anchorage
requirements encountered in clinical practice. If second molars are fully erupted, they should be included in the
posterior segment. Reprinted with permission.2
<<    
     Article
      >> Home | TOC |          
Index

En Masse Space Closure 143

versus time portion of each of the graphic rep-

resentations to follow is the physical amount of
tooth movement resulting from the deactivating
force system applied by the arch wire. Extending
the rate of tooth movement as a function of
applied stress to include the third (time) axis
aids understanding the simply achieved anchor-
age control observed clinically with this particu-
lar arch wire. Calculations to estimate the actual
values of stress involved are presented in Appen-
dix B.
The osteologic curve is shown as the dotted
Figure 3. Torquing auxiliary overlay providing addi- curve in Figure 4A. In this, and all graphs to
tional mesial protraction force to the maxillary poste- follow, the initial displacement of the teeth in
riors. Reprinted with permission from JCO, Inc.10
their viscoelastic PDL and the next quiescent
period when the osteoprogenitor cells are mo-
bilized and differentiate into osteoclasts13 are
Rates of Tooth Movement
ignored. Those events occur during the time
Quinn and Yoshikawa11 concluded that the most
likely description of the rate of tooth movement
as a function of stress in the periodontal liga-
ment-root-bone interfaces resulting from ap-
plied orthodontic force systems takes a simple
ramp form when graphed. A more recent semi-
nal article by Meisen12 modifies that form into
one, still with a plateau over much of the stress
range, that matches results from the orthopedic
research literature and unifies orthodontic and
orthopedic bone formation/resorption/remod-
eling research results.
That analysis relates bone formation/resorp-
tion to strain in the peridontal ligament (PDL)
produced by the applied force system. For orth- >C~^
PDL Stress
odontic tooth movement the rate limiting pro-
cess is bone resorption, not apposition.13 PDL
compression side phenomena limits tooth move-
B
ment rates. The PDL stress-strain curve is non-
linear in compression. The osteologic graphic
form remains valid if represented with a nonlin-
ear stress axis in place of the linear strain hori-
zontal axis. It is more straightforward to relate
phenomenon produced by orthodontic force
systems to the resulting PDL stresses than to its
accompanying strains.
This osteologic graphic form is the basis for
the theoretical explanation of the mode of ac-
tion of the Opus Loop arch wire but the rate as PDL Stress
a function of applied stress graphic representa-
tion is extended to include a third axis: time. Figure 4. Graph of the osteologic curve. Tooth move-
ment rate as a function of stress applied to the PDL.
This model examines the rate of tooth move- The curve is denoted by the dotted line (A). Graph of
ment as the looped arch wire deactivates; it is tooth movement, in time, as the result of translatory
important to note that the area under the rate stress (B).
<<    
     Article
      >>
144 Raymond E. Siatkowski
°-22 Threshold
(g/mrn2) PDL Stress
Figure 5. Graphic representation of the modes of
action of the Opus Loop arch wire, being the rate of
tooth movement as a function of both PDL stress and
time.
nearest the axis origins, signified by the break
along the time axis nearest to its origin.
When a force system is applied to the teeth,
after the quiescent period delay the initial rate
of tooth movement will be that at a point on the
dotted curve corresponding to the value of the
applied stress in the PDL, such as point 2 in
Figure 4B.
It is important to note that the model is valid
only for uniform PDL stress along the full tooth
root. That is, by definition, the PDL stress distri-
bution produced by an applied force system with
a constant M/F that results in translation of the
teeth (not net translation resulting from con-
trolled tipping followed by root uprighting over
time). This model is quite specific to Opus Loop
arch wires. Further, these arch wires are acti-
vated to produce uniform PDL stress levels far
less than individual patient's systolic blood pres-
sure, by definition the stress level at which PDL
ischemic cell death (hyalinization) begins.12 The
translator^ PDL stress levels produced by the
Opus Loop arch wire activations suggested later
take advantage of phenomena described at the
left end of the osteologic curve to produce dif-
ferent predetermined anchorage. All resulting
tooth movement is by direct resorption. Hyalin-
ization and tooth movement by undermining
resorption is not an objective.
Referring again to Figure 4B, the teeth move
at an initial rate (point 2) determined by the
uniform translatory stress in the PDL, produced
by the initial cinch-back activation of the Opus
Loop arch wire (a larger initial activation shifts
Home | TOC |          
Index
the initial rate farther to the right on the osteo-
logic curve and a lesser activation shifts the ini-
tial rate farther to the left). As the teeth move,
time flows and the arch wire loops deactivate,
delivering the energy stored from the initial ac-
tivation. The magnitudes of the moment and
force delivered from the loops declines, though
the M/F remains constant. The teeth continue
to move in translation, at ever-decreasing rates.
Eventually, the loops reach complete deactiva-
tion and tooth movement ends.
The initial arch wire loop cinch-back activa-
tion determines just where on the osteologic
curve the earlier-mentioned results play out.
Various chosen cinch-back activations can shift
relative movement rates between anterior and
posterior teeth and therefore meet desired an-
chorage requirements.
The graphic representation of the rate of en
masse tooth movement from one activation of
the Opus Loop Arch wire as a function of time
and the resulting stress at the root/PDL inter-
face is shown in Figure 5. This representation is
complex and will be explained by isolating the
information relating to each of the three an-
chorage groups. The numbered curves in Figure
5 are tabulated in Table 1 for each of the three
anchorage groups.
Group B Anchorage (Moderate Anchorage)
For Group B Anchorage cases, the force system
applied is just enough to drive the stress in the
PDL of the posteriors onto the plateau of the
osteologic curve (150-200 gm/side). This is
shown in Figure 6A, which has isolated the rel-
evant curves from Figure 5. As a consequence,
the stress level in the PDL of the anteriors,
though higher, still remains on that plateau.
Therefore, the rates of tooth movement of the
anteriors and posteriors is nearly identical. Be-
Table 1. Tabulation of Numbered Curves in Figure
5 for Each of the Three Anchorage Groups
Group A maximum anchorage
Curve 2: Anteriors, retract
Curve 3: Posteriors, little change
Group B moderate anchorage
Curve 1: Anteriors, retract
Curve 2: Posteriors, protract
Group C minimal anchorage
Curve 4: Anteriors, no change
Curve 1: Posteriors, protract
<<    
     Article
      >>
En Masse Space Closure
cause the area under each curve represents the
physical movement of the teeth, both anteriors
and posteriors move equally to close the avail-
able space. This is further shown in Figure 6B, a
view of the rate versus time axes as if seen from
the far right of Figure 6A.
Group C Anchorage (Minimal Anchorage)
In Group C Anchorage, the level of force deliv-
ered by the Opus Loop arch wire (75 gm/side)
results in a calculated stress of 0.22 g/mm2,
somewhat below the threshold stress level neces-
sary for any tooth movement (by definition be-
cause 75 gm/side results in no tooth movement
of the anteriors).2 This is shown as point 4 in
Figure 7A. Additional force is applied to the
posteriors only, via intermaxillary elastics/
springs or an overlay TP 256 auxiliary. That ad-
ditional posterior force is sufficient to drive the
Group B - Moderate Anchorage
Both anteriors, curve 1, and
posteriors, curve 2, move equally
to close the space.
PDL Stress
Group B - Moderate anchorage. Both anteriors,
B - curve 1, and posteriors, curve 2,
move equally to close the space.
Figure 6. Group B moderate anchorage curves iso-
lated from Figure 5 (A). The rate versus time curves of
Figure 6A, as if viewed from the extreme right of that
figure (B). Both anteriors, curve 1, and posteriors,
curve 2, move equally to close the space.
Home | TOC |          
Index
145
Group C - Minimal Posterior Anchorage
Posteriors protract: curve 1
Anteriors do not move: point 4
PDL Stress
B Group C - Minimal posterior anchorage
Posteriors protract: curve 1
Anteriors do not move: point 4
Time
Figure 7. Group C minimal posterior anchorage
curve isolated from Figure 5 (A). The rate versus time
curve of Figure 7A, as if viewed from the extreme right
of that figure (B). Posteriors protract: curve 1; ante-
riors do not move: point 4.
stress level in the PDL of the posterior teeth
onto the plateau of the os teologie curve as
shown in Figure 7A, which has isolated the rel-
evant information from Figure 5. Figure 7B
shows a view of the rate versus time axes of
Figure 7A as if seen from the far right of that
figure.
Group A Anchorage (Maximum Anchorage)
The level of force delivered by the Opus Loop
arch wire in Group A cases is selected (100-150
gm/side) so that the stress level in the PDL of
the anteriors is just at the beginning of the pla-
teau (curve 2, Fig 8A). Because the surface area
of the posteriors exceeds that of the anteriors,
the PDL stress level is less for the same applied
force, and though exceeding the threshold, re-
mains well below the plateau (curve 3, Fig 8A).
There is minimal movement of the posteriors
<<    
     Article
      >>
146
Group A - maximum posterior anchorage
Anteriors retract: curve 2
Minimal posterior protraction: curve 3
PDL Stress
D Group A - maximum posterior anchorage
^ * Anteriors retract: curve 2
Minimal posterior protraction: curve 3
Figure 8. Group A maximum posterior anchorage
curves isolated from Figure 5 (A). The rate versus
time curves of Figure 8A, as viewed from the extreme
right of that figure (B). Anteriors retract: curve 2;
minimal posterior protraction: curve 3.
mesially compared with the amount of the ante-
riors' lingual movement (Fig 8B).
Discussion
The graphic descriptions of the three anchorage
cases for the Opus Loop arch wire can provide
further insights. For example, if the arch wire in
a Group A case is reactivated before full deacti-
vation of the loops (Fig 9A), the rate of anterior
tooth movement returns to the plateau rate, its
maximal rate, then follows the original deactiva-
tion sequence of Figure 8A. This occurs because
the osteoclasts originally mobilized and differen-
tiated still remain active at the PDL-bone inter-
face of the anterior teeth; this is in agreement
with the findings of King et al.14 If that reactiva-
tion, however, is delayed long enough for the
osteoclasts of the posterior teeth to become qui-
Home | TOC |          
Index
Raymond E. Siatkowski
escent, further mesial movement of the posteri-
ors can be minimized (Fig 9B).
There would be no biologic reason to delay
reactivating the loops in Group B or C cases; the
clinician can reactivate to the maximum cinch-
back whenever appointments are scheduled. If
using the TP 256 overlay in Group C cases, it
should be recinched as the posteriors move me-
sially. Because the torquing auxiliary wire has a
long range of action, the intervals between such
recinching are not critical; in fact, the axial in-
clinations of the central incisors change imper-
ceptibly over the time period that the protrac-
tion takes place, so the overlay is active in
delivering 150 gm/side continuously. For exam-
ple, if the Opus Loop arch wire is in 0.017" X
0.025" TMA, the posteriors move 2.5 mm before
the Opus Loops are completely deactivated (Fig
2C). Longer than usual intervals between ap-
pointments can be scheduled if the patient can
PDL Stress
p Group A - maximum posterior anchorage
Anteriors retract: curve 2
Minimal posterior protraction: curve 3
Archwire reactivated at time, R
Figure 9. Anterior tooth movement curve with an
arch wire reactivation at time, R (A). Maximum pos-
terior anchorage. Rate as a function of time when the
Opus Loop arch wire is reactivated at time, R. Ante-
riors retract: curve 2; minimal posterior protraction:
curve 3 (B).
<<    
     Article
      >>
En Masse Space Closure
be trusted to call for an emergency appointment
in the event of damage to the appliances.
If the anchorage unit were to incorporate
additional teeth in Group A cases, the PDL stress
level in the posterior teeth would fall, curve 3
would shift farther to the left in the osteologic
curve in Figure 8A, the posterior maximal rate
would fall, and net mesial movement of the pos-
teriors would be lessened. This is in agreement
with common clinical observations for most
types of space-closing mechanics. An exception
is mechanics that begin with a phase of uncon-
trolled tipping of anteriors and posteriors (such
as using a relatively small size unlooped straight
arch wire compared with slot size), followed by
root uprighting. The posteriors move at about
the same rate as the anteriors in uncontrolled
tipping. This phase generates high PDL stress
levels at the marginal ridges and apices, produc-
ing hyalinization and movement via undermin-
ing resorption. The stress levels are to the right
of the osteogenic curve, and anterior and poste-
rior tooth movement rates are approximately
equal. Clearly, Opus Loop arch wire mechanics
do not take that approach.
If a Group A patient has particularly critical
anchorage requirements supported by extraoral
traction, the patient should be urged to be dili-
gent with headgear wear for a few days after arch
wire reactivation. Figure 9B shows that the pos-
teriors will tend to move at that time.
The situation depicted in Figure 9B is that
found by using a 0.017" X 0.025" TMA Opus
Loop arch wire; just one reactivation is required
to close up to 8 mm of space when using the
arch wire in that size with that alloy (Fig 2A).
The arch wire can be activated asymmetrically
or unilaterally for asymmetric intra-arch space
closure. For example, if one side requires Group
A anchorage and the other side Group B, the
appropriate activations for each side are selected
from Figure 2. However, if one side requires
Group C anchorage and the other side Group A
or B, the Group A or B side alone should first be
addressed via an appropriate activation selected
from Figure 2. No activation should be placed
on the Group C side. After the space is com-
pletely closed on the Group A or B side, space
closure can then begin on the Group C side with
a unilateral activation chosen from Figure 2C as
appropriate in combination with the additional
auxiliary force required for posterior protrac-
Home | TOC |          
Index
147
tion. This sequence allows the TP 256 auxiliary
to be used (it cannot be activated unilaterally,
but will have no effect on the Group A or B side
after that space is closed).
Conclusions
After estimates of PDL stresses induced by the
precise force system applications made possible
by the Opus Loop arch wire with its easily iden-
tified neutral position, the rates of tooth move-
ment as a function of stress and time are
presented for the three anchorage cases encoun-
tered in clinical practice. Graphic representa-
tions of these rates, incorporating the Meisen
osteologic refinement of the Quinn/Yoshikawa
model, provide insight into how the anteriors
and posteriors respond in each anchorage situ-
ation and agree with past and recent findings of
tooth movement investigations.
Appendix A
The advantage of having the loop formed in 0.017"
X 0.025" TMA is that it provides a relatively long
range of activation (Fig 2). Unfortunately, there
are three clinical disadvantages to having the full
closing loop arch wire in TMA:
1. It is difficult to bend the TMA arch wire with
sufficient incisor twist to eliminate wire-bracket
play. With insufficient incisor root-lingual twist,
incisor axial inclination control is lost.
2. It is difficult for clinicians to contour the
looped TMA arch wire for patient comfort on
one side without affecting the contours of the
anterior portion and that of the opposite side.
3. Ten different anterior circumference-sized
wires in 3-mm increments are necessary to
have on hand to cover the range of all possi-
ble tooth sizes in both arches.
These three disadvantages can be overcome by
joining an anterior wire of Niti alloy with two
separate 0.017" X 0.025" TMA posterior wire
portions containing the Opus Loops. A sche-
matic drawing of this approach is shown in Fig-
ure 10. The disadvantages cited earlier are cor-
rected because:
1. An anterior wire size is chosen to completely
fill the incisor brackets. Incisor axial inclina-
tions are under control when pretorqued in-
<<    
     Article
      >> Home | TOC |          
Index

148 Raymond E. Siatkowski

One size: anterior wire marked, cinched at posterior of 4 Cc |V2

cross tube, then cut A = —j=\ ^y dy \ sin <* da (2)
V™ I
\ J Q
I
J Q

Niti* TMA loop & post, wire where the constant, c, is the mean root length,
again found from Wheeler6 to be:
3- Central incisor: 13.0 mm
Lateral incisor: 13.0 mm
^ Forestadent #760-0062 or
760-0063 cross tube Canine: 17.0 mm
Figure 10. Schematic drawing of TMA loop and pos- Results
terior wire joined to Niti anterior wire via Forestadent
cross tubes (Pforzheim, Germany). *Size to fill the Solving equation 2, the area in the direction of
brackets: 0.0215 X 0.028 for 0.022 slots; 0.018 X 0.025 translatory movement for maxillary anteriors is:
for 0.018 slots.

cisor brackets are used. It is simple to place A=4[fH e [- c ° sa] ° /z

V« L å Jo
one root-buccal twist on each side just distal
to the loops to eliminate TMA wire-bracket /l = 4 ( | c5 3 / 2 ) ( 0 - ( - l ) ) (3)
third-order play for the posteriors. \ « V-
2. Clinicians can contour each TMA side for
c 3/2
patient comfort without any effect on the A=
anterior wire or on the opposite side. 3V*
3. The anterior Niti wire can be supplied with a Substituting values for c and k into equation 3,
circumference large enough to fit any anterior the individual tooth areas are:
arch perimeter in any patient. The anterior Central incisor: 121.33 mm2
wire is placed, marked at the distal of the cross- Lateral incisor: 86.67 mm2
tubes abutted to the distal wing of the most Canine: 136.00 mm2
distal anterior segment tooth on each side, then
annealed, cinched, and cut there. Only one size The total area in the direction of translatory
arch wire need be kept on hand. tooth movement for the maxillary six anteriors is
then summed to be 688.0 mm2. By using
midrange applied force values for each of the
Appendix B three anchorage cases (found from clinical use
A paraboloid of revolution form is chosen to of the arch wire), the estimated root-surface
model the roots of the anterior teeth (Fig 11). stress levels are found by dividing the force by
This idealized three-dimensional model has the total area:
proved to provide reasonable estimates of actual
centers of resistance, centers of rotation, and
stress levels in previous studies.3'15 The parabolic
form is expressed by the equation,
y = kx^

y = kx2 (1) where k = 0.97072 for mx. central

= 0.69338 for mx. lateral

The values for the constant, k, are calculated R=x

from mean dimensions of maxillary anteriors Area in direction of movement =

from Wheeler6 to be: _£ /fy" dy / sin a da

N /
= 121.33mm2 for mx. central
Central incisor: 0.97072 = 86.67 mm2 for mx. lateral
= 136.00 mm2 for mx. canine
Lateral incisor: 0.69338 Stress
Canine: 1.88889 o - 0.22 g/mm2 = 22 g/cm2
o^ = 0.36 g/mm2 = 36 g/cm2
a =0.51 g/mm 2 = 51 g/cm2
At the root surface, the root area in the direction
of translatory tooth movement is described by Figure 11. Outline of area and PDL root stress calcu-
the equation: lations based on an idealized root form.
<<    
     Article
      >>
En Masse Space Closure
Group A, maximum anchorage required: 0.36
g/mm2
Group B, moderate anchorage required: 0.51
g/mm2
Group C, minimal anchorage required: 0.22
g/mm2
PDL hyalinization begins when the induced PDL
stress exceeds the individual's systolic blood
pressure. For one with a pressure of 120 mm Hg,
this is 1.56 g/mm2.
References
1. Siatkowski RE. Continuous Arch wire closing loop de-
sign, optimization, and verification. Part I. Am J Orthod
Dentofac Orthop 1997;! 12:393-402.
2. Siatkowski RE. Continuous Arch wire closing loop de-
sign, optimization, and verification. Part II. Am J Orthod
Dentofac Orthop 1997; 112:487-495.
3. Bowley WW, Burstone CJ, Koenig HA, et al. Prediction of
tooth displacement using laser holography and finite
element technique. In: Heron RE (ed). Biostereometrics
74. Falls Church, VA: American Society of Photogram-
metry, 1974, pp 241-273.
4. Siatkowski RE. Force system analysis of V-bend sliding
mechanics. J Glin Orthod 1994;28:539-546; addendum
1995;29:37-38.
Home | TOC |          
Index
149
5. Burstone CJ, Koenig HA. Optimizing anterior and ca-
nine retraction. Am J Orthod 1976;70:1-20.
6. Wheeler RC. A Textbook of Dental Anatomy and Phys-
iology. Philadelphia: Saunders, 1965.
7. Sebanc J, Brantley WA, Pincsak JJ, et al. Variability of
effective root torque as a function of edge bevel on
orthodontic arch wires. Am J Orthod 1984;86:43-51.
8. Kusy RP, WhitleyJQ. Assessment of second-order clear-
ances between orthodontic archwires and bracket slots
via the critical contact angle for binding. Angle Orthod
1999;69:71-80.
9. Siatkowski RE. Loss of anterior torque control due to
variations in bracket slot and arch wire dimensions.
J Glin Orthod 1999;508-510.
10. Siatkowski RE. Torquing auxiliary for posterior protrac-
tion. J Glin Orthod 2000;34:156-157.
11. Quinn RS, Yoshikawa DK. A reassessment of force mag-
nitude in orthodontics. Am J Orthod 1985;88:252-260.
12. Meisen B. Biological reaction of alveolar bone to orthodon-
tic tooth movement. Angle Orthod 1999;69:151-158.
13. Roberts WE, Goodwin WC, Heiner SR. Cellular response
to orthodontic force. Dent Clin North Am 1981;25:1-16.
14. King GJ, Archer L, Zhou D. Later orthodontic appliance
reactivation stimulates immediate appearance of osteo-
clasts and linear tooth movement. Am J Orthod Dento-
fac Orthop 1998;114:692-697.
15. Siatkowski RE. Optimal space closure for adult patients. In:
Nanda R (ed). Adult Orthodontics, Dental Clinics of North
America. Philadelphia: Saunders, 1996, pp 837-873.
<<    
     Article
      >> Home | TOC |          
Index

Cantilever Springs: Force System and Clinical

Applications
Andrew J. Kuhlberg

Cantilever springs are simple and efficient orthodontic appliances with a

wide variety of clinical uses. Biomechanically, cantilevers are able to pro-
duce statically determinant force systems, giving the clinician the opportu-
nity to deliver qualitatively and quantitatively precise forces. Cantilever
springs have a large range of clinical applications. They can be used in first-,
second-, and third-order problems. The basic design of cantilever springs
and their various clinical applications are discussed. (Semin Orthod 2001;7:
150-159.) Copyright © 2001 by W.B. Saunders Company

s the field of orthodontics has evolved, the
A options and techniques of mechanotherapy
have expanded significantly. Advances in
bracket design, wire alloys, and even bonding
techniques have increased clinical options. Al-
though bracket designs and proprietary treat-
ment protocols are broadly useful for many clin-
ical circumstances, achieving predictable and
efficient orthodontic tooth movement requires
more than simply selecting a particular bracket
style or arch wire sequence. The fundamental
basis of orthodontic therapy remains the ap-
plication of mechanical forces to produce
tooth movement. Force-driven appliance de-
signs are the ultimate approach in directing
treatment techniques toward sound biome-
chanical foundations.1'2 Across the wide array
of orthodontic devices, it is important to rec-
ognize the similarities between various mech-
anisms.3 One of the common designs is the
cantilever spring.
Cantilevers are beams supported at one end.
A schematic diagram of a cantilever is shown in
Figure 1. The key feature of the cantilever spring
is that the free end only may generate a single
From the Department of Orthodontics, University of Connecticut,
School of Dental Medicine, Farmington CT.
Address correspondence to Andrew J. Kuhlberg, DMD, MDS,
Assistant Professor, Department of Orthodontics, University of
Connecticut, School of Dental Medicine, 263 Farmington Ave,
MCI 725, Farmington CT 06030.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0703-0002$35.00/0
doi:10.1053/sodo.2001.26689
force (ie, there is no applied couple). Equilib-
rium requires that the force acting at the free
end must be balanced by an equal and oppo-
site force at the supported end. These two
equal and opposite forces are a couple, in this
case producing clockwise rotation. Therefore,
an additional moment must be acting on the
spring at the supported end in the counter-
clockwise direction. Thus, the conditions of
static equilibrium are fully satisfied and the
complete force system acting on the spring is
shown in Figure IB.4'6
For orthodontic applications, the fixed end
of the cantilever is the end of the spring in-
serted into a bracket or a tube (Fig 2A). The
free end applies a point contact; it does not
engage a bracket slot or tube. The spring is
activated by applying a force to this end; the
force is represented by the weight suspended
from the wire in Figure 2B. The bracket/tube
exerts an opposing force on the other end of
the spring. These forces constitute a couple,
therefore, it must be countered by another
couple. This couple is produced by the bracket
(tube). Thus, the force system on the wire
includes the two couples, the forces acting at
each end of the wire and the intrabracket
forces. The force system acting on the teeth is
simply the reverse of this force system (Fig
2C). The expected clinical movements follow
the forces acting on the teeth and are dia-
gramed in Figure 2D. The two couples are of
equal magnitude but opposite in direction.
The magnitude of the moment (couple) is the

150 Seminars in Orthodontics, Vol 7, No 3 (September), 2001: pp 150-159

<<    
     Article
      >>
Cantilever Springs
1 a method of incisor movement with minimal
Figure 1. The general force system from cantilever
springs. A point force acts on the free end of the
spring (A). The equilibrium force system includes an
opposing force and a concurrent moment acting at
the fixed end (B). The arrows represent the forces
and moments acting on the spring.
product of the force magnitude multiplied
by the distance between the forces of either
couple.
Because a cantilever is a simple two-tooth ap-
pliance, its force system is statically determinant.
The forces and the moments can be readily mea-
sured, thus, no unknown forces are acting on
the teeth. By working with measurable forces
and moments, use of this type of appliance per-
mits greater control by the orthodontist and
improves the predictability of movement. This
minimizes the potential for unexpected tooth
movement during orthodontic treatment.
Two extremely important and distinct advan-
tages characterize the cantilever design. First,
the anchorage or reactive teeth can be rigidly
secured to adjacent teeth with heavy arch wires
or segments, thus, reducing their potential
movement. Second, the cantilever can be fabri-
cated from reduced modulus wires relative to
the wire(s) supporting the anchor units. This, in
combination with the introduction of a helix at
the fixed end, will produce a more constant
Home | TOC |          
Index
151
force acting on the teeth (tooth) being moved.
Reactivations can thus be eliminated or signifi-
cantly reduced.
First-Order Cantilevers
With respect to the occlusal plane, the possibil-
ities of a cantilever force system are shown in
Figures 3A-D. The cantilever can be fixed poste-
riorly or anteriorly. In this plane, a cantilever
produces transverse forces with the rotational
moments at the fixed end.
Midline correction with a cantilever provides
side effects.7-8 This technique may be used when
either a tipping movement or translation is the
required movement. When the incisors are
tipped (Fig 4A), frequently associated with ec-
topic eruptions or the premature loss of primary
teeth, a simple force is needed to upright the
incisors and establish midline coincidence. In
contrast, the use of an arch wire for alignment
may result in future problems that would require
additional correction procedures. First, indis-
criminant leveling may create a cant to the an-
terior occlusal plane. Also, this approach re-
n
Figure 2. A cantilever inserted into an orthodontic
bracket. Passive spring (A). Force system on the wire
(B). Force system acting on the teeth (C). The ex-
pected movements from a cantilever (D). The shad-
owed bracket/wire reveals the previous position. The
force system on the wire includes the two couples, the
forces acting at each end of the wire (large arrows),
and the intrabracket forces (small arrows) Note: ar-
row size is not representative of the force magnitudes.
<<    
     Article
      >>
152 Andrew J. Kuhlberg
Figure 3. Applications of the cantilever force system
to first-order orthodontic problems. A cantilever in-
serted into the molar tube may be activated to apply a
force toward the midline (A) or away from the mid-
line (B). The total force system acting on the teeth is
shown. A cantilever inserted into a tube at the canine
or in the anterior region. The cantilever can be acti-
vated to produce either an expansion (C) or constric-
tion force (D). The arrows represent the forces/mo-
ments applied to the teeth.
quires sliding brackets (teeth) along the arch
wire. The force of friction acts in the opposite
direction of the intended movement, resisting
movement of the dental midline in the desired
direction. The teeth may upright without obtain-
ing the midline correction. The cantilever pro-
vides an alternative mechanism that avoids these
potential difficulties. The point force may be
Figure 4. A midline discrepancy caused by tipping of
the lower incisors. A simple force at the crowns of the
teeth (without an arch wire) will upright the incisors
and achieve midline coincidence (A). Midline correc-
tion by tipping (B).
Home | TOC |          
Index
applied to the anterior teeth before placing an
aligning wire. The cantilever can provide a pull-
ing force to shift the midline. Each incisor needs
to be independently tipped to correct the mid-
line. By tying the brackets together in a "Figure
8" and attaching the cantilever at the level of the
brackets, this simple tipping movement easily
corrects the midline discrepancy (Fig 4B).
An additional problem in midline correction
occurs when translation movement is required
(Fig 5A). Cantilever mechanics allows the point
of force application to be varied as needed.
Bodily movement occurs when a force is applied
through the center of resistance of the body (Fig
5B). By extending a passive loop apically toward
the center of resistance of the anterior teeth, the
spring can be attached to produce the force at
the desired level.
Transverse discrepancies in the posterior den-
tition can also be addressed with cantilevers. The
clinical options can be ascertained by reviewing
the possibilities shown in Figure 3. When attached
to the molar buccal tube, the cantilever spring can
be activated for simultaneous molar expansion
and mesiobuccal rotation. The cantilever can be
inserted into a vertical tube at the canine or from
an auxiliary tube attached to a base arch wire.
Emanating from the anterior, the cantilever pro-
vides an expansion force at the molar useful for
the correction of single-tooth dental cross-bites.
An interesting application of the cantilever
Figure 5. Midline correction by translation. An anterior
wire with a loop extended apically to approximate the
center of resistance of the incisor teeth to provide a contact
point for the force (A). A force applied through the center
of resistance will produce translation (B).
<<    
     Article
      >>
Cantilever Springs
force system is in the expansion for unilateral
cleft palate/alveolus correction. Common orth-
odontic problems in the unilateral cleft include
posterior cross-bite with rotation of the lesser
segment, resulting in a more severe cross-bite in
the primary canine region compared with the
molar region. Also, the greater segment and
the anterior teeth are tipped toward the cleft.
The objectives of orthodontic treatment include
posterior expansion with concurrent mesiobuc-
cal rotation of the lesser segment whereas the
greater segment/midline often requires trans-
verse movement away from the cleft to facilitate
surgical alveolar repair. Figure 6A shows these
common problems. Figure 6B shows the move-
ments needed to correct these problems and
meet the objectives of this stage of orthodontic
treatment. Figure 6C is a schematic of the repo-
sitioned dental segments. The movements re-
quired are effectively produced by the force sys-
tem of cantilever springs.
Figures 7A-H is an example of a cantilever
spring used for the presurgical orthodontic
treatment of a unilateral cleft lip and palate.
Figures 7A and 7B show the common clinical
problems described earlier. The molar attach-
ments include an auxiliary tube and the
posterior segment is splinted rigidly with fiber-
Figure 6. Common problems associated with unilateral
cleft lip and palate. Maxillary constriction, mesiolingual
rotation of the lesser segment, and rotation of greater
segment toward cleft area with maxillary incisor midline
toward cleft (A). The force system produced by a canti-
lever provides a means of correction for these problems.
The movements required for correction of these prob-
lems (B). Idealized objective of orthodontic treatment
of unilateral cleft palate (C).
Home | TOC |          
Index
153
reinforced composite.9 The anterior teeth are
bracketed and a passive heavy (0.017 X 0.025-
inch stainless steel) arch wire is inserted (Fig
7C). The cantilever spring (0.017 X 0.025-inch
stainless steel [SS]) is designed to rotate the
anterior segment to the patient's right, and to
expand and rotate the posterior segment. Figure
7D shows the passive cantilever, Figure 7E shows
the active cantilever and its force system. At ini-
tial insertion, the cantilever tips the incisors/
greater segment to the patient's right, expand-
ing the maxillary arch (Figure 7F). Subsequently, a
second cantilever was fabricated that extended far-
ther anteriorly to improve the range of activation.
Figures 7G and 7H show the outcome of the ex-
pansion and maxillary arch formation along with
the midline correction. This approach to appli-
ance design can be especially beneficial when the
placement and adjustment of palatal appliances
stimulates powerful gag reflexes, not uncommon
in cleft patients. This spring provides an alternative
to the use of Quad-helices and other palatal appli-
ances. The primary difficulty with a cantilever de-
sign for expansion is generation of sufficient ex-
pansion forces.
Second-Order Cantilevers
From the second-order perspective, the cantile-
ver spring force system provides vertical forces
and tip-forward/tip-back rotational moments
(Figs 8A-D). Cantilever springs are useful for the
application of vertical forces (intrusion, extru-
sion) or adjustments of the axial inclination of
teeth (tip-back, root correction).10'13
Perhaps the most common cantilever spring
design is the anterior intrusion arch. Intrusion
arches are characterized by the point force ap-
plication on the incisors. The force system from
intrusion arches includes anterior intrusion,
posterior extrusion, and molar tip-back (crown-
distal rotation). The basic design is shown in
Figure 9. The elegance of the intrusion arch
design is revealed by the variety of clinical solu-
tions it provides. Classically, the intrusion arch
has been used for anterior deep overbite correc-
tion while permitting the simultaneous correc-
tion of Class II molar relationships by the molar
tip-back.
One of the nuances of intrusion mechanics is
the ability to select the point of force applica-
tion.10 Selecting the location of the point of
<<    
     Article
      >> Home | TOC |          
Index

154 Andrew J. Kuhlberg

Figure 7. Maxillary expansion for a left unilateral cleft lip and palate. Pretreatment maxillary view (A),
pretreatment left buccal view (B), diagram of the initial appliance set-up (C). The molars are banded, the
incisors bracketed, a stiff SS segment secures the greater segment; the primary teeth in the less segment are
splinted to the molar (represented in gray). Diagram of the passive cantilever spring (D). Diagram of the
activated cantilever spring and the force system acting on the teeth (E). Initial placement, frontal view (F).
The anterior/greater segment wire is passive 0.017 X 0.025-inch SS. The cantilever pushes on the distal aspect
of the maxillary left central incisor bracket. Note that the upper midline is the full width of a lower incisor to the
left. Maxillary arch after expansion and alveolar bone graft (G). Anterior view after expansion and bone graft
(H). The cantilever had been replaced to increase its length and range of activation; it pushed laterally on the
mesial aspect of the right central incisor bracket; note the midline correction.

force application greatly increases the clinical
possibilities. Properly positioning and directing
the force relative to the center of resistance of
the teeth capitalizes on the effect of moments of
forces. This allows increased control of changes
to the axial inclination of the teeth during
intrusion (Figs 10A-D). Conversely, a lack of
awareness of the effect of moments of forces may
result in unexpected problems; for example, the
point of force application anterior to the center
of resistance of the incisors for the midline cor-
rection options described previously (Figs 4 and
5) would tend to rotate the anterior teeth in the
plane of occlusion. Frequently, this moment is
small because the distance between the force
application and the center of resistance is small.
Recognition of these effects allows the clinician
to plan accordingly.
Extrusion springs are the reverse of intrusion
mechanics. Cantilevers have been used for ex-
trusive tooth movements for high or impacted
canines and anterior open-bite correction (Figs
11A and 11B).3>14'15 The force system on the
molar tube tends to produce mesial tip-forward
movement and intrusion of the molar. These
reactive teeth can be appropriately supported by
a relatively stiff arch wire, thus, eliminating or
reducing this side effect.
<<    
     Article
      >> Home | TOC |          
Index

Cantilever Springs 155

Figure 9. The intrusion arch is a common cantilever.

Although intrusion and extrusion springs rely

on the vertical force (s) of cantilevers to achieve
the treatment goals, the moment produced by
cantilever springs can also be exploited for ef-
fective tooth movement. Canine root axial cor-
rection may be necessary after extraction space
closure (Fig 12A).16 A cantilever spring inserted
into the bracket slot of the canine is a means of
achieving distal root correction (Fig 12B). Ex-
tending the spring distally generates a greater
moment on the canine without heavy vertical
forces. Extrusion of the canine can be prevented
by stepping a stiff by-pass wire incisal to the
bracket and the space closure can be retained by
a "Figure 8" tie-back to the posterior teeth.

Third-Order Cantilevers
Third-order tooth movements are those that
change the buccolingual axial inclination of
teeth. The edgewise bracket, with the rectangu-
lar slot combined with rectangular arch wires, is
a commonly recognized approach to generating
torque and third-order tooth movement. Canti-
lever springs are also capable of producing these
buccal-lingual axial inclination corrections, of-

Figure 8. Second-order cantilever applications. In-

serting the cantilever into the molar tube allows either
anterior intrusion, posterior extrusion, and molar tip-
back (A), or anterior extrusion, posterior intrusion,
and molar tip-forward (B). An anteriorly placed can-
tilever that extends posteriorly allows either anterior
extrusion, anterior distal root movement, and poste-
rior intrusion (C), or anterior intrusion, anterior me-
sial root movement, and posterior extrusion (D).
<<    
     Article
      >> Home | TOC |          
Index

156 Andrew J. Kuhlberg

Figure 10. The location of the point of force application affects the type of tooth movement. The rotational
movement produced by the force is dependent on the moment of the force. The moment of the force is a
function of the point of force application and the distance to the center of resistance. A force at the bracket of
a flared incisor (A). A force slightly distal to the bracket (B). A force positioned further distally to pass through
the center of resistance (C). A force posterior to the center of resistance (D). The shadowed teeth show the
previous tooth position.

ten without the need to resort to heavy rectan-
gular wires engaged into all teeth.
Excessively upright incisors may occur af-
ter retraction and overjet reduction, especially
when teeth are retracted on round arch wires or
with a differential-moment anchorage strategy.16
An anterior root correction spring is a variation
of a cantilever designed to improve the incisor
axial inclination (Figs ISA and 13B). Anterior
root springs are fabricated from rectangular

Figure 11. A cantilever for extrusion of an impacted Figure 12. Separate canine root correction with a
or high canine. Force system and appliance design cantilever. Force system and appliance design (A).
(A). Treatment objective of canine extrusion (B). Treatment objective of canine root correction (B).
<<    
     Article
      >>
Cantilever Springs
Figure 13. Third-order tooth movement with a can-
tilever anterior root correction. Force system and ap-
pliance design (A). The cantilever is fabricated with a
full-bracket sized rectangular wire. Treatment objec-
tive of anterior root correction (B).
wires that fully engage the bracket slot. The
spring is activated to apply an intrusive force in
the posterior region. As with the canine root
correction spring, a base arch wire should pass
incisal to the anterior brackets to prevent the
extrusive side effect.
Rectangular orthodontic wires afford another
means of cantilever activation. Placing a perma-
nent twist in a curved section of wire is an alter-
native approach to cantilever activation (Fig 14).
Torsional forces from full-sized wires within
edgewise tubes or brackets generate a third-or-
der couple acting on the bracket/slot tube.
One of the challenges of vertical tooth move-
ments is prevention of unwanted side effects.
For instance, in the treatment of an anterior
open bite with an extrusion arch, the side effect
on the molar/posterior teeth may be a tip-for-
ward moment. Tip-forward movements of the
posterior teeth tend to increase occlusal plane
problems associated with open bites. The use of a
twist or third-order activation to an extrusion can-
tilever can be a means of reducing this side effect.
Figures 15A-I show an anterior open bite cor-
rected by extrusion with twist-activated cantilevers.
Home | TOC |          
Index
157
Fabricating Cantilevers
Cantilever springs can be fabricated from almost
any orthodontic wire. Stainless steel and beta-
titanium wires are popular choices because of
their formability. Because of the relatively high
stiffness of stainless steel, helices aid in reducing
the force levels of SS springs while also increas-
ing the springs' range of activation. Nickel-tita-
nium wires have also been used in cantilever
applications; however, these springs must be pre-
fabricated by the manufacturer.17 Rectangular
wires are generally preferred for making canti-
lever springs because they resist rolling within
the bracket or tube, thus, ensuring accurate con-
trol of the direction of force application.
The force generated by the spring can be mea-
sured with a force gauge. The moment magnitude
is the product of the force multiplied by the dis-
tance between the attachments. The moment mag-
nitude can be increased or decreased by changing
the length of the cantilever spring. This allows
qualitative and quantitative control of the applied
force systems. The direction of the force vector is
determined by the activation of the spring.
Figure 14. Placing a twist about the long axis of a
curved section of a rectangular arch wire. The twist
creates a third-order activation that can be used for
cantilever force generation. To flatten the wire (the
force system on the wire) would require a downward
force at one end opposed by an upward and torsional
force on the opposite end.
<<    
     Article
      >> Home | TOC |          
Index

158 Andrew J. Kuhlberg

Figure 15. Anterior open-bite correction with third-order activation of a cantilever. Pre treatment right (A),
frontal (B), and left views (C). The cantilever springs passively inserted into auxiliary tubes on molars and twist
activations into curved wire segments. Hooks are bent into the anterior end of the springs to engage the anterior
segment (D). Buccal view of activated spring; the spring exerts an extrusive force on the incisor segment (E).
Occlusal view with springs inserted. A passive transpalatal arch is placed to prevent third-order movement of the
molars (F). Posttreatment right (G), frontal (H), and left views (I).

Managing Side Effects and
the Reactive Forces
Because the force system of cantilever springs
can be accurately determined, the potential
orthodontic side effects (unwanted tooth
movement) can also be predicted. Recogniz-
ing the possible side effects allows one to pre-
pare for them at the onset of treatment rather
than discovering perplexing midcourse prob-
lems. Palatal and lingual arches are beneficial
in maintaining arch widths as well as third-
order side effects on the molars.18 Headgear
and intermaxillary elastics can be useful in
controlling occlusal plane effects. Undesirable
vertical movements can be restrained by heavy
by-pass wires stepped incisal to the brackets to
prevent eruptive side effects.16 Solidly joining
many teeth into the anchor units with either
rigid wires or splinting helps minimize un-
wanted effects.
Summary
Cantilever springs generate a predictable force
system that is applicable to a wide variety of
orthodontic problems. Especially in situations
in which a point force is required, cantilever
springs offer a simple option that is easily tai-
lored to an individual patient's needs. With their
simple design, these springs may be used in
many creative orthodontic solutions.
<<    
     Article
      >>
Cantilever Springs
References
1. Braun S, Marcotte MR. Rationale of the segmented ap-
proach to orthodontic treatment. Am J Orthod Dento-
facial Orthop 1995;108:l-8.
2. Burstone C. The Biomechanical Rationale of Orthodon-
tic Therapy. In: Meisen B (ed). Current Controversies in
Orthodontics. Chicago, IL: Quintessence Books, 1991,
pp 131-146.
3. Lindauer SJ, Isaacson RJ. One-couple orthodontic appli-
ance systems. Semin Orthod 1995;l:12-24.
4. Mulligan TF. Common sense mechanics. 1. J Glin
Orthod 1979;13:588-594.
5. Mulligan TF. Common sense mechanics. 2. J Glin
Orthod 1979;13:676-683.
6. Mulligan TF. Common sense mechanics. 3. J Glin
Orthod 1979;13:762-766.
7. Nanda R, Margolis MJ. Treatment strategies for midline
discrepancies. Semin Orthod 1996;2:84-89.
8. van Steenbergen E, Nanda R. Biomechanics of orth-
odontic correction of dental asymmetries. Am J Orthod
Dentofacial Orthop 1995;107:618-624.
9. Burstone C, Kuhlberg A. Fiber-reinforced composites in
orthodontics. J Glin Orthod 2000;34:27l-279.
Home | TOC |          
Index
159
10. Burstone CR. Deep overbite correction by intrusion.
Am J Orthod 1977;72:l-22.
11. Nanda R. Correction of deep overbite in adults. Dent
Clin North Am 1997;41:67-87.
12. Roberts WWD, Chacker FM, Burstone CJ. A segmental
approach to mandibular molar uprighting. Am J Orthod
1982;81:177-184.
13. Shroff B, Yoon WM, Lindauer SJ, et al. Simultaneous
intrusion and retraction using a three-piece base arch.
Angle Orthod 1997;67:455-461.
14. Fischer T, Ziegler F, Lundberg C. Cantilever mechanics
for treatment of impacted canines. J Clin Orthod 2000;
34:647-650.
15. Bishara SE. Clinical management of impacted maxillary
canines. Semin Orthod 1998;4:87-98.
16. Burstone C, van Steenbergen E, Hanley K. Modern
Edgewise Mechanics and the Segmented Arch Tech-
nique. Glendora, CA: Ormco Corp, 1995.
17. Nanda R, Marzban R, Kuhlberg A. The Connecticut
Intrusion Arch. J Clin Orthod 1998;32:708-715.
18. Burstone CJ, Manhartsberger C. Precision lingual arches.
Passive applications. J Clin Orthod 1988;22:444-451.
<<    
     Article
      >> Home | TOC |          
Index

Orthodontic Planning and Biomechanics for

Transverse Distraction Osteogenesis
Harry L. Legan

Orthodontic treatment planning in the transverse dimension has historically

been based on the mandible because of the interest in keeping this dental
arch width more or less constant for reasons of stability. However, the
advent of mandibular (with or without maxillary) transverse distraction
osteogenesis (TDO) has allowed the practitioner to achieve results previ-
ously thought to be impractical and/or unattainable. There are numerous
indications for incorporating TDO into patients' treatment plans because it
may lead to enhanced facial esthetics, prevent dental extractions, and im-
prove stability. Planning treatment requires not only an astute diagnosis
and the establishment of appropriate goals, but an understanding of the
biomechanics. Orthodontic management of the dentition during the predis-
traction and postdistraction period is discussed. The article also describes
the planning, construction, mechanics, rigidity, placement, activation, and
stabilization of the expansion appliance. TDO has been shown to be an
effective technique for maxillary and mandibular widening in some situa-
tions in which other orthodontic and orthognathic procedures have been
lacking. (Semin Orthod 2001;7:160-168.) Copyright© 2001 by W.B. Saunders
Company

T ransverse distraction osteogenesis in the

maxilla and mandible has dramatically in-
creased the options available for treating orth-
odontic patients. Distraction osteogenesis is the
biologic process of new bone formation between
bone segments that are gradually separated by
incremental traction.1 Expanding the jaws is
most obviously indicated for absolute transverse
deficiencies. Other indications include posterior
lingual cross-bites, Brodie bites, various syn-
dromes (Fig 1), arch length deficiencies, con-
genitally missing teeth, early loss of teeth, tipped
teeth in dentally compensated skeletal malocclu-
sions, large buccal corridors, removal of possible
deleterious effects on temporomandibular struc-
From the Division of Orthodontics, Vanderbilt University Med-
ical Center, Nashville, TN.
Address correspondence to Harry L. Legan, DDS, Professor and
Director, Division of Orthodontics, Vanderbilt University Medical
Center, 1500 21st Avenue South, Suite 3400, Nashville, TN
37212.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0703-0003$35.00/0
doi; 10.1053/sodo. 2001.26
tures, and improvement of nasal respiration. Be-
cause dental arch expansion has been histori-
cally unpredictable and unstable, most patients
with the aforementioned problems have been
treated orthodontically with reduction of tooth
mass by either extractions or reproximation.
Other patients' treatment plans have included
dental flaring (ie, crown buccal/labial tipping)
to alleviate dental crowding caused by inade-
quate basal bone, even though there is good
evidence that dental (not skeletal) arch expan-
sion is largely unstable.2 In addition to instabil-
ity, other negative sequelae of orthodontically
compromising for inadequate basal bone by ex-
tracting, reproximation, or flaring are periodon-
tal problems and disappointing facial esthetics.
Although rapid palatal expansion for growing
patients has been used successfully for many
years,3 an early report of transverse maxillary
distraction osteogenesis (surgically assisted rapid
palatal expansion) appeared in the literature in
1976 by Bell and Epker.4 This procedure greatly
enhanced the ability to widen the maxilla in
adults, correcting asymmetric maxillae and very

160 Seminars in Orthodontics, Vol 7, No 3 (September), 2001: pp 160-168

<<    
     Article
      >>
Transverse Distraction Osteogenesis
Figure 1. An indication for TDO is hypoglossia-hypodactylyia syndrome. In the frontal view there is an obvious
buccal cross-bite, also referred to as Brodie bite or scissors bite (A). Occlusal view of the mandible shows extreme
constriction (B).
large transverse discrepancies. This skeletal ex-
pansion could be accomplished more predict-
ably, more physiologically, and with improved
stability. However, even with enhanced ability to
expand the maxilla, ultimate arch width was still
dictated by the sanctity of the mandibular arch
width.5 It was not until the introduction by Guer-
rero and Contasti6 of a procedure to surgically
widen the mandible by symphyseal osteotomy
and gradual distraction that practitioners were
able to have freedom to plan adequately in the
transverse dimension. Given the capability to
expand both or either arch, orthodontic plan-
ning can be based on valid decisions, achieving
good facial esthetics, arch dimensions, and
stability.
Diagnosis and Treatment Planning
Evaluation of the transverse dimension typically
begins with the clinical facial examination, as-
sessing the breadth of the smile and whether the
dental arches adequately fill the oral cavity, or
whether there appear to be large, dark buccal
corridors caused by insufficient arch dimension.
Inadequate transverse dimension, even in the
absence of posterior cross-bites, can be cor-
rected via bimaxillary expansion. Posterior skel-
etal lingual cross-bites (posterior cross-bite is
described relative to the position of the upper
molars) and buccal cross-bites (Brodie bites)
can be readily corrected with maxillary and
mandibular transverse distraction osteogenesis
(TDO), respectively. Posterior cross-bite can be
dental, skeletal, or a combination. Posterior-an-
Home | TOC |          
Index
161
terior cephalograms, submentovertex radio-
graphs, and study models are useful tools for
making that determination. For complex cases
requiring TDO, plastic skull/jaw replicas con-
structed from three-dimensional (3-D) com-
puted tomography scans may be useful.
Arch form is evaluated as broad, constricted,
tapered, ovoid, square, u-shaped, or v-shaped.
Inadequate arch length as determined by occlu-
sogram analysis7 in the presence of constricted,
tapered arch form and/or undesirable facial es-
thetics is an indication for TDO, as opposed to
extracting, reproximation, flaring, or tipping
teeth. An accurate and efficient method of de-
termining the required amount of expansion to
achieve the necessary additional arch length has
been reported.8 During expansion, the amount
of change in the anterior and posterior arch are
typically not equal because the line of action of
the expanding force is anterior to the center of
resistance. For this reason, various canine to
molar transverse modifications were considered,
and simple linear functions were offered for
predicting changes in arch length.
Predistraction Orthodontics
After establishing the treatment plan, the re-
quired orthodontic mechanotherapy is begun.
Because TDO is typically accomplished early in
the orthodontic treatment sequence, presurgical
orthodontic mechanics is primarily aimed at ex-
pediting placement of the distraction appliance
and making adequate space for the interdental
osteotomy. If at all possible, teeth bearing the
<<    
     Article
      >> Home | TOC |          
Index

162 Harry L. Legan

distraction appliance should not be moved be-
fore TDO because these anchor teeth ideally
should not be mobile. However, if the initial
positions of these teeth are so tipped, rotated, or
otherwise out of alignment as to prevent appli-
ance insertion, the necessary tooth movement is
achieved. Transpalatal and lingual arches made
of 0.032" to 0.036" stainless steel or beta titanium
are efficient means of aligning severely malposi-
tioned first molars.
Even though the symphyseal interdental os-
teotomy can be achieved between the central
and lateral incisors or between the lateral incisor
and canine if it is apparent initially that the most
interradicular bone is between those teeth, it is
beneficial to make the cut in the midline be-
tween the central incisors. This avoids the neces-
sity of making a horizontal osteotomy below the
apex of an incisor to bring the osteotomy into
the center of the chin, which is necessary to
avoid creating a chin asymmetry (Fig 2). A me-
ticulous examination of the panoramic and par-
ticularly the periapical radiographs is performed
to assess the positions of the roots and to decide
on the best interdental osteotomy site. In addi-
tion, root length and form as well as periodontal
status are evaluated. Several methods are avail-
able for creating ample divergence of the roots
at the planned osteotomy site. It is important to
ensure that adequate alveolar bone remains in-
tact on either side of the distraction gap so that
bone regenerate formation will emanate from
both sides.9 Placing bends in the arch wire, po-
sitioning brackets predistraction with an exag-
gerated second-order inclination (Fig 3), and
repositioning normally postdistraction, and/or
inserting efficient root springs are all useful
techniques.

Figure 2. Ideally, the mandibular interdental cut is made in the midline between the central incisors (A). If
necessary, to make the cut in an area of more sufficient bone, the surgeon can make the interdental cut more
laterally, though the osteotomy must be stepped back into the midline of the symphysis (B) to avoid creating a
chin asymmetry.
<<    
     Article
      >>
Transverse Distraction Osteogenesis
Figure 3. Brackets positioned on incisors to help
achieve adequate root divergence before interdental
osteotomy.
When only one arch is being expanded, the
other arch becomes the template arch. Conven-
tional bands and brackets are placed in the tem-
plate arch with appropriate wires to align, level,
torque, tip, and achieve planned arch depth and
width to guide expansion and any other planned
movements in the TDO arch. Ideally, a rectan-
gular stainless steel arch wire is placed in the
template arch and tied in with steel ligatures
before expansion. In some cases, primarily asym-
metries, interarch elastics will be used to in-
fluence the expansion, and the more rigid the
template arch the better.
Placement of Expansion Appliance
A few weeks before distraction, separators are
placed, typically at the first molars and first pre-
Figure 4. Insertion of the expansion appliance in this v-shaped maxilla shows a more anterior placement (A).
At conclusion of appliance activation, there is more expansion anteriorly. Notice buccal segment wires to
increase rigidity (B).
Home | TOC |          
Index
163
molars. Approximately 1 week later, bands with
buccal attachments are fitted, alginate impres-
sions taken, bands placed in the impression, and
models poured. The expansion screw is adapted
and soldered to the bands. In the maxilla the
all-metal appliance is placed comfortably in the
palate as anterior as possible for more anterior
expansion, and placed as posterior as possible
for relatively more posterior expansion (Fig 4).
Because the appliance is below the maxillary
center of resistance10 in the frontal view, rigidity
of the appliance is important to approach trans-
lation of the segments. By increasing the rigidity
of the expander and the wires attaching it to the
teeth, the moment induced by the necessary
offsets are reduced, resulting in reduced equiv-
alent moment-to-force ratios at the center of
resistance. This causes the center of rotation to
travel superiorly (in the frontal view), reducing
the amount of tipping. In the occlusal view, the
center of rotation would move posteriorly, re-
sulting in a more parallel separation of the mid-
palatal suture.11
In the mandible, to accommodate the tongue,
the all-metal expansion screw is positioned as
anterior and vertical to the symphysis as feasible,
taking care not to contact the tissue (Fig 5).
Infrequently, the difficulty of placing a lingual
tooth-borne appliance because of a severely con-
stricted mandibular arch or exceptionally mal-
posed posterior teeth dictates the use of a labial
bone-borne or hybrid appliance (Fig 6). Use of
the bone-borne appliance requires a much
<<    
     Article
      >>
164 Harry L. Legan
Figure 5. The mandibular tooth-borne expansion appliance is constructed on the lingual with the screw as
anterior as feasible for tongue comfort (A). Posterior teeth must be in sufficient alignment to allow appliance
insertion (B).
longer surgery time because the surgeon must
insert the appliance as well as perform the sym-
physeal osteotomy. Also, the risk of poor healing
is increased because more reflection of the mu-
coperiosteum is necessary to screw the legs into
the bone. Because the line of force of expansion
is necessarily anterior to the center of resistance
of the mandible (in the occlusal view), more
expansion is typically achieved anteriorly, though
once again the rigidity of the expansion appli-
ance is significant. As viewed frontally, several
experienced clinicians have reported that the
bone-borne appliance creates more expansion
Figure 6. The mandibular bone-borne or hybrid
(ie, attached to bone and teeth) appliances inserted
labial to the arch are used when it is unrealistic to use
the tooth-borne appliance because of tooth malposi-
tion or extremely constricted arch dimension.
Home | TOC |          
Index
inferiorly (skeletal) whereas the tooth-borne ap-
pliance achieves more expansion superiorly
(dentoalveolar).12 However, our experience has
not revealed a clinically significant difference in
mandibular widening when comparing bone-
borne and tooth-borne appliances. Both appear
to produce balanced movement of the teeth and
bone, and parallel opening of the symphyseal
distraction gap (Fig 7).
Distraction
On completion of the osteotomies but before
soft-tissue closure (Fig 8), the appliance is acti-
vated 2 mm. Particularly in the maxilla this ex-
pansion must occur with no resistance, or the
osteotomies must be reviewed to make sure they
are complete and there are no remaining areas
of resistance. Beginning 1 week postsurgically
(latency period), the appliance is activated at a
rate of 1 mm/day. Based on the patient and
family, the patient is either seen everyday and
the appliance is activated the full l mm, or the
patient activates the appliance at home 0.5 mm
in the morning and 0.5 mm at night (rhythm).
There is generally no practical limitation to the
amount of attainable expansion by using the
correct surgical technique, latency, rate, rhythm,
and vector. Intermaxillary cross-arch elastics are
occasionally used, particularly in asymmetric
cases, to increase the expansion on one side
and/or inhibit expansion on the opposite side.
On completion of the desired amount of move-
ment, the distraction screw is tied off.
Potentially, one of the most important side
<<    
     Article
      >> Home | TOC |          
Index

Transverse Distraction Osteogenesis 165

ogy. Nevertheless, histologic changes were seen

in the fibrous layer, cartilaginous layer, and car-
tilage/bone interface. The investigators con-
cluded that the changes were correlated with the
likely rotational forces directed at the condyle
on the posterolateral and anteromedial surfaces.
By using computer modeling, Samchukov et al14
showed lateral rotational movement of the con-
dyles subsequent to mandibular TDO. They de-
scribed 0.34° rotation of each mandibular con-
dyle for every 1 mm of mandibular midline
widening. Careful immediate postsurgical clini-
cal and radiographic evaluation of our patients
has shown an apparent tendency for the man-
dibular segments to laterally translate more than
rotate (Fig 9). Of interest, the translation that is
seen on the submental vertex film usually can-
not be confirmed when measuring the inter-
condylar width on the posterior-anterior ceph-
alogram. Many possible explanations for the
variations include a combination of condylar
translation and rotation, and morphology of the
temporomandibular joints including the rela-

Figure 7. Radiograph confirms parallel opening of

the mandible.

effects of mandibular TDO is on the temporo-

mandibular joint. Harper et al,13 by using Ma-
caca mulatta monkeys and tooth-borne appli-
ances, considered the histologic changes in the
condyle. They stated that the change in the con-
dyles was minor and limited to atypical morphol-

Figure 8. Before soft-tissue closure, expansion screw Figure 9. Submentovertex radiograph with mandibu-
is activated 2 mm without resistance to confirm that lar buccal segment wires is used to document centers
osteotomies are adequate. of rotation of mandibular widening.
<<    
     Article
      >> Home | TOC |          
Index

166 Harry L. Legan

Figure 10. Once the required expansion is achieved, an arch wire is placed anteriorly, incorporating a coil
spring (A) or pontic tooth (B) to prevent adjacent teeth tipping uncontrolled into the distraction gap.

tionship of the condyle to the ramus, areas of
condylar resorption, lack of precision in tracing
and superimposing radiographs, and expansion
appliance rigidity. Fortunately, the human con-
dyle is known to possess a certain degree of
physiologic adaptability. Several investigators
agree with our clinical observations that there
are few if any temporomandibular joint (TMJ)
symptoms after mandibular TDO.15 Further in-
vestigations of the effects of mandibular TDO on
the TMJ are surely needed.
Postdistraction Orthodontics
After achieving the required expansion, brackets
are bonded on any unbracketed teeth, and a
round stainless steel arch wire is tied in. The
interdental space at the distraction gap is main-
tained for 30 to 60 days to allow for some healing
before tooth movement. This space may be held
open by steel tying the teeth together on either
side of the gap, by placing something between
the teeth adjacent to the gap, such as a pontic
tooth tied into the arch wire or plastic tubing, or
a coil spring placed over the arch wire (Fig 10).
It is important postsurgically to prevent transsep-
tal fibers from causing uncontrolled tipping of
the incisors toward the distraction gap, creating
possible periodontal problems. Panoramic, pos-
teroanterior cephalometric, and/or periapical
radiographs are useful in assessing bone forma-
tion in the gap for planning when and how to
move teeth into the regenerate.
The distraction appliance is removed 3
months postsurgically and all teeth are banded
and bonded. Transpalatal and/or lingual arches
made of 0.032" to 0.036" stainless steel are in-
serted into the first molar lingual sheaths to aid
in holding the expansion (Fig 11). Any brackets
initially placed in an extreme second-order po-

Figure 11. Transpalatal (A) and lingual (B) arches are used to stabilize expansion throughout orthodontic
treatment.
<<    
     Article
      >> Home | TOC |          
Index

Transverse Distraction Osteogenesis 167

Figure 12. Models made before and after maxillary

TDO (A). Mandibular anterior root torquing spring
(BandC).

Figure 13. Pretreatment (A) and posttreatment (B) appearance of TDO patient shows broader smile and
reduction of dark buccal corridors, with resulting esthetic improvement.
<<    
     Article
      >>
168 Harry L. Legan
sition to help diverge roots away from the inter-
dental osteotomy site should now be reposi-
tioned ideally. Anterior teeth should be moved
toward the distraction gap along a fairly stiff
stainless steel wire with minimal force, achieving
a more advantageous moment-to-force (M/F)
ratio approaching 10:1 for translation. If an
acrylic denture tooth was used to hold the space
it must be sequentially reduced in diameter dur-
ing space closure.
In patients in whom little or no dental crowd-
ing was initially present, as arch width is in-
creased arch depth decreases (Fig 12A). This
usually results in upright incisors that require a
considerable amount of lingual root torquing
postsurgically to attain more normal angula-
tions. A carefully constructed root torquing aux-
iliary spring inserted into the anterior brackets
will generate ample root lingual moment. The
distal lever arms are made an adequate length
and are activated occlusally with sufficient force
to create a moment of approximately 2,000
gram-mm (m = f X d). In Figures 12B and 12C
also note that the main arch wire is stepped
incisally to prevent the eruptive side effect. Lev-
eling, arch coordination, root paralleling and
torque, and finishing alignment are accom-
plished by routine orthodontic mechanics.
Good retention starts with the appropriate diag-
nosis and treatment plan followed by sufficient
treatment. Well-planned and executed osteodis-
traction to widen the jaws can be adequately
retained in selected cases by Hawley-type retain-
ers, fixed lingual wires, invisible (suck down)
retainers, and positioners.
Conclusion
The orthodontist's function in the planning and
biomechanical aspects of distraction osteogene-
sis is of critical importance. By thorough evalu-
ation of the clinical findings, radiographs, study
models, occlusogram, photographic records,
and other imaging techniques, the orthodontist
and surgeon can plan and execute the proper
magnitude and 3-D direction of jaw expansion.
Carefully planned and executed predistraction
and postdistraction orthodontic mechanother-
apy help assure treatment goals of good oral
Home | TOC |          
Index
health, function, stability, and esthetics (Fig 13).
Distraction osteogenesis to widen the jaws has
significantly expanded the orthodontist's ability
to achieve improved results for the patient.
References
1. Ilizarov GA. The tension-stress effect on the genesis and
growth of tissues: Part 1. The influence of stability of
fixation and soft tissue preservation. Glin Orthop 1989;
238:249-281.
2. Little RM, Reidel RA, Artun J. An evaluation of changes
in mandibular anterior alignment from 10 to 20 years
post-retention. Am J Orthod Dentofac Orthop 1988;93:
423-428.
3. Haas AJ. Palatal expansion: Just the beginning of dento-
facial orthopedics. Am J Orthod 1970;57:219-255.
4. Bell WH, Epker BN. Surgical-orthodontic expansion of
the maxilla. Am J Orthod 1976;70:5l7-528.
5. Strang RHW. Textbook of Orthodontia. Philadelphia:
Lea & Febiger, 1933.
6. Guerrero C, Contasti G. Transverse (horizontal) man-
dibular deficiency. In: Bell WH (ed). Modern Practice in
Orthognathic and Reconstructive Surgery (vol. 3). Phil-
adelphia: Saunders, 1992, pp 2283-2402.
7. Marcotte M. The use of the occlusogram in planning
orthodontic treatment. Am J Orthod 1976;69:655-667.
8. Hnat WP, Braun S, Chinhara A, et al. The relationship of
arch length to alterations in dental arch width. Am J
Orthod Dentofac Orthop 2000;118:184-188.
9. Bell WH, Gonzalez M, Samchukov ML, et al. Intraoral
widening and lengthening of the mandible in baboons
by distraction osteogenesis. J Oral Maxillofac Surg 1999;
57:548-562.
10. Lee KG, Ryu YK, Park YC, et al. A study of holographic
interferometry on the initial reaction of maxillofacial
complex during protraction. Am J Orthod Dentofac Or-
thop 1997;lll:623-632.
11. Braun S, BottrellJA, Lee KG, et al. The biomechanics of
rapid maxillary sutural expansion. Am J Orthod Dento-
fac Orthop 2000;118:257-261.
12. Guerrero CA, Bell WH, Contasti GI, et al. Mandibular
widening by intraoral distraction osteogenesis. Br J Oral
Maxillofac Surg 1997;35:383-392.
13. Harper RP, Bell WH, Hinton JR, et al. Reactive changes
in the temporomandibular joint after mandibular mid-
line osteodistraction. Br J Oral Maxillofac Surg 1997;35:
20-25.
14. Samchukov ML, Cope JB, Harper RP, et al. Biomechani-
cal considerations of mandibular lengthening and wid-
ening by gradual distraction using a computer model.
J Oral Maxillofac Surg 1998;56:51-59.
15. Kewitt GF, VanSickels JE. Long-term effect of mandibu-
lar midline distraction osteogenesis on the status of the
temporomandibular joint, teeth, periodontal structures
and neurosensory function. J Oral Maxillofac Surg 1999;
57:1419-1425.
<<    
     Article
      >> Home | TOC |          
Index

Cephalometric Changes After Long-Term

Early Treatment With Face Mask and
Maxillary Intraoral Appliance Therapy
Prinda Lertpitayakun, Kuniaki Miyajima, Ryuzo Kanomi,
and Pramod K. Sinha

This article reports on a retrospective study of 25 children (mean age, 4 years

2 months) exhibiting Class III malocclusions and anterior cross-bites who
were treated with a face mask and a maxillary intraoral appliance. Cepha-
lometric radiographs were taken for all treated patients at three intervals:
before treatment (TO), after treatment (T1), and at posttreatment follow-up
(T2). A control group consisted of 10 untreated Class III children (mean age,
3 years 11 months). Cephalometric radiographs were taken periodically for
observation in this group. Paired t tests and independent t tests were
performed to determine the significance of skeletal and dental changes
related to treatment. Early therapy produced significant skeletal and den-
toalveolar changes. The maxilla moved further forward in the treated group.
Mandibular growth was similar in both treated and untreated groups. There
was an improvement in the maxillomandibular relationship in the treated
group. This was because of the proclination of the maxillary incisors and the
retroclination of the mandibular incisors. Self-correction of the original an-
terior cross-bite in the untreated group occurred. Long-term follow-up re-
vealed a decrease in overjet mainly caused by the proclination of the man-
dibular incisors. However, positive overjet was maintained throughout the
study period. Despite some relapse, the treated group showed a net positive
improvement in occlusion. (Semin Orthod 2001;7:169-179.) Copyright ©
2001 by W.B. Saunders Company

reduce the amount of dental compensations to

T he term early treatment simply means orth-
odontic therapy undertaken during the
most active stages of dentition and craniofacial
skeletal growth. Joondeph1 stated that "the ob-
jective of early orthodontic treatment is to create
a more favorable environment for future dento-
facial development. Interceptive treatment can
From private practice, Bangkok, Thailand; Department of Orth-
odontics, St. Louis University, Center for Advanced Dental Ed-
ucation, St. Louis, MO; private practice, Himeji City, Hyogo-ken,
Japan.
Address correspondence to Kuniaki Miyajima, DDS, MS, PhD,
Department of Orthodontics, St. Louis University, Center for Ad-
vanced Dental Education, 3320 Rutger Street, St. Louis, MO,
63104.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0703-0004$35.00/0
dot: 10.1053/sodo. 2001.26691
skeletal discrepancy that are often associated
with a more severe malocclusion in late adoles-
cence."
The goals of early interceptive treatment may
include:1'2
1. Prevent progressive, irreversible soft-tissue or
bony changes;
2. Reduce skeletal discrepancies and provide
a more favorable environment for normal
growth;
3. Improve occlusal function;
4. Enhance and possibly shorten phase II com-
prehensive treatment; and
5. Provide a more pleasing facial esthetic, po-
tentially improving the psychosocial develop-
ment of the child.

Seminars in Orthodontics, Vol 7, No 3 (September), 2001: pp 169-179 169

<<    
     Article
      >>
170 Lertpitayakun et al
Susami3 studied 409 cephalograms of Japa-
nese patients with anterior cross-bites. He found
that maxillary growth retardation in the decidu-
ous and early mixed dentition tended to con-
tinue into adulthood, and the relatively exces-
sive growth of the mandible increased until the
end of growth. Clinical studies have used maxil-
lary protraction in the late-mixed to early-perma-
nent dentition stages of development to take
maximum advantage of growth. If the opportu-
nity exists, treatment should begin in the decid-
uous dentition, after the child is 5 years of age,
but it also has a significant orthopedic effect in
the mixed dentition.4"6 According to da Silva
Filho et al,7 from the permanent dentition stage
on, its effect is essentially limited to dentoal-
veolar changes. Cozzani8 stated that treatment
should be started as early as 4 years of age. The
extraoral traction that pulls the maxilla forward
functions in the same general direction as the
direction of development and thus appears to
have a better chance of remaining stable.
There are multiple factors that affect the re-
sults of face mask therapy. The differing effects
of traction of the maxilla depend on the direc-
tion and point of force application.9 Age of the
patient and duration of application of traction
also play a role.10 There have been several stud-
ies on the effect of maxillary protraction appli-
ances in the treatment of anterior cross-bite
both clinically and experimentally. The follow-
ing treatment results have been reported and
agreed on by many investigators:
1. Maxillary anterior displacement,4'7'11-29
2. Counterclockwise rotation of the maxilla,4'7'17'24'28
3. Mandibular backward and downward rota-
tion 4,7,15-20,22-26,28
4. Improvement in facial profile,7'11-12'15'17-24-25
5. Proclination of the maxillary incisors,7'17'22'25-26'28
6. Retroclination of the mandibular inci-
sors,7'17'19'23'25'26 and
7. Increase in vertical dimension.7,13,16-18,22,25
Long-term stability of protraction therapy has
been reported. Williams et al22 observed 28
growing children posttreatment with rapid pala-
tal expansion (RPE) and maxillary protraction.
The anterior component of movement of the
maxilla resulting from treatment was stable dur-
ing the period of observation, and, in fact, the
maxilla continued to move anteriorly after treat-
ment. This may be attributed to normal growth
Home | TOC |          
Index
after treatment. The maxillary incisors showed
further proclination. The positive overjet and
overbite were maintained. The effects of maxil-
lary protraction appear to be stable.
After active protraction of the maxilla with a
face mask, relapse was reported by a few investi-
gators. In a study by Gallagher et al,19 the maxilla
relapsed by rotating clockwise, negating some of
the treatment results. The mandible resumed a
normal growth direction (downward and for-
ward) , and the mandibular incisors flared more
than normal.
Relapse in the overjet corrected by reverse
headgear treatment appeared to be caused by a
combination of posttreatment forward growth of
the mandible and proclination of lower incisors
compared with the clockwise rotation of the
mandible and retroclination of the lower inci-
sors observed at the end of active treatment.30
Because of the variability in facial growth,
accurate individualized growth prediction is not
possible. Ngan et al31 found that treatment re-
sults were stable 2 years after removal of the
appliances. At the end of a 4-year posttreatment
observation period, 15 of the 20 patients main-
tained a positive overjet or an end-to-end incisal
relationship. Patients who reverted to a negative
overjet were found to have excess horizontal
mandibular growth that was not compensated by
proclination of the maxillary incisors. Overcor-
rection of the overjet and molar relationship was
recommended to anticipate subsequent hori-
zontal mandibular growth. Petit32 suggested the
Frankel III regulator be used for 6 months after
protraction therapy.
Purpose of the Study
A number of clinical studies have been per-
formed documenting the initial and short-term
response to maxillary expansion and protrac-
tion. Data on the long-term effects of maxillary
protraction, and the longitudinal data on un-
treated patients with Class III malocclusions and
anterior cross-bites are limited with regard to
sample size and duration of longitudinal record
keeping. Most studies featured few patients and
short observation intervals. The purpose of this
study was to evaluate the long-term changes of
face mask therapy combined with a maxillary
intraoral appliance in the correction of Class III
malocclusions in a sample of Japanese patients
<<    
     Article
      >> Home | TOC |          
Index

Maxillary Protraction 171

in the primary dentition and compare the find-

ings with an untreated Class III sample. This
retrospective study followed-up patients from
primary dentition to permanent dentition.

Materials and Methods

Patients
The treatment group consisted of pretreatment,
posttreatment, and retention lateral cephalograms
of 25 Japanese children with Class III malocclu-
sions and anterior cross-bites who were treated
with protraction headgear and a maxillary in-
traoral appliance in the office of Dr. Kanomi. Ten
boys and 15 girls were selected with the mean age
at the start of treatment of 4 years 2 months
(range, 2 years 11 months to 6 years 1 month). The
average treatment time was 16.12 months. None of
the patients had a history of craniofacial anomalies
or had undergone prior orthodontic treatment.
The control sample consisted of 10 untreated
Japanese children with Class III malocclusions
and anterior cross-bites. Six boys' and four girls'
records were retrieved from the same private
practice and were matched for age as best as
possible with the experimental group. The mean
age at the start of observation was 3 years 11
months with an age range of 2 years 7 months to
5 years 5 months. Cephalometric radiographs were
taken periodically for observation (Table 1).
Appliance Design for Treatment Group
The maxillary intraoral removable appliance
consisted of an acrylic posterior bite plate with
Adam's clasps, labial bow, and two lingual
springs acting on the maxillary incisors. Two
hooks were placed between the deciduous ca-
nines and first deciduous molars for engaging
elastics to the face mask (Figs 1 and 2). The face
mask is shown in Figures 3 and 4. Approximately
Figure 1. Maxillary intraoral appliance.
250g of protraction force was delivered per side
to the hooks, with elastics adjusted to effect a
downward and forward pull at 30° to the occlusal
plane. The lingual springs were activated peri-
odically during treatment. The patients were in-
structed to wear the face mask 10 hours per day
and were treated until a positive overjet had
been attained. After the treatment was com-
pleted, the maxillary intraoral removable appli-
ance was used as a retainer. The patients wore
the removable retainer during sleep for 1 year.
Cephalometric Analysis
Cephalometric radiographs were taken for all
treated patients at three intervals: before treat-
ment (TO), after treatment (Tl), and at fol-
low-up (T2). In the control sample, serial lateral
Cephalometric radiographs were collected to
match time as accurately as possible, corre-
sponding to the treatment and posttreatment
periods of the treated group. The Cephalometric
radiographs were taken in centric occlusion with
the same cephalostat.

Table 1. Mean Ages of the Treated and the

Untreated Control Groups
Treated Group Untreated Control
(N= 25) (N= 10)
TO 4 yr 2 mo 3 yr 9 mo
Tl 5 yr 6 mo 7 yr 10 mo
T2 13 yr 1 mo 1 1 yr 9 mo
TO-T1 1 yr 4 mo 4 yr 1 mo
T1-T2 7 yr 7 mo 3 yr 11 mo
8 yr 11 mo 8yr
Figure 2. Elastics engaging the hooks between decidu-
TO-T2
ous canines and first deciduous molars to the face mask.
<<    
     Article
      >>
172 Lertpitayakun et al
Figure 3. Frontal view of a patient wearing the face
mask appliance.
All lateral cephalometric radiographs were
manually traced on tracing film with a mechanical
pencil and 0.03-mm lead. Digitization for cephalo-
metric analysis was performed with the Dentofacial
Planner software 7.0 program (Dentofacial Soft-
ware Inc., Toronto, Ontario, Canada) on each
landmark of all tracings. Skeletal and dental mea-
surements were obtained from the computer dig-
itizing program. Thirty angular and linear skeletal
and dental measurements were used in this study.
Method Error
The reproducibility of the measurements was
evaluated by statistically analyzing the difference
between double measurements made at least 1
month apart of 10 randomly selected patients.
The cephalograms were retraced and redigi-
tized. The error of the method was calculated
with Dahlberg's formula33:
Sx =
where d is the difference between the repeated
measurements and n is the number of double
measurements made. The error for angular and
linear measurements on the cephalometric ra-
diographs did not exceed 0.60° and 0.34 mm,
respectively.
Statistical Analyses
Paired t tests (P < .05) were performed to com-
pare skeletal and dental changes within groups.
Independent t tests (P < .05) were used to
compare skeletal and dental changes between
groups.
Home | TOC |          
Index
Results
At Tl, 50% of the untreated patients (5 of 10
patients) exhibited a self-correction of the orig-
inal anterior cross-bite. Cross-bite was observed
in two of the remaining five patients, and three
exhibited an edge to edge incisor relationship.
At T2, 9 of the 10 untreated patients showed
positive over] e t by self-correction and 1 pre-
sented with an edge to edge incisor relationship.
At TO, the maxillomandibular sagittal rela-
tionship, as indicated by the ANB angle, Wits,
and overjet, tended more toward a skeletal Class
III pattern in the treated group than in the
untreated control group (Table 2).
At Tl, the control group showed significant
proclination of both maxillary and mandibular
anterior teeth as presented by Ul to SN (P <
.05), incisal mandibular plane angle (IMPA)
(P< .001), LI to A-Pog (P< .001), and Ul to LI
(P< .001) (Table 3).
At T2, no significant differences were seen
between the treated and untreated groups. How-
ever, maxillary and mandibular lengths as indi-
cated by ptm-pt A and Co-Gn were significantly
larger in the treated patients than in the un-
treated ones. The y axis (FH/S-Gn) tended to
open more in the untreated group (64.02° v
61.40°, at P < .05) (Table 4).
The cephalometric changes from TO to Tl (Ta-
ble 5) showed a significant increase in SNA, ANB,
and Wits (functional) in the treated group com-
pared with the control (SNA, 1.07 v -0.96, P <
.01; ANB, 1.95 v -0.25, P < .001; Wits, 3.05 v
Figure 4. Side view of a patient wearing the face mask
appliance. Approximately 250g of protraction force
delivered per side with a downward and forward pull
at 30° to the occmsal plane.
<<    
     Article
      >> Home | TOC |          
Index

Maxillary Protraction 173

Table 2. Pre treatment (TO) Cephalometric Comparison Between the Treated Group and the Untreated
Control Group
Treated (n = 25) Control (n = 10)
Variable Mean SD Mean SD T Value P Value Sign
Maxillary skeletal
SNA 80.12 4.28 82.12 3.91 1.28 .2108 NS
Co-pt A (mm) 73.88 3.30 73.19 3.51 -0.55 .5890 NS
ptm-pt A (mm) 41.02 2.36 40.84 2.44 -0.21 .8379 NS
Maxillary dental
Ul-SN 88.80 7.19 85.54 4.02 -1.35 .1876 NS
Mandibular skeletal
SNB 80.30 3.83 79.78 2.40 -0.39 .6959 NS
SNPog 79.61 3.71 79.34 2.21 -0.21 .8329 NS
Y-axis (FH/S-Gn) 60.74 2.81 61.46 2.52 0.70 .4871 NS
Co-Gn (mm) 94.34 4.22 91.95 3.65 -1.57 .1256 NS
Mandibular dental
IMPA 79.88 6.00 81.87 4.26 0.96 .3465 NS
LI to A-Pog 2.94 1.41 2.12 1.36 -1.57 .1253 NS
Maxillomandibular relationship
ANB -0.17 1.73 2.35 2.96 2.52 .0275 *
Wits appraisal (mm) -5.53 2.23 -3.75 1.30 2.36 .0246 *
Wits functional (mm) -6.15 2.40 -4.04 1.32 2.61 .0135 *
U1-L1 157.27 11.22 157.88 6.88 0.16 .8738 NS
Overjet (mm) -2.67 1.02 -1.70 0.93 2.59 .0143 *
Overbite (mm) 1.89 1.77 0.67 0.94 -2.05 .0483 *
Vertical relationship
Occlusal plane angle (SN-OP) 18.87 3.18 19.34 3.63 0.38 .7052 NS
Occlusal plane angle (SN-Function OP) 20.04 3.77 19.91 2.74 -0.10 .9219 NS
Palatal plane angle (SN/ANS-PNS) 6.65 3.50 6.39 1.40 -0.32 .7543 NS
Mandibular plane angle (SN-GoMe) 34.58 3.98 35.41 3.48 0.58 .5685 NS
Gonial angle (Ar-Go-Gn) 127.72 6.33 128.21 3.80 0.23 .8227 NS
UAFH (N-ANS) (mm) 43.29 2.98 42.52 2.17 -0.74 .4638 NS
LAFH (ANS-Me) (mm) 56.98 3.88 56.85 2.79 -0.10 .9216 NS
AFH (N-Me) (mm) 99.31 5.63 97.81 3.63 -0.78 .4421 NS
PFH (S-Go) (mm) 64.86 3.27 63.20 2.32 -1.46 .1544 NS
PFH/AFH (%) 64.40 3,27 64.26 2.47 -0.12 .9067 NS
Soft tissue
Nasolabial angle 97.04 10.18 102.94 12.72 1.44 .1590 NS
Upper lip to E plane 0.97 1.42 1.10 1.87 0.22 .8272 NS
Lower lip to E plane 2.88 1.95 2.00 1.61 -1.27 .2146 NS
Cant of upper lip 21.90 7.03 17.77 9.24 -I A4 .1604 NS

*P < .05.
Abbreviation: NS, not specified.

- 0.48, P < .001). Maxillary length was significantly
less in the treated group as determined by variable
Co-pt A (3.16 mm v 7.9 mm, P < .001) as was
mandibular length (Co-Gn, 3.10 mm v 13.49 mm,
P < .001). Moreover, maxillary and mandibular
dental measurements (Ul-SN, IMPA, LI to A-Pog,
and U1-L1) showed that the control group had a
greater tendency of proclination of incisors than
did the treated patients. Improvement of soft-tis-
sue profile was shown in the treated group com-
pared with the untreated patients. No significant
changes occurred in the occlusal plane and palatal
plane angles between the two groups but the man-
dibular plane angle appeared to have increased in
the untreated control.
After long-term follow-up from Tl to T2 (Ta-
ble 6), the changes between the treated and
untreated groups showed no significant increase
in SNA, SNB, ANB angles, and Wits. An increase
in maxillary and mandibular lengths was ob-
served in the treated group compared with the
untreated group. There was also an increase in
proclination of maxillary and mandibular inci-
sors in the treated group. There was a significant
increase in the palatal plane angle in the treated
group when compared with the untreated group
(1.80 v -0.29, P= .047).
Discussion
Many previous studies regarding the correction
of Class III malocclusions with face mask therapy
<<    
     Article
      >> Home | TOC |          
Index

174 Lertpitayakun et al

Table 3. Posttreatment (TI) Cephalometric Comparison Between the Treated Group and the Untreated
Control Group
Treated (n = 25) Control (n= 10)
Variable Mean SD Mean SD T Value P Value Sign
Maxillary skeletal
SNA 81.19 3.50 81.16 3.74 -0.02 .9810 NS
Co-pt A (mm) 77.03 3.48 81.09 4.13 2.95 .0057 ##
ptm-pt A (mm) 42.59 2.12 44.24 2.75 1.91 .0649 NS
Maxillary dental
Ul-SN 98.80 7.81 106.61 8.59 2.60 .0139 *
Mandibular skeletal
SNB 79.40 2.84 79.07 2.55 -0.32 .7544 NS
SNPog 79.08 2.68 78.93 2.73 -0.15 .8796 NS
Y-axis (FH/S-Gn) 61.55 2.40 63.45 3.20 1.92 .0629 NS
Co-Gn (mm) 97.45 5.03 105.44 3.92 4.49 <.0001 ***
Mandibular dental
IMPA 77.94 8.42 89.30 3.11 5.83 <.0001 ***
LI to A-Pog 0.93 2.05 3.85 1.44 4.09 .0003 *#*
Maxillomandibular relationship
ANB 1.78 1.67 2.10 3.18 0.31 .7655 NS
Wits appraisal (mm) -2.49 1.65 -2.42 2.64 0.10 .9228 NS
Wits functional (mm) -3.10 2.41 -4.52 3.10 -1.45 .1574 NS
U1-L1 149.24 15.69 128.03 8.95 -4.00 .0003 *#*
Overjet (mm) 2.50 0.89 2.20 2.60 -0.36 .7284 NS
Overbite (mm) 1.61 1.37 1.66 1.81 0.09 .9323 NS
Vertical relationship
Occlusal plane angle (SN-OP) 17.11 3.06 17.45 4.32 0.26 .7951 NS
Occlusal plane angle (SN-Function OP) 17.99 3.27 20.46 4.24 1.85 .0726 NS
Palatal plane angle (SN/ANS-PNS) 6.62 2.98 8.11 1.89 1.46 .1526 NS
Mandibular plane angle (SN-GoMe) 34.65 3.98 37.24 4.17 1.72 .0955 NS
Gonial angle (Ar-Go-Gn) 125.58 6.84 126.41 3.67 0.36 .7214 NS
UAFH (N-ANS) (mm) 44.95 2.95 50.27 3.02 4.79 <.0001 ##*
LAFH (ANS-Me) (mm) 59.84 4.78 73.54 4.61 2.09 .0444 *
AFH (N-Me) (mm) 103.46 6.10 112.38 6.51 3.84 .0005 ***
PFH (S-Go) (mm) 67.46 3.85 71.07 2.85 2.68 .0115 *
PFH/AFH (%) 64.56 3.15 63.88 2.88 -0.59 .5616 NS
Soft tissue
Nasolabial angle 104.83 10.51 97.34 12.51 -1.81 .0801 NS
Upper lip to E plane 1.76 1.69 1.73 2.06 -0.05 .9600 NS
Lower lip to E plane 2.25 2.03 2.96 2.23 0.91 .3689 NS
Cant of upper lip 16.88 6.98 18.38 7.55 0.56 .5771 NS
*P < .05.
**P< .01.
***P< .001.
Abbreviation: NS, not specified.

have not included a control group or Class I
patients. The lack of data is probably owing to
the low prevalence of this type of malocclusion,
and the ethical question of treating the problem
when it exists. Fortunately, untreated Class III
samples were available for use in this study as a
control group. In a retrospective study, it is al-
most impossible to assemble ideally matched
groups. Children in the control group tend to
exhibit milder incisor malocclusion with a
greater degree of dentoalveolar compensation
and many do not wish to wear appliances. Chil-
dren in the treated groups, by definition, had a
clear therapeutic need.34 Ages at each stage in
Table 1 showed slightly different times when
cephalometric radiographs were taken for both
groups. The reader should keep in mind that
growth played an important role in the interpre-
tation of this study.
At pre treatment (TO), the severity of Class III
malocclusions as indicated by ANB, Wits, and
overjet variables was significantly less in the un-
treated control group.
After therapy, the results showed that treat-
ment induced significant skeletal and dentoalve-
olar changes. The maxilla moved forward (1.07°
increase in SNA and 1.95° in ANB). An increase
in the maxillary incisor inclination and the cor-
<<    
     Article
      >> Home | TOC |          
Index

Maxillary Protraction 175

Table 4. Post-Follow-up (T2) Cephalometric Comparison Between the Treated Group and the Untreated
Control Group
Treated (n = 25) Control (n = 10)
Variable Mean SD Mean SD T Value P Value Sign
Maxillary skeletal
SNA 81.51 2.61 82.32 2.97 0.80 .4295 NS
Co-pt A (mm) 89.96 5.54 87.16 2.76 -1.98 .0562 NS
ptm-pt A (mm) 49.32 3.27 47.43 1.69 -2.24 .0328 #
Maxillary dental
Ul-SN 110.22 6.11 111.05 3.27 0.41 .6869 NS
Mandibular skeletal
SNB 80.67 3.13 80.48 2.52 -0.17 .8669 NS
SNPog 81.44 3.04 80.71 2.95 -0.64 .5250 NS
Y-axis (FH/S-Gn) 61.40 2.89 64.02 2.61 2.49 .0179 *
Co-Gn (mm) 120.14 7.66 115.88 3.93 -2.16 .0387 *
Mandibular dental
IMPA 91.24 6.50 89.75 5.63 -0.64 .5290 NS
LI to A-Pog 3.74 2.34 4.50 2.48 0.85 .3998 NS
Maxillomandibular relationship
ANB 0.82 2.32 1.84 2.78 1.11 .2764 NS
Wits appraisal (mm) -3.22 3.01 -3.22 1.62 0.00 .9969 NS
Wits functional (mm) -5.31 3.39 -4.43 2.17 0.76 .4537 NS
U1-L1 126.19 8.06 123.95 8.76 -0.72 .4738 NS
Overjet (mm) 3.14 1.09 3.21 1.48 0.15 .8851 NS
Overbite (mm) 2.42 1.31 2.00 1.51 -0.81 .4218 NS
Vertical relationship
Occlusal plane angle (SN-OP) 15.08 3.78 16.50 3.85 1.00 .3234 NS
Occlusal plane angle (SN-Function OP) 17.84 3.75 18.22 4.06 0.26 .7928 NS
Palatal plane angle (SN/ANS-PNS) 8.42 3.06 7.82 1.87 -0.57 .5718 NS
Mandibular plane angle (SN-GoMe) 33.49 4.87 36.41 4.24 1.66 .1069 NS
Gonial angle (Ar-Go-Gn) 120.75 7.54 125.12 4.18 1.72 .0946 NS
UAFH (N-ANS) (mm) 56.96 4.15 55.14 2.30 -1.30 .2027 NS
LAFH (ANS-Me) (mm) 69.48 6.46 68.59 3.30 -0.53 .5975 NS
AFH (N-Me) (mm) 125.45 8.74 122.32 3.45 -1.52 .1384 NS
PFH (S-Go) (mm) 83.76 7.01 78.94 4.21 -2.02 .0513 NS
PFH/AFH (%) 67.05 3.88 65.10 3.07 -1.42 .1650 NS
Soft tissue
Nasolabial angle 97.56 8.78 96.76 9.24 -0.24 .8127 NS
Upper lip to E plane 0.22 1.86 0.60 2.66 0.48 .6332 NS
Lower lip to E plane 1.85 1.96 2.37 3.80 0.41 .6901 NS
Cant of upper lip 18.27 6.91 17.21 6.76 -0.41 .6823 NS

*P< .05.
Abbreviation: NS, not specified.

rection of the anterior cross-bite in the treated
group were caused by activated lingual springs of
the removable appliance. All patients exhibited
positive over]et. Even though there was no sig-
nificant difference when compared with the un-
treated control, the treatment was considered
successful when compared with the original se-
verity. In addition, the eruption of maxillary
incisors associated with an increase in labial in-
clination may have contributed to the correction
of the anterior cross-bite. In a study of Japanese
children, Susami3 reported that patients with
anterior cross-bite showed more labial inclina-
tion of maxillary incisors than did patients with
normal occlusion. Miyajima et al35 studied the
craniofacial growth in the untreated Class III
Japanese girls with anterior cross-bite. They
found that the maxillary incisors were tipped
labially and the mandibular incisors were tipped
lingually during development. This tendency be-
came greater as the dental stages advanced, pre-
sumably to compensate for the underlying skel-
etal discrepancy.
There was no significant difference in the
mean change of the palatal plane angle from TO
to Tl between the treated and the untreated
groups (-0.04° v 1.72°). The untreated group
exhibited an increase in the mandibular angle
when compared with the treated group (1.83° v
0.07°, P = .0149). The clinically significant rota-
tional effect caused by protraction headgear did
not occur in this study. The effects of growth
<<    
     Article
      >> Home | TOC |          
Index

176 Lertpitayakun et al

Table 5. Comparison of Cephalometric Changes From Pretreatment (TO) to Posttreatment (Tl) Between
the Treated Group and the Untreated Control Group
Treated (n = 25) Control (n = 10)
Variable Mean Change SD Mean Change SD T Value P Value Sign

Maxillary skeletal
SNA 1.07 1.82 -0.96 1.54 3.10 .0039 **
Co-pt A (mm) 3.16 2.34 7.90 2.48 -5.32 <.0001 ##*
ptm-pt A (mm) 1.56 1.78 3.40 1.25 -2.97 .0055 *#
Maxillary dental
Ul-SN 10.00 8.02 21.07 10.78 -3.34 .0021 **
Mandibular skeletal
SNB -0.90 1.81 -0.71 1.70 -0.28 .7776 NS
SNPog -0.52 1.85 -0.41 1.64 -0.17 .8662 NS
Y-Axis (FH/S-Gn) 0.81 1.45 1.99 2.58 -1.36 .1990 NS
Co-Gn (mm) 3.10 3.78 13.49 3.57 -7.46 <.0001 *##
Mandibular dental
IMPA -1.94 9.70 7.43 5.83 -2.84 .0077 ##
LI to A-Pog -2.01 1.35 1.73 0.93 -8.00 <.0001 ##*
Maxillomandibular relationship
ANB 1.95 0.99 -0.25 1.30 5.41 <.0001 #**
Wits appraisal (mm) 3.04 1.65 1.33 2.73 1.85 .0896 NS
Wits functional (mm) 3.05 2.09 -0.48 2.53 4.25 .0002 ***
U1-L1 -8.03 15.57 -29.85 12.86 3.92 .0004 ***
Overjet (mm) 5.17 1.50 3.90 2.89 1.32 .2141 NS
Overbite (mm) -0.28 1.53 0.99 2.30 -1.91 .0655 NS
Vertical relationship
Occlusal plane angle (SN-OP) -1.76 2.56 -1.89 2.93 0.13 .8941 NS
Occlusal plane angle (SN-Function OP) -2.05 3.80 0.55 2.94 -1.94 .0613 NS
Palatal plane angle (SN/ANS-PNS) -0.04 2.45 1.72 2.14 -1.98 .0561 NS
Mandibular plane angle (SN-GoMe) 0.07 1.84 1.83 1.81 -2.57 .0149 *
Gonial angle (Ar-Go-Gn) -2.14 1.96 -1.80 3.49 -0.29 .7766 NS
UAFH (N-ANS) (mm) 1.66 2.17 7.75 2.79 -6.92 <.0001 *#*
LAFH (ANS-Me) (mm) 2.85 2.43 6.69 2.43 -4.22 .0002 ###
AFH (N-Me) (mm) 4.15 4.18 14.57 4.79 -6.39 <.0001 *#*
PFH (S-Go) (mm) 2.60 3.03 7.87 2.46 -4.89 <.0001 *#*
PFH/AFH (%) 0.16 1.64 -0.38 1.63 0.88 .3856 NS
Soft tissue
Nasolabial angle 7.79 12.78 -5.60 8.63 3.03 .0047 **
Upper lip to E plane 0.79 1.74 0.63 1.33 0.26 .7929 NS
Lower lip to E plane -0.64 2.10 0.96 1.74 -2.12 .0417 *
Cant of upper lip -5.03 7.17 0.61 5.85 -2.20 .0346 *

*P < .05.
**P< .01
***P< .001.
Abbreviation: NS, not specified.

were probably greater than the effects of the
orthopedic force applied.
Mean changes from posttreatment (Tl) to
post-follow-up (T2) of the treated group were
more than the untreated control because obser-
vation time was longer in the treated group (7
years 7 months v 3 years 9 months). Accordingly,
the reported changes were not entirely gener-
ated by therapy. The favorable treatment results,
however, were maintained in the long-term ob-
servation. The improvement in the maxilloman-
dibular relationship was less significant at the
time of follow-up than immediately after the
treatment. The treatment effects of increased
over]et were diminished, mainly because of
proclination of the mandibular incisors. Such
relapse has been reported in previous re-
search.23'30'36 In addition to the transition from
primary dentition to permanent dentition, the
retroclination of the mandibular incisors during
treatment was important for maintenance of the
overjet correction. At the end of T2, 90% of the
untreated control patients exhibited correction
of anterior cross-bites, but 100% of the treated
patients that were originally more severe in
the malocclusion showed positive overjet. The
treated group would most likely have ended the
long-term observation with negative overjet if
<<    
     Article
      >> Home | TOC |          
Index

Maxillary Protraction 177

Table 6. Comparison of Cephalometric Changes From Posttreatment (Tl) to Post-Follow-up (T2) Between
the Treated Group and the Untreated Control Group
Treated (n = 25) Control (n = 10)
Variable Mean Change SD Mean Change SD T Value P Value Sign

Maxillary skeletal
SNA 0.32 2.64 1.16 1.09 -1.34 .1899 NS
Co-pt A (mm) 12.93 5.28 6.07 3.41 3.79 .0006 **#
ptm-pt A (mm) 6.73 2.90 3.19 1.52 4.70 <.0001 #*#
Maxillary dental
Ul-SN 11.41 6.92 4.44 9.56 2.41 .0217 *
Mandibular skeletal
SNB 1.27 2.60 1.41 0.80 -0.24 .8129 NS
SNPog 2.35 2.41 1.78 1.16 0.94 .3521 NS
Y-axis (FH/S-Gn) -0.15 1.61 0.57 1.70 -1.18 .2465 NS
Co-Gn (mm) 22.70 7.81 10.44 7.32 4.27 .0002 ***
Mandibular dental
IMPA 13.30 11.19 0.45 4.44 4.87 <.0001 *#*
LI to A-Pog 2.81 2.31 0.65 1.67 2.67 .0116 *
Maxillomandibular relationship
ANB -0.95 1.85 -0.26 1.16 -1.09 .2827 NS
Wits appraisal (mm) -0.73 2.79 -0.80 2.02 0.07 .9448 NS
Wits functional (mm) -2.21 3.26 0.09 2.41 -2.01 .0522 NS
U1-L1 -23.05 15.42 -4.08 11.83 -3.49 .0014 ##
Over) et (mm) 0.64 1.25 1.01 1.55 -0.73 .4705 NS
Overbite (mm) 0.80 1.54 0.34 1.74 0.78 .4436 NS
Vertical relationship
Occlusal plane angle (SN-OP) -2.04 3.89 0.95 2.99 -0.79 .4346 NS
Occlusal plane angle (SN-Function OP) -0.15 3.95 -2.24 2.56 1.54 .1321 NS
Palatal plane angle (SN/ANS-PNS) 1.80 2.96 -0.29 1.85 2.06 .0470 *
Mandibular plane angle (SN-GoMe) -1.16 3.23 -0.83 1.25 -0.44 .6662 NS
Gonial angle (Ar-Go-Gn) -4.84 4.09 -1.29 1.96 -3.45 .0016 *#
UAFH (N-ANS) (mm) 12.00 3.89 4.87 2.39 5.38 <.0001 #**
LAFH (ANS-Me) (mm) 9.64 4.71 5.05 4.57 2.63 .0130 *
AFH (N-Me) (mm) 21.99 7.13 9.94 6.66 4.60 <.0001 ***
PFH (S-Go) (mm) 16.30 6.26 7.87 4.33 3.89 .0005 ***
PFH/AFH (%) 2.50 2.89 1.22 0.90 1.98 .0562 NS
Soft tissue
Nasolabial angle -7.28 13.76 -0.58 12.91 -1.32 .1951 NS
Upper lip to E plane -1.54 1.94 -1.13 2.57 -0.52 .6067 NS
Lower lip to E plane -0.40 2.20 -0.59 3.46 0.20 .8434 NS
Cant of upper lip 1.40 6.42 -1.17 8.94 0.95 .3473 NS

*P < .05.
**P< .01.
***P< .001.

not for the treatment. The growth redirection of
maxilla was more forward to improve the skele-
tal discrepancy. Despite mandibular growth in
the pubertal growth spurt, the occlusion was
maintained in a favorable arrangement. The
findings of this study indicate that early interven-
tion of Class III malocclusion with face mask and
intraoral appliance therapy is beneficial.
Conclusions
This was a retrospective study of the long-term
stability of face mask therapy along with maxil-
lary intraoral appliance in patients with anterior
cross-bite. The records of 25 Class III patients
were compared with those of 10 untreated pa-
tients with Class III malocclusion. Growth played
an important role in the interpretation of the
results. The major findings follow:
1. The early correction of Class III malocclu-
sions with maxillary protraction headgear
combined with a maxillary intraoral appli-
ance produced significant skeletal and den-
toalveolar changes. The maxilla moved signif-
icantly farther forward in the treated group.
Mandibular growth was similar in both
treated and untreated groups.
2. There was an improvement in maxilloman-
dibular relationship after treatment. The re-
<<    
     Article
      >>
178 Lertpitayakun et al
suit was caused by the maxillary proclination
of the maxillary incisors and the retroclina-
tion of the mandibular incisors. This likely
occurred as a result of treatment and the
transition from primary dentition to mixed
dentition.
3. Self-correction of the original anterior cross-
bite in the untreated control group occurred.
Eruption of the maxillary incisors associated
with an increase in labial inclination may
have contributed to the correction of the an-
terior cross-bite.
4. The clinically significant rotational effect ex-
pected from the treatment of the maxilla and
the mandible did not occur in this study. The
individual growth potential was probably
greater than the effect of the protraction
force applied with regard to the rotational
effect.
5. After long-term follow-up, the changes be-
tween the treated and the untreated groups
showed no significant increase in SNA, SNB,
ANB, and Wits. Increased over] e t was dimin-
ished, mainly because of the proclination of
the mandibular incisors. Positive overjet was
maintained throughout the study period. De-
spite some relapse, the patients showed a net
positive improvement in occlusion. Early in-
tervention of Class III malocclusion with face
mask and maxillary intraoral therapy is ben-
eficial.
Acknowledgment
The authors wish to express their sincere gratitude to Drs.
Donald J. Ferguson, Dennis M. Killiany, and Gus G. Sotiro-
poulos for their valuable help and comments in preparing
the article.
References
1. Joondeph DR. Early orthodontic treatment. Am J
Orthod Dentofacial Orthop 1993;104:199-200.
2. Campbell PM. The dilemma of Class III treatment: Early
or late? Angle Orthod 1983;53:175-191.
3. Susami R. A cephalometric study of dentofacial growth
in mandibular prognathism. J Jpn Orthod Soc 1967;26:
1-34.
4. Ishii H, Morita S, Takeuchi Y, et al. Treatment effect of
combined maxillary protraction and chincap appliance
in severe skeletal Class III cases. Am J Orthod Dentofa-
cial Orthop 1987;92:304-312.
5. Takada K, Petdachai S, Sakuda M. Change in dentofacial
morphology in skeletal Class III children treated by a
modified maxillary protraction headgear and a chin cup:
Home | TOC |          
Index
A longitudinal cephalometric appraisal. Eur J Orthod
1993;15:211-221.
6. Irie M, Nakamura S. Orthopedic approach to severe
skeletal Class III malocclusion. Am J Orthod Dentofacial
Orthop 1975;67:377-392.
7. da Silva Filho OG, Magro AC, Capelozza Filho L. Early
treatment of the Class III malocclusion with rapid max-
illary expansion and maxillary protraction. Am J Orthod
Dentofacial Orthop 1998;! 13:196-203.
8. Cozzani G. Extraoral traction and Class III treatment.
Am J Orthod Dentofacial Orthop 1981;80:638-650.
9. Tanne K, Sakuda M. Biomechanical and clinical changes
of the craniofacial complex from orthopedic maxillary
protraction. Angle Orthod 1991;61:145-152.
10. Delaire J. Maxillary development revisited: Relevance to
the orthopaedic treatment of Class III malocclusions.
Eur J Orthod 1997;19:289-331.
11. Pangrazio-Kulbersh V, Berger J, Kersten G. Effects of
protraction mechanics on the midface. Am J Orthod
Dentofacial Orthop 1998;! 14:484-491.
12. Saadia M, Torres E. Sagittal changes after maxillary pro-
traction with expansion in Class III patients in the pri-
mary, mixed, and late mixed dentitions: A longitudinal
retrospective study. Am J Orthod Dentofacial Orthop
2000;117:669-680.
13. Mermigos J, Full CA, Andreasen G. Protraction of the
maxillofacial complex. Am J Orthod Dentofacial Orthop
1990;98:47-55.
14. Shanker S, Ngan P, Wade D, et al. Cephalometric A
point changes during and after maxillary protraction
and expansion. Am J Orthod Dentofacial Orthop 1996;
110:423-430.
15. Kapust AJ, Sinclair PM, Turley PK. Cephalometric effects
of face mask/expansion therapy in Class III children: A
comparison of three age groups. Am J Orthod Dentofa-
cial Orthop 1998;! 13:204-212.
16. Ucuncu N, Ucem TT, Yuksel S. A comparison of chincap
and maxillary protraction appliances in the treatment of
skeletal Class III malocclusions. Eur J Orthod 2000;22:
43-51.
17. Macdonald KE, Kapust AJ, Turley PK. Cephalometric
changes after the correction of Class III malocclusion
with maxillary expansion/face mask therapy. Am J
Orthod Dentofacial Orthop 1999;116:13-24.
18. Alcan T, Keles A, Erverdi N. The effects of a modified
protraction headgear on maxilla. Am J Orthod Dento-
facial Orthop 2000; 117:27-38.
19. Gallagher RW, Miranda F, Buschang PH. Maxillary pro-
traction: Treatment and post treatment effects. Am J
Orthod Dentofacial Orthop 1998;! 13:612-619.
20. Ngan P, Wei SHY, Hagg U, et al. Effect of protraction
headgear on Class III malocclusion. Quintessence Int
1992;23:197-207.
21. Ngan P, Hagg U, Yiu C, et al. Soft tissue and dentoskel-
etal profile changes associated with maxillary expansion
and protraction headgear treatment. Am J Orthod
Dentofacial Orthop 1996;109:38-49.
22. Williams MD, Sarver DM, Sadowsky PL, et al. Combined
rapid maxillary expansion and protraction face mask in
the treatment of Class III malocclusions in growing
children: A prospective long-term study. Semin Orthod
1997;3:265-274.
<<    
     Article
      >>
Maxillary Protraction
23. Chong Y-H, IveJC, ArtunJ. Changes following the use of
protraction headgear for early correction of Class III
malocclusion. Angle Orthod 1996;66:351-362.
24. Nartallo-Turley PE, Turley PK. Cephalometric effects of
combined palatal expansion and face mask therapy on
Class III malocclusion. Angle Orthod 1998;68:2l7-224.
25. Kilicoglu H, Kirlic Y. Profile changes in patients with
Class III malocclusions after Delaire mask therapy. Am J
Orthod Dentofacial Orthop 1998;113:453-462.
26. Baik HS. Clinical results of the maxillary protraction in
Korean children. Am J Orthod Dentofacial Orthop
1995;108:583-592.
27. Sung SJ, Baik HS. Assessment of skeletal and dental
changes by maxillary protraction. Am J Orthod Dento-
facial Orthop 1998;114:492-502.
28. Yoshida I, Ishii H, Yamagushi N, et al. Maxillary protrac-
tion and chincap appliance treatment effects and long-
term changes in skeletal Class III patients. Angle Orthod
1999;69:543-552.
29. Baccetti T, McGill JS, Franchi L, et al. Skeletal effects of
early treatment of Class III malocclusion with maxillary
expansion and face mask therapy. Am J Orthod Dento-
facial Orthop 1998;3:333-343.
30. Gu Y, Rabie B, Hagg U. Treatment effects of simple fixed
appliance and reverse headgear in correction of anterior
Please see Commentary regarding biomechanics of Lertpitayakun et al on next page.
Home | TOC |          
Index
179
crossbites. Am J Orthod Dentofacial Orthop 2000; 117:
691-699.
31. Ngan P, Hagg U, Yiu C, et al. Treatment response and
long-term dentofacial adaptations to maxillary expan-
sion and protraction. Semin Orthod 1997;3:255-264.
32. Petit H. Adaptation following accelerated facial mask
therapy. In: McNamara JA Jr, Ribbens KA, Howe PR
(eds). Clinical Alteration of the Growing Face. Mono-
graph 14. Craniofacial Growth Series. Ann Arbor, MI:
Center for Human Growth and Development, University
of Michigan, 1983, pp 253-289.
33. Dahlberg G. Statistical methods for medical and biolog-
ical students. London: Allen and Unwin, 1940, pp 122-
132.
34. Battagel JM, Orton HS. A comparative study of the ef-
fects of customized face mask therapy or headgear to the
lower arch on the developing Class III face. Eur J Orthod
1995;l7:467-482.
35. Miyajima K, McNamara JA, Sana M, et al. An estimation
of craniofacial growth in the untreated Class III female
with anterior crossbite. Am J Orthod Dentofacial Orthop
1997;! 12:425-434.
36. Wisth PJ, Tritrapunt A, Rygh P, et al. The effect of
maxillary protraction on front malocclusion and facial
morphology. Acta Odont Scand 1987;45:227-237.
<<    
     Article
      >> Home | TOC |          
Index

Commentary: Biomechanical Considerations

in Maxillary Protraction Therapy
Stanley Braun

Until recently, the most common method of

maxillary protraction consisted of bilateral
forces applied at the first molar or at the canine
regions. In this study, the protraction forces
were applied bilaterally at the deciduous canine
regions. The occlusogingival angle of the pro-
traction forces in the sagittal view is dictated by
the commisure of the lips. If the protraction
forces impact on either lip, usually from elastics,
the resulting discomfort would cause an imme-
diate reduction in patient cooperation. The ge-
ometry, as seen on a tracing of a lateral cepha-
logram (Fig 1), resulted in the forces being
directed at an angle to the functional occlusal
plane. Thus, protraction efficiency, when mea-
sured relative to the functional occlusal plane, is
encumbered because a portion of the protrac-
tive forces produces an eruptive component.
This can be significant because, in this article,
the reported downward angle of 30° relative to
the occlusal plane resulted in a total eruptive
force of 250 g (500 g X sin 30°), acting 10 hours
per day, and a reduced pro tractive force of 433 g
(500 g X cos 30°), acting 10 hours per day.
Considering the biomechanics from a more
comprehensive perspective, one must under-
stand that any constrained body (ie, a tooth, a
group of teeth, or an osseous structure joined to
other osseous structures through viable sutures)
will react to the forces applied to it relative to its
center of resistance.1'2 The location of the cen-
ters of resistance of the dentomaxillary complex
in adults, in addition to its clinical implications,
has recently been determined.3'4 They are lo-
cated on a line drawn perpendicular to the func-
tional occlusal plane through the distal contacts
From the Vanderbilt University Medical Center, Nashville, TN
and the St. Louis University Centerf or Advanced Dental Education,
St. Louis, MO.
Address correspondence to Stanley Braun, DDS, MME, 7940
Dean Road, Indianapolis, IN 46240.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0703-0005$35.00/0
doi:10.1053/sodo.2001.26692
A = early age dentomaxillary center of
resistance
F = protraction force
FOP = functional occlusal plane
Y = moment arm of protraction force
Figure 1. The relationship between a protraction
force to the dentomaxillary complex center of resis-
tance in an early-aged individual. A, early age den-
tomaxillary center of resistance; F, protraction force;
FOP, functional occlusal plane; Y, moment arm of
protraction force.
of the maxillary first molars as seen on a sagittal
cephalogram. They are further identified, on
the aforementioned perpendicular line, at one
half of the distance from the functional occlusal
plane to a line drawn parallel to the functional
occlusal plane through the inferior border of
the orbit (Fig 1). Because the dentomaxillary
complexes of the group studied were immature,
the centers of resistance are shifted anteriorly to
approximate the center of the second deciduous
molar seen in Figure 1. Consequently, any pro-
tractive forces attached to either the molar or
canine regions and forced to exit through the
commisure of the lips will always cause a coun-
terclockwise moment to act relative to the cen-
ters of resistance of the dentomaxillary complex
(Fig 1). As a result, the dentomaxillary complex
will rotate about a point slightly superior to its
centers of resistance.2 It is thus important to

180 Seminars in Orthodontics, Vol 7, No 3 (September), 2001: pp 180-181

<<    
     Article
      >>
Commentary
Figure 2. Protraction face bow that permits the ap-
plied forces to pass through the centers of resistance
of the dentomaxillary complex (A). Inner bow of the
protraction face bow entered through the distal of the
maxillary first molar headgear tubes (B).
realize that the type of protraction used in this
study does not cause protraction; it causes den-
tomaxillary rotation. This accounts for the statis-
tically significant findings cited in the manu-
Home | TOC |          
Index
181
script (ie, an increase in anterior facial height
and a decrease in upper facial height).
It should be noted that there are effectively two
centers of resistance in the dentomaxillary com-
plex. This is caused by the presence of a viable
midpalatal suture that can permit each half of the
dentomaxillary complex to act separately.4 How-
ever, the centers of resistance are superimposed
on each other in the sagittal view and therefore the
dentomaxillary complex can be treated as having
only one center of resistance in this view.
Recently, a protraction design has been reported5
that permits protraction force (s) to be applied
through the centers of resistance of the den-
tomaxillary complex (Figs 2A and 2B). This con-
sists of an ordinary face bow contoured so as to
insert from the distal headgear tubes attached to
the molars. The outer bow can be adjusted so
that the protractive forces will pass through the
centers of resistance of the dentomaxillary com-
plex and be parallel to the functional occlusal
plane, or at a specific upward or downward an-
gle if desired. The joint between the inner and
outer bows would lie at the commisure of the
lips when the protractive forces are acting. Con-
sequently, the patient will not experience lip
discomfort. With this appliance design the den-
tomaxillary complex can be translated forward,
parallel to the functional occlusal plane, or it
may be translated at an angle thereto, depend-
ing on the treatment objective.
It would be beneficial to see protractive stud-
ies similar to the one reported with the use of
the improved design.
References
1. Nanda R, Bruce G. Biomechanical approaches to the
study of alterations of facial morphology. Am J Orthod
1980;78:213-226.
2. Marcotte MR. Biomechanics in Orthodontics. Philadel-
phia: BC Decker, 1990.
3. Lee K, Ryu Y, Park Y, et al. A study of holographic inter-
ferometry on the initial reaction of the maxillofacial com-
plex during protraction. Am J Orthod Dentofac Orthop
1997;lll:623-632.
4. Braun S, Bottrel AJ, Lee K, et al. The biomechanics of
maxillary sutural expansion. Am J Orthod Dentofac Or-
thop 2000;118:257-261.
5. Braun S, Lee K, Legan HL. A re-examination of various
extraoral appliances in light of recent research findings.
Angle Orthod 1999;69:81-84.
<<    
     Article
      >> Home | TOC |          
Index

The Biomechanics of Canine Retraction

With Arch Wire Guidance
Robert J. Nikolai

An often required segment of active orthodontic therapy is the distal dis-

placement of canine teeth. The appliance used may include a continuous
arch wire to influence the displacement path and orientation of the canine
during tooth movement. If the distal driving force of the appliance mechan-
ics is delivered adjacent to the facial crown surface, the mechanical moment
of that force has two dental reference-frame components, representing
tendencies to distal crown tip and distolingually rotate the canine. Both
rotations are often unwanted, and the latter may be substantially sup-
pressed by partitioning the driving force faciolingually. An important addi-
tional challenge is the maintenance of appropriate intraoral anchorage. The
focus of this article is the orthodontic displacement of the canine as viewed
from a facial perspective. A plane analysis is undertaken that must neces-
sarily consider the mechanics of the appliance action and the biomechanics
of the periodontal response. An objective is to revisit several thought-
provoking clinical questions. The principal inquiry is into the form of the
displacement in the sagittal plane throughout the time period of this phase
of orthodontic therapy. (Semin Orthod 2001;7:182-190.) Copyright© 2001 by
W.B. Saunders Company

t the start of canine retraction mechanics,

A significant space exists distal to the canine;
perhaps the first premolar has been extracted.
Initially, here, the canine is assumed to be ide-
ally oriented; that is, the tooth is not impacted, it
is not tipped or rotated, and its root is not
against the facial or lingual cortical plate. In this
instance, the chosen appliance mechanics in-
clude dividing the total distal driving force be-
tween the facial and lingual crown surfaces to
eliminate the possibility of significant long-axis
rotation of the canine during displacement.
From an occlusal perspective, because of the
curvature of the dental arch, the crown center
From the Graduate Program in Orthodontics, Center for Ad-
vanced Dental Education, Saint Louis University, St. Louis, MO.
Address correspondence to Robert J. Nikolai, PhD, Graduate
Program in Orthodontics, Center for Advanced Dental Education,
Saint Louis University, 2075 Dreiling-Marshall Hall, 3320 Rutger
Street, St. Louis, MO 63104.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0703-0006$35.00/0
doi:10.1053/sodo.2001.26693
point is to follow a curvilinear path, but the
initial conditions imposed enable the reasonably
valid use of a two-dimensional model to analyze
the biomechanics. The appliance component
providing the distal driving force is to be a
spring or an elastomeric element (eg, the latter
a module, chain, o-ring, or tied thread). This
assumption is made simply to imply that the
driving force magnitude, while the component
is in place, will decrease—as typically occurs in
the clinical setting—with distal movement of the
canine crown center relative to a posterior den-
tal unit. A continuous arch wire engages crown
attachments affixed to the facial surfaces of the
teeth. In particular, the wire within an orthodon-
tic bracket attached to the canine crown and
supported at neighboring posterior and perhaps
anterior dental sites is intended to guide the
tooth during its distal displacement.
Orthodontic tooth movement occurs as a re-
sult of mechanical force exerted on the crown
and maintained there over some finite period
of time. This force is transmitted internally

182 Seminars in Orthodontics, Vol 7, No 3 (September), 2001: pp 182-190

<<    
     Article
      >>
Canine-Retraction Biomechanics
through the tooth, delivered by the root(s) to
the periodontium, and remodeling results from
the superposition of that force (carried into the
ligament and underlying bone) on the ongoing
physiologic processes there. Substantial evi-
dence exists to relate two of three characteristics
of crown-delivered force and the displacement
format of the tooth. More than 30 years ago,
Merrifield and Cross1 emphasized the relation-
ship of concentrated force direction to the de-
sired displacement. The importance of the loca-
tion of the line of the force to the resulting
displacement is implied by the wide acceptance
of the concept of the center of resistance of a
tooth.2 Orthodontic researchers, though, have
been engaged in a long-term inquiry toward un-
derstanding the relationship of delivered force
magnitude, that magnitude as some function of
time, and the resulting displacement rate. Rela-
tively few controlled clinical studies of tooth
movement in humans have been reported in the
literature,3'8 and the outcomes have been gener-
ally inconclusive toward establishment of an ac-
ceptable model (that would include force mag-
nitudes) beyond the three-stage framework
proposed by Reitan.9 In recent years, much of
the tooth movement research has been con-
ducted on the cellular level, and these studies
have primarily concentrated on enhancements
to displacement rate and the widespead concern
for root resorption.10'14
The activated orthodontic appliance will gen-
erally make a two-part mechanical delivery to the
canine crown. A resultant, distally directed force
will be exerted at the occlusoapical level of the
crown center. The appliance component(s) gen-
erating this force will, individually, be oriented
and activated mesiodistally to achieve the de-
sired force direction. The arch wire assumedly
engages a canine edgewise bracket. If and when
this wire fully contacts the edgewise slot, that
contact will be split between diagonally opposite
slot edges, producing two-point contact from a
facial perspective, and the wire will exert a pair
of parallel, equal in magnitude, noncollinear
forces to form a mechanical couple. (The two
forces will be of the same magnitude if the wire,
because of its occlusoapical location and that of
the bracket, generates no net potential to ex-
trude or intrude the tooth.) The couple will be
in the faciolingual plane; the direction of its
Home | TOC |          
Index
183
displacement potential would be the same,
whether delivered adjacent to the facial or to the
lingual surface of the crown. Consider a right
maxillary canine viewed from the facial perspec-
tive. The general, crown-delivered force system
consists of a distally directed, concentrated
force, having a clockwise mechanical moment
about the center of resistance of the canine, and
a mechanical couple with an inherent counter-
clockwise moment viewed from the facial per-
spective. Because the mechanical moment of the
driving force represents a tendency for distal
crown tipping, the moment of the couple, hav-
ing the opposite sense, is typically described as
countertipping.
The problem at hand is biomechanical, but
the basic laws of Newtonian mechanics apply to
the essentially nondeformable canine. For this
part of the analysis, consider the tooth as iso-
lated from both the appliance and the periodon-
tium. The mechanical action is delivered to the
crown (by the appliance) and consists of a force
and a couple. To partially characterize the an-
ticipated displacement, a mechanically equiva-
lent action, referenced to the center of resis-
tance (ere), may be determined. That equivalent
action generally consists of a force at the ere, the
force having the same magnitude and distal di-
rection as the driving force, and a couple that in
part compensates for the change in rotational
potential associated with relocating the force.
The equivalent action could be a force alone or
a couple alone, though, depending on the given
couple-force ratio at the crown center level, the
force direction referenced to that of the long
axis of the canine, and the occlusoapical dis-
tance from the crown center point to the center
of resistance. This equivalent action is obtained
because the direction of the force component
will be the direction of the displacement of the
ere and the plane, and the sense of the couple
will predict the direction of the rotation of the
tooth as a whole.2
A mechanical response to the crown action
is exerted on the tooth root (by the perio-
dontium) . During active orthodontic treatment,
because the tooth moves so slowly, its inertia is
negligible. As a result, the mechanical response
against the root is almost exactly equal in mag-
nitude, but opposite in direction/sense, to the
action from the appliance. This response is ac-
<<    
     Article
      >>
184 Robert J. Nikolai
Figure 1. Canine in the ideal start position at the
instant the distal driving force (Fa) is delivered. The
resultant response in the form of a force (Fp) and a
couple (Cp) is referenced to the center of resistance
of the tooth.
tually distributed over much of the root sur-
face—that which is contacting the periodontal
ligament and the free gingiva, but it is mechan-
ically equivalent for the problem at hand of a
single force and a couple that may be referenced
to the canine's center of resistance. (In general,
inertia has two components, one translational
and the other rotational. In the absence of sig-
nificant inertia, the action and responsive force
systems virtually balance one another. If both
force systems are referenced to the ere of the
canine, then essentially the paired comparable
components are mechanical opposites of one
another.) Accordingly, characteristics of the ex-
pected displacement of the canine, indicated
earlier, may be related to the opposites of the
associated characteristics of the responsive force
system. Also relevant here is the application of
the general action-reaction law of mechanics at
the contacting interface of the root and peri-
odontium. The periodontium with its response
against the root attempts to prevent tooth move-
ment. Also existing is an equal and opposite
distributed force system exerted by the root on
the periodontium, and it is this force system
that, when maintained over time, catalyzes peri-
odontal remodeling that permits orthodontic
tooth movement.
Home | TOC |          
Index
Force-Displacement Relationships
The retraction process as envisioned begins with
the canine in ideal orientation. If the canine
bracket is conventional (ie, not preangulated)
and properly positioned on the facial surface,
and if no occlusogingival bends are placed in the
arch wire, before the distal driving force is acti-
vated the engaged wire exerts no force on the
bracket slot. If, in addition, some occlusogingi-
val clearance between slot and wire exists, at
activation and for some time period thereafter,
no slot-wire contact will be present. Figure 1
depicts a right maxillary canine at activation and
before any displacement has occurred. Orthog-
onal distal (d) and occlusal (o) dental reference-
frame axes are indicated. With no wire-slot con-
tact, the distal driving force (magnitude Fa;
where a indicates from the auxiliary) is the sole
action component. The resultant of the distrib-
uted response from the periodontium (thus, the
subscripts p) may be expressed as the force-
couple pair shown, referenced to the center of
resistance. (The weight of the tooth is reason-
ably assumed to be comparatively negligible; lig-
ament-fiber tensions, primarily near the root
apex, negate the small tendency for extrusion.)
In the absence of occlusion, the driving force is
the only significant action, and the response all
but offsets or balances that action. The transla-
Figure 2. Canine at a later point in time after tipping
has caused the initial clearance between the arch wire
and bracket-slot to disappear. Wire-slot contact pro-
duces the counter-tipping couple (Cw).
<<    
     Article
      >>
Canine-Retraction Biomechanics
tional potential of Fa is nearly negated by Fp, and
its rotational potential (the moment of Fa about
the ere) is opposed by the resultant couple Gp.
From previous comments regarding mechanics
analysis, partial displacement predictions origi-
nate with the cited responsive components. The
ere will move dis tally (opposite in direction to
that of Fp), and the tooth will rotate clockwise
(opposite in sense to that of Cp) about a facio-
lingual axis. This combination suggests a center
of rotation (cro) located apical of the ere and a
distal crown tipping overall format as the retrac-
tion-displacement begins.
Figure 1 is the first of four sketches of the
canine to augment explanations of the mechan-
ics. Each figure represents an instant of time
during the retraction process. The force system
shown is exerted on (not by) the canine; accord-
ingly, the symbols for the delivered force and the
couple partially represent their displacement
potentials. Because a mechanical couple can by
itself only produce rotation, the curved arrow
notation that defines a plane and a sense is
appropriate. To clarify, two action systems exist
in this problem: (1) the force system delivered
by the appliance to the tooth crown; and (2) the
force-system exerted by the tooth root on the
periodontium. The second results from and is
the mechanical equivalent of the first. The latter
is the action-reaction counterpart of the respon-
sive force system shown in the sketch.
In Figure 2, the canine is shown slightly
tipped such that the aforementioned clearance
has been eliminated. Arch wire-slot contact
now exists, and the countertipping couple (Cw;
where w denotes wire) has appeared. This sketch
depicts the canine somewhat later in time, rela-
tive to Figure 1. Alternatively, if the long axis was
parallel to the occlusoapical axis, the mechanics
immediately after activation with the guiding
arch wire engaged in a preangulated bracket slot
would be shown. In these sketches of the isolated
canine, the relative length of the force symbol
and the diameter of the couple symbol are in-
dicative of relative magnitudes. With reference
to Figure 1 then, in Figure 2 the driving force
component has deactivated slightly, Fp has be-
come smaller, and the appearance of Cw—simi-
lar to Cp also counterclockwise—has contrib-
uted to a lessened responsive couple. The
continued (or initial) existence of both respon-
Home | TOC |          
Index
185
sive components with the direction and sense
shown indicate that distal crown tipping should
(still) be the displacement format, though the
cro has now progressed apically (or is apical) of
the known simple-tipping location for a single
rooted tooth. (With regard to magnitude associ-
ations, for each sketch two independent rela-
tionships exist. One relationship says that the
two force magnitudes must be virtually equal,
and the other that the moments of the active
and responsive forces and couples about the ere
must virtually balance because the translational
and rotational inertias, respectively, of the ca-
nine are negligible. To estimate all component
magnitudes at an instant of time, then, one or
two of the three or four magnitudes must be
measurable at that timepoint.)
The magnitude of Cw is, principally, directly
related to the local bending of the guiding arch
wire at the canine bracket site. The size of Cw is
also, to a much lesser extent in context, associ-
ated with the location of the canine bracket
relative to support sites mesial and distal to it.15
This bending is a localized rotation of the wire in
the faciolingual plane; this rotation is the differ-
ence between the amount of tipping and the
initial occlusogingival/rotational clearance, if
any. With a preangulated bracket slot, the initial
clearance is likely zero with some local second-
order rotation required to engage the wire in
the slot. If this is the case, Cw exists from the start
of the retraction process. Also note that, as Cw
appears, some frictional resistance to these slid-
ing mechanics arises, but is assumed to be small.
The instantaneous magnitude of Fa then be-
comes the difference between the size of the
force originating with the auxiliary and the mag-
nitude of the opposing frictional force. Without
invalidating the current model, frictional resis-
tance is here assumed to be a relatively small
perturbation on the auxiliary-force magnitude.16
At some point in time after initial activation,
remodeling of the periodontium begins to con-
tribute to the displacement prediction. In addi-
tion, in time the distal driving force component
of the appliance mechanics may be replaced
and/or reactivated. For now, discussion of these
contributions is deferred. The assumption is
temporarily made that (1) the appliance compo-
nent that activates the mechanics is left in place
for a between-appointments period of perhaps
<<    
     Article
      >>
186 Robert J. Nikolai
several weeks or more, and (2) the periodon-
tiurn continues to exhibit a springback potential
somewhat similar to that in response to inter-
rupted, short-term, masticating action.
As distal crown tipping continues, the magni-
tude of Cw increases directly with the local wire
bending deformation. (Assumedly, the arch wire
maintains its elasticity throughout the retraction
process.) With the accompanying distal displace-
ment of the crown center, perhaps also with
relaxation of the driving component of the ap-
pliance, Fa decreases in magnitude. The possi-
bility then arises that the couple-force ratio
(Cw/Fa) may be reduced to nearly equal the
distance between the crown center and the ere
of the canine. This mechanical configuration is
shown in Figure 3. The magnitude of Cp has
decreased to zero, signifying that the cro has
migrated apically and the tipping displacement
has potentially transformed into bodily move-
ment. Notably, throughout the period between
the time points depicted in Figures 2 and 3, the
couple Cw is, in one manner of speaking, part of
the overall force system that responds to Fa. This
couple exists primarily because the distal driving
force has tipped the canine. If Fa is removed,
and if the periodontium maintains some spring-
back potential, the tooth tends to upright and,
correspondingly, the magnitude of Cw lessens.
Figure 3. Canine at a still later point in time. Tipping
has continued. The ratio of magnitudes of Cw to Fa
equals that of the moment-arm of Fa referred to the
center of resistance, producing bodily movement at
this instant.
Home | TOC |          
Index
Figure 4. The driving-force magnitude Fa continues
to decrease with time, such that the couple-force ratio
now exceeds that for bodily movement, and the ca-
nine begins to upright, evidenced by the reappear-
ance of Cp, but with sense of opposite to that in
Figures 1 and 2.
Within this scenario, Cw will not even partially
drive the displacement. In other words, if the
displacement fully transforms from crown tip-
ping to bodily movement, with Fa decreasing in
magnitude with time, the wire couple will have
reached its maximum value, and the canine ori-
entation will be at its greatest distal-crown-lead-
ing angulation during the retraction process.
Consider now the continued deactivation
from the Figure 3 configuration of the driving
force magnitude Fa. The bodily movement dis-
placement format may only exist momentarily.17
With the size of Cw controlled by the local bend-
ing of the arch wire at the bracket site and,
therefore, by the angulation of the tooth, a de-
creasing Fa magnitude increases the couple-
force ratio. This occurrence changes the charac-
ter of the tooth displacement potential again,
now toward mesiodistal rotation. With the po-
tential for tipping reduced because of the
smaller Fa, the magnitude of Cw attempts to
lessen, but the size of Cw will decrease only if the
angulation of the tooth diminishes. Examine
Figure 4, particularly in comparison to Figure 3.
An increase in the ratio of Cw to Fa causes, in the
absence of inertial influences, the reappearance
of a couple component of the resultant peri-
odontal response. Notice, though, that the sense
<<    
     Article
      >>
Canine-Retraction Biomechanics
of Cp in Figure 4 is opposite to that in Figures 1
and 2. As long as Fa remains sufficiently large,
the potential for the canine's center of resis-
tance to move distally will continue to exist. The
sense of Cp says, however, that the tooth as a
whole should begin to rotate counterclockwise
as viewed. The overall tooth displacement would
then migrate toward second-order torquing; the
center of rotation reappears, now occlusal to the
ere.
Previously, two aspects of a viable biome-
chanical model of canine retraction on a guid-
ing arch wire were temporarily set aside. First
was the consideration of disengagement and
replacement/reactivation of the driving force
component of the appliance. Such a change
could occur as often as once per day if the
component is an o-ring. More likely, though,
is the replacement (of the elastomeric compo-
nent) or perhaps only a reactivation (of a
spring) at each appointment. It is reasonable to
expect that a change would occur at or beyond
the time point represented in Figure 2. Disen-
gagement would temporarily remove Fa, the
tooth would respond by tending to instanta-
neously upright somewhat, and Cw would de-
crease with the long-axis angulation. Assumedly,
replacement or reactivation of the component
would restore the approximate initial magnitude
of Fa, causing the tooth to tip slightly (against a
somewhat reduced Cw accompanying the poten-
tial uprighting), increasing the countertipping
couple magnitude. Reengagement would then
effectively reverse the overall process thus far in
relative time toward the Figure 2 configuration,
but perhaps with the canine tipped farther than
at the comparable state in the previous activa-
tion-deactivation cycle. If, before disengage-
ment, the mechanics had proceeded to the Fig-
ure 3 configuration or beyond, reengagement
would, with the increase in couple-force ratio,
produce a similar "stepped-back restart" to the
process as described. The reactivated appliance
mechanics would have a configuration between
those of Figures 2 and 3, and the process
would again proceed with time toward the con-
figuration of Figure 4. Clearly, the reason for
partitioning the overall process with periodic
reactivations (possibly accompanied by compo-
nent-replacements) is to maintain sufficient Fa
Home | TOC |          
Index
187
magnitude to sustain continuing distal displace-
ment of the center of resistance of the canine.
The second aspect to be restored and com-
plete a viable representation of clinical canine
retraction is that of the remodeling of the peri-
odontium. Resorption of bone in pressure zones
and apposition and ligament fiber reorgan-
ization in periodontal zones in tension likely
modify the pattern of distributed force at the
root-ligament interface toward reducing concen-
trations of internal force and a more uniformly
varying response with a somewhat smaller result-
ant magnitude. This lessened response magni-
tude permits the appliance action to dominate a
bit, permitting the (Reitan's) third stage of orth-
odontic tooth movement to occur, which, in
turn, slightly deactivates Fa in particular toward
temporary near restoration of mechanical action
response balance. Over significant time, the per-
manent position and orientation of the canine
changes. Again recall, though, that the magni-
tude of Fa is determined only in part by the
location of the crown center, but that of Cw is
directly related to the angulation of the canine.
The effect of the latter, after remodeling has left
the canine permanently tipped, is to permit the
wire couple to partially control subsequent dis-
placement. Three possibilities require review, re-
lating the instantaneous magnitude of Fa to that
of Cw, divided by the moment-arm of Fa with
respect to the canine ere. If Fa is larger than the
couple magnitude to moment-arm ratio, the po-
tential for further distal crown tipping is present.
If Fa is equal to the aforementioned ratio, the
potential is for (momentary) bodily movement.
If Fa is less than the ratio, the displacement
format potential is toward torquing. Again, re-
call that Fa cannot increase in magnitude with
time without disengagement and reactivation or
replacement.
Summary, Conclusions, and Suggestions
The active orthodontic treatment process of ca-
nine retraction on a guiding arch wire, presum-
ably into a site created by a first premolar extrac-
tion, has been reviewed with emphasis on the
detailed format of the displacement. The prob-
lem was simplified somewhat by specifying the
start configuration of the canine, suppressing
the potential for long-axis rotation, and repre-
<<    
     Article
      >>
188 Robert}. Nikolai
senting frictional resistance within the sliding
mechanics as negligible,16 but the model argu-
ably does not invalidate its reasonable applica-
bility within the clinical setting. The intent was
also to present a procedure by which the dy-
namic process of tooth movement may be exam-
ined by partitioning it, considering a sequence
of views of the force systems at notable time
points, and extrapolating forward from one
characteristic state to the next. The laws/princi-
ples of mechanics, appropriately applied, serve
to help describe the overall displacement in
steps. The matter of displacement rate, associ-
ated with the magnitude of appliance-delivered
force as a function of time and the biomechani-
cal response in the individual patient, is not part
of the present discussion.
Distal displacement of the canine is consid-
ered as two or three subprocesses, the begin-
nings and ends of which are defined by three or
four instantaneous views of the mechanics. Seg-
ments of the displacement within the subpro-
cesses are predicted from the mechanically
equivalent actions at their starts, referenced to
the canine's center of resistance, argued as also
essentially equal to the ere referenced results of
the distributed forces exerted by the root on the
periodontium. A single activation and an elastic
or viscoelastic periodontal response are initially
assumed; subsequently the likely occurrences of
disengagements and reactivations and the effect
of periodontal remodeling are added to the
model analysis.
With respect to the dental reference frame
and with the initial position and orientation of
the canine, the idealized intent is that the net
displacement of the canine be distal bodily
movement (translation). Modeling eliminates
the tendency for long-axis rotation to be a con-
voluting part of the displacement, and such po-
tential may be substantially reduced by using
driving force sites adjacent to the facial and
lingual crown surfaces. Subsequent to the fore-
going analysis, the following summarizing state-
ments may be made:
1. The displacement begins as simple distal
crown tipping if any occlusogingival clear-
ance initially exists between wire and bracket
slot.
2. If no clearance exists at the start or after some
Home | TOC |          
Index
tipping has eliminated the initial clearance,
the displacement format continues as distal
crown tipping. Flexibility of the guiding arch
wire, enhanced in particular by characteristic
lengths mesial and distal to the canine
bracket, enable the driving force to domi-
nate, and tipping continues (occurs) because
of local (elastic) wire bending at the canine
bracket site.
3. Decrease in the driving force magnitude be-
cause of distal displacement of the canine's
crown center and increase in the countertip-
ping couple magnitude directly related to
long-axis angulation can cause the crown me-
chanics to reach a state for which the mo-
ments offset one another and the displace-
ment format momentarily becomes bodily
movement.
4. With the countertipping couple magnitude
maintained by the angulation of the canine,
further degeneration of the driving force
magnitude would transform the displace-
ment format toward that of second-order
torquing.
5. Remodeling of the periodontium reduces the
capability of the countertipping couple to de-
crease in magnitude when, for example, the
distal driving force component is disengaged
before replacement or reactivation.
6. The four sketches represent the mechanics of
the retraction process at subsequent points in
time, assuming that the distal driving compo-
nent remains in place to the state of Figure 4
and perhaps beyond. Disengagement of this
component at some timepoint to reactivate
or replace it effectively takes the shown pro-
gression of tooth movement backward slightly
in relative time, and the displacement restarts
with reactivation.
The following conclusion can be drawn. Even
though late in the sequence of subprocesses the
displacement format can become that tending
toward root movement, a net bodily movement
displacement is impossible practically with the
chosen appliance mechanics. The driving force
must dominate to displace the center of resis-
tance of the canine distally. The greater the
bending stiffness of the guiding arch wire,
the more upright it will keep the tooth during
the displacement. Increasing the wire stiffness
<<    
     Article
      >>
Canine-Retraction Biomechanics
has the effect of decreasing the magnitude of tip
together with the time period between Figure 1
(or 2) and Figure 4, but the overriding factor is
different origins of the crown force (Fa) and
couple (Cw). A first displacement objective
would be to achieve the desired crown center
location. Seemingly, the best ending for the pro-
cess would be with the net Fa becoming near
zero, with the couple still existing because of
some, however small, long-axis angulation. The
process would then finish with the center of
rotation at or near the ere, and the crown center
moving mesially, defeating the first objective.
The appliance delivering force to the canine
crown, in the problem modeled into two dimen-
sions, consists of two principal deformable com-
ponents. The driving force component and the
guiding arch wire act independently of one
another. Assumedly, from the time of the first
two-point, wire-slot contact, the countertipping
couple exists continuously until the entire re-
traction process has been completed, despite
several potential intermediate patient appoint-
ments. The direct relationship between couple
magnitude and long-axis angulation depends
primarily on the second-order rotational bend-
ing stiffness of the arch wire at the bracket site.
Absolute magnitudes of force system compo-
nents are not part of the current discussion, nor
is the factor of wire-slot frictional resistance
(which may or may not be a significant influence
on the delivered net distal driving force), so no
comment regarding selection of guiding arch
wire or canine bracket is appropriate here.
Despite the fact that the components exerting
the distal driving force and the countertipping
couple are physically independent, to control
the character of the displacement they together
produce, the two components should likely be
matched to an extent. Because the countertip-
ping couple will be continuous, an interrupted
driving force may be contraindicated; the inter-
rupted driving action would apparently provoke
a sequence of cyclic, rotational perturbations (as
the Cw magnitude oscillated) on the primary
displacement format. The magnitude of the
countertipping couple will generally be increas-
ing with or maintained over time, governed by
the angulation of the canine's long axis with the
occlusoapical reference. The magnitude of the
distal driving force should not be permitted to
Home | TOC |          
Index
189
unduly deteriorate, lest Cw dominate and the
crown center reverse its displacement direction.
If the force is derived from a spring, the spring
should have a low stiffness so that its action is
continuous. If the force is obtained from an
elastomeric component, because of relaxation
potential the component should be replaced
periodically—in the case of o-ring use with a
cooperative patient, every day. Without ques-
tion, advantage should be taken of the opportu-
nity to replace or reactivate the distal driving
component at each appointment. Also, perhaps
the initial magnitude of distal driving force
should be increased somewhat at the second
retraction process appointment with the aim to
enhance the displacement rate after the peri-
odontium has become accustomed to the inva-
sive effect of the superimposed mechanical
force.
The suggestions in the previous paragraph
are just that, proposed enhancements to the
clinical regimen that emerge from a detailed,
hypothetical examination in this article of the
orthodontic mechanics of canine retraction on
a guiding arch wire. These suggestions may be
controversial to some, and they might preface a
proposal for hypothesis testing within a needed
extensive, in vivo study of the process.
References
1. Merrifield LL, Cross JJ. Directional forces. Am J Orthod
1970;57:435-464.
2. Smith RJ, Burstone CJ. Mechanics of tooth movement.
Am J Orthod 1984;85:294-307.
3. Andreasen G, Johnson P. Experimental findings on
tooth movements under two conditions of applied force.
Angle Orthod 1967;37:9-12.
4. Hixon EH, Atikan H, Callow GE, et al. Optimal force,
differential force, and anchorage. Am J Orthod 1969;55:
437-457.
5. Hixon EH, Aasen TO, Arango J, et al. On force and
tooth movement. Am J Orthod 1970;57:476-489.
6. Boester CH, Johnston LE. A clinical investigation of the
concepts of differential and optimal force in canine
retraction. Angle Orthod 1974;44:113-119.
7. Andreasen GF, Zwanziger D. A clinical evaluation of the
differential force concept as applied to the edgewise
bracket. Am J Orthod 1980;78:25-40.
8. Kula K, Phillips C, Gibilaro A, et al. Effect of ion implan-
tation of TMA archwires on the rate of orthodontic
sliding space closure. Am J Orthod Dentofac Orthop
1998;114:577-580.
9. Reitan K. Some factors determining the evaluation of
forces in orthodontics. Am J Orthod 1957;43:32-45.
<<    
     Article
      >>
190 Robert J. Nikolai
10. Davidovitch Z. Tooth movement. Grit Rev Oral Biol Med
1991;2:411-450.
11. Davidovitch A, Finkelson MD, Steigman S, et al. Electric
currents, bone remodeling, and orthodontic tooth
movement II. Am J Orthod 1980;77:33-47.
12. Kharbanda OP, Mohapatra PK. Role of messenger sys-
tem in orthodontic tooth movement. Indian J Dent Res
1995;6:1-12.
13. Owman-Moll P. Orthodontic tooth movement and root
resorption with special reference to force magnitude
Home | TOC |          
Index
and duration. A clinical and histological investigation in
adolescents. Swed Dent J 1995;105:l-45 (suppl).
14. Detrich PR. Guided tissue regeneration associated with
orthodontic therapy. Semin Orthod 1996;2:39-45.
15. Nikolai RJ. Bioengineering Analysis of Orthodontic Me-
chanics. Philadelphia, Lea & Febiger, 1985, p 250.
16. Braun S, Bluestein M, Moore BK, et al. Friction in perspec-
tive. Am J Orthod Dentofac Orthop 1999; 115:619-627.
17. Isaacson RJ, Lindauer SJ, Davidovitch M. On tooth
movement. Angle Orthod 1993;63:305-309.
<<    
     Article
      >> Home | TOC |          
Index

The Mechanical Plan of the Segmented

Arch Technique
Michael R. Marcotte

The purpose of this article is to describe how an orthodontic mechanical

plan can be implemented with the segmented arch technique. An orthodon-
tic mechanical plan, like a flight plan, lists the steps that must be completed
to reach a certain destination or to achieve certain treatment objectives. The
mechanical plan has been divided into an initial stage, an intermediate
stage, and a finishing stage of treatment. Various procedures in the initial
stage of treatment, such as intrasegmental alignment, incisor intrusion,
buccal segment eruption, and minor and major cuspid retraction, are de-
scribed and shown. Clinical photographs taken during the intermediate
stage of treatment show the various methods of extraction site closure,
depending on the anchorage classification from the occlusogram. The im-
portance of the anteroposterior position of the T-loop retraction spring is
stressed. The finishing stage of treatment is actually completed early-on
because the preliminary bracket alignment stage ideally aims to align the
teeth intrasegmentally. A simulated mechanical plan for a patient is de-
signed by using the terms and principles shown in the article. (Semin Orthod
2001;7:191-206.) Copyright © 2001 by W.B. Saunders Company

his article describes one approach of imple- Stages of Treatment

T menting the mechanical plans of the seg-
mented arch technique.1'2 An orthodontic me-
chanical plan is a sequence of procedures that,
when completed, will produce specific treat-
ment objectives. Having an orthodontic me-
chanical plan is similar to having a flight plan,
which requires both a starting point (the case
analysis) and the destination (the specific treat-
ment objectives; eg, mandibular incisors re-
tracted 3.5 mm and intruded 2.0 mm). Planning
the mechanical steps to achieve these treatment
objectives allows the orthodontist to ideally
"treat the patient" before any appliances are
placed, anticipating most of the problems that
may occur along the way.
From private practice, Bristol, CT.
Address correspondence to Michael R. Marcotte, DDS, MSD, 5
Center Street, Bristol, CT 06010.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0703-0007$35.00/0
doi:10.1053/sodo.2001.26694
In the segmented arch technique, a patient's
mechanical plan is generally divided into three
stages: an initial, intermediate, and finishing
stage. The initial stage of treatment is involved
with transforming each segment of a malocclu-
sion into an ideal segment of teeth in all planes:
in extraction treatment, an anterior segment
(AS) of teeth is the group of teeth anterior to
the extraction site whereas the posterior or buc-
cal segment (BS) of teeth is the group of teeth
posterior to the extraction site. Also involved in
this initial stage of treatment is the initiation of
any intersegmental movements such as BS re-
traction with headgear, deep overbite or open-
bite correction, correction of asymmetric natu-
ral planes of occlusion (NOP), 3 and so forth.
Oftentimes, these intrasegmental and interseg-
mental procedures can be telescoped into a
single step, such as in intrusion of the incisor
segment while accomplishing its preliminary
bracket alignment.
The intermediate stage of treatment is in-
volved with the intersegmental alignment and
approximation of the segments to each other.

Seminars in Orthodontics, Vol 1, No 3 (September), 2001: pp 191-206 191

<<    
     Article
      >> Home | TOC |          
Index

192 Michael R. Marcotte

The approximation of the segments is accom-
plished according to the anchorage classifica-
tion, which is obtained from the occlusogram.4
Figure 1 represents the occlusogram of a patient
in whom 2 mm of mandibular incisor retraction
was deemed necessary to produce the desired lip
protrusion. Positions 1 and 3 in Figures 1A and
IB represent the distal surface of the second
bicuspid if the total mesiodistal widths of the
teeth were marked off on the inner contact line,
starting at the treatment midline. The distance
from lines 1 and 3 to the mesial of the first molar
is the inadequacy or redundancy, depending on
whether the line is distal or mesial (respectively)
to the mesial of the first molar. It can be seen,
for example, that a 3-mm arch length inade-
quacy exists in the lower right quadrant, and a
4-mm inadequacy in the lower left quadrant.
Positions 2 and 4 in Figures 1A and IB represent
the mesial surface of the first molars after the
required extractions. Looking at the numbers at
each quadrant, the top line represents the inad-
equacy-redundancy. The second line represents
the recommended extraction, and the third line
represents the amount of mesial movement
(slippage) of the posterior teeth. The bottom
line is the anchorage classification. The anchor-
age is thus classified by the amount of mesial
movement of the posterior teeth necessary to
close the extraction site.5
Group A anchorage (Fig 1B-2) shows that the
posterior teeth undergo little, if any, mesial
movement after the extraction and the AS is
retracted by using most, if not all, of the extrac-
tion site. Group A4- anchorage is indicated
when a slight distal movement of the posterior
teeth is necessary, even with the removal of a
first bicuspid (Fig 1B-4). Typically, in Group A
anchorage situations, the first bicuspids are re-
moved. Group B anchorage (Fig 1A-4) indicates
that the posterior teeth can be slipped anteriorly
up to half of the extraction site (3 mm measured
from the mesial of the mandibular left first mo-
lar to position 4), and the teeth usually removed
in Group B anchorage situations are also the
first bicuspids. Group C anchorage (Fig 1A-2)
denotes that the posterior teeth can be slipped
anteriorly more than half of the extraction site

Figure 1. Grading the anchorage is based on the amount of BS slippage: Group A = 0.0 to 0.5 mm, Group B <
one-half the extraction site, Group C > one-half the extraction site. For both occlusograms, positions 1 and 3
represent the distal surface of the second bicuspids if the total mesiodistal widths of the teeth were marked off
on the inner contact line, starting at the treatment midline. Positions 2 and 4 represent the mesial surfaces of
the first molars after the required extractions. (A) (lower left) —3.0 mm = arch length inadequacy (from
position 1 to mesial of LR6), XLR5 = recommended extraction is the lower right second bicuspid, +4.0 mm =
amount of BS protraction after the extraction (from mesial of LR6 to position 2), anchorage = Group C (^
one-half the extraction site), (lower right) —4.0 mm = arch length inadequacy (from position 3 to mesial of
LL6), XLR4 = recommended extraction is the lower left first bicuspid, + 3.0 mm = amount of BS protraction
after the extraction (from mesial of LL6 to position 4), anchorage = group B (< one-half the extraction site).
(B) (lower left) —7.0 MM = arch length inadequacy (from position 1 to mesial of UR6), XUR4 = recommended
extraction is the upper right first bicuspid, 0.0 mm = amount of BS protraction after the extraction (from mesial
of UR6 to position 2), anchorage = Group A (slippage = 0.0 mm), (lower right) —8.0 mm = arch length
inadequacy (from position 3 to mesial of UL6), XUL4 = recommended extraction is the upper left first bicuspid,
— 1.0 mm = amount of BS retraction even after extraction of UL4, Group A+ (BS retracted —1.0 mm).
<<    
     Article
      >> Home | TOC |          
Index

Segmented Arch Technique: Mechanical Plan 193

Figure 2. A version of the

segmented arch appliance.
Burstone upper first molar
bracket with 0.018 X 0.025"
auxiliary tube and hook (Al).
Burstone upper first molar
bracket with 0.049" Head-
gear tube (A2). Burstone
lower first molar bracket
with 0.018 X 0.025" auxiliary
tube and hook (A3). Second
molar 0.021 X .025" tube
(Bl). 0.022 X .028" Siamese
Twin brackets from second
bicuspids around to second
bicuspids (C). Lingual but-
tons welded on to second
molar bands; also seen is a
0.036" SS upper lingual arch
in first molar lingual sheaths
(0.036X0.072") (D). Lower
right 0.036" SS lingual arch
tab being made passive by
adjusting it so that the lower
left tab is directly over the
lower left lingual arch sheath
in all three planes (E).

(4 mm measured from the mesial of the man-
dibular right first molar to position 2). In these
instances of Group C anchorage, the second
bicuspids are usually removed. Because the man-
dibular right second bicuspid is removed, posi-
tion 2 in Figure 1A represents the mesial of the
first molar or distal of the first bicuspid.
The last or finishing stage of treatment is
involved with the detailed alignment of each
tooth within the now-idealized archform, and
because most of these tooth-to-tooth relation-
ships should have been idealized in the initial
stage of treatment, this period of treatment is
very short.
first molar is a triple buccal tube bracket (the arch
wire tube is convertible to a slot and gingival to this
slot is an 0.018 X 0.025" auxiliary tube (Fig 2A-1)
and occlusal to the slot is a 0.049" headgear tube
(Fig 2A-2); the mandibular first-molar attachment
is a double buccal tube (the arch wire tube is
convertible into a slot and gingival to this slot is an
0.018 X 0.025" auxiliary tube (Fig 2A-3). The max-
illary and mandibular second-molar bands also
have lingual buttons welded mesiolingually (Fig
2D-1).

The Appliance
Treatment with the segmented arch technique can
use regular edgewise attachments (either single-
wing or double-wing brackets) from second bicus-
pid around to the opposite second bicuspid (Fig
2). Typical second-molar tubes are placed on the
second molars (Fig 2B-1). Although these brackets
are available in 0.018 X 0.025" slot size, our pref-
erence is the 0.022 X 0.028" slot. The only unique
attachments necessary for the technique are the Figure 3. A severely tipped lower left second molar is
maxillary and mandibular first-molar bracket as- uprighted with an 0.032 X 0.032" TMA precision lin-
semblies. The buccal attachment on the maxillary gual arch.
<<    
     Article
      >> Home | TOC |          
Index

194 Michael R. Marcotte

available in 0.036" stainless steel (SS) or in 0.036"

Titanium Molybdenum Alloy (TMA; ORMCO
Corp, Glendora, CA) as well as in 0.032 X 0.032"
prefabricated lingual arch forms (Ormco Corp)
that are used with the Hinge Cap lingual arch
sheaths (Ormco Corp) (Fig 3).
Lingual arch wires are most often placed pas-
sively at the beginning of treatment as part of
the appliance. If necessary, they can be used to
idealize the first permanent molars: to correct
either rotations, buccolingual or mesiodistal tip-
ping. In Figure 3, a mesially tipped mandibular
left second molar is uprighted with the 0.032 X
0.032" Precision Lingual Arch (Ormco Corp,
Glendora, CA) by using the reinforced anchor-
age segment from the right posterior teeth to
the left bicuspids. An 0.018 X 0.025" segment of
SS wire was placed passively into the malaligned
Figure 4. 0.017 X 0.025" TMA rectangular loops al-
low the placement of pure couples to teeth and/or teeth to allow them to act as a reinforced an-
permit the management of inconsistent force systems.
Because the cuspids are rotated mesial in-distal out,
the required CRot for their correction is the long axis
of each tooth or the CRes in the first order view.
Couples produce this CRot and a couple can be pro-
duced by using a 0.017 X 0.025" TMA rectangular
loop equally preactivated in both vertical legs so that
there is no bucco-lingual component of force when
the activation moment is placed. It can also be noticed
that the bracket is centered in the rectangular loop,
resulting in as much wire mesially as there is distally
(A-C). This .017 X .025" TMA rectangular loop is
preactivated by twisting both vertical legs with two sets
of flat-beaked pliers. This allow the preactivation
bends to be placed in the entire length of the vertical
lag. They have a long range of activation because the
activation is by torsion, rather than by bending (D).
Some dental corrections require an inconsistent force
system when the moment of force is inconsistent with
the direction of the force (ie, second bicuspids ro-
tated mesial out or second molars rotated distal out
and the corrections are made in the initial buccal
segment wire). Rectangular loop configurations per-
mit the management of these inconsistent force sys- Figure 5. Leveling of the lower curve of Spee by BS
tems and, if symmetrical, a lingual arch cancels out eruption in a growing patient. 0.018" SS anterior seg-
the undesirable side effects on the first molars so that ment extends from cuspid-to-cuspid with an .018 X
the net effect will be the correction of these symmet- 0.025" SS base arch wire attached with chain elastic
rical rotations (E-F). piggy-back style from lateral-to-lateral (A). The 0.018
X 0,025" SS base arch wire extends from the first
molar auxiliary tube around to the opposite first mo-
Both the maxillary and mandibular first-molar lar auxiliary tube. The base arch is preactivated to
bands have welded lingual arch sheaths. The deliver 200 g in the midline, as measured with the
0.036" maxillary lingual arch (LA) is inserted from Correx gauge. Initial intra-orals showing the deep
the mesial (Fig 2-D) whereas the mandibular lin- curve of Spee on Mary 24th (B-C). Intra-oral photo-
gual arch (/LA) is inserted from the distal (Fig graphs showing the eruption of the BS in approxi-
mately one month (D-E). Frontal intra-oral photo-
2-E); latching indents on the sheaths opposite the graphs showing little, if any, depression of the
point of insertion are sufficient to hold the 0.036" anterior segment of teeth, despite the heavy intrusive
lingual arch wires in place. Lingual arch wires are force used (F).
<<    
     Article
      >>
Segmented Arch Technique: Mechanical Plan
Figure 6. Leveling of a deep curve of Spec by incisor
intrusion in a nongrowing patient. 0.018" SS anterior
segment extends from lateral-to-lateral. The 0.018 X
0.025" SS base arch wire from the molar auxiliary tube
around to the opposite first molar auxiliary tube (A).
The base arch wire is preactivated to deliver 40 g in
the midline, as measured with the Correx gauge (B).
The preactivated base arch is activated and connected
piggy-back style over the lateral-to-lateral segment. If
no advancement of the incisors is desired, the base
arch wire is tied back at the helicies and first molar
attachment. If advancement of the incisors is desired,
no tie-back is indicated (C).
chorage unit, pitting the entire unit against the
uprighting of the tipped second molar.
Initial Stage of Treatment
The initial stage of treatment has the overall
goal of producing ideal intrasegmental align-
ment in three planes. This initial stage is per-
haps the most unique stage and no general
method can be recommended; each segment is
different and the mechanical plan is therefore
unique for this initial stage. Generally speaking,
lighter, low load-deflection rate wires are used
to reposition the teeth into their ideal positions.
Once corrected, these teeth are held in place
with the more rigid 0.018 X 0.025" or heavier
steel wire segments, called a steel anterior stabiliz-
Home | TOC |          
Index
195
ing segment or steel buccal stabilizing segment of
wire (SASS or SBSS, respectively).
Many intrasegmental discrepancies can be
corrected by using the traditional L, T, or verti-
cal loops made from SS or by using nonlooped
low-modulus wires such as Nitinol, NITI, or
TMA. However, when couples are required (Figs
4A, 4B, and 4C), or when inconsistent force
systems are present (Figs 4E and 4F), 0.017 X
0.025" TMA rectangular loops (R-loops) are
used and the wire preactivation can be placed as
torsion rather than by bending (Fig 4D).
The leveling of a deep curve of Spec requires
different mechanics depending on the amount
of facial growth expected. For patients with good
facial growth increments still remaining, this lev-
eling can be performed via BS eruption (Fig 5),
using heavy forces anteriorly to six anterior teeth
(—200 g in the midline). In patients in whom
growth is slight to nil, this leveling is accom-
plished by incisor intrusion by using 40 g in the
Figure 7. Curves of Spee in the lower arch can still be
leveled while preliminary bracket alignment is occur-
ing in the BS. The lower right cuspid is being rotated
mesial in-distal out with a first-order couple produced
by the rectangular loop (A). The 0.018 X 0.025" in-
trusive base arch is connected to the .018" SS AS that
extends from lateral-to-lateral (B). Although the
lower left second bicuspid being rotated mesial-out,
the mesial edge of the bracket is against the distal
surface of the first bicuspid requiring that the rectan-
gular loop be connected to only the distal tie-wing of
the Siamese twin bracket (C).
<<    
     Article
      >> Home | TOC |          
Index

196 Michael R. Marcotte

pid retraction is often required to align the an-

terior segment of teeth. Cuspid retraction is ei-
ther major or minor, depending on the amount
of necessary retraction. Minor cuspid retraction
(MiCR) uses 0.016" SS retraction springs (Fig
10A) when the necessary retraction is 2 mm or
less and when the retraction can be performed
by uncontrolled tipping. The posterior anchor-
age should be fairly rigorous (Group B + to A)
and the distal force should be less than 200 g;
Figure 8. Three-piece intrusion arch. First piece is
the 0.018 X 0.025" anterior segment with a distal the springs are cinched distally out of the molar
extension out of the lateral incisors. An .018 X 0.025" auxiliary tubes (Figs 10B and IOC). Because of
SBSS is present from the first molar to the first bicus- the elastic properties of the 0.016" SS wire, the
pid. The second and third pieces of the three-piece cuspids tend to move labially as they rotate distal
intrusive arch are the right and left 0.018 X 0.025" SS in-mesial out. This can be offset with a slight
molar uprighting springs fabricated to fit into the
molar auxiliary tube. Each can be preactivated with 20 bend at the molar, which places the spring 2 mm
g per side. The molar uprighting spring is made with
a small anterior hook that can be slipped over the
distal extension. One can, thus, choose the position of
the anterior intrusive force relative to the CRes of the
four-tooth anterior segment (ie, distal to the CRes for
uprighting or directly through the CRes for no
changes in axial inclination). Of course, the lingual
arch is present to prevent lingual-version of the BS
(A-B). Anterior view showing how the loops of the
uprighting spring can be bent to minimize soft-tissue
irritation (C).

midline for four mandibular incisors and 60 g in

the midline for four maxillary incisors, mea-
sured with a Correx (Haag-Streit, Bern, Switzer-
land) or similar gauge (Fig 6). These leveling
procedures are often accomplished while doing
simultaneous preliminary bracket alignment
(PBA) in each BS or AS (Fig 7). In patients with
flared maxillary or mandibular incisors, the in-
trusive force can also be positioned lingual to
the center of resistance (CRes) °f the anterior
segment, and intrusion plus uprighting of the
incisor segment can occur (Fig 8).
Telescoping of treatment procedures is thus
possible when treating with wire segments; inter- Figure 9. Another example of telescoping treatment
segmental and intrasegmental tooth movement procedures. Note that the upper left NPO is angled
can occur simultaneously. For example, in Fig- upward more than the upper right. Also notice how
ure 9A, intrasegmentally, the uprighting and ro- the upper left lateral incisor is slightly tipped crown
distal-root mesial (A). The right tab of the upper
tation of a maxillary left lateral incisor is occur- lingual arch has been preactivated to produce a me-
ring. A preactivation bend is also placed in the sial down movement to the upper left segment (a
maxillary right tab of the lingual arch wire (Fig faster, eruptive movement on the left; a slower intru-
9B) to rotate the maxillary left segment interseg- sive on the right) (B). The upper left lateral incisor
mentally so that the right and left NOPs will be has been aligned and rotated and the NOP of the
upper left side is now the same as the NOP on the
parallel (Fig 9C); both procedures have been right side (NOPUL = NOPUR). The cuspid extraction
telescoped into a single procedure. site on the upper left still requires complete closure
As part of the initial stage of treatment, cus- (C).
<<    
     Article
      >>
Segmented Arch Technique: Mechanical Plan
Figure 10. Minor cuspid retraction spring. 0.016" SS
minor cuspid retraction springs (A). SBSS are present
in each BS and the MiCR springs are placed into the
auxiliary tubes of the first molar brackets and are
cinched distally. The mesial in-distal out moments on
each BS are cancelled out with upper lingual arch in
place (B). The short horizontal leg of the MiCR
spring prevents the spring from rolling out into the
cheek mucosae (C).
to the lingual of the cuspid bracket. Bringing the
spring labially to the cuspid bracket produces
positive moments on the BS (mesial out-distal
in), which become equal and opposite with the
maxillary lingual arch in place (ie, they cancel
out). The small little horizontal bend at the end
of the vertical loop prevents the spring from
rolling into the cheek mucosae (Figs 10D and
10E).
Major cuspid retraction (MjCR) is performed
when the necessary cuspid retraction is more
than 2 mm. MjCR is accomplished by either
controlled tipping about their apices (moment
to force ratio [M/F] = 8:1) or by translation
(M/F = 12:1). The required anchorage for
MjCR should be between Group B and C and
more than 250 g can be used for the retraction.
The cuspid retraction T-loop (CRTL) seen in
Figures 11A and 11B can be preactivated for
either controlled tipping, or for translation of
the cuspid. For cuspid retraction by controlled
tipping, the CRTL is made of 0.017 X 0.025"
TMA wire and is made to fit passively into the
cuspid bracket (Figs 11A and 1 IB). A 45° bend is
next placed in the beta leg (as in Fig 16A); this
will produce a M/F of 11:1 posteriorly (mesial
translation of the BS). The activation moment
from the passive T-loop produces a M/F ratio of
8:1, ie, controlled tipping of the cuspids. First-
order antirotation bends (mesial in-distal out on
Home | TOC |          
Index
197
the cuspid and mesial out-distal in on the BS)
are also placed in the vertical legs of the CRTL as
seen in Figs 11D-G).
For cuspid retraction by translation, the pas-
sive 0.017 X 0.025" TMA CRTL (Figs 11A and
11B) will be preactivated to deliver 180° of mo-
ment preactivation to the cuspid bracket. With
the triple-turret plier (Hu-Frieddy 678-316; Hu-
Frieddy Orthodontics, Chicago, IL), the preacti-
vation bends to the CRTL are overbent so that,
after a trial activation, 180° of moment preacti-
vation remains (Fig 11C). The laboratory torque
tester shows that, with 180° of moment preacti-
vation, a moment of about 4,000 g/mm is pro-
duced and, between 300 to 350 g is also pro-
Figure 11. The Cuspid Retraction T-Loop, CRTL.
The CRTL is first made passively from .017 X .025"
TMA. The height of the T-loop is 6 mm high from the
cuspid slot and the T-Loop is about 10 mm long
anterior-posteriorly. The alpha leg extends to just
below the anterior corner of the T-Loop (A-B). The
CRTL is over-preactivated using the triple-turret plier
(Hu-Frieddy: 678-316). After a trial activation (neutral
position and distal activation), 180° of moment pre-
activation should still remain (C). Two pairs of flat-
beaked pliers is used to place antirotation twists into
the vertical legs of the T-Loop: 95 to 100° of mesial
in-distal out is placed in the alpha vertical leg and 95
to 100° of distal in-mesial out twist is placed in the
beta leg (D-E). About 180° of antirotation moment
preactivation remains after a trial activation (neutral
position and distal activation) (F). The beta leg of the
CRTL is placed into the auxiliary tube of the first
molar bracket and the alpha leg of the CRTL is tied
into place using metal rather than elastic ligatures.
Once tied, the beta leg can be cinched out of the
auxiliary tube 5-6 mm and can be reactivated after
every ~2 mm of cuspid retraction (—every two
months).
<<    
     Article
      >> Home | TOC |          
Index

198 Michael R. Marcotte

Figure 12. Composite view of major cuspid retraction (translation). The CRTLs are placed. The SBSS is present
from 5s to 7s and a .036" upper lingual arch is present. First appointment: About a month after the CRTLs were
placed, the patient returns and the slight distal movement of the cuspids and also the distal out-mesial in
antirotation twists taking effect can be seen. The cuspids can be seen to actually rotate in an antirotation fashion
(ie, distal out-mesial in but this is acceptable. Third appointment: 3 months have elapsed since the CRTLs were
placed. Again, the distal movement of the cuspids as well as the absence of any distal in-mesial out rotations can
be seen. Nothing noteworthy, however, is occurring in the BS. Fifth appointment: The cuspids are almost
retracted and some spacing exists anterior to the cuspids. The deband figure shows an intact upper arch with
cuspids retracted.

duced with 6 to 7 mm of distal activation of the
CRTL (-50 g/mm), that is, a M/F ratio of about
12:1 is produced for the cuspid translation.
Once the second-order moment preactivation
bends have been placed and about 180° remains
after a trial activation, first-order antirotation
twist-bends can be placed in the vertical legs of
the T-loop with two flat-beak pliers (Figs 11D
and HE). Each vertical leg is overbent to about
95° to 100° so that, after a trial activation, 90°
will remain in each vertical leg (Fig 11F); Figure
11G shows the CRTL ligated to the cuspid
bracket. Figure 12 is a composite view of the
typical major cuspid retraction procedure.
When the preliminary bracket alignment of
each segment is completed and the vertical dis-
crepancies have been corrected, a flexible arch
wire (low modulus-high springback) can be
placed from the second molar to the other sec-
ond molar (or from the first molars if they are
the last tooth in the arch) to orient each seg-
ment within the arch form (Fig 13). The maxil-
lary and mandibular lingual arch wires can be
removed and replaced when segmental approx-
imation begins; this allows each arch to assume a
harmonious arch form. These flexible arch wires
are later replaced with 0.018 X 0.025" steel arch
wires (SAW) after one or two appointments.
More importantly, these unbent, straight
wires from second molar to second molar (or
first molars) also mean that the NOPs in each
arch are level and parallel (Figs 13A-C). If one
were to place a mirror handle along the buccal
cusp tips of the posterior teeth in either arch,
the incisors would also contact the mirror han-
dle (Fig 14). The only notable feature in each
arch, then, would be the presence of two open
extraction sites. The intermediate stage of treat-
ment will approximate these segments accord-
ing to the planned anchorage.
Intermediate Stage of Treatment
When segmenting the arch, the maxillary and
mandibular 0.018 X 0.025" SS arch wires are cut
into 3 segments: an anterior segment (from cus-
pid to cuspid), and a right and left BS of wire
(from second bicuspid to second molar). On the
anterior segment of wire, 1 mm 0.018 X 0.025"
criss-cross tubes are slid onto the wire, and each
is crimped between the lateral incisor and the
cuspid (Figs 15A and 15B). Immediately distal to
<<    
     Article
      >> Home | TOC |          
Index

Segmented Arch Technique: Mechanical Plan 199

the cuspid bracket, the wire is marked (Fig 15B),

bent inferiorly (Fig 15C), and, by using the
smallest beak of the triple-turret plier or similar
plier (Fig 15D), an eyelet is formed (Fig 15E)
and cut with the distal-end cutter. The function
of the eyelets is twofold: they fix the anterior
segment of teeth and they can act as a restrain-

Figure 14. Maxillary incisors are seen contacting the

NOPU.

ing source or tie-back during the stage of root

retraction, if needed.
With these wire segments in place, three
large, multirooted teeth are formed: one ante-
rior tooth, cuspid-to-cuspid, and two posterior
teeth, second bicuspid to second molar. With
the second bicuspids removed, the anterior
tooth becomes the first bicuspid around to the
other first bicuspid and the two posterior teeth
are the first and second molars. When either the
first or second bicuspids are removed, both pos-
terior teeth can be considered another large,
multirooted single tooth when they are con-
nected with the lingual arch.

Group A Anchorage
With Group A anchorage, the posterior teeth
remain essentially ankylosed; little, if any, mesial

Figure 13. Initial stage of treatment completed.

When the intrasegmental and vertical intersegmental
discrepancies (deep overbite or openbite) have been
corrected, a low load-deflection rate continuous arch
wire can be placed from second molar to second
molar (or first molar to first molar if it is the last tooth
in the arch). Notice how the upper and lower arch-
wires are parallel (A). Lateral views of the upper and
lower continuous archwires should also be parallel.
Sometimes, chain elastics can be used to consolidate
the spaces within each segment (B and C). The upper
and lower lingual arches can be removed, and the
arches can assume a harmonious arch form. These
lingual arches may require slight readjustment when
they are replaced when the extraction sites are to be
closed (C and D).
<<    
     Article
      >> Home | TOC |          
Index

200 Michael R. Marcotte

Figure 16. First stage of extraction site closure in

Group A anchorage situations: Controlled tipping of
the anterior segment. 0.017 X 0.025" TTLRS are used
passively in the anterior or alpha position (the activa-
tion moment results in controlled tipping of the AS)
and a 45° bend is placed in the posterior or beta
position (for mesial translation of the BS) (A). As the
first step in Group A space closure, the anterior seg-
ment is seen tipping about their apices (B and C).

movement is indicated and maximum retraction

of the anterior teeth is planned. Typically, in
Group A anchorage, the first bicuspids are re-
moved. Maximum retraction is also encouraged
when the titanium T-loop retraction spring
(TTLRS) is placed close to the vertical tube (Figs
16B and 16C), ie, in the a position. To maintain
the posterior anchorage, space closure is com-
pleted in two stages: the first being the con-
trolled tipping of the AS and the second stage

Figure 15. A 0.018 X 0.025" steel anterior segment

with tubes and eyelets. Two 1-mm 0.018 X 0.025"
tubes are brazed perpendicular to each other and can
be slipped on to the steel anterior segment and
crimped between the lateral and cuspid (A). The
position of the eyelet is marked immediately distal to
the cupsid braket (B). The eyelet is started at the
mark (C). The eyelet is formed around the smallest
turret of the triple turret plier (D). The eyelet is cut at
about the 1 o'clock position, compressed slightly, and
with two pliers, twisted lingually (for comfort) (E).
<<    
     Article
      >> Home | TOC |          
Index

Segmented Arch Technique: Mechanical Plan 201

being one of root retraction of the AS. The
advantage of doing space closure in two stages is
that the retraction force level can be kept to
300 g or less, which minimizes anchorage drain.
First Stage: Controlled Tipping of the AS
For controlled tipping of the AS, a 0.017 X 0.025
TTLRS is used in a passive condition in the
anterior or alpha position (about 5-6 mm distal
to the vertical tube). A 45° bend is placed in the
posterior or beta leg (Fig 16A). With these pre-
activation bends, the AS undergoes a controlled
tipping with its CRot at the apices of the anterior
teeth while the BS tends to undergo a mesial
translation (Figs 16B and 16C). Remembering
that the cusp tips and incisal edges of the teeth
all contacted the mirror handle at the end of the
initial stage of treatment (Fig 14), the mirror
handle can be used to monitor the space closure
at each appointment until the space has been
closed (Figs 16B and 16C). The mirror handle
shows that the cuspids positioned above the mir-
ror handle are caused by an intersegmental ro-
tation rather than an intrasegmental movement,
exactly what one would expect in the controlled
tipping of the AS.
Second Stage: Root Retraction
The second stage of root retraction is accom-
plished with 0.018 X 0.025" SS double-helix
springs, which can deliver equal or unequal and
opposite couples to the anterior and posterior
segments (Fig 17). Typically, the second stage of
root retraction usually requires an alpha mo-
ment to be greater than the beta moment for a
CRot at the incisors' brackets. But, only for dem-
onstration purposes, the double-helix spring will
be shown with equal and opposite couples.

Figure 17. Second stage of extraction site closure in Group A anchorage situations: Root retraction of the
anterior segment. SS double-helix springs are used to deliver equal and opposite or unequal and opposite
couples to the anterior (a) and posterior (ß) segments. The arrows show where a round-beak plier is placed for
the preactivation bends (A). For illustrative purposes only, equal and opposite preactivaton bends are placed in
the a and ß helices (45°). Typically, the a moment is greater than the ß moment (a — 45° and ß = 15°) (B).
Anticurvature compensation bends are placed so that, when activated, the wire portion between the helices is
straight (only then will there be 45° in the a and ß helices). When a > ß, more compensation curve is placed
anteriorly and posteriorly. This can be checked by looking for a straight wire between the helices when both
helices are activated (C). Activated root springs extend from the molar auxiliary tubes to the crimped vertical
tubes on the AS. A heavy ligature tie from the BS to the eyelets results in a CRot at the brackets of the incisors
(D and E).
<<    
     Article
      >>
202 Michael R. Marcotte
The double-helix root spring is first made
passively to the anterior vertical tube and buccal
auxiliary molar tube (Fig 17A). For equal and
opposite couples, both the anterior (alpha) he-
lix and posterior (beta) helix are preactivated
equally, about 45° (Fig 17B). The turreted barrel
of the triple-turret plier is inserted into the helix
and the helix is bent (at the arrows in Fig 17A)
against the large opposing barrel for a large
diameter preactivation. The helices are preacti-
vated 45° to maintain the mesiodistal force less
than 300 g. When the required alpha and beta
moments are unequal and opposite, 15° and 45°
are used at either helix. For example, when high
alpha-low beta moments are required, the alpha
helix is preactivated 45° and the beta helix is
preactivated 15°. Once the moment preactiva-
tions have been placed, the wire segment be-
tween the helices must receive a compensation
curve (Fig 17C); this is because the activation of
the helices will cause this section of wire to bow,
reducing the activation at each end. When acti-
vated with adequate compensation curvature,
the wire between the helices should be straight
(Figs 17D and 17E).
The roots-lingual, crowns-labial moment on
the AS tends to flare the AS. This is prevented by
a heavy tie that extends from the BS to the eyelet
on the AS (Figs 17D1 and 17E1). The double-
helix root springs are secured to the vertical
tube with a ligature tie through the alpha helix
(Figs 17D2 and 17E2). When the root retraction
has been completed (ie, when the brackets are
aligned and level), a finishing wire from second
molar to second molar (or first molar to first
molar if they are the last teeth in the arch) can
be placed, giving a nice arch form to the arch.
Group B Anchorage
In Group B anchorage, the posterior teeth can
move mesially up to one half of the extraction
site; typically, first bicuspids are removed in
Group B anchorage and, typically, the posterior
teeth will move mesially the same amount as the
anterior teeth will move distally. These move-
ments are optimized by having the segments
translate toward each other. For this translation,
a 0.017 X 0.025" TTLRS is preactivated with
180° of moment preactivation (—4,000 g/mm)
and 7 mm of distal activation (—350 g). The
Home | TOC |          
Index
preactivated TTLRS is placed midway (the JUL
position) between the anterior vertical tube and
the auxiliary molar tube (Fig 18). It is crucial
that the M/F ratio (11:1) is delivered so that the
segments do not change their axial inclinations.
During the space closure, the brackets should be
aligned just as they were at the end of the initial
stage of treatment (ie, almost as if a straight,
unbent wire could be placed from second molar
to second molar). A mirror handle can also be
used to check that the AS is translating distally
along the level plane of occlusion. The segments
appear to be translating on the right side (Fig
18A) but, it appears as though inadequate mo-
ment or too much force exists on the left side
(Fig 18B); this left TTLRS should be removed
Figure 18. A mirror handle can be placed on the
plane of occlusion, and the orientation of the seg-
ments to that plane can be checked. Relative to the
mirror handle, both the AS and the BS appear to be
translating toward each other. The segments are just
as they were at the end of the initial stage of treatment
(A). Relative to the mirror handle, the left cuspid is
lifting up slightly. One can suspect that the upper left
TTLRS has insufficient moment to too much force,
tending to lower the M/F ratio below 11/1. The
upper left TTLRS should be removed, and the preac-
tivation bends again checked as well as the neutral
position. It should then be reinserted with an M/F
ratio > 11/1, either more moment or less force to get
the cuspid back onto the plane of occlusion by the
next appointment. Then, the TTLRS can be read-
justed to produce a M/F of 11/1 (less moment or
increased force (B).
<<    
     Article
      >> Home | TOC |          
Index

Segmented Arch Technique: Mechanical Plan 203

and the neutral position checked again. The

TTLRS should be reactivated after every 2 mm
of closure (~2 months) until the extraction site
is closed.

Figure 20. An 0.018 X 0.025" SS double helix spring

is used to deliver ß > a moments (ß = 45° and a =
15°) for a CRot at the distal marginal ridge of the
second molars (root uprighting of the BS) (A and B).

Group C Anchorage
Group C anchorage exists when the posterior
teeth must be moved mesially one half or more
of the extraction site. To encourage this BS pro-
traction, second bicuspids are usually, but not
always, removed. For example, the patient in
Figures 19A and 19B had her first premolars
removed because she just had extensive restor-
ative procedures on the second premolars.
As with Group A anchorage treatment, extrac-
tion site space closure under Group C anchor-
age conditions involves two stages: the first stage

Figure 19. First stage of extraction site closure in

Group C anchorage situations: controlled tipping of
the buccal segments. The TTLRS is placed in the ß
position and is used passively with a 45° bend in the a
position, pitting controlled tipping of the BS and
distal translation of the AS (A and B). Class III elastics
can be used to augment the protraction of upper BS
(C). As the BS are protracted, they occupy a narrower
position on the arch form. This constriction of arch
widths can be accomplished with a lingual arch with a
constrictive omega loop (D).
<<    
     Article
      >> Home | TOC |          
Index

204 Michael R. Marcotte

Figure 21. Importance of A-P position of the TTLRS (always place the TTLRS where one expects most of the
tooth movement to occur). Right cuspids are Class I, 3 mm of buccal protraction desired. 0.017 X 0.025" TTLRS
is positioned in the ß position with 45° a preactivation, and the TTLRS is used passively to pit anterior distal
translation against controlled tipping of the BS with a later stage of root uprighting. Left cuspids are Class I, 3
mm of anterior retraction is desired. 0.017 X 0.025" TTLRS is preactivated with 180° of moment preactivation
for distal translation of the AS. This movement will close the spaces by retracting the incisor segment and
improving the midline relationship (B). First deband figure: canine relationship still Class I. Space has been
closed by about 3 mm of buccal protraction (C). Second deband figure: canine relationship still Class I. Space
has been closed by 3 mm of distal translation of the incisor segment (D). Initial midline relationship: upper
dental midline is about 3 mm to the right of the lower dental midline (E). Deband midline relationship: upper
dental midline is about 1 mm to the right of the lower dental midline with nominal changes in axial inclination
(F).

pits controlled mesial tipping of the BS against

the more resistant distal translation of the AS.
This differential anchorage encourages buccal
protraction. The second stage of Group C space
closure involves the uprighting of the tipped BS.
The required force system is delivered with a
0.017 X 0.025" TTLRS in the beta position,
about 5 mm anterior to the molar bracket (Figs
19A and 19B). The T-loop is used in a passive
condition with its activation moment resulting in
a CRot at the root apices of the posterior teeth.
With 5 mm of distal activation to the TTLRS, the
beta leg of the TTLRS is against the molar tube
and reactivations are performed in the alpha
position. Buccal protraction is also encouraged
with the use of Class III elastics (Fig 19C). In
Group C anchorage, the posterior teeth are be-
Figure 22. Maxillary and mandibular 0.018 X 0.025"
ing protracted to a narrower position on the finishing wires. Note how upper and lower 0.018 X
arch form, usually requiring constriction of the 0.025" SS arch wires are parallel to each other. Both
arch widths. In Figure 19D, this arch width con- wires are cinched distally, which allows the use of
striction has been accomplished with a trans- intermaxillary elastics as necessary to produce canine
palatal lingual arch with an omega loop. Class I and midline correspondence (A and B). Upper
and lower finishing wires are parallel (C). Upper and
The second stage of root uprighting again lower occlusal views showing the finishing wires in
uses the 0.018 X 0.025" double-helix SS spring place. Upper and lower lingual archwires have also
preactivated with a beta moment greater than been removed (D and E).
<<    
     Article
      >>
Segmented Arch Technique: Mechanical Plan
the alpha moment, ie, beta preactivation of
45° and alpha preactivation of 15° (Fig 20).
This produces a CRot at the distal marginal
ridge of the second molars and the BS will be
seen to rotate down to or up to the occlusal
plane, depending on which arch is involved.
When the brackets are aligned and level and
the segments are in correct alignment, tooth
positioner (TP) impressions are made and fin-
ishing wires can be placed.
The importance of the anteroposterior po-
sition of the TTLRS for anchorage control is
seen in the uniarch treatment shown in Figure
21. In Figure 21A, 3 mm of buccal protraction
is required. For this, a ß-positioned TTLRS is
placed with only the 45° alpha moment preac-
tivation. The right BS rotates about its apices
whereas the AS undergoes the more resistive
distal translation. When the protraction has
been completed, a second stage of BS upright-
ing is required. On the left side (Fig 21B), 3
mm of retraction of the AS is required to close
the space between the lateral and the cuspid
and to improve the midline relationship. The
left TTLRS is placed in the alpha position with
180° of moment preactivation for distal trans-
lation of the AS. Both left and right TTLRSs
Table 1. Example Mechanical Plan
Maxillary Arch: X4/4; Group A
1. Band 7,6,5; bond 3-3; LA
passive
2. 0.017 TMA R-loop to 7's;
0.016" SAS from 3-3
3. 0.017 X 0.025" TBS segment:
5-7; 0.018" SAS 3-3
4. 0.018" Niti arch wire 7-7 with
CE to consolidate segments
5. 0.018 X 0.025" SAW 7-7 (LA
removed)
6. 0.018 X 0.025" SAW
segmented: SBSS and SASS
with tubes and eyelets; LA
replaced, 0.017 X 0.025
TTLRS: «-passive, ß = 45°
7. 0.018 X 0.025" double-helix
root spring: a > ß with heavy
ligature tie from BS to AS
8. 0.018" NITI -» 0.018 X 0.025"
SAW 7-7; TP for finishing
details
9. Maxillary Hawley retainer: 24/7
for 6 mo; PM only for next 6
mo.
Abbreviations: HG, headgear; A/A, intermaxillary; SAS, steel anterior segment; SBS, steel buccal segment; TBS, TMA buccal
segment; CE, chain elastic.
Home | TOC |          
Index
205
have 180° of antirotation twist placed in the
vertical legs. The results show that the spaces
have been closed by the desired movement
and the midline relationship has been im-
proved (Figs 21C-F).
Finishing Stage of Treatment
The finishing wires are 0.018 X 0.025" SS arch
wires, which are used to improve the tooth-to-
tooth relationships, usually as torque in the lat-
eral incisors or canines (Fig 22). The use of Class
II or Class III elastics could be used for any slight
improvements needed in the canine or midline
relationships. At the same appointment in which
these finishing wires are placed, tooth positioner
(TP) impressions are made. Most of the tooth-
to-tooth relationships have been idealized in the
initial stage of treatment so that the finishing
stage is quite short, ie, 2 to 3 appointments.
When the appliances are removed, the pa-
tient is given their custom-made TP. Their
instructions are to use it "26 hours a day" for 2
weeks to take full advantage of the fact that
their teeth will remain slightly mobile for
about 2 weeks; they always laughingly correct
us about how many hours there are in a day. At
A/A Mandibular Arch: X 4/4; Group B
Combee HG with 1. Band 7,6,5; bond 3-3; LA passive
pull-thru CRes 2. 0.018 X 0.025" SBS 5-7 ideal; 0.014"
of maxilla "26" V-loop AS from 3-3
h/day during 3. 0.018 X 0.025" SBS: 7,6,5,3; 0.018"
steps 6A and SAS 2-2
6B 4. 0.018 X 0.025" SS intrusive arch 40
g/mdL
5. 0.018" NITI 7-7 with CE to
consolidate segments
6. 0.018 X 0.025" SAW 7-7 (LA
removed)
7. 0.018 X 0.025" SAW segmented:
SBSS and SASS with tubes and
eyelets; LA replaced
8. 0.017 X 0.025" TTLRS with 180°
moment preactivation for
translation AS
9. 0.018" NITI -» 0.018 X 0.025" SAW
7-7; TP for finishing details
10. Mandibular Hawley retainer: 24/7
for 6 mo; PM only for next 6 mo.
<<    
     Article
      >>
206 Michael R. Marcotte
the next appointment in 2 weeks, deband
records are made and the use of the TP is
reduced to 4 to 5 hr/day for the next 6 weeks,
at which time impressions for Hawley retainers
are made. When the Hawley retainers are de-
livered, the patient has basically completed
active treatment.
These, then, are the basic steps of a mechan-
ical plan using the principles of the segmented
arch technique. Once each patient's specific
treatment objectives have been determined, the
mechanical plan can be formed (Table 1). From
the lateral treatment plan tracing, our example
patient required 3.0 mm of mandibular incisor
Home | TOC |          
Index
retraction and 2.0 mm of mandibular incisor
intrusion.
References
1. Burstone CJ. The rationale of the segmented arch. Am J
Orthod 1962;48:805-821.
2. Burstone CJ. Mechanics of the segmented arch tech-
nique. Angle Orthod 1966;36:99-120.
3. Burstone CJ, Marcotte MR. Problem Solving in Orth-
odontics. Chicago: Quintessence Publishing Co, 2000,
p 31.
4. Marcotte MR. The use of the occlusogram in planning
orthodontic treatment. Am J Orthod 1976;69:655-667.
5. Marcotte MR. Biomechanics in Orthodontics. Chicago:
Quintessence Publishing Co, 1990, p 35.
<<    
     Article
      >> Home | TOC |          
Index

Three-Dimensional Force Systems From

Activated Orthodontic Appliances
Steven J. Lindauer, Robert J. Isaacson, and A. Denis Britto

A thorough understanding of the mechanical force systems generated by

orthodontic wire activations is important for producing efficient tooth
movement directed toward achieving predetermined treatment goals. The
two-dimensional force systems produced by short segments of wire in-
serted into orthodontic brackets have been well-documented previously.
Most orthodontic appliances, however, act in three planes of space. Once a
full arch wire leaves the relatively straight posterior region and curves
around the canine to the incisors, two-dimensional analyses can no longer
fully explain the force systems produced. Simple v-bend activations in wires
inserted into two coplanar brackets cause the wire to act in bending at both
sites. When the brackets are oriented in different planes, such as on a molar
and incisor for example, rectangular wires will act in both bending and
torsion, altering the force systems produced. Any two-dimensional analysis
will inherently ignore forces and moments produced in the out-of-plane
dimension. Static equilibrium, the condition under which all interpretations
of orthodontic appliance activations are analyzed, must be met in all three
dimensions. Awareness of the force systems produced by orthodontic ap-
pliances in all three planes of space increases the ability to predict and
control both desired and unwanted tooth movements during orthodontic
treatment. (Semin Orthod 2001;7:207-214.) Copyright © 2001 by W.B. Saun-
ders Company

rthodontists are adept at viewing their
O three-dimensional patients as a series of
two-dimensional images. Clinically, and with the
aid of photographs and cephalometric radio-
graphs, measurements are made to analyze a
patient's skeletal, dental, and soft-tissue relation-
ships. In the lateral view, facial profile and lip
support are evaluated. The lateral cephalomet-
ric film helps to elucidate anterior-posterior as
well as vertical relationships of the face. From
From the Department of Orthodontics, School of Dentistry, Vir-
ginia Commonwealth University, Richmond, VA.
Supported in part by the American Association of Orthodontists
Foundation and the Medical College of Virginia Orthodontic Edu-
cation & Research Foundation.
Address correspondence to Steven J. Lindauer, DMD, MDSc,
Department of Orthodontics, School of Dentistry, Virginia Common-
wealth University, Richmond, VA 23298-0566.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0703-0008$35.00/0
doi:10.1053/sodo.2001.26696
the frontal perspective, overall facial symmetry
and midline coincidence are assessed and a pos-
terior-anterior cephalometric radiograph helps
to evaluate skeletal symmetry and transverse
relationships. Together, these views can be
summed to represent a whole patient and, dur-
ing the treatment planning process, plaster
study models help to emphasize the three-di-
mensional nature of the patient.
Orthodontic appliances are also three-dimen-
sional but the three-dimensional force systems
they produce are rarely recognized until the
unwanted side effects become apparent clini-
cally. Unanticipated molar torque or unin-
tended incisor tip may often be thought of as a
consequence of poor bracket placement or in-
advertent wire activation, but can also be an
inseparable byproduct of otherwise well-planned
treatment mechanics. The current trend is to-
ward increased use of wires with a greater range
of action, by appliances made of new materials

Seminars in Orthodontics, Vol 7, No 3 (September), 2001: pp 207-214 207

<<    
     Article
      >>
208 Lindauer, Isaacson, and Britto
and with longer interbracket spans. This enables
an orthodontic appliance to remain active for
longer periods of time between appointments
but also magnifies the undesirable side effects of
incompletely conceived appliance activations. It
is therefore important to understand in more
detail the force systems produced by orthodon-
tic wire activations or by ideal arch wires inserted
into malaligned brackets.
Two-Dimensional Force Systems
The two-dimensional force systems produced by
straight segments of wire inserted into mala-
ligned orthodontic brackets have been thor-
oughly analyzed and are well understood. They
were first described by Burstone and Koenig1 in
1974. The results of their findings are shown in
Figure 1 and are based on the principles of static
equilibrium. When a straight wire is inserted
into two equal and oppositely angled brackets,
equal and opposite couples are produced. If the
brackets are unequally angled, a larger couple is
produced at the bracket that is more greatly
angled. Equal and opposite forces are produced
at the two brackets to form a couple in a direc-
tion opposite to the couple at the more greatly
angled bracket. A smaller couple may also be
produced at the lesser angled bracket, but will
be ignored for this discussion. When the two
brackets are angled equally in the same direc-
tion, equal couples are produced at both brack-
ets and equal and opposite forces are present at
the brackets. The forces produce a couple equal
and opposite to the sum of the two couples at
the brackets.
Analogously, the static force systems gener-
ated by placing wires with v- and step-bends into
aligned, coplanar orthodontic brackets have
been well documented.2'3 These force systems
are shown in Figure 2. If the v-bend is placed
symmetrically, halfway between two brackets,
equal and opposite couples are transmitted. As
the bend is moved closer to one bracket, that
bracket experiences a greater couple and equal
and opposite forces are produced at the two
brackets to form a couple in a direction opposite
to the couple at the bracket closer to the bend.
Depending on the location of the bend, a
smaller couple may also be produced at the
bracket farther from the bend, but is ignored in
this discussion. If a step bend is placed between
Home | TOC |          
Index
A
.X
NT /^
a V
B /,
/
V
I t
7, C /,
/ /
\* \j
Figure 1. Two-dimensional force systems produced
by inserting straight wires into malaligned brackets.
Equally and oppositely angled brackets result in equal
and opposite couples (A). If the brackets are un-
equally angled, the larger couple is produced at the
more greatly angled bracket and equal and opposite
forces result. A smaller couple (not shown) will also
be produced at the lesser-angled bracket (B). Equally
angled brackets in the same direction result in equal
couples in the same direction and equal and opposite
forces that form a couple equal in magnitude and
opposite in direction to the sum of the couples at the
two brackets (C).
two brackets, regardless of its location, equal
couples are produced at the two brackets. Equal
and opposite forces, that form a couple equal in
magnitude to the sum of the couples at the
brackets and opposite in direction, are pro-
duced at the two brackets.
The information derived from two-dimen-
sional biomechanical models can be used to de-
sign appliances to perform numerous ortho-
dontic tooth movements. For example, a high
canine can be extruded by using a long-arm or
cantilever wire that extends from a molar auxil-
iary tube and tied to, but not inserted into the
bracket of the canine. A v-bend is placed close to
the molar to produce the required extrusive
force at the canine. Because the bend is close to
<<    
     Article
      >>
Three-Dimensional Force Systems
A spring is inserted into both the molar and ca-
B of the canine, the extruding wire should not be
V extrusive force by the wire at the canine mea-
J t
C and canine brackets is 30 mm, then the two
Figure 2. Two-dimensional force systems produced
by inserting active wires into aligned brackets. A v-
bend placed symmetrically between two brackets re-
sults in equal and opposite couples (A). If the v-bend
is asymmetrically placed, the larger couple is pro-
duced at the bracket closer to the bend and equal and
opposite forces result. A smaller couple (not shown) is
also produced at the bracket farther from the bend
(B). A step bend, regardless of its location between
two brackets, results in equal couples in the same
direction and equal and opposite forces that form a
couple equal in magnitude and opposite in direction
to the sum of the couples at the two brackets (C).
the molar bracket, the larger couple will be ex-
pressed there. In this case, the couple will be in
a direction to cause mesial crown and distal root
tip of the molar. If the wire is engaged into the
canine slot as in Figure 3, a couple is also pro-
duced at the canine. This is explained in more
detail later. For the appliance to be in equilib-
rium, equal and opposite forces will be present
at the molar and canine brackets: intrusive at the
molar and extrusive at the canine. Those two
forces also form a couple on the wire, opposite
to the couple causing the molar to tip. For pur-
poses of illustration, it is interesting to analyze
the force systems in more detail.
In the case shown in Figure 3, the extrusive
Home | TOC |          
Index
209
nine brackets. Because the wire is inserted into
both brackets, a couple is also present at both
brackets, though the couple at the molar bracket
is greater. The couple at the canine bracket will
result in a change in axial inclination as it is
erupted. To avoid any alteration in the long axis
placed into the slot. A point contact is preferred,
as seen in Figure 4A.
Using the example in Figure 4A in which the
wire is tied to the canine as a point contact, the
sures 50 g. For the appliance to be in equilib-
rium, an intrusive force at the molar of 50 g is
also present. If the distance between the molar
forces create a couple on the wire of 1,500
g-mm. The couple expressed at the molar
bracket must be equal and opposite to the cou-
ple created by the two forces, 1,500 g-mm in a
crown mesial-root distal direction. The next
step is to determine how the teeth will move.
Figure 4B shows the forces and moments in
the frontal view as each tooth would "feel" them
at their respective centers of resistance. The cal-
culations assume that the perpendicular dis-
tances from the brackets to the centers of resis-
tance are both 5 mm. In addition to the 1,500
g-mm couple causing the molar to tip mesially,
there is a 50 g intrusive force at the molar.
Because that force is acting 5-mm buccal to the
molar center of resistance, the molar would ex-
perience a 50 g intrusive force at the center of
resistance plus a 50 g X 5 mm, or 250 g-mm,
Figure 3. A long arm or cantilever used to extrude a
previously high buccal canine. The active v-bend is
close to the molar, resulting in a large couple to tip
the molar crown mesial-root distal and equal and
opposite forces to extrude the canine and intrude the
molar. A couple is also present at the canine because
the wire is engaged in its bracket. This will result in an
axial inclination change of the canine.
<<    
     Article
      >>
210 Lindauer, Isaacson) and Britto
250 g-mm
250 g-mm
Figure 4. A long arm or cantilever used to extrude a
high canine. The wire is tied to the canine as a point
contact, guaranteeing that a couple is only produced
at the molar. Buccal view showing the forces and
couple produced by the wire (A). Frontal view show-
ing the forces and moments as felt by the teeth at
their centers of resistance (black dots) (B).
moment in a crown buccal-root palatal direc-
tion. The canine would similarly experience a
50 g extrusive force plus a 50 g X 5 mm, or 250
g-mm moment in a crown palatal-root buccal
direction.
Home | TOC |          
Index
Three-Dimensional Force Systems
Two-dimensional models do not adequately ex-
plain the force systems developed by fully con-
toured arch wires inserted into molar and inci-
sor brackets. Because the molar and incisor
brackets are in different planes, wires activated
by bending act both in bending and in torsion at
the two attachment sites. Because wire proper-
ties differ in bending and torsion and because
different degrees of bending and torsion will
occur at each site, a bend placed halfway be-
tween molar and incisor brackets will not result
in equal and opposite couples. This problem has
been explored to some degree through finite
element modeling and the results have been
reported.4'5 Effects will differ depending on arch
shape, wire material, and wire cross-sectional di-
mensions because these characteristics affect rel-
ative bending and torsional properties. To sim-
plify the discussion here, it will be assumed that
three-dimensional wires are inserted only into
molar or incisor brackets, but not both.
Despite the added complication of having a
three-dimensional wire curve out of the plane of
analysis into the third dimension, the require-
ments of static equilibrium in all planes of space
still apply. That is, the force systems expressed by
the wire will be in static equilibrium in each
plane of analysis. To fully understand the effects
of a three-dimensional wire, the force systems
must be viewed from both the lateral and frontal
aspects.
The Intrusion Arch
One commonly used appliance that is clearly
three-dimensional in nature is the intrusion
arch. Its effects are usually examined only from
the lateral view, but analysis from the frontal
aspect shows the importance of a three-dimen-
sional assessment.
Classically, as described by Burstone,6'7 the
intrusion arch is inserted into the molar tubes
and tied to a series of points on an intermediate
anterior segment that engages the incisor brack-
ets. The anterior teeth are joined together by a
rigid or nonrigid segment. A tip-back bend at
the molar, with or without a helix added to
decrease the load-deflection rate, provides the
activation necessary to transmit an intrusive
<<    
     Article
      >>
Three-Dimensional Force Systems
force to the incisor segment as shown in Fig-
ure 5A.
In the example in Figure 5A, only the two
central incisors will be intruded so a force of 20 g
per tooth is used.7 For simplicity, only one side
(one molar and one incisor) will be discussed. If
the intrusive force at the incisor is 20 g, then
there is also an extrusive force at the molar of
20 g. The perpendicular distance from the mo-
lar to the incisor bracket in the lateral view in
the example is 30 mm, so the force creates a
couple of 20 g X 30 mm or 600 g-mm.
The intrusion arch must also satisfy the laws
of static equilibrium in the frontal view and this
is often overlooked. The force system expressed
by the intrusion arch at one incisor bracket in
the frontal view is shown in Figure 5B. As in the
lateral view, there is a 20 g extrusive force at each
molar and a 20 g intrusive force at each incisor.
Because the molar and incisor brackets are sep-
arated by a distance of 10 mm in the frontal view,
a 20 g X 10 mm or 200 g-mm couple is exerted
on the intrusion arch by the two forces. The
molar, therefore, experiences a 200 g-mm cou-
ple, opposite in direction to the couple gener-
ated by the intrusive and extrusive forces, tend-
ing to torque the molar crown buccally, and the
root palatally.
To predict how the molars and incisors will
actually move, the forces and moments each tooth
will feel at their respective centers of resistance
must be determined. To do this, the information
learned by both the lateral and frontal view analy-
ses are combined and shown in Figures 5C and 5D.
The intrusion arch generates 20 g of intrusive
force at each incisor and 20 g of extrusive force at
each molar bracket; these forces are shown in both
the lateral (Fig 5A) and frontal (Fig 5B) views. The
tip-back couple on the molar is 600 g-mm (Fig 5A).
The crown buccal-root lingual couple on the mo-
lar is 200 g-mm (Fig 5B). No couples are expressed
at the incisors because the intrusion arch is not
engaged in the bracket slot.
The molar will experience a tip-back couple of
600 g-mm from the lateral view analysis, so the
molar feels a crown distal-root mesial moment of
600 g-mm shown in the lateral view (Fig 5C).
There will be a 20 g force tending to extrude the
molar (Figs 5C and 5D) and, because that force is
applied 5-mm buccal to the center of resistance
(Fig 5B), the molar will also feel a 20 g X 5 mm or
100 g-mm crown palatal-root buccal moment (Fig
Home | TOC |          
Index
211
5D). However, there is also a 200 g-mm crown
buccal-root palatal couple from the frontal view
analysis (Fig 5B) and this will more than counter-
act the 100 g-mm moment in the opposite direc-
tion (Fig 5D). The incisors will each experience a
20 g intrusive force (Figs 5C and 5D) and, because
that force is 7-mm facial to their centers of resis-
tance (Fig 5A), each incisor will also experience a
20 g X 7 mm or 140 g-mm crown facial-root
lingual moment (Fig 5C).
The Anterior Root Spring or
Torquing Arch
To increase incisor lingual root torque, the an-
terior root spring or torquing arch has been
described.8"11 The spring is inserted into the in-
cisor brackets and bent apically at a point distal
to the incisor brackets so that, when activated, it
will torque the incisors in a crown facial-root
palatal direction. The distal ends of the spring
may be hooked onto the arch wire mesial or
distal to the molar brackets. To simplify this
discussion, the spring will be inserted only into
the two central incisor brackets and activated by
bringing the distal extensions coronally and
hooking them on the arch wire mesial to the
molar brackets as shown in Figure 6A.
If a 1,500 g-mm crown facial-root palatal cou-
ple is desired at the incisors, and assuming the
lateral view distance from the incisor to the mo-
lar point of attachment is 30 mm, the root spring
will require an activation to produce 50 g of
intrusive force mesial to the molar (Fig 6A), and
50 g X 30 mm equals 1,500 g-mm. If the intru-
sive force near the molar is 50 g, then there is an
extrusive force at the incisor of 50 g to satisfy the
conditions of static equilibrium.
As in the example of the intrusion arch de-
scribed earlier, the conditions of static equilib-
rium must also be met in the frontal view for the
anterior root spring or torquing arch (Fig 6B).
The 50 g intrusive force near the molar and 50 g
extrusive force at the incisors are still present in
the frontal view. Because the molar and incisor
brackets are separated by a distance of 10 mm in
the frontal view in the example, a 50 g X 10 mm
or 500 g-mm couple is exerted by the two forces.
The appliance is not inserted into the molar
bracket so, in this case, the incisor experiences a
500 g-mm couple tending to tip the incisor
crown mesially, and the root distally.
<<    
     Article
      >>
212 Lindauer, Isaacson, and Britto
200 g-mm
100 g-mm
Figure 5. Three-dimensional force systems produced
by an intrusion arch. The intrusion arch (black wire)
is tied as point contacts to the anterior segment (gray
wire) joining the two central incisors, to ensure that
couples are produced by the wire only at the molars.
Buccal view showing the forces and couple (black)
produced by the wire (A). Frontal view showing the
forces and couple (black) produced by the wire (B).
Buccal view showing the forces and moments as felt by
the teeth at their centers of resistance (black dots)
including intrusive and extrusive forces (gray), mo-
ment (gray) produced by the intrusive force acting
facial to the incisor center of resistance, and moment
(black) from the couple acting on the molar (C).
Frontal view showing the forces and moments as felt
by the teeth at their centers of resistance including
Home | TOC |          
Index
To predict how the molars and incisors will
actually move, the forces and moments each
tooth will feel at their respective centers of resis-
tance must be determined. To do this, the infor-
mation learned from both the lateral and frontal
view analyses are combined and shown in Fig-
ures 6C and 6D. The torquing arch generates
50 g of extrusive force at each incisor and 50 g of
intrusive force mesial to each molar bracket;
these forces are shown in both the lateral (Fig
6A) and frontal (Fig 6B) views. The crown fa-
cial-root palatal couple on the incisor is 1,500
g-mm (Fig 6A). The crown mesial-root distal
couple on the incisor is 500 g-mm (Fig 6B). No
couples are expressed at the molars because
the torquing arch is not engaged in the molar
brackets.
The incisor will experience a crown facial-
root palatal couple of 1,500 g-mm from the lat-
eral view analysis, so the incisor feels a crown
facial-root palatal moment of 1,500 g-mm
shown in the lateral view (Fig 6C). There will be
a 50 g force tending to extrude the incisor (Figs
6C and 6D) and, because that force is applied
7-mm facial to the center of resistance (Fig 6A),
the incisor will also feel a 50 g X 7 mm or 350
g-mm crown palatal-root lingual moment (Fig
6G) that decreases the effect of the 1,500 g-mm
moment. In the frontal view, the incisor feels the
same 50 g extrusive force plus a 500 g-mm crown
mesial-root distal moment (Fig 6D). It should
be noted that the 50 g per incisor extrusive force
is resisted by the stepped arch wire. The molars
will each experience a 50 g intrusive force (Figs
6C and 6D). Because that force is 5-mm anterior
to the molar center of resistance (Fig 6A), each
molar will also experience a 50 g X 5 mm or 250
g-mm crown mesial-root distal moment shown
in the lateral view (Fig 6C). In the frontal view,
the 50 g intrusive force is 5-mm buccal to the
molar center of resistance (Fig 6B), so each
molar will also feel a 50 g X 5 mm or 250 g-mm
crown buccal-root palatal moment (Fig 6D).
the same intrusive and extrusive forces (gray), mo-
ment (gray) produced by the extrusive force acting
buccal to the molar center of resistance, and moment
(black) from the couple acting on the molar (D).
<<    
     Article
      >>
Three-Dimensional Force Systems
B extrusive force. Likewise, in a three-dimensional
350 g-mm
250 g-mi
1500 g-mm
250 g
Figure 6. Three-dimensional force systems produced
by an anterior root spring or torquing arch. The
anterior root spring or torquing arch (black wire) is
hooked to the main arch wire (gray wire) as a point
contact anterior to the molar bracket to ensure that
couples are produced only at the incisors. Buccal view
showing the forces and couple (black) produced by
the spring (A). Frontal view showing the forces and
couple (black) produced by the spring (B). Buccal
view showing the forces and moments as felt by the
teeth at their centers of resistance (black dots) includ-
ing intrusive and extrusive forces (gray), moments
(gray) produced by the intrusive force acting anterior
to the molar center of resistance and extrusive force
Home | TOC |          
Index
213
Considerations and Solutions
In two-dimensional and three-dimensional orth-
odontic appliances, the forces and moments
generated are mathematically balanced to satisfy
the conditions of static equilibrium. One cannot
be altered without affecting the others. In the
canine extrusion example (Fig 4), if the molar
crown mesial-root distal couple is undesirable,
the spring cannot be bent to avoid this side
effect without eliminating the intended canine
appliance, the forces and moments as viewed
from both the lateral and frontal aspects are
intimately related.
One of the side effects of the intrusion arch is
the crown buccal-root palatal molar couple as
viewed from the frontal aspect (Figs 5B and 5D).
This effect is partially, but not completely, ne-
gated by the moment caused by the extrusive
force acting buccal to the molar center of resis-
tance (Figs 5B and 5D). Twisting the intrusion
arch wire mesial to the molar to create crown
palatal-root buccal torque on the molar would
eliminate the effect completely. However, this
would be accompanied by extrusive force at the
incisor and intrusive force at the molar that
would also negate the originally intended incisor
intrusive force. An alternate approach would be
to place a separate appliance, such as a rigid
transpalatal arch, to stabilize the molars against
each other. This would prevent the molar
crowns from torquing buccally without affecting
the force system generated by the intrusion arch.
Another possibly undesirable effect of the in-
trusion arch as described is the crown facial-root
lingual moment on the incisor caused by the
intrusive force acting facial to the incisor center
of resistance (Fig 5C). If the intrusion arch itself
is altered by torquing it to cancel this moment
and inserting it into the incisor brackets, the
intrusive force on the incisors would increase
and the effects of the intrusion arch become
acting facial to the incisor center of resistance, and
moment (black) from the couple acting on the incisor
(C). Frontal view showing the forces and moments as
felt by the teeth at their centers of resistance includ-
ing the same intrusive and extrusive forces (gray),
moment (gray) produced by the intrusive force acting
buccal to the molar center of resistance, and moment
(black) from the couple acting on the incisor (D).
<<    
     Article
      >>
214 Lindauer, Isaacson, and Britto
statically indeterminate.7 Alternatively, the intru-
sive force could be applied closer to the lateral
view center of resistance of the incisors by tying
the intrusion arch more distally as described by
Burs tone.7 This would decrease or eliminate the
moment tending to flare the incisor crowns fa-
cially.
For the anterior root spring or torquing arch,
undesirable side effects may occur at both the
molars and incisors. In the frontal view, the in-
cisors experience a significant moment tending
to tip their crowns mesially and roots distally,
resulting in a reverse-smile configuration (Figs
6B and 6D). Curving the anterior portion of the
appliance to eliminate this couple will also elim-
inate the extrusive force at the incisors and in-
trusive force at the molars (Fig 6B). Without
these forces, the crown facial-root lingual cou-
ple at the incisors, which was the original intent
of placing the appliance, would also be elimi-
nated (Fig 6A). The side effect is best avoided by
using a relatively rigid stainless steel arch wire; as
an example, one of 0.017" X 0.025" rectangular
cross-section in an 0.018" slot system.
Effects from the molar crown buccal-root lin-
gual moment caused by the intrusive force act-
ing buccal to the molar center of resistance in an
anterior root spring or torquing arch (Fig 6D)
can be negated by placing a transpalatal arch to
stabilize the molars. The transpalatal arch acts
independently and does not alter the force sys-
tem generated by the appliance.
Similar to changing the point of force appli-
cation to the incisors in an intrusion arch, the
point of force application on the molars can be
altered when using an anterior root spring or
torquing arch. Rather than hooking the distal
end of the appliance anterior to the molar caus-
ing the molar crown to tip mesially (Fig 6C), the
intrusive force can be applied distal to the molar
crown, causing it to tip distally if this is more
desirable.
Conclusion
Awareness of the interdependent nature of the
forces and moments generated in both two-di-
Home | TOC |          
Index
mensional and three-dimensional orthodontic
appliances improves the ability of orthodontists
to predict both the desired and adverse effects of
appliance activations. Undesirable actions of an
appliance can rarely be eliminated by altering
the configuration of the appliance itself without
negating the effects originally intended. By an-
ticipating side effects before they occur, the
orthodontist may choose to reduce or eliminate
them by applying independent force systems
from additional appliances placed specifically
for that purpose, thus, eliminating "round trip-
ping" teeth during treatment.
Acknowledgment
The authors would like to thank Ms. Carol Wilkins for her
help in preparing the illustrations for this article.
References
1. Burstone CJ, Koenig HA. Force systems from an ideal
arch. Am J Orthod 1974;65:270-289.
2. Burstone CJ, Koenig HA. The force system from step and
v bends. Am J Orthod Dentofac Orthop 1988;93:59-67.
3. Ronay F, Kleinen MW, Meisen B, et al. Force system
developed by v bends in an elastic orthodontic wire.
Am J Orthod Dentofac Orthop 1989;96:295-301.
4. Lindauer SJ, Isaacson RJ, Conley PA, et al. Force systems
from three-dimensional orthodontic archwires, in Lan-
grana NA, Friedman MH, Grood ES (eds). Proceedings
of the 1993 Bioengineering Conference, New York,
American Society of Mechanical Engineers, 1993;40:
262-265.
5. Isaacson RJ, Lindauer SJ, Conley P. Responses of 3-d
arch wires to vertical v bends. Semin Orthod 1995;!:
57-63.
6. Burstone CJ. Deep overbite correction by intrusion.
Am J Orthod 1977;72:l-22.
7. Burstone CJ. Biomechanics of deep overbite correction.
Semin Orthod 2001;7:26-33.
8. Burstone CJ. The mechanics of the segmented arch
techniques. Angle Orthod 1966;36:99-120.
9. Isaacson RJ. Moments with the edgewise appliance: In-
cisor torque control. Am J Orthod Dentofac Orthop
1993;103:428-438.
10. Isaacson RJ, Rebellato J. Two-couple orthodontic appli-
ance systems: Torquing arches. Semin Orthod 1995;!:
31-36.
11. Shroff B. Root correction during orthodontic therapy.
Semin Orthod 2001;7:50-58.
<<    
     Article
      >> Home | TOC |          
Index

An Examination of the Effects of Leveling

With Nickel Titanium Rectangular Arch
Wires Combined With Torqued Incisor
Brackets
Stanley Braun

Leveling the curve of Spee with sequential round cross-section arch wires
characteristically results in incisor proclination. To prevent this, the use of
low modulus, rectangular cross-section arch wires combined with torqued
incisor brackets has been recommended by some clinicians. Clinical data
were analyzed to determine whether this is the case. It showed that procli-
nation does occur at a lesser angle and at a mean center of rotation more
apical to that of the mean center of rotation resulting from leveling with
successive round arch wires. A probability calculation suggests that in a
random selection of 2 patients, in which patient 1 was treated by round wire
leveling and patient 2 was treated by rectangular wire/torqued bracket
leveling, the odds are approximately 2 to 1 in favor of patient 2 having more
labial bone stressed than patient 1. This is primarily caused by the incisors'
centers of rotation being displaced more apically. This negative effect is
reduced somewhat by increase intercuspid canine width, a characteristic of
low modulus nickel titanium rectangular arch wire forms. It should be noted,
however, that earlier studies have shown that increased canine cross-arch
widths potentiate posttreatment instability. (Semin Orthod 2001;7:215-220.)
Copyright © 2001 by W.B. Saunders Company

In an unpublished thesis,1 it was shown that
curve of Spee leveling with low modulus,
nickel titanium rectangular arch wires, com-
bined with labial root torque built into the
incisor brackets, recommended by some clini-
cians,2'3 does not prevent the incisors from flar-
ing (Fig 1) The primary effect is to alter the
incisors' centers of rotation. More often than
not, when leveling with nickel titanium arch
wires, incisor proclination is masked because the
intercanine widths are characteristically in-
creased.4 As an example, in one typical thesis
From the Vanderbilt University Medical Center, Nashville, TN
and the St. Louis University Centerfor Advanced Dental Education,
St. Louis, MO.
Address correspondence to Stanley Braun, DDS, MME, 7940
Dean Road, Indianapolis, IN 46240.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0703-0009$35.00/0
doi:10.1053/sodo.2001.26697
study participant, an increase of 1.4 mm in in-
tercanine width occurred during leveling.1 This
resulted in a calculated decrease of 3.32° of
incisor proclination.1'5 The measured incisor
proclination as obtained from Tl (cephalogram
taken before leveling) and T2 (cephalogram
taken after completion of leveling) lateral
cephalograms was 6.0°. If the intercanine width
had not been altered, the true incisor proclina-
tion would have been 9.32° (6.0° + 3.32°), a
55.3% increase (Fig 1).
In the past, it was thought that incisor procli-
nation is a natural consequence of leveling be-
cause the arch length of a flat plane is less than
that of a curved one. This has been shown to
be incorrect because the arch length change is
quite small and does not substantiate the degree
of incisor proclination seen.6 The incisor procli-
nation is primarily caused by the intrusive forces
being applied by the arch wire anterior to their
centers of resistance (Fig 2)

Seminars in Orthodontics, Vol 7, No 3 (September), 2001: pp 215-220 215

<<    
     Article
      >>
216 Stanley Braun
3.4° Group II
5.6° Group I
18.4
center of rotation
Group I
.center of rotation
Group II
Group I: leveled with round archwires
Group II: leveled with rectangular archwires
Combined with torqued incisor brackets
Figure 1. Mean locations of the centers of rotation
and corresponding mean angles of incisor proclina-
tion related to leveling with round arch wires or rect-
angular arch wires combined with torqued incisor
brackets.
It is generally undesirable to procline the in-
cisors, either temporarily or permanently, be-
cause posttreatment stability and facial esthetics
may be affected and, most importantly, the labial
supportive tissue is placed at risk.5
Burstone and others7'9 have shown that var-
ious moment-to-force (M/F) ratios applied at
the bracket slots will result in forecastable den-
tal centers of rotation. In the previously men-
tioned thesis,1 the incisors' centers of rotation
were located at a mean of 4.9 mm (± 1.8
mm = 1 SD) apical to the incisors' centers of
resistance when the dental arches were leveled
with rectangular arch wire combined with
torqued brackets. In a similar group of pa-
tients whose mandibular arches were leveled
with sequential round cross-section arch wires,
the centers of rotation were located at a mean
of 1.8 mm (±1.1 mm = 1 SD) apical to their
centers of resistance.1 These findings correlate
with the fact that M/F ratios approximating 15
to 17 will produce a center of rotation very
near the center of resistance of a tooth,7 and
Home | TOC |          
Index
as the M/F ratio is reduced somewhat (be-
cause of the rectangular cross-section arch
wires combined with torqued brackets), the
centers of rotation migrate further apically
(Fig 3). It is noted that an independent t test
determined the differences in the locations of
the centers of rotation to be statistically signif-
icant (P< .05).l
The mean angle of incisor proclination of
patients whose teeth were leveled with the low
modulus rectangular arch wires/torqued
brackets combination was 3.4° (± 2.8° = 1
SD).1 A similar patient group whose dental
arches were leveled with sequential round
cross-section arch wires displayed a mean pro-
clination angle of 5.6° (2.9° ± 1 SD).1 An
independent t test, when applied to these find-
ings, showed the difference in mean angle of
proclination to be statistically significant (P <
.05).1 The incisors' angle of proclination and
their centers of rotation are shown in Fig 1.
Both methods of leveling resulted in incisor
proclination, although at a somewhat lesser
mean angle in the group leveled with rectan-
gular cross-section arch wires/torqued brack-
ets. The reader should not be misled by this
because the incisors' centers of rotation are
located significantly more apical in those pa-
tients whose teeth were leveled with arch wires
of rectangular cross-section. Both the angles of
proclination and their corresponding centers
of rotation are interrelated and may have an
important effect on the labial supportive tis-
sues. Consequently, a formula was developed
to evaluate the labial bone impacted by incisor
proclination at various centers of rotation and
various angles of proclination (Fig 4). Calcu-
lations (see Appendix) were subsequently
/"
Center
Of
Rotation
Approximating
Center of Resistance
Figure 2. Typical arch wire intrusive forces acting
anterior to the centers of resistance of the incisors
<<    
     Article
      >>
Leveling With Rectangular Arch Wires
oo
M/F Ratio
Center of Resistance
Figure 3. Locations of centers of rotation related to
various M/F ratios applied at the bracket of a man-
dibular incisor.
*-D
M90-<e+4>»
A = mandibular central incisor crown height (14) = 8.8mm
B = distance from incisal tip to center of rotation
C = Yi labiolingual diameter of crown cervix (14) = 5.3/2 = 2.65 mm
6 = corrected angle of tip
E = vertical height of bone impacted by tooth tipping
tanfy) = C/(B-A); C = (B-A)tan(«j>)
tanOjn-0) = (C+D)/(B-A); D={(B-A)tan(<|>+0)} - C
tan{90-(0+<|>)} = E/D
therefore, E=Dtan{90-(0+<J>)} = {(B-A)tan(<j>+0) -CKtan(90-[0-Kj>])}
Figure 4. Derivation of a formula for the labial bone
impacted by mandibular incisor proclination with var-
ious centers of rotation and angulations.
Home | TOC |          
Index
217
2.96 M S.O.)
-p 2.25 (+1S.D.)
1.98 (mean)
1.45 (mean)
LOO (-1S.D.)
0.65 (-1 S.D.)
; /
Round Cross-Section
Archwire
Rectangular Cross-Section
Archwire/Bracket
Combination
Figure 5. Means and standard deviations of the levels
of labial bone stressed by round and rectangular arch
wire leveling methods.
made to determine the amount (mm) of labial
bone stressed in each participant in the group
whose teeth were leveled with sequential
round arch wires and in each participant in
the group whose teeth were leveled with low
modulus rectangular arch wires/torqued inci-
sor brackets. The results are shown in Figure 5.
When a calculation was made (see Appendix)
as to the probability of potential labial bone
stress, it was found that in 2 out of 3 occasions
greater stress is probable when leveling with
rectangular arch wires/torqued incisor brack-
ets than with round arch wires alone. As noted
previously, preformed nickel titanium arch
wires characteristically increase the cross-arch
canine width over that of the natural human
arch form. This will, in turn, reduce incisor
proclination and reduce the potential harmful
effects of leveling with rectangular cross-sec-
tion arch wires in combination with torqued
incisor brackets.
Leveling, whether by round cross-section
arch wires or rectangular cross-section arch
wires combined with torqued incisor brackets,
is clinically popular because of its simplicity.
In either method, only one outcome occurs at
the end of leveling: posterior dental elevation
and proclination of the incisors (or masking it
by a cross-arch canine width increase). The
clinician has no choice in the matter. The
appliance determines the outcome, regardless
of the treatment objective. Posterior dental
elevation should be avoided in the nongrow-
<<    
     Article
      >> Home | TOC |          
Index

218 Stanley Braun

ing patient or in patients with limited growth Mathematics and Actuarial Science at Butler
potential because this would impinge on the University, Indianapolis, IN, who analyzed the
inter-jaw vertical dimension. Under certain data.
circumstances, it should be avoided even in a
growing patient. For example, if a patient dis-
plays a relatively severe Class II relation in Appendix
which a significant curve of Spee is often
present, posterior dental elevation will rotate El = the vertical height of bone impacted
the mandible, accentuating the Class II rela- during round wire leveling. E2 = the vertical
tion, which will then require exuberant addi- height of bone impacted during rectangular
tional growth to compensate for this iatro- wire/torqued bracket leveling. The distribu-
genic effect. tion of El across a sample of 25 patients
The clinician should consider a more so- seems to be reasonably normal with mean
phisticated approach to leveling the curve of /ji(El) near 1.45 and standard deviation cr(El)
Spee. From a treatment objective perspective, near .80.
it may be advantageous in a given patient, to
level via true incisor intrusion (absent tipping) Table 1. Summary of No Selector
without posterior dental elevation. In another El
patient, however, it may be desirable to inten- Count 25
tionally erupt the posterior teeth without al- Mean 1.44834
tering the positions of the incisors in any way. SD 0.795279
In yet another patient, it may be desirable to
level with a specific, predetermined amount of
The distribution of E2 across a sample of 21
true incisor intrusion, combined with a spe-
patients seems to be reasonably normal with
cific predictable amount of posterior dental
mean jn(E2) near 1.98 and standard deviation
elevation. Means of achieving any of these al-
o-(E2) near .97.
ternatives have been delineated by Burst-
one10'11 and others12'13 and should be carefully
considered by the modern clinician who will Table 2. Summary of No Selector
practice in the new millenium. E2
Count 21
Mean 1.97877
SD 0.972174
Acknowledgment
The author wishes to extend a special thanks We first perform a 2-sample t test of H0:
to Dr. John Gaisser, Associate Professor of jLi(E2) = JUL(EI) versus H a :/x(E2) > /m(El) at

Histogram Normal Probability Plot

3.00

2.25
A

1.50
E
2 - 1 0.75

H- -+-

0. 0 1. 5 -1 0 Figure 6. Histogram and

3.0
Normal Probability Plot of
E1 nscores El.
<<    
     Article
      >> Home | TOC |          
Index

Leveling With Rectangular Arch Wires 219

8 --
3.00 ••
6 --
2.25 -•
4 -- E 1.50 --
2
2 -- 0.75 -•

-+- -+-
-1 0 1
0.00 1.50 3.00
Figure 7. Histogram and nscores
E2
Normal Probability Plot of
E2. Histogram Normal Probability Plot

significance level a = .05. We are able to reject Table 5. 2-Sample t Interval for jul - ju2
HO in favor of Ha at this level. The observed No Selector
p-value is .0263. Individual CI 90%
Bounds
Lower Bound < JUL! - jm2 < Upper Bound
Table 3. 2-Sample t Test of jul-ju,2 With 90% CI, 0.0835762 < jx(E2) - jut(El) < 0.9772727
No Selector
Individual Alpha Level 0.05
Ho: jul - ju2 = 0 Ha: jiil - jLi2 > 0 leveling and patient 2 by rectangular wire/
torqued bracket leveling. The odds are about 2
to 1 in favor of patient 2 having more bone im-
Table 4. E2-E1 pacted than patient 1.
Test Ho: /i(E2) - //.(El) = O v Ha: /*(E2) - /i(El) > 0
Difference between means = 0.5304244
t statistic - 2.000 w/38 df
Reject Ho at Alpha = 0.05 References
P = .0263 1. Aim S. An evaluation of the effect on the mandib-
ular incisors in leveling with round and rectangular
arch wires [master's thesis]. St. Louis, MO: Center for
We obtain a 90% confidence interval (CI) Advanced Dental Education, St. Louis University,
for jm(E2) — jm(El) because 2001.
2. Alexander RG. The Alexander Discipline. In: Alexander
RG (ed). Modern Concepts and Philosophies. Glendora,
(E2 - El) - ( M (E2) ~ n(El)) CA: Ormco Corp, 1986, chap 5 and 8.
has an approxi-
Sj S2 3. Ferguson JW. Lower incisor torque: The effects of rect-
angular arch wires with a reverse Curve of Spec. Br J
25 21 Orthod 1990;17:311-315.
4. Braun S, Hnat WP, Leschinsky R, et al. An evaluation of
mate t(38) distribution. Note that El (E2) de- the shape of some preformed nickel titanium archwires.
notes the average of the 25 round wire levelings Am J Orthod Dentofacial Orthop 1999;116:1-12.
(21 rectangular wire levelings) whereas Sf (S|) 5. Braun S, Hnat WP. Dynamic relationships of the man-
denotes their sample variance. dibular anterior segment. Am J Orthod Dentofacial Or-
thop 1997;lll:518-524.
Assuming El and E2 are independent and
6. Braun S, Hnat WP, Johnson BE. The Curve of Spec revis-
E2-E1 approximately normally distributed with a ited. Am J Orthod Dentofacial Orthop 1996;! 10:206-210.
mean of (1.98-1.45) = .53 and a standard devi- 7. Tanne K, Koenig HA, Burstone CJ. Moment-to-force
ation of V.802 + .972 = 1.26, it follows that ratios and the centers of rotation. Am J Orthod Dento-
facial Orthop 1988;94:426-431.
Prob(E2 > El) - Prob((E2 - El) > 0) 8. Burstone CJ, Pryputniewicz R. Holographic determina-
tion of the centers of rotation produced by orthodontic
/(E2 - El) - .53 \ forces. Am J Orthod 1980;77:581-588.
= Prob( — >-.42)~.66. 9. Nikolai RJ. Bioengineering Analysis of Orthodontic Me-
chanics. Philadelphia, PA: Lea & Febiger, 1985.
Simply put, suppose two patients are randomly 10. Burstone CJ. Deep overbite correction by intrusion.
selected. Patient 1 is treated by round wire Am J Orthod 1977;72:l-22.
<<    
     Article
      >> Home | TOC |          
Index

220 Stanley Braun

11. Burstone CJ. Biomechanics of deep overbite correction.
Semin Orthod 2001;7:26-33.
12. Marcotte MR. Biomechanics in Orthodontics. Philadel-
phia, PA: BC Decker, 1990.
13. Braun S. Diagnosis Driven vs Appliance Driven Treat-
ment Outcomes, in: Sachdeva RCL, Bantleon HP, White
LW, Johnson J (eds). Orthodontics for the Next Mille-
nium. Glendora, CA: Ormco Corp, 1997, pp 32-45.
14. Ash MM. Wheeler's Dental Anatomy, Physiology and
Occlusion, 7/e. Philadelphia, PA: WB Saunders.
<<    
     Article
      >> Home | TOC |          
Index

Starting in i u ne 2001!

Announcing a new quarterly journal!

The Journal of Evidence- }

Based Dental Practice
is designed to show you which practices and procedures
deliver the best outcomes for your patients. It will help
you make sound clinical decisions and choose the most
cost-effective approaches when you are faced with a
question concerning diagnosis, treatment, prognosis, or
potential harm.This innovative new resource presents an
EVIDENCE
objective analysis of hundreds of papers published in
journals around the world. Each article in The Journal
BASED
D EH T A L P Px A C T J C E
of Evidence-Based Dental Practice will...
A formulate a hypothesis by asking an evidence-based
question
Full-text
* review all the current research applicable to online access
included for
this question print subscribers!
f evaluate the validity and Importance of these
scientific studies
M offer practical recommendations based on
objective analysis

Respected leaders from every dental discipline and

subspecialty will contribute to The Journal of
Evidence-Based Dental Practice, ensuring that
you receive authoritative guidance in every issue.
You will find original and review articles as well as a
series on the dental team/patient partnership and serial-
ized topics such as a primer on evidence-based methods. Individual $59.00
The Journal of Evidence-Based Dental Practice Institution $89.00
is dedicated to facilitating clinical decisions, improving Student/Resident* $29.00
patient outcomes, enhancing research planning, and
supporting policy development. Subscribe today! * Please supply, on institution letterhead, your name, dates
of study/residency, and signature of program coordinator.
Orders will be billed at the individual rate until proof of status
is received.

To order, call toll-free: 1-800-654-2452

(7:30 AM-7:00 PM ET) ISSN 1532-3382

For more information or foreign prices, contact:

The Curtis Center, Independence Square West
Mosby
M Harcourt Health Sciences
Philadelphia, PA 19106-3399 - Attn: Periodicals Marketing
Or visit our home page: www.harcourthealth.com

) 2001 Mosby. Offer valid in USA only. Prices are subject to change without notice. Add applicable sales tax for your area.
<<    
     Article
      >> Home | TOC |          
Index

W. B. S A U N D E R S

JOURNALS Essential Information f or Today's Professionals from the Leading Health Gare Publisher

ANESTHESIOLOGY American Journal of Kidney Diseases—The Official Journal RADIOLOGY

Journal of Cardiothoracic and Vascular Anesthesia
Journal of Pain—Official Journal of the American Pain Society
Regional Anesthesia and Pain Medicine
Official Journal of the American, Asian and Oceanic,
and Latin American Societies of Regional Anesthesia
Seminars in Anesthesia
Seminars in Cardiothoracic and Vascular Anesthesia
Techniques in Regional Anesthesia and Pain Management
CARDIOVASCULAR DISEASES
Progress in Cardiovascular Diseases
CRITICAL CARE MEDICINE
Journal of Critical Care
DENTISTRY
Journal of Oral and Maxillofacial Surgery—Official Journal of
the American Association of Oral and Maxillofacial Surgeons
Journal of Prosthodontics—Official Journal of The American
College of Prosthodontists
Seminars in Orthodontics
DERMATOLOGY
American Journal of Contact Dermatitis—The Official Journal
of the American Contact Dermatitis Society
Seminars in Cutaneous Medicine and Surgery
EMERGENCY MEDICINE
American Journal of Emergency Medicine
Clinical Pediatric Emergency Medicine
ENDOCRINOLOGY
Metabolism—Clinical and Experimental
GASTROENTEROLOGY/HEPATOLOGY
Clinical Perspectives in Gastroenterology—The Official Clinical
Practice Journal of the American Gastroenterological Association
Gastroenterology— Official Journal of the American
Hepatology—Official Journal of the American Association for
the Study of Liver Diseases
Liver Transplantation—An Official Publication of the American
Association for the Study of Liver Diseases and The International
Seminars in Gastrointestinal Disease
Techniques in Gastrointestinal Endoscopy
HEMATOLOGY/ONCOLOGY
Seminars in Hematology
Seminars in Oncology
Seminars in Radiation Oncology
Transfusion Medicine Reviews
INFECTIOUS DISEASES
Seminars in Infection Control
Seminars in Pediatric Infectious Diseases
Seminars in Respiratory Infections
MEDICAL TRANSCRIPTION
The Latest Word
NEONATAL/PERINATAL MEDICINE
Newborn and Infant Nursing Reviews
Seminars in Perinatology
NEPHROLOGY
Advances in Renal Replacement Therapy—A Journal of
©2001 W.B. SAUNDERS
of The National Kidney Foundation Journal of Digital Imaging—The Official Journal of the Society
Journal of Renal Nutrition—The Official Journal of The Council for Computer Applications in Radiology
Seminars in Breast Disease
Seminars in Nephrology Seminars in Nuclear Medicine
Seminars in Radiologie Technology
NEUROLOGY Seminars in Roentgenology
Journal of Pain—Official Journal of the American Pain Society Seminars in Ultrasound, CT and MRI
Journal of Stroke and Cerebrovascular Diseases—Official Journal Techniques in Vascular and Interventional Radiology
of the National Stroke Association and the Japan Stroke Society
Seminars in Cerebrovascular Diseases and Stroke RHEUMATOLOGY
Seminars in Pediatric Neurology Seminars in Arthritis and Rheumatism
NURSING SURGERY
Applied Nursing Research Journal of Pediatric Surgery—Official Journal of the Section on
Archives of Psychiatric Nursing—Official Journal of the SERPN Surgery of the American Academy of Pediatrics, British Association
Division, International Society of Psychiatric -Mental Health Nurses ofPaediatric Surgeons, American Pediatric Surgical Association,
Journal of Pediatric Nursing—Nursing Care of Children and Families Canadian Association ofPaediatric Surgeons and Pacific
Journal of Pediatric Oncology Nursing—Official Journal of the
Association of Pediatric Oncology Nurses Operative Techniques in General Surgery
Journal of PeriAnesthesia Nursing—Official Journal of the American Operative Techniques in Gynecologic Surgery
Operative Techniques in Neurosurgery
Journal of Professional Nursing—Official Journal of the American Operative Techniques in Plastic and Reconstructive Surgery
Association of Colleges of Nursing Operative Techniques in Thoracic and Cardiovascular Surgery—
Nurse Practitioner Forum An Official Publication of The American Association for
Pain Management Nursing—Official Journal of the American Society Thoracic Surgery
Seminars in Colon and Rectal Surgery
PeriAnesthesia and Ambulatory Surgery Nursing Update—Official Seminars in Laparoscopic Surgery
Publication of the American Society of PeriAnesthesia Nurses Seminars in Pediatric Surgery
Seminars for Nurse Managers Seminars in Spine Surgery
Seminars in Oncology Nursing Seminars in Thoracic and Cardiovascular Surgery—An Official
Seminars in Perioperative Nursing Publication of The American Association f or Thoracic Surgery
Seminars in Thoracic and Cardiovascular Surgery: Pediatric Cardiac
OBSTETRICS AND GYNECOLOGY Surgery Annual—An Official Publication of The American
Clinical Journal of Women's Health Association for Thoracic Surgery
Operative Techniques in Gynecologic Surgery Seminars in Urologie Oncology
Seminars in Vascular Surgery
ORTHOPEDICS
Arthroscopy: The Journal of Arthroscopic and Related Surgery— TRANSPLANTATION
Official Publication of the Arthroscopy Association of North America Liver Transplantation—An Official Publication of the American
and the International Society of Arthroscopy, Knee Surgery, and Association for the Study of Liver Diseases and the International
Orthopaedic Sports Medicine Liver Transplantation Society
Journal of the American Society for Surgery of the Hand—An Official Transplantation Reviews
Journal of the American Society for Surgery of the Hand
Journal of Hand Surgery—An Official Journal of the American UROLOGY
Society for Surgery of the Hand Seminars in Urologie Oncology
Operative Techniques in Orthopaedics
Operative Techniques in Sports Medicine VETERINARY MEDICINE
Seminars in Arthroplasty Advances in Small Animal Medicine and Surgery
Seminars in Spine Surgery Clinical Techniques in Small Animal Practice
Seminars in Avian and Exotic Pet Medicine
OTORHINOLARYNGOLOGY Veterinary Surgery—The Official Journal of The American
American Journal of Otolaryngology College of Veterinary Surgeons, Inc. and The European College
Operative Techniques in Otolaryngology—Head and Neck Surgery of Veterinary Surgeons
PATHOLOGY For more information about these journals,
Annals of Diagnostic Pathology
Human Pathology please contact:
Seminars in Diagnostic Pathology Periodicals Marketing
PHYSICAL MEDICINE I W.B» SAUNDERS
Archives of Physical Medicine and Rehabilitation—Official Journal Harcourt Health Sciences
of the American Congress of Rehabilitation Medicine and the The Curtis Center
American Academy of Physical Medicine and Rehabilitation
Independence Square West
PSYCHIATRY Philadelphia, PA 19106-3399
Comprehensive Psychiatry—Official Journal of the American Phone (215) 238-5614
Seminars in Clinical Neuropsychiatry Or visit our homepage at:
www.wbsaunders.com
<<    
     Article
      >> HOME
Vol 7, No 4 December 2001

Seminars in

IJÜI
P. Lionel Sadowsky, DMD
Editor

Three-Dimensional Diagnosis
and Treatment in
Orthodontics
Sheldon Baumrind, DDS,MS
Robert L. Boyd, DDS, MEd
Guest Editors

W. B. Saunders Company • A Harcourt Health Sciences Company

<<    
     Article
      >>
Seminars in Orthodontics
EDITOR
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent
Professor and Chairman
Department of Orthodontics
University of Alabama
1919 Seventh Avenue South
Birmingham, AL 35294
Fax: (205) 975-7590
Seminars in Orthodontics (ISSN 1073-8746) is published
quarterly by the W.B. Saunders Company. Months of issue are
March, June, September, and December. Corporate and
Editorial Offices: The Curtis Center, Independence Square
West, Philadelphia, PA 19106-3399. Accounting and Circulation
Offices: 6277 Sea Harbor Drive, Orlando, FL 32887-4800.
POSTMASTER: Send change of address to: Seminars in
Orthodontics, W.B. Saunders Company, Customer Service, 6277
Sea Harbor Drive, Orlando, FL 32887-4800.
Editorial correspondence should be addressed to:
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent, Editor,
Seminars in Orthodontics, Professor and Chairman, Department
of Orthodontics, University of Alabama, 1919 Seventh Avenue
South, Birmingham, AL 35294-0007; fax: (205) 975-7590.
Correspondence regarding subscriptions or change of
address should be directed to Seminars in Orthodontics, W.B.
Saunders Company, Periodicals Department, P.O. Box 628239,
Orlando, FL 32862-8239 or e-mail hhspcs@harcourt.com.
Change of address notices, including both the old and new
addresses of the subscriber and the mailing label, should be
sent at least 1 month in advance.
Customer Service: 1-800-654-2452
Yearly subscription rates: United States and possessions:
individual, $125.00; institution, $154.00; student and resident,
$72.00; single issue, $47.00. All other countries: individual
$156.00; institution, $186.00; student and resident, $94.00;
single issue, $47.00. For all areas outside the United States and
possessions, there is no additional charge for surface delivery.
For air mail delivery, add $16.00. To receive student/resident
rate, orders must be accompanied by name of affiliated
institution, date of term, and the signature of program/residency
coordinator on institution letterhead. Orders will be billed at
individual rate until proof of status is received.
Prices are subject to change without notice. Current prices
are in effect for back volumes and back issues. Single issues,
both current and back, exist in limited quantities and are
offered for sale subject to availability. Back issues sold in
conjunction with a subscription are on a prorated basis. Checks
should be made payable to W.B. Saunders Company and sent
to Seminars in Orthodontics, W.B. Saunders Company, Periodicals
Department, 6277 Sea Harbor Drive, Orlando, FL 32887-4800.
Copyright © 2001 by W.B. Saunders Company. All rights
reserved. No part of this publication may be reproduced or
transmitted in any form or by any means, electronic or
mechanical, including photocopy, recording, or any information
storage and retrieval system, without permission in writing
from the Publisher. Printed in the United States of America.
Correspondence regarding permission to reprint all or
part of any article published in this journal should be
W.B. SAUNDERS COMPANY
A Division of Harcourt Brace & Company
Home | TOC |          
Index
addressed to Journal Permissions Department, W.B. Saunders
Company, 6277 Sea Harbor Drive, Orlando, FL 32887-4800.
Telephone number: 1-407-345-2500.
The appearance of the code at the bottom of the first page
of an article in this journal indicates the copyright owner's
consent that copies of the article may be made for personal or
internal use, or for the personal or internal use of specific clients,
for those registered with the Copyright Clearance Center, Inc.
(222 Rosewood Drive, Danvers, MA 01923; (508) 750-8400;
www.copyright.com). This consent is given on the condition that
the copier pay the stated per-copy fee for that article through the
Copyright Clearance Center, Inc. for copying beyond that
permitted by Sections 107 or 108 of the US Copyright Law.
This consent does not extend to other kinds of copying, such
as copying for general distribution, for advertising or promotional
purposes, for creating new collective works, or for resale.
Absence of the code indicates that the material may not be
processed through the Copyright Clearance Center, Inc.
Advertising representative: MJ. Mrvica Associates, Inc,
2 West Taunton Ave, Berlin, NJ 08009. Telephone (609) 768-
9360. Fax (609) 753-0064.
Publication of an advertisement in Seminars in Orthodontics
does not imply endorsement of its claims by the Editor(s) or
Publisher of the journal.
The contributors have checked generic and trade names and
verified drug doses for accuracy according to the standards
accepted at the time of publication. The ultimate
responsibility, however, lies with the prescribing physician.
Please convey any errors to the Editor.
The ideas and opinions expressed in Seminars in
Orthodontics do not necessarily reflect those of the Editor or the
Publisher. Publication of an advertisement or other product
mention in Seminars in Orthodontics should not be construed as
an endorsement of the product or the manufacturer's claims.
Readers are encouraged to contact the manufacturer with any
questions about the features or limitations of the products
mentioned. Neither the Editor or Publisher assume any
responsibility for any injury and/or damage to persons or
property arising out of or related to any use of the material
contained in this periodical. The reader is advised to check the
appropriate medical literature and the product information
currently provided by the manufacturer of each drug to be
administered to verify the dosage, the method and duration of
administration or contraindications. It is the responsibility of
the treating physician or other health care professional, relying
on independent experience and knowledge of the patient, to
determine drug dosages and the best treatment for the patient.
Seminars in Orthodontics is indexed in the Cumulative
Index to Nursing and Allied Health Literature® print index
and the Cinahl® database.
<<    
     Article
      >>
Seminars in Orthodontics
EDITOR
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent
EDITORIAL BOARD
Richard G. Alexander, Arlington, TX
Rolf G. Behrents, Memphis, TN
Samir E. Bishara, Iowa City, I A
Robert Boyd, DDS, San Francisco, CA
Larry M. Bramble, Cypress, CA
John S. Casko, Iowa City, IA
Harry L. Dougherty, Van Nuys, CA
T.M. Graber, Evanston, IL
Robert J. Isaacson, Richmond, VA
Alexander Jacobson, Birmingham, AL
Lysle E.Johnston, Jr., Ann Arbor, MI
Gregory J. King, Seattle, WA
Vincent G. Kokich, Tacoma, WA
Steven J. Lindauer, Richmond, VA
INTERNATIONAL
Zeev Abraham, Herzliya, Israel
W.G. Evans, Johannesburg, South Africa
Roberto Justus, Mexico City, Mexico
Home | TOC |          
Index
James A. McNamara, Jr, Ann Arbor, MI
Robert N. Moore, Grand Island, NE
Ravindra Nanda, Farmington, CT
Perry M. Opin, Milford, CT
Sheldon Peck, Newton, MA
William R. Proffit, Chapel Hill, NC
Cyril Sadowsky, Chicago, IL
David M. Sarver, Birmingham, AL
T. Michael Speidel, Minneapolis, MN
William J. Thompson, Bradenton, FL
James L. Vaden, Cookeville, TN
Robert L. Vanarsdall, Jr., Philadelphia, PA
Katherine Vig, Columbus, OH
C.B. Preston, Buffalo, NY
Shinkichi Namura, Tokyo, Japan
George Skinazi, Paris, France
Björn U. Zachrisson, Oslo, Norway
<<    
     Article
      >> Home | TOC |          
Index

United States Postal Serv

Statement of Ownership, Management, and Circulation

Seminars in Orthodontics 1 0 7 3 8 6 9/15/01

4. Issue Frequency 5. Number of Issu s Published Annually 6. Annual Subscription Price

Mar, Jun, Sep, Dec 4 $125.00

7. Complete Mailing Address of Known Office of Publication (Not printer) (Street, city, county, \taie, a dZlP+4) Contact Person
W.B. Saunders Company, Elsevier Science
6277 Sea Harbor Drive, Orlando, FL 32887-4800, Orange County Telephone

215-238-8319
Complete Mailing Address of Headquarters or General Business Office of Publisher (Not printer)

W.B. Saunders Company. The Curtis Center. Independence Square West. Philadelphia. PA 19106-3399
9. Full Names and Complete Mailing Addresses of Publisher, Editor, and Managing Editor (Do not leave blank)
Publisher (Name and complete mailing address)

Jane Grochowski. W.B. Saunders Company. The Curtis Center. Independence Square West. Philadelphia. PA 19106-3399
Editor (Name and complete mailing address)

P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent, Professor and Chairman, nt of Orthodontics, University of Alabama, 1919
Seventh Avenue South, Birmingham, AL 35294

Michael Miller, W.B. Saunders Company. The Curtis Center, Independence Square West. Philadelphia. PA 19106-3399

Textbook of names and addresses of the individual owners. If owned by a partnership or other unincorporated firm, give its name and address as well as those of

Orthodontics Full Name

Wholly owned subsidiary of

Complete Mailing Address

4520 East-West Highway

Samir E. Bishara, DOS, MS Reed/Else vier, US holdings Bethesda, MD20814

with 24 expert contributors

This straightforward, comprehensive
book covers the key elements of
orthodontics with extensive case
examples and illustrations that relate
foundational concepts to clinical
applications!
2001 • Approx. 704 pp.,
962 illus. • 0-7216-8289-8 • $74.00
A W.B. Saunders title
'n Bondholders, Mortgagees, and Other Security Holders Owning
Holding 1 Percent or More of Total Amount of Bonds, Mortgages, or
Other Securities. If none, check box
Complete Mailing Address
nprofit rates) (Check one)
The purpose, function, and nonprofit status of this organization and the
3 Has Not Changed During Preceding 12 Months
H Has Changed During Preceding 12 Months (Publisher must submit explanation of change with th
(See Instructions on Reverse)

Craniofacial
PS Form 3526, October 1999

Distraction
Osteogenesis Seminars in Orthodontics
15.
Extent and Nature of Circulation
June 2001
Average No. Copies Each Issue
During Preceding 12 Months
No. Copies of Single Issue
Published Nearest to Filing Date
Mikhail L. Samchukov, MD; a. Tota, Number of Cop.es (/Vf,pr™>
2700 2600

Jason B. Cope, DOS, PhD; 1454 1421

(1) Form 3541 . (Include advertiser's proof and exchange copies)
and Alexander M. Cherkashin, MD
Requested (2, (Include advertiser's proof and exchange copies)
Circulation
One of today's hottest topics! This (3) Counter Sales, and Other Non-USPS Paid Distribution
518 501

book examines extraoral and intraoral (4, OtheraassesMaifedT^ghtheUSPS

distraction appliances, including tooth- (Sum ofJSb. ( ). 12), (3), and (4)] ^
1972 1922

borne, bone-borne, and hybrid fixation d. Free 124 124

Distribution (1) Outside-County as Stated on Form 3541
methods - illustrated in full color by Mail
(Samples,
compliment- (2) In-County as Stated on Form 3541
alongside realistic case studies. ary, and

(3) Other Classes Mailed Through the USPS

2001 • Approx. 605 pp., e. Free Distribution Outside the Mail
1,350 illus. • 0-323-01134-9
124 124
$179.00 f Total Free Distribution (Sum of I5d. and ISe. ) ^
A Mosby title 2096 2046
g. Total Distribution (Sum oflSc. andlSf.) ^
h. Copies not Distributed 604 554

i. Total (Sum o/75g. and h.) 2700 2600

94% 94%
(15c. divided by 15g. (ime.s 100)
Publication of Statement of Ownership
ill be printed in
1. Signature and Title of Editor, Publisher. Business Manager, or Owner

i^OUjL^^J'^Ut-)
KaTnleenUwler. Vice President

PS Form 3526, October 1999 (Rev

<<    
     Article
      >> Home | TOC |          
Index

Seminars in Orthodontics
VOL 7, NO 4 DECEMBER 2001

Three-Dimensional Diagnosis and Treatment in Orthodontics

Sheldon Baumrind, DDS, MS
Robert L. Boyd, DDS, MEd
Guest Editors
CONTENTS

Editor's Note 221

P. Lionel Sadowsky

Introduction 222
Sheldon Baumrind and Robert L. Boyd

Integrated Three-Dimensional Craniofacial Mapping: Background,

Principles, and Perspectives 223
Sheldon Baumrind

Three-Dimensional Imaging: The Case Western Reserve University Method 233

Mark Guenther Hans, Juan Martin Palomo, David Dean, Banu (galärer,
Kyoung-June Min, Seungho Han, and B. Holly Broadbent

Three-Dimensional Imaging and Motion Animation 244

Orhan C. Tuncay

Technology to Create the Three-Dimensional Patient Record 251

James Mah and Axel Bumann

Integrated Three-Dimensional Craniofacial Mapping at the Craniofacial

Research Instrumentation Laboratory/University of the Pacific 258
Sean Curry, Sheldon Baumrind, Sean Carlson, Andrew Beers,
and Robert Boyd

The Digital Orthodontic Office: 2001 266

W. Ronald Redmond

Three-Dimensional Diagnosis and Orthodontic Treatment of Complex

Malocclusions With the Invisalign Appliance 274
Robert L. Boyd and Vicki Vlaskalic

Annual Index 296

<<    
     Article
      >> Home | TOC |          
Index

Seminars in Orthodontics
Future Issues

Vol 8 No 1 (March 2002)

CLINICAL UPDATE ON TECHNOLOGICAL ADVANCES IN ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS
Gregory King, DMD, DMSc
Vol 8 No 2 (June 2002)
BIOSTATISTICS FOR THE ORTHODONTIC CLINICIAN
Rose D. Sheats, DMD, Guest Editor

Recent Issues

Vol 7 No 3 (September 2001)

TOPICS IN BIOMECHANICS
Stanley Braun, DDS, MME, Guest Editor
Vol l No 2 (June 2001)
The Alexander Discipline
R.G. Alexander, DDS, MSD, Guest Editor
Vol 7 No 1 (March 2001)
CLINICAL BIOMECHANICS
Steven J. Lindauer, DMD, MDSc, Guest Editor
Vol 6 No 4 (December 2000)
PSYCHOLOGIC ISSUES RELATED TO ORTHODONTIC TREATMENT AND PATIENT COMPLIANCE
Pramod K. Sinha, DDS, BDS, MS, Ram S. Nanda, DDS, MS, PhD, and Roger B. Eillingim, PhD, Guest Editors
Vol 6 No 3 (September 2000)
BIOLOGY OF ORTHODONTIC TOOTH MOVEMENT: CLINICAL IMPLICATIONS
Bhavna Shroff, DDS, MDentSc, Guest Editor
Vol 6 No 2 (June 2000)
MOLAR DISTALIZATION
George J. Cisneros, DMD, MMSc, Guest Editor
Vol 6 No 1 (March 2000)
OBJECTIVES-DRIVEN ORTHODONTICS: EFFECTIVENESS OF MECHANOTHERAPY
Cyril Sadowsky, BDS, MS, Guest Editor
<<    
     Article
      >>
Editor's Note
This issue of Seminars in Orthodontics is presented
to inform the readership of new technologies
that are currently being developed and/or im-
proved for use in various aspects of clinical ortho-
dontics. There are numerous commercial inter-
ests mentioned in the text. We wish to state that
neither the Editor nor the publisher endorses
any product or service nor claims made and
discussed in the text. In addition, no editorial
Copyright © 2001 by W.B. Saunders Company
doi:10.1053/sodo.2001.25388
Seminars in Orthodontics, Vol 7, No 4 (December), 2001: p 221
Home | TOC |          
Index
review has been made of any material not in the
text of this issue of Seminars in Orthodontics. Some
of the authors may have proprietary interests in
the material discussed in some of the articles
and the readership is alerted to this fact. The
objective of this issue is to provide information
and provoke discussion on how technology may
assist the clinical orthodontist.
P. Lionel Sadowsky, DMD, BDS,
DipOrth, MDent
Editor
221
<<    
     Article
      >>
Seminars in Orthodontics
VOL 7, NO 4
Introduction
T his issue of Seminars in Orthodontics explores
recent developments in three-dimensional
(3D) diagnosis, treatment planning, and treat-
ment analysis. Contributions from six cooperat-
ing and competing groups are presented. Each
contributor discusses his own region of interest
from his own perspective and in his own words.
No attempt has been made by the Editors to
modify the substance of any of the contribu-
tions. This approach leads to some redundancy,
because different contributors sometimes ap-
proach the same problems from different per-
spectives. We believe that this redundancy will
be of great advantage to the reader, since it
provides him or her with the opportunity to see
how similar conceptual and technical problems
are solved when investigated from different
points of view.
Even a casual glance at the text and the ac-
companying materials will show that the very
considerable recent advances reflected in this
volume involve the application of highly sophis-
ticated technologies from the fields of digital
imaging, computer graphics, robotics, computa-
tional analysis, and data base management. The
specialty and the public are fortunate that all
these disciplines and others are now being inte-
grated in the interests of improving orthodontic
treatment.
Less apparent, perhaps, is the fact that the
application of these modern technologies is
driven both by the aspirations of classical orth-
odontic theory and by engineering concepts of
mapping and map integration which are at least
one hundred years old. In the background arti-
cle that follows, we will attempt to trace the
history of these relationships.
In a very real sense, all the articles in this issue
represent "works in progress." The reader is en-
couraged to evaluate them critically, comparing
Copyright © 2001 by W.B. Saunders Company
doi:10.1053/sodo. 2001.26482
222 Seminars in Orthodontics, Vol 7, No 4 (December), 2001: p 222
Home | TOC |          
Index
DECEMBER 2001
them to each other and to other publications in
the same subject area. In doing so, it is useful to
be aware that there can be a considerable differ-
ence between computer displays that look 3D
and displays that truly are 3D, ie, that contain
sufficient information for making accurate 3D
measurements. This difference can be particu-
larly great when one examines displays that
merge information from two or more different
kinds of physical record (for example, from x-
ray images and study casts, or from study casts
and facial photographs). Clearly, the accuracy of
measurements across the junctions of such
merged 3D craniofacial "maps" depends not
only on the accuracy with which measurements
are made on each individual map but also on the
accuracy with which 3D maps from different
sources can be oriented with respect to each
other. In a very real sense, this problem is a 3D
variant of the classical orthodontic problem of
superimposing two-dimensional (2D) lateral
cephalograms from different timepoints. Inter-
estingly, the 3D solution is very similar to Bjork's
solution for 2D cephalograms; it too involves the
use of unambiguous markers common to both
the images being compared.
The development of integrated 3D tools for
diagnosis and treatment planning is one of the
most exciting developments in orthodontics as
the specialty moves into the 21st century. But as
valuable as these new advances are, a strong
cautionary note is in order. No one of these
methods and indeed no combination of them
will treat malocclusions by itself. The key ele-
ment in orthodontic treatment remains a skilled
orthodontic specialist with an understanding of
the biological and biomechanical knowledge
base that our specialty has painstakingly ac-
quired in more than 100 years of collective
experience in treatment and research.
Sheldon Baumrind, DDS, MS
Robert L. Boyd, DDS, MEd
Guest Editors
<<    
     Article
      >> Home | TOC |          
Index

Integrated Three-Dimensjonal Craniofacial

Mapping: Background, Principles,
and Perspectives
Sheldon Baumrind

This article reviews the origins and history of three-dimensional (3D) mea-
surement in orthodontics. Some principles of integrated 3D craniofacial
measurement are discussed and illustrated. Present and future perspectives
of 3D measurement in orthodontics are examined through the prism of the
author's experience at the Craniofacial Research Instrumentation Labora-
tory (CRIL) of the University of the Pacific School of Dentistry. (Semin Orthod
2001;7:223-232.) Copyright © 2001 by W.B. Saunders Company

Why Do We Need Three-Dimensional

T his issue of Seminars in Orthodontics contains
several studies generated in different labo-
ratory and clinical settings. Each author tells the
Imaging in Orthodontics?
Orthodontics and dentofacial orthopedics deal
reader about his own experiences in the field.
primarily with the physical relationships among
The purpose of this review is to point to some
the parts of the human head. These physical
general considerations involved in three-dimen-
relationships exist in a usually asymmetric 3D
sional (3D) mapping of the human head and to
structure that changes through time in the
highlight for the reader several crucial issues
course of growth, development, and treatment.
that will be discussed in the studies that follow.
Our interest is in the totality of craniofacial anat-
The review deals with several separate but over-
omy and in the interactions among the parts.
lapping subjects:
The human head is a concentration of sen-
sory functions—it contains competing end or-
• Why do we need 3D Imaging in orthodontics?
gans of all five senses, sight, hearing, smell, taste,
• Historical antecedents.
touch. As part of the heritage of our quadruped
• How does one measure in 3D?—Some basic
past, the head goes first (literally, "ahead"), so it
principles.
is the first part of the body to need and acquire
• The requirement for calibration.
the sensory information for attack, defense, and
• Recent advances—3D quantitative measure-
interaction with others of like and different spe-
ment of study casts and the face.
cies. Not only does the head receive informa-
• Merging 3D maps from different sources: the
tion, but it also puts out information for other
requirement for tie points.
members of the species to see, react to, and be
• What's ahead in craniofacial measurement?
guided by. Facial conformation is extremely im-
portant to our peers. Whole social structures are
based on facial adornment and responses to dif-
ferent facial configurations.1-3
From the Craniofacial Research Instrumentation Laboratory,
University of Pacific School of Dentistry, and the University of In addition to its information processing
Medicine and Dentistry of New Jersey, NJ. functions, the head must perform such bread-
Address correspondence to Sheldon Baumrind, DDS, MS, Uni- and-butter physical functions as breathing, mas-
versity of the Pacific School of Dentistry, 2755 Webster St, San tication, and deglutition. Evolution has solved
Francisco, CA 94115.
Copyright © 2001 by W.B. Saunders Company
the problem of packing so many disparate func-
1073-8746/01/0704-0001$35.00/0 tions into so small a volume by developing a
doi:10.1053/sodo.2001.25424 structure of great physical complexity. It is this

Seminars in Orthodontics, Vol 7, No 4 (December), 2001: pp 223-232 223

<<    
     Article
      >>
224 Sheldon Baumrind
complex environment that the orthodontist
seeks to understand and modify (according to
type). To treat effectively, clinicians need to un-
derstand not only how the teeth relate to and
interact with each other, but also how they are
mounted in the bony armature of the skull and
how they affect and are affected by the soft tissue
covering of the face.
The complexity of this system is sufficiently
great that we cannot understand it well without
decomposing the whole into a set of component
parts. Therefore, our specialty has developed a
set of standard transforms, each of which en-
ables us to understand better the functioning of
part of the system by shedding confounding in-
formation about the whole. Thus we generate
plaster study casts that permit us to examine the
teeth of both jaws separately and in occlusion
but that lose all information about the skeletal
armature and the facial soft tissues. We generate
x-ray cephalograms to help us understand the
relationships between the jaws and the skull—
but despite their great advantages, they lose al-
most all information about arch form and about
the facial soft tissues. We generate photographs
of the face—but despite their unique informa-
tion content, they lose all information about
structures below the facial surface.
Each kind of transform provides much valu-
able information, but each loses much more.
Even all of them taken together lose important
information about the head and teeth in mo-
tion; about chewing, swallowing, speech and
nonverbal communication. In addition, only the
study casts retain information about all three
spatial dimensions. Both conventional skull x-ray
images and conventional facial photographs are
two-dimensional (2D). Standard 2D x-ray images
project information from all layers of the skull
upon the single plane of the film, considerably
complicating the process of interpretation. Ex-
cept for a few structures of interest which lie in
the mid-sagittal plane, it is impossible to make
accurate 2D measurements on lateral cephalo-
grams, because structures in planes lying at
different distances from the film plane are
enlarged differentially. Conventional facial pho-
tographs, even when standardized, also lose
depth information by projecting images of struc-
tures at different heights upon a single plane.
Perhaps more important than the loss of in-
Home | TOC |          
Index
formation within the individual facial transforms
is the fact that, even taken all together, the
conventional physical transforms of orthodon-
tics preserve no information that can allow us to
reassemble an integrated picture of the whole
head. Because there is no way of accurately re-
lating information from 2D lateral cephalo-
grams to information from 3D study casts, there
is no satisfactory way to measure true distances
between cranial structures and the teeth. Be-
cause there is no satisfactory way of orienting 3D
study casts to 2D facial photographs, there is no
satisfactory method for measuring the thickness
of the soft tissues covering jaws. For this reason,
accurate measurements of the relationships be-
tween different physical transforms are not pos-
sible in contemporary orthodontic practice. In-
stead, such relationships can only be estimated
or inferred by the clinician as a conceptual op-
eration.
The long-time dream of the orthodontist, to
achieve the ability to reintegrate information
from different craniofacial transforms in a man-
ner that is clinically useful, is represented sche-
matically in Figure 1. As several authors will
demonstrate later in this issue, newly available
techniques now make it possible to improve
upon this dream; to merge information from
different physical records with greater accuracy,
OtftlTAl »IAMI
Figure 1. The early 20th century orthodontists'
dream: putting the study casts into the facial picture.
<<    
     Article
      >> Home | TOC |          
Index

Background, Principles, and Perspectives 225

^^a- L2

Figure 2. The original Broadbent cephalometer. Patient positioned for exposures in the Bolton room at
Case-Western (A). The geometry of the Broadbent Cephalometer (not to scale). The frontal cephalogram is
generated from the position LI while the lateral cephalogram is generated from position L2. The two film planes
are perpendicular to each other. Note that the three schematic anatomical points in the head are each at
different distances from the lateral and frontal film surfaces. For this reason, they are magnified differently on
the two films causing the image of each point to fall at different heights on the frontal and lateral cephalograms.
This dissimilarity in y coordinate complicates landmark location when this "bi-planar" geometry is employed.
Only the images of landmarks falling on line E (the diagonal line bisecting the angle between the two film
planes) will have the same y location on both the frontal and lateral cephalogram (B).

smaller measurement errors, and greater infor-
mation content than was even thought possible
20 years ago.
Historical Antecedents
This section begins with a caveat. The present
author has been an active participant in this
research area since 1968. Although he will at-
tempt to avoid the biases of his personal experi-
ence, success in that venture cannot be guaran-
teed. The reader is accordingly forewarned.
The earliest 3D measurements of the skull
were made by anatomists and physical anthro-
pologists in the late 19th century. The reference
planes of Frankfort, His and Camper, and most
of the skeletal landmarks we now use were de-
fined and measured directly on dried skulls be-
fore 1900.4
Among the earliest systems of measuring the
spatial relationships between the teeth and the
skull in living subjects were Van Loon5 and Si-
mon.6 Simon's apparatus included a maxillary
clutch and frame that resembled and foreshad-
owed the later facebows of Hanau, McCollum,
and all their modern variants. Indeed, Simon's
apparatus and his system of "gnathostatic mea-
surement" were used by some conscientious
orthodontists as late as the 1970s. The contribu-
tions of Van Loon and Simon are especially
important to us, because they were among the
first to focus sharply on the location with respect
to the skull of the anatomical structures that
interest dentists most—the teeth and their sup-
porting alveolar structures.
By 1925, x-ray cephalometry had become fea-
sible and the stage was set for the classic work of
Broadbent (Fig 2).8 The Broadbent method,
presented in its modern form in this issue by
Hans et al, involves the integration of data from
two head films taken nearly simultaneously from
a pair of x-ray tubes so oriented that (1) the
angle of intersection between their central rays
is 90 degrees, (2) the point of intersection be-
tween the central rays is 60 inches from the focal
spot of each emitter, and (3) the two cassettes
are oriented perpendicular to each other and
<<    
     Article
      >>
226 Sheldon Baumrind
each is perpendicular to the central ray of one
emitter. The subject was placed at the point of
intersection between the central rays in such a
position that one film captured a norma lateralis
projection and the other a norma frön talis pro-
jection. In principle, the user would identify the
same landmark on each image and the three-
space position of the point would later be de-
rived from a knowledge of the system geometry.
In practice, it was extremely difficult to locate
the same anatomical feature on two such differ-
ent projections and the true 3D properties of the
system were not heavily pursued until the recent
development of computer-aided digital variants.
The Broadbent method in its original form did
not contemplate the quantitative integration of
information from study casts and photographs.
In the 1960s and 1970s, a number of investi-
gators sought to implement the use of stereo-
photogrammetric methods, originally developed
for aerial mapping to measure the skull and
other anatomical systems. Prominent among
these investigators were Rune, Sarnas, and Se-
vik.8'11 Also during this period, the present au-
thor's laboratory proposed the use of coplanar
geometry and conceptualized the use of tie
points for merging data from different skull
transforms.12'15 However, in general, the engi-
neering and medical communities were more
receptive to the new geometry than our own.16'22
In the late 1970s, computerized axial tomog-
raphy (first referred to as CAT and later as CT)
became available. For a brief period it was
thought by many that CT and the magnetic res-
onance imaging modality that followed soon af-
terward (first referred to as NMR and later as
MRI) would replace conventional projection ra-
diology. Although both technologies have an
enormously important role in medicine, they
have not proved useful for routine diagnosis and
treatment planning in orthodontics. So far as CT
is concerned, orthodontic applications have
been impractical or inappropriate because of
the following:
1. The dose of ionizing radiation has been pro-
hibitively high. The conventional fan-geome-
try CT scanners of earlier years had radiation
doses several hundred times that of a conven-
tional skull series.
2. The economic cost of CT scans for routine
Home | TOC |          
Index
diagnostic purposes has remained prohibi-
tive.
3. As an consequence of (1) and (2), the spatial
resolution of CT images in the long axis of
the body (the one which is most important to
those of us who treat vertically positioned
teeth), has been extremely poor. Radiation
and economic costs have made it impractical
to reduce slice thickness below 5 mm in rou-
tine use even though spatial resolutions of 1
mm2 on the surface of the slice have become
routinely available. Because the slices are rel-
atively thick, the visualization of tissue detail
in vertically oriented teeth has remained
quite poor.
The limiting factor in the use of MRI in orth-
odontics (aside from the question of economic
cost) has been that this modality depends for its
functionality on the presence of large numbers
of hydrogen nuclei in the tissues being imaged.
Because hard tissues such as bone, enamel, and
dentin contain few if any free hydrogen nuclei,
the use of this powerful diagnostic tool is re-
stricted in orthodontics to the visualization of
the cartilaginous components of the temporo-
mandibular joint (TMJ).
Very recently, at least one new CT-like system
that uses a different optimization strategy and
is specialized for craniofacial applications has
made an appearance. This device is called the
Newtom.23 Radiation doses associated with its
use are said to have been reduced to approxi-
mately one and a half times the level of a single
panoramic image by three strategies: (1) the use
of cone, rather than fan geometry, (2) optimi-
zation on hard tissue visualization by de-empha-
sizing the acquisition of subtle differences in the
gray scale resolution of soft tissues, and (3) the
use of advanced image intensifying algorithms
and hardware. This device has recently received
the Food and Drug Administration (FDA) ap-
proval and tests of its clinical usefulness by sev-
eral of the investigators represented in this issue
are now in progress.
How Does One Measure in Three
Dimensions?—Some Basic Principles
There are two main geometrical strategies for
measuring in three dimensions. They are 1) or-
<<    
     Article
      >> Home | TOC |          
Index

Background, Principles, and Perspectives 227

thogonal measurement and 2) measurement by
triangulation.
The general characteristic of orthogonal (ie,
"right-angular") systems is that they locate the
third dimension (usually designated "z") by a
technique separate from that used to measure
the other two dimensions (usually designated x
and y). In most orthogonal measurement, the
object to be measured is sliced into layers, either
physically or optically. An example of physically
slicing a biological system is the well-known se-
rial section of histology and pathology. Here, the
specimen is sliced into a number of layers of
known thickness. The x and y dimensions are
measured on the slice surface and the z dimen-
sion is measured by tallying how many slices into
the specimen the feature of interest lies. An
example of optical slicing in medicine is the
already mentioned CT scan. In systems of this
sort, the subject lies on a gantry and is moved
further into the imaging device a known dis-
tance between the exposure of successive slices.
Here too the x and y dimensions are measured
on the slice surface and the z dimension is mea-
sured by counting slices. The common feature of
all orthogonal measuring systems is that x and y
distances are captured by some method other
than that used for capturing z.
Systems that measure by triangulation analo-
gize the geometry of mammalian stereoscopic
vision (Fig 3A). Typically, such systems view the
object to be measured from two positions in
space and capture images from both positions
on film or some digital medium either simulta-
neously or in rapid succession. Both the biplanar
and coplanar stereo xray systems described
above are examples of triangulation geometry.
For a somewhat more extensive treatment of this
subject, see the CRIL website, www.cril.org.
All 3D measuring systems share a require-
ment that seem so self-evident as to appear trivial
but that in practice can present formable prob-
lems. Simply put, the measurement process must
be able to identify the same anatomical structure
in all three dimensions. To meet this obvious
requirement is frequently not as easy as it
sounds, especially in stereoscopic x-ray systems.
The greater the separation between the x-ray

L1

Left Photo Right Photo

Datum
Figure 3. Three applications of stereo measurement. The geometry of human vision. When we view a point at
some distance from us, our eyes converge to focus on the point. Line segments can conceptually be drawn from
the point to each eye. The included angle between the two line segments is known as the parallactic angle of the
point. Points at different distances from the observer have different parallactic angles. The smaller the parallactic
angle, the more distant from the observer the point is perceived to be. Similarly, for any plane parallel to a plane
between the eyes and a known distance from it, the lengths of the horizontal line segments connecting the two
rays of either angle will be proportional to the height. The brain uses this information to compute the 3D
location of the point (A). An application of the same principle to aerial photography. If the distance an aircraft
or satellite flies between taking two photographs is known, the distance between the two images of any point
which can be seen in both photographs can be used to measure the 3D location of that point (B). The same
principle applied to a pair of cephalometric x-ray sources. Notice that here, unlike Figure 2B, each anatomical
feature is the same distance from the film plane for each image of the stereo pair. For that reason, the vertical
(y) dimension for any landmark will be the same on both films of the stereo pair. This correspondence simplifies
the unique location of any landmark on both films (C).
<<    
     Article
      >>
228 Sheldon Baumrind
sources for two of the images of any stereopair,
the more difficult it is to identify the same land-
mark in both images.
When other factors are equal, the most pow-
erful geometrical solution for any stereoscopic
measurement occurs when the angle between
the two emitters and the object being imaged
approximates 90 degrees. However, most skull
structures of orthodontic interest look very dif-
ferent, indeed are different when viewed from
the lateral and frontal projections. Hence the
tradeoff between the coplanar and biplanar
methods. In effect, the coplanar method sacri-
fices some of the mathematical power of the
90-degree ray intersection of the biplanar system
to obtain a pair of images on which it is possible
to locate the same physical point on both images
with reduced error. Much empirical testing still
needs to be done before we establish the opti-
mum separation between emitters in x-ray ste-
reocephalometry.
The Requirement for Calibration
Most contemporary x-ray cephalometers, unlike
the earlier instruments of Broadbent and Ho-
frath, are of relatively flimsy construction. In
particular, the cassette carriers are nonrigid and
the ear rods are usually poorly aligned. It seems
self-evident, however, that if accurate physical
measurements are to be made, the dimensional
relationships between the emitter (s) and the
film plane (s) must be known with very high
accuracy. In reality, the geometry of any single
xray emitter is essentially identical with that of a
single camera and no careful worker would con-
sider making critical measurements on photo-
graphs taken with an out-of-focus camera.
If accurate measurements are to be made, the
physical relationships between the component
parts of any optical or x-ray system used must be
known with even greater accuracy. The process
of determining the relationships among the sys-
tem components is called calibration. In x-ray
stereoscopy, one needs to calibrate the spatial
relationships between the two x-ray emitters and
between each emitter and the film plane.
Stereo x-ray systems are usually calibrated by
projecting upon the film plane a 3D array of
radiopaque points whose true positional rela-
tionships with respect to each other are known
Home | TOC |          
Index
with great accuracy and precision based on pre-
vious measurement. Another part of the calibra-
tion process involves building into the cassette
holder a number of radiopaque points called
fiducials whose images are projected onto the
film plane at exposure. These fiducials facilitate
accurate and precise identification of the posi-
tion of the cassette at the time of exposure,
providing information that is necessary for sub-
sequent analytic processing. Calibration of the
system geometry is important in all x-ray cepha-
lometry but becomes particularly critical when
one attempts to merge two or more 3D cranio-
facial maps from different sources.
Recent Advances: Three-Dimensional
Quantitative Measurement of Study
Casts and the Face
Underpinning all recent developments in 3D
craniofacial mapping has been an exponential
increase in the availability of high-speed high-
capacity low-cost digital computers over the past
two decades. Without this increase in computa-
tional power, 3D x-ray mapping of the sort dis-
cussed in this issue could never have become
practical. Using this increased computational
power, several recent technical advances have
now made it practical to generate accurate 3D
digital maps of the teeth and the facial surface.
Locating the same structure in 3D in facial
and study cast mapping involves different prob-
lems from locating the same structure on stereo
x-rays. Special problems are associated with each
task. The main problem in 3D photography of
the face is that the facial surface inherently con-
tains little fine detail. This increases the diffi-
culty in identifying the set of discrete points on
the facial surface needed to construct a useful
map. Most attempts to solve this problem have
involved the projection of an array of "pseudo-
points" on the face. Some investigators have ap-
proached this problem by using laser ranging
techniques.24 These methods usually involve ro-
tating the subject around a vertical axis in a
series of very small steps. At each rotational step,
a laser projects a thin vertical line upon the face
and ranges the distance to that line. Such solu-
tions are in fact variants of the orthogonal ge-
ometry described earlier.
Other investigators, including ourselves, have
<<    
     Article
      >>
Background, Principles, and Perspectives
chosen to use what are called "structured light"
methods.25 It has long been understood that it is
possible to project a grid on a subject being
measured in such a way as to generate artificial
discrete points that can be readily measured.26
Indeed, if the system is well calibrated, the pro-
jected grid can itself constitute one image of a
triangulation-type stereo pair, because the image
of a properly projected grid will retain its shape
regardless of the shape of the object upon which
it is projected, thus reducing the amount of
measurement that needs to be done. The tradi-
tional problem with this approach had been that
the higher the resolution desired by the user,
the closer together the grid lines needed to
be. When the desired resolution approached
1 mm2, the density of the grid on the surface
made it difficult to illuminate and hence diffi-
cult to measure. In the past decade, several man-
ufacturers have implemented computerized ap-
plications of this principle in which a semi-
transparent vertical "rainbow" spectrum is
projected on the surface of the face from one
location and photographed by a digital camera
positioned a known distance from the projector.
A system of this type, developed by the 3DMet-
rics Corp. (Petaloma, CA), is in use in our lab-
oratory. This system is described and illustrated
in the accompanying paper by Curry et al (see
page 258).
The main problem in creating 3D maps of the
teeth also is the problem of locating all points of
interest without ambiguity. Here the problem is
not lack of texture but rather the existence of
undercuts, which make it impossible to see all
points of interest from any single viewing plane.
A number of investigators have attempted to
solve this problem by mounting arrays of cam-
eras surrounding the study casts or by rotating
the casts between images. But thus far, the very
wide variations in patterns of tooth irregularity
between subjects have kept such solutions from
being practical.
Fortunately, in recent years an industrial pro-
cess known as destructive scanning27 has been
used to map study casts successfully for different
purpose by two major orthodontic corpora-
tions, Align Technology (Santa Clara, CA) and
OrthoCad (Fairview, NJ). Destructive scanning is
a variant of the orthogonal slicing method of 3D
mapping described above. Typically a study cast
Home | TOC |          
Index
229
is invested in a solid matrix of contrasting color,
just as one would invest a histology or pathology
specimen in a block of paraffin or epoxy. The
surface of the block is then sliced or ground
parallel to the occlusal plane until the first trace
of the study cast becomes apparent. At this
point, a laser scan of the 2D surface is made and
stored as a layer in a computer file. An addi-
tional 0.003-inch layer of the block is now
ground away and another laser scan is made and
stored. This process is repeated until the entire
erupted dentition has been mapped in a series
of successive layers. Thus, a 3D map consisting of
stacked 2D layers has been generated using a
variant of the orthogonal method described
above.
Merging Different Three-Dimensional
Craniofacial Maps: The Role of
Tie Points
At this point we have demonstrated methods for
constructing individual 3D maps from lateral
x-ray cephalograms, frontal x-ray cephalograms,
study casts, and the facial surface, that is to say,
from each of the component layers of the head
that were discussed in the first part of this essay.
The question now arises as to how we can merge
the 3D digital data representing these several
transforms into a single reintegrated 3D cranio-
facial map. The paradigm for answering this
question is again to be found in the experience
of terrestrial mapping from aircraft and satel-
lites.
The merging of two aerial maps through the
use of tie points is discussed in the additional
materials provided on our website, www.cril.org.
In topographic mapping situations in which it is
desired to integrate different 3D maps made
from different perspectives or at different scales,
one takes advantage of the fact that any two
overlapping 3D maps can be merged accurately
(within the limits of measurement error) by
computer-conducted rotations, translations, and
rescaling of landmark coordinate values pro-
vided that the coordinates of three or more
landmarks common to the two maps are known
on each of the two maps. To generate such
unambiguously identifiable landmarks, appro-
priate markers are typically located or placed in
the region to be mapped prior to imaging. Such
<<    
     Article
      >>
230 Sheldon Baumrind
markers are called tie points. Unlike fiducials,
there is no need for the spatial locations of the
tie points to be known precisely before the gen-
eration of the 3D maps to be merged. The only
requirements are (1) that there be at least three
clearly identifiable tie points in the region of
overlap of any pair of 3D maps to be merged and
(2) that the tie points remain fixed in position
during the acquisition of the images of both
maps.
In our own craniofacial application of this
principle, triads or tetrads of small radiopaque
and photographable metal markers mounted on
paper or plastic labels are attached temporarily
to the surface of the face. Other groups of mark-
ers, mounted on separate upper and lower plas-
tic overlays provided to us by the Align Corpo-
ration are secured to the upper and lower teeth
just before imaging. After all images have been
collected, the facial tie points are located on the
3D facial surface using software provided by the
manufacturer of the facial camera. The locations
of the study cast tie points with relation to the
teeth are known from prior destructive scanning
mapping at Align. The 3D locations of both the
facial and tooth tie points with respect to the
anatomy of the skull are captured from frontal
and lateral x-ray stereopairs using software de-
veloped at CRIL. Using the tie point information
from all sources, the 3D maps of the study casts
and the 3D maps of the facial surface are now
merged into the 3D x-ray map of the skull. The
resulting integrated craniofacial model may be
Figure 4. Achieving the dream of Figure 1. Intersecting lateral and frontal cephs (A). Hanging the dentition in
its proper orientation on the xray scaffold (B). Adding the facial soft tissue in accurate registration to the xray
images and the dentition (C).
Home | TOC |          
Index
rotated, translated, or segmented as desired us-
ing the Align Corporation TREAT software or
other available systems for viewing computer il-
lustrated in Figure 4 and displayed interactively
on our laboratory website (www.cril.org).
What's Ahead in Craniofacial
Measurement?
In the very near future, orthodontists and max-
illofacial surgeons will have at their disposal an
array of information-acquisition tools to match
the complexity of the clinical problem at hand.
For some simple problems, the use of the cur-
rent nonintegrated 2D physical records may suf-
fice. For more complex situations, a graduated
series of responses will be available. At moderate
levels of complexity, existing cephalometers in
clinicians' offices can be calibrated on site, mak-
ing possible 3D reconstructions of acceptable
accuracy from a single conventional emitter.
The information source could be limited to a
single lateral cephalometric head film plus a
single frontal cephalometric head film, provided
that the x-ray system used is calibrated and that
the same set of tie-points can be located without
ambiguity on both films. Where 3D information
about the locations of discrete anatomical fea-
tures lying off the mid-sagittal plane is needed,
stereo x-ray systems equivalent to the present
one at CRIL would have to be available. Where
more extensive 3D information about cranial
surfaces and skeletal contours is needed, low-
<<    
     Article
      >>
Background, Principles, and Perspectives
emission CT scanners, such as the Newtom,23
will become available. These will probably best
be used synergistically with tie-point-based high-
resolution systems, such as that described here.
Almost certainly, clinicians will wish to add to
their armamentarium high-resolution informa-
tion about the head in motion. Recent develop-
ments in computer robotics make it certain that
such information will become available. For in-
formation about changes in the contours of the
facial surface during speech, mastication, and
deglutition, high-speed variants of the struc-
tured light camera used in our present system
will soon be here. For studies of the changing
relationships between the jaws and teeth during
function, apparatus that automatically tracks ac-
tive targets like light-emitting diodes attached to
the face have already been built and will become
increasingly practical.28'30 The use of tie points
to facilitate automatic merging of information
from different sources will become progressive
and more widely applied.
Finally, our specialty will gain from a vast
increase in our ability to share information over
distance. Tele-orthodontics (the simultaneous
viewing at distance by two or more clinicians of
relevant information on individual patients) will
be greatly facilitated, hopefully with due regard
for patient privacy. Clinical and research data-
bases containing linked 2D and 3D images, data,
and written information on growth, develop-
ment, and treatment will soon become widely
available through the Internet. Indeed, several
of the groups represented in this issue, includ-
ing our own, have made significant progress in
that direction. Page 294 of this issue contains a
list of relevant website addresses, many of which
are directly related to articles in this issue of
Seminars in Orthodontics. Truly, a new day is dawn-
ing for orthodontics!
References
1. Bull R, Rumsey N. The Social Psychology of Facial Ap-
pearance. New York: Springer-Verlag, 1988.
2. Phillips C, Tulloch C, Dann C. Rating of facial attractive-
ness. Community Dent Oral Epidemiol 1992;4:214-220.
3. Meyer E. Psychiatric aspect of plastic surgery, in Con-
verse JM (ed): Reconstructive Plastic Surgery, 1964.
4. Krogman WM, Sassouni V. A Syllabus in Roentgeno-
graphic Cephalometry. Graduate School of Medicine,
University of Pennsylvania and Philadelphia Center for
Research in Child Growth, Philadelphia, PA, 1957.
Home | TOC |          
Index
231
5. Van Loon C. Neue Method zur Festellung normaler
Bezehungen der Zahne zu den gesichtslinien. Z
Zahnheilkd. 1916;18:18-39.
6. Simon P. Fundamental proncples of a systematic diag-
nosis of dental anomalies (Translated by BF Lischer).
Boston, The Stratford Company, 1926.
7. Broadbent BH Sr. A new x-ray technique and its appli-
cation to orthodontia. Angle Orthod 1931;1:45, (Re-
printed in the Angle Orthod 1981;51:93).
8. Rune B, Sarnas KV, Selvik G, et al. Posteroanterior trac-
tion in maxillo-nasal dysplasia (Binder's syndrome): a
roentgen stereometric study with the aid of metallic
implants. Am J Orthod 1982;81:65-70.
9. Rune B, Jacobson S, Sarnas KV, et al. Roentgen stereo-
photogrammetry applied to the cleft maxilla of infants. I
Implant technique. ScandJ Plast Reconstr Surg 1997;! 1:
131.
10. Selvik G. A roengenographic sterophotogrammetric
method for the study of kinematics of the skeletal sys-
tem. Thesis, AV-Centralen, University of Lund, 1974.
11. Selvik G. Roentgen stereophotogrammetry in Lund,
Sweden: applications of human biostereometrics. Pro-
ceedings, Society of Phot-Opt Instr Eng 1978; 166:184-
191.
12. Baumrind S, Moffitt FH. Mapping the skull in 3D. J Calif
Dental Assoc 1972;48:22.
13. Baumrind S. A System for Craniofacial Mapping
Through the Integration of Data from Stereo X-Ray
Films and Stereophotographs. Technical Papers from
the Symposium on Close Range Photgrammetric System,
American Society of Photogrammetry, University of Illi-
nois, Urbana 1975;142-66.
14. Baumrind S, Moffitt FH, Curry S. Three-dimensional
X-ray stereometry from paired coplanar images: a
progress report. Am J Orthod 1983;84:292-312.
15. Baumrind S, Moffitt FH, Curry S. The geometry of three-
dimensional measurement from paired coplanar X-ray
images. Am J Orthod 1983;84:313-322.
16. Moffitt FH. Stereo x-ray photogrammetry applied to
orthodontic measurements. Proceedings of the 12th
Congress of the International Society of Photogramme-
try, Ottawa, Canada 1971.
17. Curry S, Anderson JM, Moffitt F. Calibration of a Close-
Range Stereometric Camera System. Proceedings, Amer-
ican Society of Photogrammetry Annual Convention,
Washington, DC 1981.
18. Curry S, Moffitt F, Symes D, et al. A Family of Calibrated
Stereometric Cameras for Direct Intraoral Use. Proceed-
ings, Biostereometrics '82 (SPIE), San Diego, California
1982;7-14.
19. Curry S, Baumrind S, Anderson JM. Calibration of an
Array Camera. Photogrammetric Eng Remote Sensing
1986;52:627-636.
20. Murray WR, Baumrind S, Hunter J, et al. The detection
of loosening in total hip arthroplasty: A computer-as-
sisted stereophotogrammetric method. Proceedings of
the 46th annual meeting of the American Academy of
Orthopedic Surgeons, 1979.
21. Chafetz N, Baumrind S, Murray W, et al. Subsidence of
the Femoral Prosthesis: A stereophotogrammetric eval-
uation. Glin Orthoped Rel Res 1985;201:60-67.
<<    
     Article
      >>
232 Sheldon Baumrind
22. Chafetz N, Baumrind S, Morris JE, et al. Stereophoto-
grammetry of the lumbar spine. Spine 1985; 10:368-375.
23. Mozzo P, Procacci C, Tacconi A, et al. A new volumetric
CT machine for dental imaging based on the cone-beam
technique: preliminary results. Eur Radiol 1998 ;8:1558-
1564.
24. Moss JP, Linney AD, Grindrod SR, et al. A laser scanning
system for the measurement of facial surface morphol-
ogy. Optics Lasers Engineering 1989; 10:179-190.
25. Image-Based Rendering: Structured Light. The Graphics
and Visualization Center, National Science Foundation Sci-
ence and Technology Centers. Available at: http://www.
cs.brown.edu/stc/resea/rendering/research_R6.html.
26. Symes D, Baumrind S, Jendresen M. Three-dimensional
Home | TOC |          
Index
mapping of study casts from a single photographic im-
age. J Dent Res (Special Issue) 61:300 (abstr 1099).
27. Destructive Physical Analysis, ORS Labs. Available at:
http://www.ors-labs.com/DPA.html.
28. Curry S, Baumrind S. Real Time Monitoring of the
Movement of the Mandible. Proceedings, American So-
ciety of Photogrammetry 1986;92-100.
29. Curry S, Baumrind S. Realtime Mandibular Motion Mea-
surement. Proceedings IEEE/Ninth Annual Conference
of the Engineering in Medicine and Biology Society,
Boston 1987;721-722.
30. Miyawaki S, Tanimoto Y, Inoue M, et al. Condylar mo-
tion in patients with reduced anterior disc displacement.
Dent Res 2001;80:1430-1435.
<<    
     Article
      >> Home | TOC |          
Index

Three-Dimensional Imaging: The Case

Western Reserve University Method
Mark Guenther Hans, Juan Martin Palomo, David Dean, Banu Çakirer,
Kyoung-June Min, Seungho Han, and B. Holly Broadbent

The goal of this project was to create a lifelike digital record of human dento-
facial morphology. Traditionally, orthodontists have relied on a lateral and
sometimes a frontal cephalometric radiograph, three facial and three intraoral
photographs, and upper and lower dental study casts to capture the dentofacial
morphology of their patients. Creating a unified digital record of dentofacial
morphology requires all records to share the same space. Therefore, to be
lifelike, all records should eventually be positioned within a computer (on-
screen) representation of the three-dimensional (3D) space of the patient's
head. This requirement necessitated that radiographic and facial surface mor-
phology be rendered in 3D and that 3D study casts be converted to digital
format. This article describes the Case Western Reserve University method for
(1) rendering the lateral and frontal biorthogonal cephalogram pairs in 3D; (2)
capturing the 3D surface of the human face; (3) converting the plaster dental
cast data to a 3D digital record; and (4) integrating lateral and frontal radio-
graphs, facial surface scans, and digital study models into a single 3D patient
record. In addition, the creation of standard 3D cephalometric wireframes using
the Bolton Standard subjects is described. Finally, two case reports are pre-
sented to show the use of this 3D digital record to analyze craniofacial hard and
soft tissue changes brought about by Le Fort I maxillary advancement surgery.
In the case reports, traditional cephalometric superimpositions are compared
with 3D color-coded surface superimpositions of the preoperative and postop-
erative facial images. The advantages and disadvantages of this digital out-
comes assessment method are discussed in this presentation of a model for the
future 3D orthodontic patient record. (Semin Orthod 2001;7:233-243.) Copyright
© 2001 by W.B. Saunders Company

A t the beginning of the 20th century, plaster

was the primary material used to capture
dentofacial morphology. Almost all practitioners
used this material to make casts of the teeth and
alveolar bone. These dental casts, along with a
careful clinical examination of the patient, formed
the database for orthodontic diagnosis and treat-
ment planning. One particularly ambitious practi-

From the Department of Orthodontics, Case Western Reserve University School of Dentistry; the Departments of Neurological Surgery,
Electrical Engineering and Computer Science, Case Western Reserve University; The Research Institute, University Hospitals of Cleveland; the
Bolton-Brush Growth Study Center, Cleveland, OH; and the Department of Orthodontics, School of Dentistry, Hacettepe University, Ankara,
Turkey.
Supported by the Case Western Reserve University Orthodontic Alumni Endowment Fund, the Research Foundation of the Department of
Neurological Surgery, The Research Institute, University Hospitals of Cleveland, American Association of Orthodontists Foundation grants
(JMP, MGH, BHB), a NATO B-1 post-doctoral research scholarship ( B Ç , and a Whitaker Foundation Research Grant (DD).
Address correspondence to Mark Guenther Hans, DDS, MSD, Department of Orthodontics, Case Western Reserve University, 10900 Euclid
Avenue, Cleveland, OH 44106-4905.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0704-0002$35.00/0
doi:10.1053/sodo.2001.25390

Seminars in Orthodontics, Vol 7, No 4 (December), 2001: pp 233-243 233

<<    
     Article
      >>
234 Hans et al
tioner, Calvin Case, even advocated the use of
plaster facial moulages to record facial changes
before and after treatment.1 Although we tend to
think that orthodontic records have steadily im-
proved over the years, one factor that is often not
appreciated is that these early records captured a
patient's dentofacial morphology in three dimen-
sions (3D). Technical difficulties in obtaining fa-
cial moulages and the practical problems of stor-
age prevented most practitioners from adopting
the technique. In addition, advances in photogra-
phy and radiography changed the way practitio-
ners recorded facial morphology. By the end of
the 20th century, the combination of two-dimen-
sional (2D) radiographs and photographs and 3D
dental casts were used to document a patient's
morphologic features. Recent advances in digital
photography have reduced the cost and improved
the quality of digital cameras. In fact, many con-
sider digital photography to be the current state of
the art in 2D image capture (personal communi-
cation, Dr. D. Sarver, February, 2001, Birmingham,
AL). A similar trend in digital radiography is oc-
curring and will likely result in a shift to 2D digital
cephalometries in the near future. The next logi-
cal step is to include the 3D study casts in the
digital record. Such rapid progress in acquiring
digital data has pushed the frontier of orthodontic
imaging to consideration of a 3D digital patient
record. This article describes the Case Western
Reserve University (CWRU) approach to creating
such a record.
How Is Digital Data Different from
Analog?
Although one is bombarded with advertising
that touts the superiority of digital media (eg,
digital audio compact disks provide better sound
quality than long playing vinyl records), the re-
ality is that digital is different but not necessarily
better. There is a basic difference between ana-
log and digital information. Analog data is
stored in a continuous stream limited by physical
properties of the media on which it is recorded.
In contrast, digital information must be broken
up into discreet units and therefore is limited by
the size and number of these packets. For exam-
ple, the traditional analog cephalogram records
the image of the skull on silver halide crystals
attached to acetate film. The dynamic range of
the silver halide crystals is approximately 10,000
Home | TOC |          
Index
shades of gray from white to black. Each silver
halide particle is approximately 0.05 mm. There-
fore, in traditional cephalometrics, the accuracy
of landmark identification is limited by the abil-
ity of the operator to identify a given landmark
and the sharpness of the pencil point (generally
believed to be approximately 0.3 mm with a
drafting pencil).2 In contrast, when a cephalo-
metric radiograph is scanned, whether by video
camera or flatbed scanner, the information con-
tent of the image must be divided into discreet
units called picture elements or pixels, for short.
With a digital image, the size of the pixel is one
of the limiting factors in measurement accuracy
rather than the sharpness of the pencil.
What Is Meant by the Term Image
Resolution?
Two major parameters affect the quality of
scanned images. These parameters are the spa-
tial and the grayscale resolution of the image.
Traditionally, resolution refers to the quality of
an image in terms of the fidelity of the finest
details in the content of the image. Thus, spatial
resolution refers to the image quality in terms of
the spatial detail. When the spatial resolution is
poor, two adjacent spatial features may be
blurred together so that they appear as a single
feature rather than two separate features. This
classical definition of resolution is dependent on
the image content and on the importance of
small features as carriers of image information.
In digital images, an image-independent and
display-independent specification is simply the
number of pixels in the horizontal and vertical
directions. Although this is not the only deter-
minant of spatial resolution (in terms of resolv-
ing the details in an image), it has become a
standard measure.
In Terms of Cephalometric Radiograph
Scans, What Is the Significance of the
Spatial and Grayscale Resolutions?
Suppose we wish to locate a single landmark, as
is necessary to make certain distance measure-
ments. If the spatial resolution were too low (ie,
insufficient number of horizontal and vertical
pixels in a digital image), then the image would
appear to be blurred. The blurring may com-
pletely obscure a landmark, and measurement
<<    
     Article
      >>
Three Dimensional Imaging: The CWRU Method
would be impossible. Less severe blurring would
make the landmark less "sharp," larger, and
merged with neighboring features, thus intro-
ducing ambiguity and error in the measurement
of the location of the landmark. An important
fact with regard to measuring digital images is
that we cannot add more pixels to the image
after it is converted to digital format. Therefore,
if one wants to measure more accurately on an
analog (traditional lateral cephalogram or trac-
ing), one can sharpen their pencil. On a digital
image, the measurement accuracy is limited by
the size of the pixels in the image being used.
For example, with a pixel size of 0.2 mm, the
most accurate measurement would be twice the
pixel size, or 0.4 mm (ie, ± 0.2 mm error at each
pixel).
In addition to limitations imposed by spatial
resolution, the information content of a cepha-
lometric radiograph can be obscured or lost if
too few shades of gray are available to represent
each pixel. Texts and sales persons state that the
human eye can only discern 64 gray levels and
therefore this level of resolution is sufficient for
human viewing. However, the reality is that the
human eye can only process 64 shades of gray at
a time, but the eye can pick these 64 shades out
of as many as 10,000 possible gray levels actually
present on an analog cephalometric radiograph.
Thus, the actual number of shades of gray is
highly dependent on the image content and the
actual measurement that needs to be made on
the image. In terms of the cephalometric radio-
graph scan, if a landmark feature is in an image
region with relatively slow and perhaps subtle
changes in grayscale, then too few gray levels
may obscure the landmark or change its appar-
ent location. Unfortunately, there is no theory
or equation to calculate exactly how many pixels
and gray levels to use. Generally, the maximum
number of gray levels available is used. Further-
more, the grayscale level and number of pixels
are not independent. For example, the number
of horizontal and vertical pixels may be ade-
quate for 256 gray levels, but at 64 gray levels, a
superior spatial resolution may compensate for
the loss of grayscale resolution. This trade-off
between spatial and grayscale resolution is lim-
ited. If an image has too few gray levels, increas-
ing the spatial resolution cannot compensate for
the loss of information content.
There is a practical trade-off between image
Home | TOC |          
Index
235
resolution and the image size. The higher the
resolution, the larger the file will be. Although
there is no accepted standard for digital ortho-
dontic records, we believe that a spatial resolu-
tion of 0.1 mm along with a grayscale resolution
of 12 bits (4096 gray shades) is adequate to
capture the useful information on cephalo-
grams.3
Why Do We Need a Three-Dimensional
Record?
The short answer to this question is that our
patients are 3D and, therefore, we need to
record their morphology in 3D. A slightly longer
explanation will further show the superiority of a
3D record. In traditional cephalometry, 3D
craniofacial structures are projected onto 2D
radiographic film. This process creates cephalo-
metric structures and landmarks that do not
exist in the patient. These structures are effec-
tively optical illusions of craniofacial anatomy.
Examples of such structures are the mandibular
symphysis, the pterygoid fossa, and the "key
ridge." Although orthodontists around the world
constantly refer to these structures as anatomic
landmarks, they are in fact, artifacts of the ceph-
alometric technique. Another problem arises
when bilateral structures are averaged to create
a unified anatomic outline. An example of this
process is the averaging of the right and left
inferior borders of the mandible to create the
"mandibular plane." Such averaging of bilateral
structures creates two problems. First, the
"plane" that is created is really now a line and is
an abstraction based on the anatomy of the pa-
tient. Secondly, averaging the structures results
in a loss of parasagittal information, and any
true asymmetry of the patient is lost. It is impos-
sible to determine how important this lost infor-
mation is to diagnosis and treatment planning.
The current use of both 2D and 3D orthodon-
tic patient records raises another important
point when we consider the creation of a new
standard for a digital patient record. Is it possi-
ble to accurately register the current 2D and 3D
physical records into a single space? The answer
is a resounding yes. Further, to create a unified
digital orthodontic record all morphologic in-
formation must be brought into the same 3D
space, that of the patient's head. Projecting the
3D skull onto 2D radiographic film creates a
<<    
     Article
      >> Home | TOC |          
Index

236 Hans et al

maximum projection image of the head, where

only the outmost outline is unobstructed, and all
other visible structures are to some extent over-
lain. However, when x-ray source/patient/film
orientations are standardized, such as with
the Broadbent-Bolton Roentgenographic Ceph-
alometer, sharp bony and external soft tissue
profiles are reliably visualized.3 These outlines
may be traced or viewed on screen in order to
identify the shape of craniodental or soft tissue
face landmarks that can be reliably recorded as
single points (ie, where tissues intersect or max-
imum curvature is seen). Thus we believe it is
prudent to combine the existing 2D and 3D
records to create a single, cost-effective 3D orth-
odontic patient record.

How Can We Use Our Current 2D

Cephalometric Records to Find 3D
Landmarks?
First, the records must be brought into a com-
mon reference frame. For cephalograms, our
approach uses the classic Broadbent-Bolton lat-
eral and frontal biorthogonal radiographic pair
to create a 3D reference space for the digital 3D
record.4 The lateral and frontal radiographs in
Figure 1A are taken using two different x-ray
sources positioned at right angles to each other.
The patient's head is not moved between the
exposure of the lateral and the frontal film. To
insure standardized views of the patient's pro-
jected anatomy, it is important that only the
source of the x-ray beam and the position of the
film change between the exposures of the fron-
tal and lateral cephalogram images. This is a
critical detail of the system because movement of
the patient's head between exposures generates
too much variation in the location of the land-
marks to make them clinically useful.5'7 All of
the radiographs in the Bolton-Brush collection
were taken using this system and thus 3D land-
marks can be located using the Broadbent-Bolton
orientator (Fig IB). A computer version of the
Broadbent Orientator, 3dCEPH (Subramanyan
and Dean © 1996), allows the operator to cap-
ture 3D landmark coordinates from the regis-
tered frontal and lateral cephalograms (Fig 2) .8'9
Over the next 3 years, 8 operators painstakingly
recorded the 50 landmarks that could be seen
on the lateral and frontal radiograph for the 16
boys and 16 girls that were used to create the
Figure 1. Broadbent-Bolton cephalometer (A). Broad-
bent-Bolton orientator (B). Illustrations © Bolton-Brush
Growth Study Center, reprinted with permission.
classic Bolton Standards.10-12 The 50 landmarks
were recorded three times for each biorthogo-
nal radiographic pair. The resulting dataset is
the first 3D standard of its kind that can be used
by orthodontists and other craniofacial practitio-
ners. An example of wireframes created from
the 3D landmark average locations for the age
12 Bolton Standards data are shown in Fig 3.
How Are These Biorthogonal Images
Used to Create the Case Western
Reserve University Three-Dimensional
Patient Record?
First, the analog cephalograms are scanned at
512 pixels per inch (resulting in a pixel size of
approximately 0.1 mm for an 8 x 10 inch cepha-
logram) and 12 bits of grayscale per pixel (re-
sulting in 4096 shades of gray for each pixel) on
a Howtek (Hudson, NH) Scanmaster DX. This
process results in a digital image file occupying
approximately 40M.12 The digital radiograph is
then optimized for viewing anatomic structures
on a monitor (8 bit per pixel) by histogram
enhancement. The optimized file is then stored
at a grayscale resolution of 8 bits per pixel. The
scanned images may positioned in the same
<<    
     Article
      >>
Three Dimensional Imaging: The CWRU Method
Figure 2. Computerized representation of the Broadbent-Bolton Orientator as seen in the SdCEPH program.
manner as tracings within the Broadbent Orien-
tator. The computerized implementation of the
Broadbent Orientator allows the operator to
scale the images based on their offset (distance
from) the standard beam intersection point of
each film. This provides coordinate data in units
that are accurate within 0.1 mm. In addition to
locating landmark coordinates in 3D for com-
parison to the 3D Bolton Standards, the images
may then be imported into our 3dCEPH diag-
nosis, treatment, and outcomes assessment
(DTO) software for alignment with dental cast
and soft tissue face 3D surface images.
Figure 3. Landmark wire
frame in lateral (A), frontal :r
fV
(B), and axial (C) views.
The wire frame is formed
by 50 skeletal landmarks,
and it is a three-dimen-
sional object that can be ro-
tated.
Home | TOC |          
Index
237
How Do We Obtain 3D Facial (Soft
Tissue Face) Surface Images?
The 3D surface images of the soft tissue face are
obtained by merging a series of views taken with a
laser range scanner (Vivid 700; Minolta Corp,
Ramsey, NJ; http://www.minolta3d.com/). Each
view has a resolution of 200 x 200 in the x and y
directions seen by a charge-coupled device (CCD)
through a 5X auto-focus lens. This results in an
effective pixel resolution of approximately 1 mm2.
A color texture image is aligned by parallax and
captured simultaneously for later alignment with
B
.,/>
«£
<<    
     Article
      >>
238 Hans et al
the spatial image. All the views necessary to pro-
duce a complete view of the face are merged in the
VWID 700 image manipulation tools (Fig 4). The
file is then brought into SdCEPH DTO. In the
3dCEPH environment it is possible to locate facial
landmarks and record the location in 3D. The
final, collage (ie, ear-to-ear, brow-to-chin) of all
views results in a 5 megabyte polygonal manifold
open inventor (ie, *.iv, equivalent to Virtual Reality
Modeling Language [VRML] version 1) file. The
presence of the color greatly increases the reliabil-
ity of localizing landmarks at the intersection of
different tissues. For example, some clinically im-
portant anatomic landmarks, such as the vermilion
borders of the lip and the sclera of the eyes, are
really defined by color information rather than
Figure 4. Merging of Vivid Files. After opening the
images to be merged, landmarks that can be seen in
both views are identified (A). With those landmarks,
the two images are oriented together. Based on the
previous orientation, both images are merged into a
single image that also contains color information
from both original files (B).
Home | TOC |          
Index
shape information. This illustrates the importance
of incorporating color as well as shape information
into any 3D digital record.
How Do We Obtain Three-Dimensional
Study Cast Images?
We obtain standard dental impressions of the
upper and lower teeth using a Thixotropic Vinyl
Polysiloxane crown and bridge material (Col-
tene/Whaledent, Inc, Mahwah, NJ) to insure
that the most accurate detail is captured in the
impression. The dental impressions are scanned
to create an miodel Digital Orthodontic Model
using proprietary technology available from
GeoDigm Corporation (Chanhassen, MN). The
laser sensor accuracy is 0.01 mm, which results in
an gmodel 3D surface accuracy of approximately
0.1 mm with a Polygonal Mesh Size of 30,000
polygons per jaw. The resulting *.stl files are
approximately 40 MBytes (Fig 5).
How Is Image Data from These Three
Sources Merged into the Final
Three-Dimensional Digital Record?
The three types of image data are merged in the
3dCEPH DTO program. The first step is to or-
thogonally position the two cephalogram im-
ages. The cephalograms are scaled based on the
offset distances from the beam intersection
points. These 2D images may then be aligned
orthogonally at the intersection of the maxi-
mum projection planes coincident with the cen-
tral x-rays that produced them. The horizontal
plane may need further minor alignment if the
film did not sit level in the cassette during pa-
tient imaging in the Broadbent-Bolton Roent-
genographic Cephalometer.
Next, the soft tissue face surface image can be
aligned with the cephalograms (Fig 6).
Finally, the two dental cast surface images are
imported into the 3D patient volume now com-
prising two cephalograms and the composite
laser range facial image (Fig 7). The VIVID im-
age is made transparent and the dental cast
images are made transparent. The latter are
aligned one at a time in the same way as the face
laser range images, first laterally, then frontally,
going back and forth between two until the ra-
diographic outlines of the teeth and the surface
<<    
     Article
      >>
Three Dimensional Imaging: The CWRU Method
Figure 5. Three-dimensional representation of the dental Cast (gmodel). The onodel can be rotated, zoomed,
have the archs seen individually, and even have several analysis performed directly in the computer.
images of the dental casts are superimposed in
the integrated record.
The resulting 3D record of the three different
images along with 3D landmark data can be
surveyed from any direction and manipulated
manually (Fig 8). Each individual image as well
as each landmark can be manipulated by the
software to be fully visible, transparent, or hid-
den. The system is designed to maximize flexi-
bility in viewing the various images.
Comparison of Traditional
Two-Dimensional Cephalometric
Superimposition with
Three-Dimensional Surface Matching:
Two Case Reports
Two patients are used to compare traditional
superimposition of lateral cephalometric trac-
ings before and after surgery to the use of 3D
Figure 6. Three-dimensional soft tissue image com-
bined with the cephalograms.
Home | TOC |          
Index
239
surface image matching for visualizing treat-
ment outcome. Although complete orthodontic
records were taken on each patient, this presen-
tation uses only the before and after lateral
cephalometric radiographs along with 3D digital
surface photogrammetric images. Patient 1 is a
48-year-old man with maxillary asymmetry and
patient 2 is a 38-year-old woman with mandibu-
lar prognathism. Both patients had Le Forte I
maxillary advancement.
Traditional Two-Dimensional Cephalometric
Preoperative and Postoperative
Superimposition on the Cranial Base
Preoperative and postoperative lateral and fron-
tal cephalometric radiographs of these two pa-
tients were taken using a Broadbent-Bolton
Roentgenographic Cephalometer.8 Tracings of
the radiographs were performed on a standard
x-ray light box. A matte acetate sheet was at-
tached to the radiograph and both were fixed to
the view box. A fine-point (0.5 mm) lead pencil
was used to minimize measurement error during
tracing. The resulting tracings are shown in Fig-
ures 9 and 10.
Three-Dimensional Surface Morphometrics
Preoperative and postoperative stereophoto-
grammetric images of patient 1 and patient 2
were taken via Virtuoso Shape Camera (Visual
Interfaces, Inc, Pittsburgh, PA). The Shape Cam-
era's internal flash projects a vertical stripe pat-
tern on the subject at the moment the image is
captured. The image of this stripe pattern is
captured by six black and white CCD sensors
<<    
     Article
      >> Home | TOC |          
Index

240 Hans et al

lenses on the front of the camera. The lines are

used to align these six images for calculation of
the stereophotogram. There is also a color lens
attached to the camera, which provides a color
texture that is overlain on the stereophotogram.
The resulting surface image is a color stereopho-
togram reported by the manufacturer to be ac-
curate to ± 0.5 mm. Now obtained is the facial
surface source data using the Minolta Vivid Cam-
era, rather than the Virtuoso Shape Camera.
However, the principles shown with these two
case reports are independent of the 3D image
capture device.
The preoperative and postoperative stereo-
photograms taken of patient 1 are shown in
Figure 11. To visualize the differences between
preoperative and postoperative soft tissue face
surface images each image was superimposed by
matching a range of mathematically constructed
and manually identified landmarks across the
images using a best-fit method and VI Studio
software (J. Webb, PhD, Visual Interfaces, Inc).
The areas to be compared are first registered to
other areas that have not been altered by sur-
gery. In this case, the image superimposition was
based on matching the landmarks from the two
images across the eyes and forehead.
Two methods of showing the 3D changes in
surface morphology are shown. In Figures 11
and 12, the preoperative and postoperative im-
ages are superimposed, and the differences be-
tween the pixel locations on the surfaces of the
two images are calculated. The differences be-
tween the pixel location is identified using a
color-graduated system, where darker shades in-
dicate greater differences between the location
of the pixels. Essentially this superimposition
produces a topographic map of the differences
in facial contour due to surgery. The areas of
greater change are shown in a darker shade. In
Figure 13, the alternative method is illustrated.
Here the preoperative image is rendered in
opaque flesh tones and the postoperative image
is rendered as a transparent mesh.

Figure 7. Integration of émodel to cephalograms and
landmark wire-frame (in white).
Summary of Outcomes
Patient 1.
Superimposition of preoperative and postoper-
ative lateral cephalometric tracings of patient 1
(Fig 9) showed that the maxilla was moved an-
terior and downward into a more favorable re-
<<    
     Article
      >> Home | TOC |          
Index

Three Dimensional Imaging: The CWRU Method 241

Figure 8. Single three-dimensional record. It incorporates cephalograms, dental casts, and soft tissue informa-
tion.

lationship with the mandible. The inclination of
the upper incisors and open-bite were corrected.
The hard tissue changes are reflected in the
overlying soft tissue. A more protrusive upper lip
and a less concave profile can been seen.
Preoperative and postoperative 3D facial im-
ages of patient 1 were aligned via mathematically
constructed and manually identified landmarks
across the images. The shape camera software,
VI Studio (courtesy of Dr. J. Webb), converted
the pixel distances between the preoperative
and postoperative views into a color range show-
ing the areas of greater change in a darker shade
(Fig 11). The darker shade around the nose,

Figure 9. Cephalometric superimposition of pre-sur- Figure 10. Ephalometric superimposition of pre-sur-

gical (black) and post-surgical (grey) cephalograms gical (black) and post-surgical (grey) cephalograms
for Case 1. for Case 2.
<<    
     Article
      >> Home | TOC |          
Index

242 Hans et al

Figure 11. Surface metric distance superimposition of pre-surgical and post-surgical stereophotograms for
Case 1. In this superimposition the difference between both images is represented by darker shading, the darker
the shade, the further away are those structures. A swelling under the patient's left eye was identified by this
three-dimensional method.

upper lip, lower lip, and chin areas indicates a
change caused by surgery. The asymmetric shad-
ing change on the left cheek was caused by
swelling from a postoperative sinus infection.
Patient 2.
The superimposition of preoperative and post-
operative lateral cephalometric tracings of the
patient (Fig 10) revealed that the anterior and
superior movement of maxilla and mandible
caused the profile to change from concave to
convex with an unwanted upward tilt to the tip
of the nose.
After the aligning of the preoperative and
postoperative 3D facial images of Case 2, pixel
distances were converted into different shades
(Fig 12). It appears that the most shape change
caused by surgery occurred around the upper
and lower lips and chin area, which present a
darker shade. As in patient 1, when the postop-
erative image was converted to a low-resolution
wire frame, the shape change between the im-
ages could be seen more easily (Fig 13).
Some Thoughts on the Future of
Three-Dimensional Surface Imaging in
Outcomes Assessment
Traditional evaluation of changes due to surgery
is most often via superimposition of preopera-
tive and postoperative cephalometric films along
a common reference plane such as Sella-Nasion,

Figure 12. Surface metric distance superimposition of pre-surgical and post-surgical stereophotograms for Case
2. In this superimposition the difference between both images is represented by darker shading, the darker the
shade, the further away are those structures. This three-dimensional method allows the practitioner to evaluate
both left and right sides of the face separately. This is important to evaluate asymmetric outcomes, like the one
shown in this case.
<<    
     Article
      >> Home | TOC |          
Index

Three Dimensional Imaging: The CWRU Method 243

Acknowledgment
The authors thank Dr. Jon Webb for software
used to compare the stereophotogrammetric im-
ages; Drs. Bahman Guyron, Bryan Michelow, Ed-
ward Luce, and Peter Buckley for the use of the
Shape Camera. The authors also thank the fol-
lowing colleagues who have helped with this
project over the last 12 years: Krishna Subraman-
yan, PhD; Cecil Thomas, PhD; Sean O Cal-
laghan, BScD, MSD; Manish Valiathan, BsD,
MSD; A. Gasparetto, DDS; Mike McGraw, Ja-
nardhan Kamath, MS; Tony Magni; Perry Zhang,
MEng; Dima Kalakech, DDS; Bruce Hultgren,
DDS, MSD; Soon Jung Park, DDS, MSD; and
John Zhang, DDS, PhD.

Figure 13. When the postoperative image is con-
verted to a wire frame, the shape change due to
surgery can be seen.
Frankfurt Horizontal, or some other registration
plane. The location of these planes is subject to
appreciable intraoperator and interoperator
variance, which can influence the outcome.
Quantitative results and diagnostic interpreta-
tion of traditional analysis have been shown to
vary with the clinicians preferred basis for cepha-
logram orientation and registration. Unlike
cephalometric analysis, the results of the super-
imposition of preoperative and postoperative
stereophotogram 3D surface images are inde-
pendent of patient pose during acquisition. In
this method, the image is independent of sur-
face orientation (rotation and translation). Thus
the description of the face will be the same from
any viewpoint.
With accurate stereophotogrammetric im-
ages, it is possible to quantify subtle 3D changes
not seen in cephalograms but that are probably
discernible to the patient. The comparison of
3D soft tissue facial surface changes that accom-
pany orthodontic treatment or orthognathic sur-
gery can be used to supplement traditional ceph-
alometric analysis. The 3D color-coded surface
analysis provides the clinician with new informa-
tion on parasagittal changes that are not ade-
quately documented by traditional methods.
References
1. Case CS. A practical treatise on the technics and princi-
ples of dental orthopedia. Chicago, IL: Case Company,
1908, pp 34-38.
2. Baumrind S, Frantz RC. The realiabiliry of head film
measurements: Conventional angular and linear mea-
sures. Am J Orthod 197l;60:505-5l7.
3. O'Callaghan, S. Spatial resolution of cephalometric ra-
diographs. Master's thesis, Case Western Reserve Univer-
sity, Cleveland, OH, 1993.
4. Broadbent BH Sr. A new x-ray technique and its appli-
cation to orthodontia. Angle Orthod 1931; 1:45-66.
5. Dean D, Hans MG, Bookstein FL, et al. Three-dimen-
sional Bolton-Brush Growth Study landmark data: On-
togeny and sexual dimorphism of the Bolton Standards
Cohort. Cleft Palate-Craniofac J 2000;37:145-156
6. Dean D, Palomo M, Subramanyan K, et al. Accuracy
and precision of 3D cephalometric landmarks from
biorthogonal plain film x-rays. Intl Soc Optical Engin
1998;3335:50-58.
7. Miyashita K. Contemporary Cephalometric Radiogra-
phy. Tokyo, Japan: Quintessence, 1996.
8. Broadbent BH, Broadbent BH Jr, Golden W. Bolton
Standards of Dentofacial Development. St. Louis, MO:
CV Mosby, 1975.
9. Subramanyan K, Dean D. Scanned bi-orthogonal radio-
graphs as a source for 3D cephalometric data. SPIE
1996;27lO-2773:7l7-724.
10. Grayson B, Cutting CB, Bookstein F, et al. The three-
dimensional cephalogram: theory, technique, and clini-
cal application. Am J Orthod Dentofac Orthop 1988;94:
327-337.
11. Grayson B. Cephalometric analysis for the surgeon. Clin-
ics Plast Surg 1989;16:633-644.
12. Palomo JM, Dean D, Broadbent BH Jr, et al. Three-
dimensional craniofacial shape change in sixteen female
Bolton faces. In: McNamaraJA, Jr (ed): The Enigma of
the Vertical Dimension. Center for Human Growth (vol
36). Ann Arbor, Michigan: University of Michigan, 2000,
pp 287-310.
<<    
     Article
      >> Home | TOC |          
Index

Three-Dimensional Imaging and

Motion Animation
Orhan C. Tuncay

Orthodontic treatment is aimed at affecting the craniofacial relationships in

three planes of space. Yet strangely enough, the critical diagnostic records
are two-dimensional. In an orthodontic setting, the techniques of imaging
the human face in a three-dimensional manner have been either stereo
photography, or projection of optical grids or the structured light. These
projections enable the operator to capture the facial image in a three-
dimensional manner. Unfortunately, all these methods are static in nature.
The laser scanning techniques and the availability of sophisticated software
for image manipulation, make image animation possible. Here we report the
first ever motion animation of the human face from laser-generated images
for clinical purposes. (Semin Orthod 2001;7:244-250.) Copyright© 2001 by
W.B. Saunders Company

he orthodontist's job is to fit together the
T pieces of the human craniofacial complex
puzzle. The expected outcome of this endeavor
is a harmonious rearrangement that is not only
functional, but also esthetically pleasing. Clearly,
this process must take into account the relation-
ships in all three spatial axes. Oddly enough,
while orthodontic treatment affects all three di-
mensions, many of the current tools of diagnosis
employ only a two-dimensional (2D) representa-
tion of the patient. Of course, there exist the
hospital-based three-dimensional (3D) imaging
systems (magnetic resonance imaging or com-
puted tomography [CT] scans), but unfortu-
nately, these systems are neither accurate
enough for the precision of orthodontic treat-
ment, nor practical for in-office use.
The two goals of orthodontic treatment
(function and esthetics) are dynamic entities.
The statically occluded teeth are of limited
From the Department of Orthodontics, Temple University School
of Dentistry, Philadelphia, PA.
This summarizes the thesis projects conducted at Temple by Drs.
Michiel Nuveen ('96), Can Nguyen ('98), and John Slattery ('01).
Address correspondence to Orhan C Tuncay, DMD, Department
of Orthodontics, Temple University School of Dentistry, 3223 North
Broad Street, Philadelphia, PA 19140.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0704-0003$35.00/0
doi:10.1053/sodo.2001.25402
value, though they might look good in the form
of a plaster cast. This is no different than the
good-looking and the not-so-good-looking, giv-
ing at least one pose to the photographer, where
they would appear esthetically pleasing. In the
absence of a system where function and esthetics
can be assessed, both the orthodontist and the
patient are left to imagine or fantasize, rather
than know, what the treatment outcome might
be. This study describes the characteristics of the
three different imaging systems that were devel-
oped over the past several years in an effort to
overcome this limitation.
Background
The specialty of orthodontics as we know it and
the methods of imaging are inseparable. In fact,
both the concept and need for a 3D imaging
system in orthodontics have their roots in the
early years of the specialty. The original cepha-
lometric method of Broadbent1 was designed to
analyze the craniofacial components three-di-
mensionally. Unfortunately, somewhere early in
the evolution of the specialty, cephalometrics
was reduced to the lateral film only. Currently,
the posteroanterior (PA) film has two uses. One
is to assess the symmetry of the face and denti-
tion, and the other is to justify palatal expansion.
The diagnosis of craniofacial problems three-

244 Seminars in Orthodontics, Vol 7, No 4 (December), 2001: pp 244-250

<<    
     Article
      >>
3D Motion Animation
dimensionally has become a necessity. As the
orthodontic techniques have become more and
more sophisticated, and with the advent of or-
thognathic surgery, today's clinician can affect
the face much more dramatically. There are no
standard tools available to measure the 3D
changes in a dynamic format. The most recent
analysis of facial image is the "Smile Mesh" pro-
posed by Ackerman et al.2 This most significant
step in the recent history of assessment of facial
esthetics also uses analyses of static images, albeit
taken in motion, obviously because of limita-
tions in technology.
Although the common orthodontic culture
embraced the lateral cephalogram as the stan-
dard diagnostic tool, several researchers have
tried to further develop Broadbent's 3D con-
cept.3'22 For example, Baumrind and Moffitt3
proposed the coplanar cephalometry. This tech-
nique generated a stereo image of the face, but
it could not be measured or manipulated to
satisfy the needs of the clinician especially, for
the purposes of predicting treatment outcome.
Perhaps, it was cumbersome to master and was
expensive. In 1985 Cutting et al4 introduced the
biplanar cephalometry to generate 3D tracings
of the skeleton. This technique was later im-
proved by Brown and Abbott5 and Marsh et al.6
Notwithstanding its advantages despite the cost
and radiation exposure, CT scan6'9 is not practi-
cal for the orthodontist. The mapping of soft
tissue requires that the image is captured; but
this captured image must be conducive to mea-
surements and to manipulation. We embarked
on our journey with this end result in mind.10"13
Grid Projection Techniques
The principle of image capture is straightfor-
ward: either a (grid) shadow or (visible or laser)
light is projected onto the skin, and then this
(distorted) projection is captured photographi-
cally to be used for reconstructing the facial
topography.10'11'14"20 The latest of these was de-
veloped by our group.11'12 For these studies we
used a mannequin comprised of a dried human
skull embedded in latex. The latex face had the
same radiographic density as the human flesh. A
vertical grid was projected onto the face and
then photographed and digitized. Using the
software "Form Z" on a Macintosh platform (Au-
todessys, Columbus, OH), a 3D rendition of the
Home | TOC |          
Index
245
face was possible. Subsequently, we took the lat-
eral and PA cephalograms and, using the algo-
rithm developed by Brown and Abbott,5 the
lateral and PA cephalometric tracings were com-
bined to create a "stick diagram." The tracing
was then placed behind the 3D facial image
(Fig 1). This technique delivered combined skel-
etal and facial 3D images, but was labor-intensive
and the accuracy was within a few millimeters,
no better, or perhaps worse, than a CT scan.
A remarkable photographic system for gener-
ating 3D facial images was developed by Atick et
al21 a few years ago. This technique can generate
3D facial images from a single photograph. Al-
though it has photographic and morphing dis-
tortions, such images provide the reconstructive
surgeon with a powerful guide to rebuild the
faces of trauma, cancer surgery, or burn victims.
It is not, however, accurate enough for the orth-
odontist. Generally, the photographic systems
are plagued by unavoidable inaccuracies.22'23
Structured Light
To improve on the projected grid technique, a
strategy that was in use in neurobiology was
adopted.12 Structured light (SL) had been used
to image the rat brain. To develop the system to
suit our needs, the same mannequin described
above was used (human skull embedded in la-
tex). Lateral and PA biplanar cephalometric
film tracings were made as described by Broad-
bent.1 The tracings were scanned using the
Adobe Photoshop software (Adobe Systems, Inc,
San Jose, CA) at 150 dpi resolution with a 1:1
ratio. From these digitized images, 121 land-
marks, suggested in the Michigan Growth Atlas,
were selected and a plot of the coordinates in
the manner of Brown and Abbott5 were made.
The stick diagrams generated by this process
supported rotation of the image about any axis
(Fig 2).
Different from the generation of stick dia-
grams, the technique to image the latex skin
surface relied on stereoscopy. Typically, in ste-
reoscopy, the corresponding points on the two
acquired images are compared to yield 3D coor-
dinates of those points on the imaged subject.
This is the most difficult step in stereo imaging,
but the task is significantly simplified with the
use of SL. In the SL technique, the scene is
illuminated by a light pattern and only one im-
<<    
     Article
      >>
246 Orhan C. Tuncay
Figure 1. The combined facial image and three-di-
mensional (3D) cephalometric tracing of the manne-
quin described in the text.16 The grid shadow pro-
jected onto the face of the mannequin enabled us to
capture the facial topography (A). The 3D tracing was
oriented to the face using the midline structures and
landmarks of the PA radiographs (B). This earlier
system was developed on a Macintosh system, where in
those days, graphics were superior to the personal
computer. This image could be manipulated for tasks
such as surgical or orthodontic treatment outcome
predictions. The operator could click on the skeletal
chin point for example, and move it forward. The soft
tissue chin would then morph and follow. Motion
animation was not included.
Home | TOC |          
Index
Figure 2. The three-dimensional (3D) tracings gen-
erated from the lateral and posteroanterior radio-
graphs.18 Bolton's orientator grid was used for mag-
nification corrections. This technique was proposed
by Brown and Abbott.5 The 3D tracing is capable of
revealing the asymmetries present.
age is acquired. The captured image is com-
pared to the light projection plane to extract the
3D coordinates. The technical details of this
method have been presented elsewhere.12 Per-
haps, the most important aspect of this tech-
nique is that it can be built by off-the-shelf
components, which was a very important consid-
eration 4 to 5 years ago.
For our studies, the imaging equipment con-
sisted of a black-and-white charge-coupled de-
vice (CCD) camera and a monochrome liquid
crystal display (LCD) projector connected to a
Macintosh computer. The camera and the pro-
jector were positioned at an angle of 30° to each
other. The mannequin sat on a turntable and
was rotated 180° in 10° increments, whereas the
human head was secured in the headholder of
the cephalostat and rotated in similar incre-
ments. Before data collection, the system was
calibrated to deliver 400/x accuracy. Then the
mannequin or the human head was illuminated
by SL by 25 different high-density light patterns
<<    
     Article
      >>
3D Motion Animation
Figure 3. (A-C) Randomized patterns of light projected onto the mannequin face.18 These patterns were
captured by a charge couple device camera and then stored in a Macintosh computer. The 3D coordinates of
centroids of light dots were determined by a triangulation process.
(Fig 3). Data captured by the CCD camera were
the analyzed off-line.
With the aid of the National Institutes of
Health (NIH) Image software, the centroids of
each dot were identified. These data were then
transferred to the MATLAB (The MathWorks,
Inc, Natick, MA) software for triangulation and
determination of 3D coordinates of the light dot
points. Finally, data files from different views
were merged to yield a complete 3D facial map
(Figs 2 and 3). The image could then be aligned
with the cephalometric stick diagrams.
This technique provided satisfactory accu-
racy, but proved somewhat difficult when ap-
plied to the human face. It was nearly impossible
to rotate the human head perfectly about a long
axis when the head was held in the headholder.
A modification of the headholder would have
solved the problem, but it would have been
costly. Also, it was unknown if animation of the
face would be feasible without too much effort
and computation. Eventually, further invest-
ment in this system was not chosen.
Craniofacial Imaging and Animation
with the Laser Scanner
It should be noted at the outset that much of the
difficult pioneering and significant work on la-
ser imaging was done by Moss et al.8'14-15 Al-
though their work was limited to facial scans and
Home | TOC |          
Index
247
surface characteristics, they had done all the
hard work of the earlier days. They made us
aware of the difficulties associated with measure-
ments of linear dimensions on a 3D image. They
recommend surface analyses, which represents a
significant conceptual leap.
At this point in our quest to develop a user-
friendly 3D imaging and animation system, Mi-
nolta introduced the first affordable commercial
laser scanner, Vivid 700 (Minolta USA, Ramsey,
NJ). It was much less expensive than the instru-
ment Moss et al8'14'15 used. This tiny scanner
generates a class-2 laser power for scanning of
the face. The facial photograph is taken by the
CCD camera that is adjacent to the laser beam
generator in the same box. A beam splitter facil-
itates the capture of laser scan data simulta-
neously with color texture map. The Vivid 700
requires Microsoft Windows NT 4.0 workstation.
Scanning or registration (Vivid 1.22) and tex-
ture mapping software (SurfaceSuite 1.1; Sven
Technologies, Palo Alto, CA; no longer avail-
able), which are included in the purchase of the
scanner. Our morphing and animations were
performed by 3D Studio MAX R3 (3ds max;
Autodesk, Inc/Discreet Logic, Inc, Montreal,
Quebec) program and the CAD measurements
with MicroStation 95 (Bentley Systems, Inc, Ex-
ton, PA). One of the biggest advantages this
equipment provides is the speed with which the
<<    
     Article
      >>
248 Orhan C. Tuncay
Figure 4. The jig used to orient the scans of teeth
with the facial and skeletal images. First, the plaster
teeth were scanned with the jig attached, and then the
patient's face while the jig is held between the teeth.
Subsequently, these two images are merged to orient
the teeth within the craniofacial structures.23
image is captured: it takes only 0.6 seconds to
capture the image.
As in any novel system development, certain
quirks associated with the hardware had to be
overcome. Most significantly, the laser light's
dislike for transparent, bright white, and black
objects was a major obstacle. For example, if the
face is scanned while the patient is smiling, teeth
reflect the laser light and emit spikes. Also, be-
cause of the shadowing effect, capturing a
smooth image requires several scans from differ-
ent angles. These images are then merged. The
merging, however, was difficult. Neither teeth
nor face have satisfactory landmarks for triangu-
lation and merging of the images. Jigs with
rounded surfaces (Fig 4), to make the triangu-
lation or merging of the seams of various images
possible, had to be developed.
Direct laser images of teeth are not possible
from a patient's own smiling view because of the
spikes reflected off the enamel surface. Thus, it
was necessary to adjust the tooth color. To this
end, coloring the teeth was tried, but without
much success. The solution was in pouring the
alginate impressions of teeth in green plaster.
This green color balance was satisfactory for la-
ser imaging. On average five different scans of
each plaster model are made to correct for shad-
ows that form at the undercuts, or interproximal
contact points. These images are then merged
and reconstructed using the Vivid software. Fi-
nally, the resultant image is pasted behind the
Home | TOC |          
Index
facial image. To a limited extent, the lateral and
PA cephalometric films guided the operator in
exact anatomical positioning of teeth, but the
critical positioning was facilitated by the jig
placed between the teeth. The merger of the jig
images between the patient's teeth and between
the plaster models allowed for placement of the
teeth correctly in the craniofacial complex. Pres-
ently, there are commercial laboratories that can
create 3D study model images from orthodontic
alginate impressions, but this service was not
available during the development phases of our
system, and it is cheaper for us to do our own.
The teeth as well as the facial images were
affected by the shadowing problem. It necessi-
tated two or more scans of the face from side to
side. Subsequently, these were merged to obtain
one smooth image. Depending on the patient
skin color, facial makeup was needed. The skin
was covered with an ordinary foundation cream
and then applied facial powder. In particular,
skin with very dark pigmentation (eg, African-
American skin) needed the most makeup appli-
cation. In men, the presence of facial hair (such
as a mustache or beard) is not conducive to
satisfactory scanning. The greatest difficulty to
eliminate was an artifact "ridge" between the
lips. Fortunately, the serial scanning reduced the
ridge formation to a negligible level (Fig 5).
The skeletal images were generated with the
aid of lateral and PA cephalometric films. As
described previously, the method of Brown and
Abbott5 provided the technique for landmark
identification in 3D. These landmarks were then
used to morph in 3D Studio Max, a generic 3D
skull image. Landmarks that are crucial to the
Figure 5. Laser-scanned images of a patient. The
high resolution of the images is evident. The trans-
parent nature of the eyes is not conducive to image
capture. These images require facial makeup.
<<    
     Article
      >>
3D Motion Animation
orthodontist or to the surgeon were included
but not structures beyond the reach of orth-
odontic mechanics (eg, occipital or parietal
bones).
At this stage, we had a static 3D image of the
craniofacial complex with a useful skeleton,
teeth and face. The next step was to animate the
images. We used the tools of Hollywood film-
makers for this final step. The software used in
the making of films such as Star Wars or Toy Story
and many others, was 3D Studio MAX. It suited
our needs perfectly. Even working with a me-
dium speed processor (400 MHz Pentium II),
this program enables the operator to place dif-
ferent cameras around the laser image model on
a 3D stage on the computer monitor, and then
film it. This way the image can be rotated about
any axis and studied directly on the screen.
In contrast to available videoimaging systems,
with this technology, the clinician could, for
example, look down from the forehead to the
chin, or examine the chin looking up. An infi-
nite number of positions of inspection is possi-
ble. Transparency of the skin can be adjusted to
any level to better visualize the underlying struc-
tures. This is most significant because one can
see the asymmetries that have not been possible
to diagnose with conventional methods. This is
the first ever technology, without the benefit of
a CT scan, to bring together all three tissue
systems that the clinician is interested in a non-
static manner. Our next step was the animation
of the image.
The 3D Studio Max allowed us to manipulate
the image. Our first attempt was to move the
lower jaw pivoted at the temporomandibular
joint. As can be imagined, while it sounds simple
this is a very complex animation. If the jaw
moves down a little, the skin will also be affected
a little. But as the envelope of the motion in-
creases, skin stretches more. Additionally, with
increased motion the skin higher up on the face
is also affected. Perfection of such algorithm
requires additional work. More complicated
than jaw movement is the smile animation. In
the English language there are a variety of
smiles described as smirk, insipid smile, wry
smile, sardonic smile, ironic smile, inscrutable
smile, infectious smile, warm smile, along with
the smile of Mona Lisa or Audrey Hepburn.
Ackerman et al2 have proposed the "unstrained
posed smile" to be the standard orthodontic
Home | TOC |          
Index
249
record; it is shown to be reproducible. We are
currently in the process of developing the smile
animation system with this smile as the calibra-
tion point.
Effectively, we have been able to create a mo-
tion animation system (patent pending) not
only for diagnosis and planning of treatment,
but also to solicit patient consent in a better-
informed manner. It was an evolutionary process
starting with the grid projection technique, then
structured light, and finally, manipulation of la-
ser images. To our knowledge, there is not an-
other report of a system capable of allowing the
clinician to diagnose and plan for treatment and
educate the patient with the framework of func-
tional movements. Functional movements are
defined as chewing, smiling, and speech produc-
tion.
The Future
This study describes the first-ever dynamic func-
tional assessment system for the orofacial tissues.
Clearly, in these initial stages, system develop-
ment has been our focus. We have been success-
ful and it is now a usable system in our clinic, but
it requires several hours to manipulate a single
image. The system needs to be more automated
and less labor intensive. Most importantly, how-
ever, there are no standards for 3D predictions
of treatment outcome. We are now in the pro-
cess of collecting before and after data treat-
ment to fulfill this need.
Paradigm shifts in orthodontics have oc-
curred, not singularly because of our work, but
also because of products such as the Invisalign
(Align Technology, Inc, Santa Clara, CA) sys-
tem. It made braceless braces possible for the
comprehensive treatment patient. However, the
system is still in its developmental stages and is
primitive compared to what it could be eventu-
ally. Specifically, the 3D computer-assisted de-
sign and manufacturing process deals with the
tooth crowns only. The root positions are en-
tirely (perhaps deliberately) left out of the pro-
cess. Both systems, ours and Align Technology's,
need to find a way to incorporate the images of
roots as part of the system.
The process of treating the orthodontic pa-
tient with appliances fabricated by computer-
generated images is a significant step. It repre-
sents the beginning of the closing of the cycle. In
<<    
     Article
      >>
250 Orhan C. Tuncay
the early years of orthodontics, the clinician had
to fabricate a whole new appliance, often out of
gold, at each appointment. This was custom-
made appliance therapy. Over the years, for con-
venience and efficiency, the specialty embraced
the prefabricated appliances. Teeth had to move
to positions prescribed by the prefabricated ap-
pliance. Computer-generated imagery takes us
back in time to the concept of custom-made
appliances. The difference is computer-assisted
design and manufacturing is far less labor inten-
sive than what the clinician of the earlier years
had to face. Finally, as technology and its appli-
cations force their way into orthodontics, it is
reasonable to assume that the character of the
orthodontic training program will change.
References
1. Broadbent BH. A new x-ray technique and its applica-
tion to orthodontia. Angle Orthod 1931;l:45-66.
2. Ackerman JL, Ackerman MB, Bresinger CM, et al. A
morphometric analysis of the posed smile. Clin Orthod
Res 1998;1:2-11
3. Baumrind S, Moffitt F. Mapping the skull in 3-D. J Gal
DentAssoc 1972;48:22-31.
4. Cutting C, Bookstein FL, Grayson B, et al. Three-dimen-
sional computer-assisted optimization and interaction
with cephalometric and CT-based models. Plast Recon
Surg 1985;77:877-85.
5. Brown T, Abbott AH. Computer-assisted location of ref-
erence points in three-dimensions for radiographic
cephalometry. Am J Orthod Dentofac Orthop 1989;95:
490-498.
6. Marsh JL, Vannier MW, Stevens WG, et al. Computerized
imaging for soft tissue and osseous reconstruction in the
head and neck. Glin Plast Surg 1985;12:279-291.
7. Lill W, Solar P, Ulm C, et al. Reproducibility of three-
dimensional model production in the maxillofacial com-
plex. Br J Oral Maxillofac Surg 1992;30:233-236.
8. Möss JP, Grindrod SR, Linney AD, et al. A computer
system for the interactive planning and prediction of
maxillofacial surgery. Am J Orthod Dentofac Orthop
1988;94:469-475.
9. Treil J, Casteigt J, Faure P, et al. Céphalometrié 3D:
Principes et méthodes. Le Journal de 1'Edgewise 2000;
41:69-86
Home | TOC |          
Index
10. Nuveen M. Development of a low-cost three dimensional
imaging system for orthodontic diagnosis and treatment
planning. Masters thesis. Temple University, Depart-
ment of Orthodontics, Philadelphia, PA, 1996.
11. Nguyen CX. The use of the structured light technique to
image the craniofacial complex structures. Masters the-
sis. Temple University, Department of Orthodontics,
Philadelphia, PA, 1998.
12. Nguyen CX, Nissanov J, Öztürk C, et al. Three-dimen-
sional imaging of the craniofacial complex. Clin Orthod
Res 2000;3:46-50.
13. Tuncay OC, Nuveen MJ, Nguyen CX, et al. The develop-
ment of a system for three-dimensional imaging and ani-
mation of the craniofacial complex. Ortognatodonzia Itali-
ana 2000;9:331-337.
14. Moss JP, Linney AD, Grindrod SR, et al. Three-dimen-
sional visualization of the face and skull using comput-
erized tomography and laser scanning techniques. Eur
J Orthod 1987;9:247-253.
15. Moss JP, McCance AM, Fright WR, et al. A Three-dimen-
sional soft tissue analysis of fifteen patients with Class II,
Division I malocclusions after bimaxillary surgery. Am J
Orthod Dentofac Orthop 1994;105:430-437.
16. Sassouni V. Palatoprint, physioprint, and roentographic
cephalometry , as new methods in human identification.
J Forensic Sei 1957;2:429-443.
17. Rabey GP. Current principles of morphanalysis and their
implications in oral surgical practice. Br J Oral Surg
1977-78;15:97-109.
18. Farkas LG, Bryson W, Klotz J. Is photogrammetry of the
face reliable? Plast Recon Surg 1980;66:346-355.
19. Burke PH, Banks P, Beard LFH, et al. Stereophoto-
graphic measurement of change in facial soft tissue mor-
phology following surgery. Br J Oral Surg 1983;21:237-245.
20. Motoyoshi M, Namura S, Arai H. A three-dimensional
measuring system for the human face using three-direc-
tional photography. Am J Orthod Dentofac Orthop
1992;101:431-440.
21. AttickJJ, Griffin PA, Redlich AN. Statistical approach to
shape from shading: Reconstruction of 3D face surfaces
from single 2D images. Plast Recon Surg 1996;120;432-
457.
22. CO Bourne, WJS Kerr, AF Ayoub. Development of a
three-dimensional imaging system for analysis of facial
change. Clin Orthod Res 2001;4:105-111.
23. Slattery JC. Development of the laser scan craniofacial
imaging and animation system. Masters thesis. Temple
University, Department of Orthodontics, Philadelphia,
PA, 2000.
<<    
     Article
      >> Home | TOC |          
Index

Technology to Create the Three-Dimensional

Patient Record
James Mah and Axel Bumann

The current orthodontic patient record consists of photographs, radiographs

(usually lateral and PA cephalograms and a panoramic view), and either
mounted or hand articulated study models. However, the current patient
record is limited in several respects and in need for update. Recently novel
approaches to imaging have been introduced to orthodontics, which include
three-dimensional (3D) images of the face, skeleton and dentition as well as
the ability to record mandibular position and motion in 3D. Herein, we
describe novel technologies in orthodontics that can be used to collectively
create the 3D patient record. At this time, technologies have been created
for independent and specific functions such as imaging the face or the teeth
but collectively could bring patient care to a new level. A future direction is
to integrate these separate images to produce the "virtual orthodontic
patient" upon which diagnoses, treatment simulation, planning and thera-
peutics can be performed. (Semin Orthod 2001;7:251-257.) Copyright© 2001
by W.B. Saunders Company

he current orthodontic patient record gen- Then. . .

T erally consists of: photographs, planar ra-
diographs and study models. These anatomic
representations serve key roles in diagnosis,
treatment planning, communication, treatment
progress and outcomes evaluation. However, the
current patient record has several limitations
that include two-dimensional (2D) representa-
tion of three-dimensional (3D) anatomy, poor
spatial accuracy, static in space and time, distor-
tions and information voids. The future imaging
trends for orthodontics seek to overcome these
limitations using 3D facial and dental image ac-
quisition, advanced 3D radiographic methods,
and ultrasonic sensor technology to record
movement.
From the Department of Orthodontics, University of Southern
California, Los Angeles, CA; and MEOCLINIC, International Pri-
vate, Berlin, Germany.
Address correspondence to James Mah, DDS, MSc, MRCD,
DMSc, University of Southern California, 925 W 34 Street, Suite
312, Los Angeles, CA 90089-0641. E-mail: jamesmah@usc.edu.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0704-0005$35.00/0
doi:10.1053/sodo.2001.25411
In the beginning of modern orthodontics in
1908, Calvin S. Case1 criticized the Angle classi-
fication system because he thought it was an
over-simplification of the diverse variation in
types of malocclusion. He thought Angle's sys-
tem was lacking key information necessary for
comprehensive treatment planning and utilized
plaster casts of the face to demonstrate that dif-
ferent facial configurations can occur within
each of Angles classes of malocclusion. Follow-
ing Case, van Loon,2 in 1915, held a similar view
and agreed that a 3D system was required to
determine the relation of the dentition to the
face for meaningful diagnosis and treatment
planning. He used a plaster cast of the face
that also included the labial surface of the max-
illary incisors to orient the plaster cast of the
dentition, thereby creating the "face-dentition"
(Fig 1) that could be used to develop an opti-
mized treatment plan. The practical limitation
of this method was that it was complex and
inherently limited, but it was based on a very
important and fundamental concept, that being
the importance of the relationship of the denti-
tion to the remainder of the craniofacial com-
plex. This relationship is now determined by

Seminars in Orthodontics, Vol 7, No 4 (December), 2001: pp 251-257 251

<<    
     Article
      >>
252
Figure 1. "Face-Dentition" by van Loon.
means of cephalometrics, which contains several
inherent limitations.
And Now. . .
Since these early efforts by Case and van Loon,
others such as Simon3 (1922) have attempted to
relate the study models to the craniofacial com-
plex but with the introduction and widespread
acceptance of cephalometrics these approaches
were for the most part abandoned until recent
times. As technologies available for diagnosis
and therapeutics are becoming more advanced
and sophisticated, the availability of accurate 3D
information plays an ever-increasing role in suc-
cessful outcomes. This is particularly well under-
stood by clinicians who deal with the complexi-
ties of managing craniofacial anomalies and
maxillofacial reconstructions. Indeed, much of
the early work in computer-assisted 3D surgical
planning and simulation has been in these
disciplines. Recently, methods of "computer-
assisted 3D virtual reality soft tissue planning
Table 1. Methods to Create the Virtual Orthodontic Patient: Current Methods in Orthodontics and Newer
Three-Dimensional Approaches
Methodology Current Practice
Imaging the craniofacial Cephalograms
skeleton
Recording the dentition Impressions and Plaster
models
Imaging the face Photography
Recording mandibular Wax bite, Articulator
relation and motion
Abbreviations: 3D, three-dimensional.
Home | TOC |          
Index
Mäh and Bumann
and prediction for orthognathic surgery" have
been developed by Xia et al.4"6 Unfortunately,
this method relies on a computed tomography
(CT) scan to produce 3D images of the face4-6
and dentition, both of which are limited by rel-
atively inaccurate CT source. Attempts to over-
come this limitation involve the integration of
3D images of dental models into the 3D CT
image,7-8 but reliance on CT skeletal data may
lead to significant errors in positioning. Place-
ment errors of up to 4° rotation and 4.2-mm
displacement were reported by Terai et al.8 Rec-
ognizing the errors associated with CT images,
other investigators have used 3D images recon-
structed from cephalograms onto which the im-
ages of 3D dental models9 or 3D facial images10
may be integrated. Yet others have attempted to
integrate the dental model with the 3D model of
the face11 and like the early efforts of van Loon,2
did not include the craniofacial skeleton.
All the previous investigators recognized the
tremendous clinical value of 3D approaches to
diagnosis and treatment planning but were un-
able to produce a complete, reliable and clini-
cally easy-to-use approach. Many relied on the
relatively inaccurate images of CT and others
omitted key elements such as the dentition or
the skeleton. It is logical that the records avail-
able to diagnose and treatment plan should con-
tain the face, craniofacial skeleton, dentition
and if possible motion (Table 1).
A fundamental goal of new imaging technol-
ogies is accuracy as they should produce data
and images that truly represent the anatomy and
function of the patient. Accurate and reliable
information sets the stage for better diagnosis,
treatment simulation, therapy, computer analy-
New Technology (Manufacturer/Distributor) Goal
Anatomic Reconstruction (Acuscape Intl, 3D skeletal images
Glendora, CA)
Cone Beam 3D CT (ZeroBase-USA, Inc,
Olean, NY)
3D dental scanner (OraMetrix Intl, 3D model of the
Dallas, TX) dentition
3D image acquisition (Eyetronics Corp, 3D facial images and
Leuven, Belgium) analysis
3D ultrasonic motion (Zebris 3D mandibular relation
Medizintechnik GmbH, Tubingen, and motion
Germany)
<<    
     Article
      >>
Technology to Create the Three-Dimensional Patient Record
sis (such as modeling, simulations and finite
element analysis) and overall understanding of
orthodontics. Therefore, new methods must be
at least if not many times more accurate than the
current practice. Motivation behind this accu-
racy is to maximize benefit and utility of the new
technologies. The 3D model of the dentition
will contain sufficient accuracy to construct ap-
pliances with advanced methods such as com-
puter-assisted design (CAD)/computer assisted
manufacturing (CAM) or output to robots for
computerized wire bending and other treat-
ments. In addition, skeletal morphology will be
accurate enough to construct surgical templates
and guides to assist surgeons. Accurate represen-
tation of mandibular movement and position
will allow for improved treatment simulation
and planning of orthognathic surgery. Many
other possibilities exist but all are made possible
with accurate 3D images.
Methods of Three-Dimensional
Facial Imaging
In general, there are two basic technologies
available for 3D facial image acquisition: laser
scanning and structured light methods.
Laser Scanners
These scanners record the distortion of a pro-
jected laser pattern onto the 3D object and infer
surface characteristics by the type of distortion
to provide a "surface map." Texture or color
information is recorded simultaneously by a
color digital/video camera and is layered over
the surface map. However, this method is rela-
tively slower, the faster laser scanners require
approximately 0.6 seconds/scan during which
time patient movement may occur. Since the
laser beam is a straight line, laser scanners can-
not image undercut and opposing surfaces, and
therefore multiple perspectives need to be
"stitched" together to produce a composite im-
age. In addition, while the lasers in these cam-
eras have been deemed safe for the eyes of
adults no safety guidelines exist for children
leaving their use in this age group questionable.
Structured Light
This technology uses the projection of a struc-
ture of lines, grids or other patterns onto the
Home | TOC |          
Index
253
object or face. As the projected pattern is dis-
torted by the contours of the object, the dis-
torted pattern is recorded by a digital camera/
video. Triangulation is used to calculate the 3D
points. The precision of these systems is largely
dependent upon the camera and lens. As above,
multiple perspectives are "stitched" together to
produce a 3D model. A clear advantage of these
systems is the speed of data acquisition which is
the same as the camera shutter speed. The light
source is usually an ordinary halogen white light,
thus avoiding the safety concerns of laser scan-
ners.
Methods of Three-Dimensional
Craniofacial Skeletal Imaging
Within the next one or two years, orthodontists
will have available to them 3 or 4 possible meth-
ods to obtain 3D radiographic images of pa-
tients: tomosynthesis, tuned aperture computed
tomography (TACT), anatomic reconstructions,
and cone-beam CT.
Digital sensor technology has made it possible
to use variations in exposure angles and beam
geometry to produce 3D data sets. The earliest
form of 3D digital imaging was CT and the more
recent applications include tomosynthesis and
its variation called TACT as well as the applica-
tion of photogrammetry techniques to radiology
and the latest cone-beam CT devices optimized
for imaging the head and neck.
Computed Tomography Scans
The CT scanners are relatively large, expensive
and are generally located in a dedicated medical
imaging center or hospital. The modern CT
scanners use an array of detectors mounted in a
circle around the patient positioning portal. The
x-ray tube produces a narrow fan shaped x-ray
beam and rotates around the patient during an
exposure. At any given tube location the non-
absorbed x-ray photons are projected onto mul-
tiple sensors located on the opposite side of the
portal. Each sensor receives several unique views
of the anatomy as the tube rotates around the
patient. The patient can be incrementally moved
through the scanning portal to incrementally
expose tissue layers. The various views of each
tissue layer are integrated with mathematical al-
gorithms to compute the attenuation values of
<<    
     Article
      >>
254 Mäh and Bumann
volumes of tissues and display them as 2D pic-
tures. The attenuation values for multiple con-
tiguous tissue layers are solved to provide 3D
data for visualization. Post-processing software
allows for reconstruction of a two dimensional
image along a user prescribed tissue layer or
curve located in axial, coronal, sagittal or
oblique planes.
Advantages of CT scans include the recording
of hard and soft tissues, visualization of the anat-
omy in 3D and the ability to interactively display
anatomy from a desired view point. The main
disadvantages of CT scans include high cost,
high radiation exposure and relatively poor an-
atomic detail.
Tomosynthesis and Tuned Aperture
Computed Tomography
These are mathematical reconstruction tech-
niques that require multiple transmission type
x-ray projections acquired at various projection
angles. This can be accomplished with one or
more digital sensor and one x-ray source that
move between exposures. The reconstruction
algorithms used with tomosynthesis require that
the projection geometry and location of sen-
sor (s) and x-ray source are known. TACT
projects fiducial marker (s) onto the image plane
and these markers assist in the reconstruction of
the image when arbitrary or unknown projec-
tion geometry was used. These techniques allow
for the reconstruction of an infinite number of
thin image sections from a small number of
unique images.
Combining amorphous silicon sensors, ro-
botic x-ray units and TACT or tomosynthesis
algorithms would allow for the reconstruction of
the entire head. The advantages of TACT or
tomosynthesis when compared to CT scans in-
clude low dose, low cost and improved detail.
Anatomic Reconstructions
Knowledge of the spatial relationships between
the source, sensor and the imaged anatomy with
7 degrees of freedom (DOF) (x,y,z, yaw, pitch,
roll and focal length) creates the ability to com-
bine multiple images into a 3D database for
future analytical or reconstruction procedures.
Anatomic reconstructions use close-range pho-
togrammetry algorithms to determine the pre-
cise location (7 DOF) of the source, sensor and
Home | TOC |          
Index
anatomy by measuring geometric effects of the
projection geometry on a calibration frame
placed into the field of view and rigidly attached
to the patient during imaging sessions (Fig 2).
The measurements can be used to construct
models, spatially stitch together various image
sets and populate a morphometric database with
3D locations of selected anatomic structures.
The calibrated images allow for 3D cephalomet-
ric and photographic measurements with an ac-
curacy in the range of 0.1 mm. The advantages
of this system include the ability to calibrate the
standard 2D images currently used in orthodon-
tics (lateral and PA cephalograms) without the
addition of capital equipment and combine
them into a single 3D database for measurement
and anatomic reconstruction in the form of a
digital model (Fig 3).
Cone Beam Computed Tomography
These devices are based on conventional CT
technology but contain a number of enhance-
ments to optimize them for imaging the head
and neck. A reduced chamber volume, small
enough for just the head and neck, in itself
allows for a significant reduction in radiation
exposure. Real-time feedback between the digi-
tal sensor and x-ray source allow for increases or
reductions in x-ray energy to account for varia-
tions in patient size and tissue density as the
patient is being imaged to provide optimal im-
ages while further reducing radiation exposure.
Additional reductions result from the cone-
beam projection of x-rays, which produces a
more focused beam and much less radiation
scatter compared to the conventional fan-shape
projection of conventional CT devices. Total ra-
Figure 2. Calibration Headframe rigidly attached to
patient during imaging sessions.
<<    
     Article
      >>
Technology to Create the Three-Dimensional Patient Record
Figure 3. Anatomic Reconstruction. 3D image ren-
dered from lateral and frontal cephalograms using
Acuscape Sculptor. (Courtesy of Acuscape Interna-
tional, Glendora, CA.)
diation exposure of current units is approxi-
mately 20% of conventional CT. In addition, the
"slices" are sagittal and constructed transversely
providing for the image quality desired in orth-
odontics. The manufacturer reports a precision
of 0.28 mm, which is approximately a 5 to 10-
fold improvement on conventional CT. Speed of
image acquisition is also greatly improved. The
patient's head is in the imaging chamber for a
just over 1 minute of which only 18 seconds is
exposure time.
Methods of 3D Intraoral Dental Imaging
Intraoral 3D Camera
The technologies to image the face in 3D, such
as laser scanning and structured light, may be
applied on a smaller and more confined scale in
the patient's mouth. A concern of imaging pa-
tient's teeth is movement during the process.
For this reason lasers may be difficult to work
with in addition to safety issues related to the
laser. Therefore the structured light techniques
are most applicable to scanning the dentition
(Fig 4). A video camera records the structured
light distortions on the dental crowns as it is
passed over the dentition over a time period of
approximately one minute. The stream of im-
ages is fed back to a computer and processed
and stitched together to create a complete den-
tal arch. Indeed this 3D intraoral camera has
been demonstrated at the recent American As-
Home | TOC |          
Index
255
sociation of Orthodontists (AAO) meeting and
will be commercially available in 2001.
Methods of Capturing Mandibular
Motion in 3D
Ultrasonic Motion Capture
These systems allow for recording of mandibular
movements in real time, recording and display
of the 3D movements in digital form. Following,
the parameters of functional analysis, in addi-
tion to the settings of a fully adjustable articula-
tor (hinge axis [HA], condylar inclination [CI]
and immediate-side-shifts [ISS]) are calculated
and issued in a graphic report. The system is
based upon the transmission time measurement
of ultrasound impulses with highly sensitive sen-
sors located on a head frame secured to the
patients head (Fig 5). The ultrasound emitter
array is bonded to the labial surfaces of the
mandibular teeth using a jig customized with
cold cure acrylic. The mandibular component is
sufficiently lightweight (25gm) that it does not
interfere with mandibular motions. Reference
points are entered via a sensor pen and permits
re-registration between recording sessions. The
manufacturer performance specifications are
measurement resolution of 0.01 mm and mea-
surement rate of 100 measurements per second.
Conclusions
We have described several novel technologies
that can be used to create a 3D patient record,
including images of the craniofacial skeleton,
dentition, face, and motion. This new informa-
Figure 4. OraScanner*, an intraoral 3D camera. (Im-
age Courtesy of OraMetrix, Inc.)
<<    
     Article
      >>
256 Mäh and Bumann
Figure 5. Ultrasonic Motion Capture. The head-
mounted sensor detects movement of the ultrasonic
emitter attached to the mandibular teeth.
tion will provide benefits in the areas (1) diag-
nosis; (2) treatment planning, simulation and
therapeutics; (3) development of future tech-
nologies and approaches to orthodontics; and
(4) research - treatment outcomes, evidence-
based orthodontics.
Diagnosis
Potential and immediate applications of these
new technologies would seem to be in patient
diagnosis. They would literally add new dimen-
sions to allow us to evaluate patients more accu-
rately and thoroughly. Databases of 3D patient
records may be used for comparison and evalu-
ation and would provide valuable information to
the clinician.
A large step forward would be accurate re-
cording of mandibular motion. In current prac-
tice of orthodontics, recording of mandibular
movements is not widespread and of those prac-
tices that keep these records, they are mostly
limited to articulated study models with mount-
ings in centric relation (CR) and centric occlu-
sion (CO). Indeed the validity and usefulness of
these type of records is often questioned and
remains controversial. This may in part be due
to their limited description of the true biologic
state that is dynamic, involves muscles and artic-
ular discs, may be growing and exists in 3D.
Nevertheless, the goal of recording mandibular
movement is a worthy one. We need to under-
Home | TOC |          
Index
stand mandibular movement for diagnosis of
parafunction and to predict response to a variety
of treatments such as bite-opening/closing, re-
moval of occlusal interferences, splint therapy,
functional appliance treatments and orthog-
nathic surgery. The 3D records of mandibular
movement address this void in the patient
record and serve as a very powerful method to
assist in patient diagnosis and treatment.
Treatment Planning, Simulation,
and Therapeutics
Computer-assisted treatment planning in 2D is
current practice in orthodontics. The third di-
mension will serve to further develop and refine
these methods. In addition, treatment simula-
tions may be more realistic and accurate. With
dimensionally accurate records, not only may
treatment be planned and simulated but imple-
mented through methods such as computerized
wire bending and fabrication of appliances by
CAD/CAM. These approaches potentially offer
increased efficiencies with reduction in errors
related to materials, construction of appliances,
and hand-skills. For these reasons, there have
been developments in medicine to allow new
technologies such as computer vision and robots
to assist in planning and implementation of
complex surgeries.
As current treatment modalities in orthodon-
tics are becoming more sophisticated the de-
mands of having accurate 3D patient records are
evermore critical. For example during distrac-
tion osteogenesis, one of the most significant
challenges is to navigate and position the dis-
tracted segment in 3D to achieve symmetry, oc-
clusal harmony and function. In this instance
planning and execution of the distraction pro-
cedure could be simulated and monitored.
Development of Future Technologies and
Approaches to Orthodontics
Accurate patient records and reliable informa-
tion is key to our understanding of orthodontics
and opens the door for future developments
using methods such as computer modeling and
analysis of biomechanics. Scientists can model
atomic explosions, design spacecraft, and con-
duct wind tunnel testing on the computer with-
out having to carry out the physical construction
and testing. In medicine, computer simulation
<<    
     Article
      >>
Technology to Create the Three-Dimensional Patient Record
of biologic events such as an asthma attack has
lead to development of new drugs. Methods
such as this would clearly benefit orthodontics.
Novel approaches to orthodontics could be crit-
ically evaluated, tested and developed using evi-
dence based methods before they are carried
out on patients. An attractive feature of com-
puter modeling is that as more is learned about
the details of tooth movement and orthodontics
in general, this information can be integrated
into the model to continue refining and updat-
ing it. The goal would be to develop methods
with which clinicians can accurately simulate dif-
ferent treatment scenarios and select optimal
biomechanics and treatment for patients.
Research
In orthodontics, one need not look far to find
information voids, assumptions, and misrepre-
sentations. Unfortunately, this has lead to con-
troversy and in many instances misdiagnosis and
improper treatment. One reason for this situa-
tion is that our current method of patient eval-
uation and analysis is limited. The patient
record (photographs, radiographs and study
models) has not changed for decades despite
the abundant literature on its limitations. As-
sumptions and "clinical experience" are used to
fill in the information voids. Methods need to be
developed that allow for accurate, unambiguous
patient assessment and analysis.
In this vein, these methods and newer ap-
proaches will allow objective review and investi-
gation of clinical diagnosis and treatments to
determine if our knowledge based on 2D
records is accurate and appropriate. These
methods offer potential to profoundly expand
and deepen our understanding of growth and
Home | TOC |          
Index
257
development and therapy, and overall benefit
our patients.
References
1. Case CS. Dental Orthopedia. CS Case, Chicago, 1908.
2. Van Loon JAW. A New method in dento-facial orthope-
dia, Parts 1 and 2. Dental Cosmos. 1915;57:1093-
1101,1229-1235.
3. Simon PW. Grundzüge einer systematischen Diagnostik
der Gebiß-Anomalien. Meusser, Berlin, 1922.
4. Xia J, Ip HHS, Samman N, et al. Computer-assisted three-
dimensional surgical planning and simulation: 3D virtual
osteotomy. IntJ Oral Maxillofac Surg 2000;29:11-17.
5. Xia J, Samman N, Yeung RWK, et al. Computer-assisted
three-dimensional surgical planning and simulation: 3D
soft tissue planning and prediction. IntJ Oral Maxillofac
Surg 2000;29:250-8.
6. Xia J, Wang D, Samman N, et al. Computer-assisted
three-dimensional surgical planning and simulation: 3D
color facial model generation. IntJ Oral Maxillofac Surg
2000;29:2-10.
7. Nishii Y, Nojima K, Takane Y, et al. Integration of the
maxillofacial three-dimensional CT image and the three-
dimensional dental surface image. J Japan Orthod Soc
1998;57:189-94.
8. Terai H, Shimahara M, Sakinaka Y, et al. Accuracy of
integration of dental casts in three-dimensional models.
J Oral Maxillofac Surg 1999;57:662-5.
9. Okumura H, Chen LH, Tsutsumi S, et al. Three-dimen-
sional virtual imaging of facial skeleton and dental mor-
phologic condition for treatment planning in orthog-
nathic surgery. Am J Orthodont Dentofac Orthop 1999;
116:126-31.
10. Chen LH, Chen WH. Three-dimensional computer-as-
sisted simulation combining facial skeleton with facial
morphology for orthognathic surgery. In J Adult Orthod
Orthognath Surg 1999;14:140-5.
11. Sohmura T, Kojima T, Wakabayashi K, et al. High speed
3D shape measurements of teeth model and face (Part
3). An attempt for clinical application of facial and
dental surface data [abstract]. The 33rd general session
of the Japanese Society for Dental Materials and Devices
1999.
<<    
     Article
      >> Home | TOC |          
Index

Integrated Three-Dimensional Craniofacial

Mapping at the Craniofacial Research
Instrumentation Laboratory/University
of the Pacific
Sean Curry, Sheldon Baumrind, Sean Carlson, Andrew Beers,
and Robert Boyd

This article describes the integrated three-dimensional craniofacial mapping

system that has been developed and is currently in use in the Craniofacial
Research Instrumentation Laboratory at the University of the Pacific School
of Dentistry, San Francisco, CA. (Semin Orthod 2001;7:258-265.) Copyright©
2001 by W.B. Saunders Company

Developing practical systems for generating
integrated three-dimensional (3D) cranio-
facial maps by merging information from x-ray
cephalograms, study casts, and facial photo-
graphs has been a focus of interest of our re-
search group since 1968.1'3 Collaborations with
the Department of Civil Engineering, University
of California Berkeley, led relatively early to
conceptual solutions, that analogize standard
methods of topographic mapping.4-9 A major
advance was the recognition that the use of
radiopaque "tie points" (removable temporary
variants of the implants of Bjork10'11) would fa-
cilitate the merging of information from differ-
ent sources with high accuracy and precision.
The conceptual basis for the use of tie points to
merge 3D data from cephalometric xrays, study
From the Craniofacial Research Instrumentation Laboratory,
Drpartment of Orthodontics, University of the Pacific, School described
Dentistry, San Francisco, CA.
Development of the CRIL hardware and software systems re-
ported in this paper were supported in part by the Align Technology
Corporation and the Gendex Corporation. Earlier investigations that
led to the development of the present system were supported in part by
NIH-NIDR Grants #DE03598, DE03703, and DE07817.
Address correspondence to Sean Curry, PhD, Craniofacial Re-
search Instrumentation Laboratory, Department of Orthodontics,
University of the Pacific, School of Dentistry, 2155 Webster Street,
San Francisco, CA 94115.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0704-0006$35.00/0
doi:l 0.1053/sodo. 2001.25422
casts, and facial photographs is explored in this
issue by Baumrind.13
Clinically related publications growing out of
this collaboration were published in the engi-
neering,13-20 medical,21-26 and orthodontic27'28
literature. Meanwhile, investigators in other lab-
oratories and clinics were conducting parallel
investigations, only a few of which can be cited
here.29-35
Until approximately 10 years ago, the data-ac-
quisition and data-processing techniques available
for applications of this type were very slow and
labor intensive. Fortunately, three developments
of the past 10 years have facilitated progress. These
are (1) the increased availability of low-cost high-
speed computing, (2) the availability of structured
light systems for 3D facial photography,36 and (3)
the implementation of destructive scanning meth-
ods for efficient 3D mapping of study casts.37'38 In
combination, these advances have made possible
the development of the general system, that is
of in this study.
Creation of an Integrated
Three-Dimensional Model
A major focus of the Craniofacial Research In-
strumentation Laboratory (CRIL) at the Univer-
sity of the Pacific School of Dentistry (UOP) has
been the development of instrumentation, soft-
ware, and procedures for the creation of an
accurate, integrated 3D craniofacial data model.

258 Seminars in Orthodontics, Vol 7, No 4 (December), 2001: pp 258-265

<<    
     Article
      >>
Integrated Three-Dimensional Craniofacial Mapping
The model is built using data from the following
sources:
A calibrated stereo x-ray device, using the Den-
Optix digital imaging system (Gendex Corp,
Des Plaines, IL).
A calibrated stereo camera from 3DMetrics, Inc
(Petaluma, CA).
Three-dimensional digital models of the upper
and lower study casts, created using technology
from Align Technology, Inc (Santa Clara, CA).
The resulting model contains 3D data on the
facial surface, the upper and lower dentition,
and the skeletal anatomy. All these data are ac-
curately merged together in a single anatomically-
determined frame of reference using a special
version of Align Technology's TREAT software.
Emphasis has been placed on optimizing the 3D
geometric accuracy at each step of the process
through the use of rigorous measurement and
calibration processes, as described below.
A key feature of the CRIL system is the meth-
odology for the accurate merging of 3D data
from multiple sources using tie points. The pro-
cess consists of the following steps:
1. A patient is fitted with a set of tie points,
which are radiopaque markers that are at-
tached to the teeth. The patient is also fitted
with a second set of tie points that consists of
radiopaque markers on the face.
2. Using CRIL's calibrated stereo x-ray machine,
controlled lateral and frontal stereo x-ray im-
age pairs are obtained.
3. Using CRIL's data collection and analysis sys-
tem, 3D coordinates are computed for the tie
points on the teeth, the tie points on the face,
and specific anatomic landmarks visible in
the stereo x-rays.
4. Using a commercially available digital stereo
camera system, 3D coordinates are computed
for the tie points on the face.
5. Using Align technology, 3D coordinates are
computed from the study casts for the tie
points on the teeth, by creating and measur-
ing a standard Align study cast.
6. After all this processing, 3D coordinates have
been gathered for the following:
a. Skeletal anatomic features from the stereo
x-ray images.
b. Tie points on the upper and lower denti-
tion from the Align digital model.
Home | TOC |          
Index
259
c. Tie points on the face from the 3DMetries
camera model.
d. Tie points on the face and the upper and
lower dentition from the stereo x-ray im-
ages.
7. Through a series of mathematical transforma-
tions:
a. The tie points on the teeth are trans-
formed to the anatomic system defined by
the anatomic features from the x-ray im-
ages.
b. The models of the upper and lower denti-
tion are transformed to the same anatomic
system using the common tie points on the
teeth.
c. The facial imagery is transformed to the
same anatomic system using the common
tie points on the face.
Thus, the anatomic features located on stereo
x-ray images act as a framework or scaffold on
which data from the other sources (study cast
and facial images) are hung. In this way, the
study cast data and the facial image data can be
visually and analytically compared with each
other, though there is no direct data connection
between the two. Also, all the data can be refer-
enced to an anatomic frame of reference.
Calibrating the Stereo X-Ray System
The heart of the CRIL data collection system is
the calibrated stereo x-ray machine (Fig 1). This
device uses twin x-ray emitters mounted in a
coplanar orientation that mimics the geometry
of human vision and of conventional terrestrial
mapping from airplanes and satellites. It makes
possible the acquisition of high accuracy 3D co-
ordinates of the tie points, required for the sub-
sequent merging of data from different sources.
In addition, it facilitates the capture of 3D coor-
dinate information for key anatomical structures
in the cranial skeleton. Before data collection
begins, the stereo x-ray system must be cali-
brated.
Calibration of the x-ray system consists of the
accurate determination of the two emitter loca-
tions in 3D with respect to the cassette that holds
the image-recording medium, a digital DenOp-
tics plate (Gendex Corporation). The cassette is
positioned in a specialized holder that carries a
series of radiopaque fiducial markers on acrylic
<<    
     Article
      >> Home | TOC |          
Index

260 Curry et al

Figure 1. The Craniofacial Research Instrumentation Laboratory/University of the Pacific coplanar cephalom-
eter. Emitter 1 generates a standard lateral or frontal cephalogram. Emitter 2 generates an offset frontal or
lateral cephalogram. Overall view (A). Close-up of Twin emitters (B).

plates (Fig 2). These fiducial markers have accu- It consists of three parallel acrylic plates, each
rately known two-dimensional (2D) coordinates, containing a series of small radiopaque markers.
previously determined using a precision coordi- The 3D coordinates of the markers are known to
nate measuring machine. The images of the fi- an accuracy of ±.02 mm from prior measure-
ducial marks appear on all exposed plates and
allow us to mathematically transform each x-ray
image to a constant location with respect to the
cassette holder.
A calibration array (Fig 3) has been devel-
oped by CRIL for calibration of the x-ray system.

Figure 3. The calibration cage. This device has eigh-

Figure 2. An array of radiopaque fiducial markers is
mounted in front of the film plane. These points are
projected upon each image at the time of exposure
and define the precise position of the cassette. The
locations of the fiducial markers on the cassette
holder.
teen radiopaque metal markers mounted in three
carefully milled plastic planes such that the maximum
number of markers will be projected on the image
surface at exposure from each emitter. The positions
of the markers on the planes are known with great
accuracy by previous measurement. Their projected
images on the film plane allow us to calculate the true
spatial relationships between the two emitters, the
fiducial markers, and the film plane with high accu-
racy and precision.
<<    
     Article
      >> Home | TOC |          
Index

Integrated Three-Dimensional Craniofacial Mapping 261

ment of the array with a precision coordinate

measuring system. The array is placed in the
x-ray field of view, and a separate exposure is
obtained from each emitter. The DenOptix
plates are then scanned, and both digital images
are processed using CRIL software to obtain im-
age coordinates for all of the array points.
The image coordinates are processed using a
numerical analysis package called a bundle ad-
justment, which uses a least squares technique to
compute the emitter locations. Tests of the sys-
tem after calibration indicate that we can com-
pute coordinates of unambiguously identifiable
targets with an absolute accuracy of approxi-
mately ±0.1 mm in all three dimensions. Once
calibration has been completed, the acquisition
of an integrated 3D data set can begin. No fur-
ther calibration is required so long as the system
geometry remains stable. Figure 4. Upper and lower tie-point bearing Aligners
The data acquisition procedure involves a se- positioned in the mouth.
ries of steps as described here.
The camera projects a color-coded light pattern
Step 1: Generating Three-Dimensional Digital
onto the face before each image is acquired
Models of the Upper and Lower Teeth, and
(Fig 5D). The pattern is displaced by the con-
Creating Tie-point Bearing Aligners
tours of the face, allowing the software to later
Accurate and stable poly vinyl siloxane (PVC) automatically generate an accurate 3D model or
impressions of the upper and lower teeth are Stereoimage. A matching view with no projected
obtained. Using these, Align creates 3D digital pattern is also acquired. The 3DMetrics camera
models of the upper and lower teeth for later and associated software can acquire and com-
merging with the facial and x-ray data. Align pute a 3D surface of the face with a lateral
also constructs, to our specifications, upper resolution of approximately 1.0 mm, and a
and lower Aligners with small radiopaque depth resolution of approximately 0.2 mm.
spherical tie-points added to each, as shown in Normally, at least one frontal and two lateral
Figure 4. The Aligners are placed on the pa- oblique Stereoimages are taken, to ensure com-
tient's teeth during the later x-ray imaging plete coverage of the face. Each Stereoimage is
process. used to generate a separate 3D model. Cur-
rently, the individual facial models from the sev-
Step 2: Placing Facial Tie Points eral Stereoimages are "stitched" together using
the 3DMetries software, which uses only 3 com-
Another set of radiopaque tie points is placed on mon points for merging each pair of images. We
the patient's face. These spheres will appear in are currently adapting our mathematically rigor-
the facial 3D model as well as the x-ray images, ous transformation software to allow merging
allowing later merging of the data (Fig 5D). the 3D information from all the patient's stereo-
Their exact locations on the facial surface are images simultaneously using all available facial
not critical, but they should be fairly evenly dis- tie points. This should result in facial reconstruc-
tributed over the entire area of interest. tions of much greater accuracy.

Step 3: Generating a Three-Dimensional Step 4: Generating a Three-Dimensional X-Ray

Photographic Model of the Face Model of the Teeth, Face, and Skull
The subject is seated in front of the 3DMetries Frontal and lateral x-ray pairs are generated us-
camera and a series of stereo-images is collected. ing the calibrated x-ray emitters and DenOptix
<<    
     Article
      >> Home | TOC |          
Index

262 Curry et al

Figure 5. Measurement of
the facial surface. The 3DM-
etrics camera system (A).
This system consists of 3
components mounted in a
fixed relationship to each
other: (1) a projector which
casts a rainbow grid on the
surface of the face, (2) a
digital camera (camera 1)
which photographs the pro-
jected grid, and (3) a second
digital camera which cap-
tures a color photograph of
the face. The rainbow grid as
it would appear when viewed
from the perspective of the
projector (B). The rainbow
grid as it appears viewed
from Camera 1. The distor-
tion of the grid between the
projector view and the Cam-
era 1 view is used to com-
pute 3D measurements (C).
The color image of the sub-
ject as viewed from Camera
2 (D). Merged panoramic
view made by semi-automati-
cally assembling information
from one frontal and two lat-
eral exposures of the 3D
Metrics system (E).

imaging plates (Fig 6). Fiducial marks on each
film are used to reference the digital image to
the calibrated x-ray system. Note also the tie
points imaged on the films—both those on the
face and those on the teeth. A big advantage of
the DenOptix system is that it provides us with a
large dynamic range in the images, making it
possible to create good images for clinical eval-
uation while still allowing the clear identification
of fiducial and tie points. The resulting digital
images are analyzed using CRIL software. This
analysis yields 3D coordinates for all the tie
points, as well as for any anatomic features of
interest.
<<    
     Article
      >> Home | TOC |          
Index

Integrated Three-Dimensional Craniofacial Mapping 263

Figure 6. Lateral and frontal stereopairs showing facial and tooth tiepoints. In this figure, the left image pair
(A and B), and the right image pair (C and D) are coplanar stereopairs generated using the CRIL co-planar
apparatus illustrated in Figure 1 while images A and C, taken together, approximate a Broadbent bi-planar
stereopair.

Step 5: Merging the Several Step 6: Viewing the Integrated

Three-Dimensional Models
The UOP/CRIL software is used to compute the
transformations between the individual 3D mod-
els so that they can be merged into a single
frame of reference (Fig 7). Each model is trans-
formed with 7 parameters (3 rotations, 3 trans-
lations, and 1 scale factor) to the common coor-
dinate system. At least three common tie points
are required in each overlapping 3D model to
compute this transformation, but we use addi-
tional points to strengthen the solution and to
allow error checking. The transformation is
computed using a rigorous least-squares adjust-
ment, which also produces statistics on the qual-
ity of the fit (Fig 8).
Three-Dimensional Model
The resulting integrated 3D craniofacial model
can be viewed interactively by using Align's
TREAT software. Individual components of the
model can be turned on and off separately, and
the transparency of each component can be var-
ied separately. The integrated 3D model can be
rotated freely around any desired axis under
user control. Any surface or group of surfaces of
interest can be made visible and invisible, and
the transparency of each surface can be changed
separately as desired. In practice, this means that
the clinical orthodontist will have complete free-
dom to peel away the virtual layers of the face as

Figure 7. Representative views of the integrated three-dimensional craniofacial map. Lateral and frontal
cephalograms with oriented study casts viewed from the lateral aspect (A), viewed from the frontal aspect (B),
viewed from the 45 degree oblique aspect (C).
<<    
     Article
      >>
264 Curry et al
Figure 8. Representative additional capabilities. Facial wire frame surface model from SDMetrics Camera 1
merged with Lateral Gendex/DenOptix X-Ray Image (A), facial surface model and image from SDMetrics
Camera 2 merged with Lateral Gendex/DenOptix X-Ray Image (B), representative conventional cephalometric
measures overlaid on an integrated model (C).
desired and to view regions of interest from any
desired angle, entirely according to his or her
personal taste (Fig 8).
Conclusions
The orthodontist and maxillofacial surgeon will
in the very near future, have at his or her dis-
posal an array of information-acquisition tools to
match the complexity of the clinical problem at
hand. For some simple problems, the use of the
current nonintegrated 2D physical records may
suffice. For more complex situations, a gradu-
ated series of responses will be available. At a
moderate level of complexity, existing cepha-
lometers in clinicians' offices can be calibrated
in site, making possible 3D reconstructions of
acceptable accuracy from a single conventional
emitter. The data source could be limited to a
single lateral ceph plus a single frontal ceph,
provided the system was calibrated and that the
same set of tie-points could be located without
ambiguity on both films. Where 3D information
about the location of discrete anatomical fea-
tures lying off the mid-sagittal plane is needed,
stereo x-ray systems equivalent to the one at
CRIL would have to be available. Where more
extensive 3D information about cranial surfaces
and skeletal contours is needed, low-emission com-
puted tomographies scanners such as the New-
torn39 are becoming available. These might best be
used synergistically with tie-point-based high-reso-
lution systems, such as that described here.
Almost certainly, clinicians will wish in the
near future to add to their armamentarium
Home | TOC |          
Index
high-resolution information about the head in
motion. For information about changes in the
contours of the facial surface during speech,
mastication, and deglutition, high-speed variants
of the structured light camera used in our
present system will soon become generally avail-
able. For studies of the changing relationships be-
tween the jaws and teeth during function, appara-
tus that automatically tracks active targets like light-
emitting diodes attached to the face have been
built and will become increasingly practical.40'41
The use of tie-points to facilitate automatic merg-
ing of information from different sources will be-
come progressive and more widely applied.
References
1. Baumrind S, Moffitt FH. Mapping the Skull in 3D. J
California Dental Assoc 1972;48:22.
2. Baumrind S. A System for Craniofacial Mapping
Through the Integration of Data from Stereo X-Ray
Films and Stereophotographs. Technical Papers from
the Symposium on Close Range Phto gramme trie System,
American Society of Photogrammetry, University of Illi-
nois, Urbana, IL, 1975;142-166.
3. Moffitt FH. Stereo x-ray photogrammetry applied to
orthodontic measurements. Proceedings of the 12th
Congress of the International Society of Photogramme-
try, Ottawa, Canada, 1971.
4. Curry S, Anderson JM, Moffitt F. Calibration of a Close-
Range Stereometric Camera System. Proceedings, Amer-
ican Society of Photogrammetry Annual Convention,
Washington, DC, 1981.
5. Curry S, Moffitt F, Symes D, et al. A Family of Calibrated
Stereometric Cameras for Direct Intraoral Use. Proceed-
ings, Biostereometrics '82 (SPIE), San Diego, California
1982;7-14.
6. Isaacson RJ, Baumrind S, Curry S, et al. Semi-Real Time
<<    
     Article
      >>
Integrated Three-Dimensional Craniofacial Mapping
Monitoring of the Functional Movements of the Mandi-
ble. Proceedings, Society of Photo-Optical Instrumenta-
tion Engineers 1982;361, paper #4.
7. Baumrind S, Moffitt FH, Curry S, et al. A Dedicated
Stereophtogrammetric X-Ray System for Craniofacial
Research and Treatment Planning. Proceedings, Society
of Photo-Optical Instrumentation Engineers 1982; 361;
paper #38.
8. Moffitt FH, Baumrind S, Chafetz N, et al. A Stereoen-
tengenographic System with Portable Calibration Cage for
Use in Clinical Medicine. Proceedings, Society of Photo-
Optical Instrumentation Engineers 1982;361, paper #39.
9. Korn EL, Baumrind S, Chafetz N, et al. Establishing
Quantitative Within-Subject Confidence Limits for Clin-
ical Stereogenographics. Proceedings, Society of Photo-
Optical Instrumentation Engineers 1982;361, paper #40.
10. Bj0rk A. Variations in the growth pattern of the human
mandible: Longitudinal radiographic study by the im-
plant method. J Dent Res 1963;42:400-411.
11. Bj0rk A, Skieller V. Facial development and tooth erup-
tion: An implant study at the age of puberty. Am J
Orthod 1972;62:339-383.
12. Baumrind S: Background, principles, and perspectives.
Sem Ortho 2001;7:223-232.
13. Curry S, Baumrind S. Analysis of Stereo Cranial X-Rays
using Digital Images. Close Range Photogrammetry and
Surveying Symposium, American Society of Photogram-
metry 1984;35-46.
14. Curry S, Anderson JM, Baumrind S, et al. Stereo Camera
and Stereo X-Ray Devices: Comparison of Biostereomet-
ric Measurements. Photo gramme trie Engineering and
Remote Sensing 1985;51:1597-1603.
15. Baumrind S, Curry S. Merging of Data from Different
Records in Craniofacial Research and Treatment. Close
Range Photogrammetry and Surveying Symposium,
American Society of Photogrammetry 1984;35-46.
16. Curry S, Baumrind S. Real Time Monitoring of the
Movement of the Mandible. Proceedings, American So-
ciety of Photogrammetry 1986;92-100.
17. Curry S, Baumrind S, Anderson JM. Calibration of an
array camera. Photogrammetric Eng Remote Sensing
1986;52:627-636.
18. Curry S, Baumrind S. Digital Methods for Mandibular
Motion Measurement. Proceedings DOCUMED, Am-
sterdam 1987.
19. Curry S, Baumrind S. Realtime Mandibular Motion Mea-
surement. Proceedings IEEE/Ninth Annual Conference
of the Engineering in Medicine and Biology Society,
Boston, MA, 1987;721-722.
20. Baumrind S, Curry S. Integrated Craniofacial Data Anal-
ysis System. Proceedings IEEE/Ninth Annual Confer-
ence of the Engineering in Medicine and Biology Soci-
ety, Boston, MA 1987;723-724.
21. Murray WR, Baumrind S, Genant HK, et al. The detec-
tion of loosening in total hip arthroplasty: A computer-
assisted stereometric method. Proceedings of the Cana-
dian Orthopaedic Research Society 1979.
22. Hunter J, Baumrind S, Genant HK, et al. The detection
of loosening in total hip arthroplasty: description of a
Home | TOC |          
Index
265
stereophotogrammetric computer-assisted method. In-
vest Radiol 1979;14:323-329.
23. Chafetz N, Baumrind S, Murray W, et al. Femoral
prosthesis subsidence in asymptomatic patients: a ste-
reophotogrammetric assessment. Invest Radiol 1984;
19:235-241.
24. Baumrind S. Integrated Surface and Deep Structure
Mapping of the Human Anatomy. Proceedings, Section
on Kinanthropommetry, 1984 Olympic Scientific Con-
gress, Eugene, Oregon.
25. Chafetz N, Baumrind S, Murray W, et al. Subsidence of
the femoral prosthesis: A stereophotogrammetric evalu-
ation. Glin Orthoped Rel Res 1985;201:60-67.
26. Chafetz N, Baumrind S, Morris JE, et al. Stereophoto-
grammetry of the lumbar spine. Spine 1985;10:368-375.
27. Baumrind S, Moffitt FH, Curry S. Three-dimensional
X-ray stereometry from paired coplanar images: a
progress report. Am J Orthod 1983;84:292-312.
28. Baumrind S, Moffitt FH, Curry S. The geometry of three-
dimensional measurement from paired coplanar X-ray
images. Am J Orthod 1983;84:313-322.
29. Hallert B. X-ray Photogrammetry. New York: Elsevier
Publishing Company, 1970.
30. Rune B, Jacobson S, Sarnas KV, et al. Roentgen stereopho-
togrammetry applied to the cleft maxilla of infants. I Im-
plant technique. Scand J Plast Reconstr Surg 1997;11:131.
31. Rune B, Sarnas KV, Selvik G, et al. Posteroanterior trac-
tion in maxillonasal dysplasia (Binder's syndrome): a
roentgen stereometric study with the aid of metallic
implants. Am J Orthod 1982;81:65-70.
32. Selvik G. Roentgen stereophotogrammetry in Lund,
Sweden: applications of human biostereometrics. Pro-
ceedings, SPIE 1978;166:184-191.
33. Burke PH, Beard LFH. Stereophotogrammery of the
face. Am J Orthod 1967;53:769.
34. Berkowitz S, Prusansky S. Stereophotogrammetry of sev-
eral casts of cleft palate. Angle Orthod 1968;28:136.
35. Berghagen N, Ronnerman A, Adolfsson B. Determina-
tion of the movement of impacted upper canines by
x-ray photogrammetric methods. Acta Odontol Scand
1964;22:4.
36. Image-Based Rendering: Structured Light, The Graphics
and Visualization Center, National Science Foundation
Science and Technology Centers. Available at: http://www.
cs.brown.edu/stc/resea/rendering/research_R6.html.
37. Destructive Physical Analysis, ORS Labs. Available at:
http://www.ors-labs.com/DPA.html.
38. CAIP Rutgers, The State University of New Jersey, Intro-
duction to Stereolithography. Available at: http://www.
ciap.rutgers.edu/~kbhiggin/VDF/SLA.html.
39. Mozzo P, Procacci C, Tacconi A, et al. A new volumetric
CT machine for dental imaging based on the cone-beam
technique: preliminary results. Eur Radiol 1998;8:1558-
1564.
40. Baumrind et al, Mandibular motion monitoring system.
United States Patent #4,836,778 June 6, 1989.
41. Miyakawi S, Tanimoto Y, Inoue M, et al. Condylar mo-
tion in patients with reduced anterior disc displacement.
Dent Res 2001;80:1430-1435.
<<    
     Article
      >> Home | TOC |          
Index

The Digital Orthodontic Office: 2001

W. Ronald Redmond

The practice of orthodontics has been transformed by the computer revo-

lution of the 1990s. Digital orthodontics, including digital photographs,
radiographs, treatment records, and three-dimensional study models, has
created a paradigm shift in practice management. The orthodontic practice
of the 1970s and 1980s can be seen in high contrast to the dynamic practice
of the new millenium. With treatment records always at the orthodontist's
fingertips, orthodontic treatment has streamlined and patient management
has reached levels of sophistication never before possible. The Internet and
the development of high-speed communication modalities have enabled
group practices, with multiple locations, to access records in outlying loca-
tions electronically. With proper backup protocols, patient records will never
again be lost or misplaced. This paradigm shift will propel orthodontics well
into the future. (Semin Orthod 2001;7:266-273.) Copyright © 2001 by W.B.
Saunders Company

Informationand communications are vital en-
tities to any business and the practice of orth-
odontics is also knowledge dependent. As we
have moved into the digital age, access to infor-
mation has increased exponentially. Computers,
modems and large databases have caused an
overload of information. An orthodontic prac-
tice in 1970, although not entirely isolated from
the outside, was far more provincial than the
dynamic orthodontic practice environment of
today. Multiple practice locations, multiple doc-
tor practices, and the combination of both have
increased dramatically over the last 30 years.
Technological advances in orthodontic appli-
ances, combined with increased auxiliary utiliza-
tion have had a profound effect on the number
of active patients in treatment by the orthodon-
tist. Management skills have gone through a par-
adigm shift to allow the modern orthodontist to
handle the increased patient load. Practice man-
agement consultants have proliferated in re-
sponse to the, often overwhelming, frustration
From Private Practice and the Department of Orthodontics,
University of Southern California, Orange County, CA.
Address correspondence to W. Ronald Redmond, DDS, MS, 33
Creek Road, Suite 280, Irvine CA 92604.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0704-0007$35.00/0
dot: 10.1053/sodo.2001.25423
felt by many practitioners. The ability to treat
more patients has had a very positive effect on
orthodontic fees. The relatively decreased ex-
pense of treatment and increased public aware-
ness of the health and social benefits of orth-
odontics have also had an impact on the
demand for treatment. When these factors are
combined with the rapid increase in third party
involvement, the stage was set for the most dra-
matic change in the practice of orthodontics
within recent history.
Digital Orthodontics
The computer revolution, started in the 1970s,
has been vital to the paradigm shift that has
occurred in orthodontics. The ability to store
and retrieve information electronically has
opened the door to knowledge transference
never before possible to the practitioner. Com-
puter utilization lagged behind in the typical
orthodontic practice because of computers ini-
tial limitations and expense. As computers be-
came more dynamic and reliable, orthodontic
practitioners started to use computers unique
organizational strengths to help manage their
practices. Orthodontic practice management
software proliferated and tasks traditionally rel-
egated to paper and pencil soon became auto-
mated. The typewriter was one of the first items

266 Seminars in Orthodontics, Vol 7, No 4 (December), 2001: pp 266-273

<<    
     Article
      >>
The Digital Orthodontic Office
to disappear from the orthodontic practice,
closely followed by the appointment book and
patient financial ledgers. These systems, which
had been in place for decades, were being re-
placed by practice management programs that
not only provided greater facility for entry and
retrieval, but increased accuracy and safety. One
only needs to imagine the "old days" of a hand-
written appointment book, with weeks, or possi-
bly months of appointments, that has been lost
or destroyed. Once orthodontists had a glimpse
of digital management, the course for the future
was clear.
Today, the progression to a digital orthodon-
tic practice has transcended simple practice
management and entered the arena of digital
orthodontic records and the associated process
of diagnosis and treatment planning. Digital
photography, and digital radiography have be-
come an integral part of the modern orthodon-
tic practice. On the horizon for the modern
digital orthodontic practice are numerous three-
dimensional (3D) imaging programs, all de-
signed to further our knowledge of growth and
development and increase our diagnostic acu-
men. This paper will provide information for the
practicing orthodontist in the area of digital
diagnostic records and the dissemination of the
acquired digital information.
Digital photography has quickly replaced tra-
dition film-based photography. Digital photog-
raphy today, with charge-coupled device (CCD)
receptors in place of film and mega-pixel single
lens reflex (SLR) cameras, has made a tremen-
dous impact on the orthodontic practice. No
longer is the doctor tied to the inherent delay of
film processing. Out of focus and improperly
composed photographs can be immediately re-
taken, without inconveniencing the patient or
stressing the doctor and staff. Digital radiogra-
phy has also had a major impact on the orth-
odontic practice. Large CCD devices, capable of
capturing a panoramic or head exposure, have
decreased in cost to permit the orthodontist to
justify their purchase. A recent university study
by Lee1 determined that digital radiographic im-
ages, although not at the same level of resolu-
tion as film based radiography, were more con-
sistent because of decreased operator error
associated with digital radiography. In addition,
a radiographic CCD requires less x-ray exposure
Home | TOC |          
Index
267
than film to capture the same image, thereby
reducing the radiation exposure to the patient.
Digital photographs and radiographs can be
stored magnetically or optically for future re-
trieval. This method of storage additionally facil-
itates backup of the data for offsite storage.
Gone are the days of calamity, fire or flood,
destroying the patient photographs and radio-
graphs. Magnetic records, stored offsite, have
been the saviors of many practitioners.
Three-Dimensional System
Recently, an orthodontic system that had not
changed for decades, has submitted to the digital
age. Orthodontic study casts, traditionally made
from plaster-of-Paris, have become digital 3D rep-
resentations. OrthoCad software (Fairview, NJ),2
capable of capturing and presenting 3D study
models, has provided the orthodontic office with
another digital system. For decades, study models
have been used by the profession for diagnosis and
treatment planning, progress assessment and post-
treatment evaluation. Traditional study models are
hand-held, provide an accurate representation of
the malocclusion and some soft tissues, and have
been economical to produce. However, study
models are labor-intensive to produce and their
fragility is a constant cause for concern. In addi-
tion, study model storage and retrieval is in com-
plete contradiction to the benefits afforded by dig-
ital photographic and radiographic image storage
and retrieval. The digital orthodontic office was
faced with the dilemma of separate storage sys-
tems, one for computerized patient treatment
notes and records, and one for plaster study mod-
els. In many orthodontic practices, the difficulty in
retrieval of study models is reducing their usage
and some practices have eliminated their fabrica-
tion entirely. In an age of increased demand on
the orthodontist for interdisciplinary care, second
opinions, and transfer of records for continuity of
care, the limitations of stone casts have become
increasingly apparent.
Discussion
OrthoCad software for 3D digital study models
was developed, not to replace stone casts, but in
an attempt to remove the limitations imposed by
the traditional casts. The orthodontist still takes
alginate impressions of the maxillary and man-
<<    
     Article
      >>
268 W. Ronald Redmond
dibular dentition and a bite registration, but this
is where the similarity to the traditional process
ends. The impressions and bite registration are
sent, overnight, to an OrthoCad processing fa-
cility and within a few days the 3D study models
are downloaded to the orthodontic office.
The process requires an Internet connection,
a download utility, and viewing or analyzing soft-
ware. The file size of the 3D study model is
approximately 3 MB and can be downloaded in
20 to 30 seconds over a digital subscriber line
(DSL) or 10 minutes over a 56-Kbps connection.
The download time is irrelevant, however, be-
cause the downloading is accomplished when
the office is closed, thus consuming no office
time. The download utility provides the process-
ing facility access to a system folder at the orth-
odontist's computer where 3D study models are
stored. Once the download has completed, the
3D study model is available for viewing and an-
alyzing. OrthoCad software, supplied at no
Figure 1. The Penta-view. Each image can be rotated or tipped. This view is best for printing.
Home | TOC |          
Index
charge and downloadable from the Internet, is
compatible with Microsoft Windows-based sys-
tems and the 3D study models files are accessible
from remote locations. With this software, digital
study models are available chairside, remotely at
the doctor's home or referral doctor's office and
at specialist's offices for interdisciplinary care.
With increased availability, 3D study models will
produce enhanced diagnostic skills as the orth-
odontist has the opportunity to compare the
progression of treatment to the original condi-
tion. Similar orthodontic and skeletal conditions
can be reviewed from the database, with relative
ease, to hone diagnostic skills.
The OrthoCad viewing software allows for var-
ious views for diagnostic purposes. The basic
OrthoCad display is shown in Figure 1. Each
view of the study casts exists in its own separate
window, and the contents of each window can be
manipulated and measured separately in three
dimensions. An interactive example of the Or-
<<    
     Article
      >>
The Digital Orthodontic Office
thoCad manipulations can be viewed on the
company's website.2 The ability to rotate the
models and view them from different perspec-
tives provides the orthodontist with opportuni-
ties for diagnosis heretofore only available with
stone casts.
OrthoCad Diagnostic Tools included with the
software are, as follows (see Figs 2-5):
(1) Measurement analyses: Bolton, width, and
arch length analyses are a few of the measure-
ment tools provided by the software. The mea-
surements are recorded and saved for future
reference, which is a significant improvement
over stone casts.
(2) Midline Analysis: The virtual study models
can be "split" in the maxillary, mandibular, or
skeletal midline for comparative analysis.
(3) Overbite and Overjet Analyses: Magnifica-
tion and computer modeling allow increased
accuracy in overbite and overjet determination.
Figure 2. Measurement analyses: Bolton, width, and arch length analyses are a few of the measurement tools
provided by the software.
Home | TOC |          
Index
269
(4) Occlusogram: The bite registration is an-
alyzed to determine occlusal contacts and the
occlusogram is color coded to allow the orth-
odontist to visually assess the occlusion. This
analysis is particularly useful to compare and
contrast pretreatment occlusal analysis to post-
treatment analysis to determine the efficacy of
the treatment regimen. In addition, the occlu-
sogram may prove to useful in TMJ/TMD treat-
ment.
(5) Magnification: Details of the occlusion
that have not been available to the orthodontist
in the past are achieved through magnified views
of the occlusion.
(6) A/P and Transverse Adjustment: The soft-
ware provides for anterior-posterior and trans-
verse adjustments in the relationship between
the maxillary and mandibular arches. This en-
ables the orthodontist to compensate for slight
bite registration inaccuracies or to simply test
<<    
     Article
      >> Home | TOC |          
Index

270 W. Ronald Redmond

Figure 3. Occlusogram: The bite registration is analyzed to determine occlusal contacts and the occlusogram is
color-coded to allow the orthodontist to visually assess the occlusion. This analysis is particularly useful to
compare and contrast pretreatment occlusal analysis to posttreatment analysis to determine the efficacy of the
treatment regimen. In addition, the occlusogram may prove to be useful in TMJ/TMD treatment.

the interdigitation potential of different A/P or
transverse positions.
(7) Notes: Diagnostic or treatment notes can
be attached to the study models for future ref-
erence or reference in interdisciplinary cases.
The notes can be included when printing a view.
In addition to the diagnostic tools already
mentioned, the software provides the orthodon-
tist the ability to print the various views, to save
the views as Joint Photographic Experts Group
(JPEG) files, and to email files to other practi-
tioners directly from the program.
Magnetic and optical storage is particularly
efficient and cost effective when compared to
traditional study models. Two hundred 3D study
model files can be stored on a CD-ROM with
650MB of storage space. A 30 gigabyte hard
drive, with a current cost of $150, can store
approximately 10,000 3D study models. Com-
pare the cost of magnetic storage to the cost of
the physical facilities necessary to store 10,000
traditional study casts and you will note that the
difference is astounding.
Digital Orthodontic Practice
I would be remiss in this article if I did not
describe our orthodontic practice.3 My two sons
and I maintain six orthodontic offices in Orange
County, California. Five of our offices and the
doctor's homes are connected through an Intra-
net with DSL or cable connections at each loca-
tion. The sixth office, containing our servers, is
connected to the Intranet with a Tl line. The Tl
provides upload and download speeds of 1.544
megabits per second, whereas, cable and DSL
have significantly lower upload speeds. We main-
tain four servers: 1) Santa Cruz Operation
<<    
     Article
      >> Home | TOC |          
Index

The Digital Orthodontic Office 271

Figure 4. Anterior-posterior and transverse adjustment: The software provides for anterior-posterior and trans-
verse adjustments in the relationship between the maxillary and mandibular arches. This enables the orthodon-
tist to compensate for slight bite registration inaccuracies or to simple test the interdigitation potential of
different anterior-posterior or transverse positions.

(SCO) Unix server running Orthotrac4 practice
management software, 2) Microsoft Windows 98
server5 running Sidexis6 digital radiographic
software, 3) Microsoft Windows 98 running Or-
thotrac Imaging software and OrthoCad 3D
Study Model software, and 4) Microsoft Win-
dows NT 4.0, Terminal Server Edition,7 running
Citrix8 Metaframe 1.8. Most readers will be
familiar with the aforementioned software, ex-
cept Citrix Metaframe 1.8. Citrix has developed
cross-platform software that integrates with
all our software to provide a novel way of net-
working our digital orthodontic practice. Citrix
Metaframe 1.8 allows software programs to re-
side on the servers, and not at each chair or
workstation, but to be "run" at each chair or
workstation. This feat is accomplished by "thin-
slice" software management. Thin-slice means
that a patient's x-rays, photographs, and study
models can be viewed simultaneously at 30 work-
stations, without the imaging software being
present at the workstations. The workstations act
only as viewers and input devices (mouse and
keyboard). The numbers of simultaneous view-
ings are determined by licensing provided
through Citrix. This powerful software can trans-
form the way a network is developed. Tradition-
ally, networks are a series of PCs all connected
through a local area network (LAN) or wide
area letwork (WAN). Software resides on each
PC to process the data that is stored on a central
server. When software updates are encountered,
each PC must be updated. With Citrix, only the
server software needs to be updated. Imagine
the simplicity and power of centralized data and
programs.
In addition to the ease of software deploy-
ment provided by Citrix and the phenomenon
<<    
     Article
      >> Home | TOC |          
Index

272 W. Ronald Redmond

Figure 5. Notes: Diagnostic or treatment notes can be attached to the study models for future reference in
interdisciplinary cases. The notes can be included when printing a view.

of thin-slice software, network devices referred
to as "thin-clients" have been developed. Wyse
Technology, Inc. has developed a thin-client de-
vice called the Winterm.9 This device, which is
the size of a cigar box, has ports for the video
screen, keyboard, mouse, and network cable. It
does not have a hard drive or any moving parts.
The Winterm is preprogrammed with Citrix cli-
ent software and searches throughout the net-
work, Intranet or the Internet for the server.
Once the connection has been established with
the server, all the programs and data are avail-
able. Imagine carrying a cigar box sized Win-
term in your briefcase and connecting it to the
Internet anywhere in the world and instantly
having access to your programs and data. Win-
term devices are relatively inexpensive, with the
cost ranging between $250 and $350. Citrix cli-
ent can also be downloaded from the Internet,
at no charge, and programmed to allow your
laptop or desktop to act as a terminal. Even
more impressive is the ability of Citrix client to
be downloaded to cross-platform devices with
operating system such as Mac OS, Unix, Linux,
or Windows CE, and to run the programs from
the server. One only needs to remember that the
device is simply acting as a video screen, key-
board, mouse, and network connection to un-
derstand this cross-platform ability.
Digital orthodontic records have enabled our
practice to establish a website for the sharing of
patient records. The website is linked to the
servers and access to pertinent patient photo-
graphs, radiographs, study models and treat-
ment records is limited and protected through
the use of usernames and passwords. The tradi-
tional process of copying photographs, radio-
graphs, study models, and treatment records for
transfer patients is an exercise of the past. To-
day, the transferring orthodontist simply needs
<<    
     Article
      >>
The Digital Orthodontic Office
to email a username and password to the doctor
continuing the orthodontic care. No lost or mis-
placed transfer records to delay orthodontic
treatment.
Conclusion
Orthodontic treatment and interdisciplinary
care will benefit from the improved flow of dig-
ital patient information. Imagine, if you will, the
oral surgeon, periodontist, orthodontist, prosth-
odontist, and general dentist, all viewing the
patient's digital records simultaneously, discuss-
ing treatment options and objectives and deter-
mining the treatment sequencing. Imagine the
time saving considerations for the doctors and
patients. Consider the databanks that will de-
velop and the pretreatment and posttreatment
records that will be available. And finally, imag-
ine the effect on core orthodontic knowledge
and teaching. Smile!
Home | TOC |          
Index
273
References
1. Lee JE. Comparison of Reproducibility and Dimensional
Distortion in CCD, Storage Phosphor and Film Cephalo-
metric Imaging Systems [master's thesis]. Los Angeles,
CA: University of California, Los Angeles School of Den-
tistry, 2001.
2. Cadent Incorporated, Fairview, NJ. Available at: www.
orthocad.com. Accessed June 20, 2001
3. Redmond WR, Redmond Wf, Redmond MJ. Clinical Im-
plications of Digital Orthodontics, AJO-DO, February
2000.
4. Practice Works, Inc, Norcross, GA. Available at: www.
practiceworks.com. Accessed June 20, 2001.
5. Microsoft Corporation, Redmond, WA. Available at: www.
microsoft.com. Accessed June 20, 2001.
6. Sirona Corporation, Charlotte, NC. Available at: www.
sirona.com. Accessed June 20, 2001.
7. Microsoft Corporation, Redmond, WA. Available at: www.
microsoft.com. Accessed June 20, 2001.
8. Citrix Systems, Inc, Fort Lauderdale, FL. Available at:
www.citrix.com. Accessed June 20, 2001.
9. Wyse Technology, Inc, San Jose, CA. Available at: www.
wyse.com. Accessed June 20, 2001.
<<    
     Article
      >> Home | TOC |          
Index

Three-Dimensional Diagnosis and

Orthodontic Treatment of Complex
Malocclusions With the Invisalign Appliance
Robert L. Boyd and Vicki Vlaskalic

Recent developments in software technology have made it possible to

create a virtual three-dimensional (3D) model of the dental arches from
digitally scanned impressions of a patient's dentition. This model may then
be manipulated with software to produce stages of tooth movement from
the initial malocclusion to the final desired occlusion. A stereolithographic
model is made for each stage of tooth movement which is the basis for
construction of a series of clear, thin, overlay appliances. These appliances
are worn full time by the patient to move the teeth according to the
programmed stages of movement. Malocclusions involving mild to moder-
ate crowding and space closure have been proven to be successfully treated
with this appliance. The present study shows orthodontic treatment of
patients with more complex orthodontic problems, requiring dental expan-
sion, Class II and Class III correction, extraction treatment and correction of
overbite. Experience with this appliance, thus far, has demonstrated excel-
lent patient compliance with less discomfort, and improved esthetics and
oral hygiene, when compared with fixed orthodontic appliances. Orthodon-
tic treatment with this appliance is a potentially useful alternative approach
to fixed appliances for treatment of a variety of malocclusions in patients
with fully erupted permanent teeth. (Semin Orthod 2001;7:274-293.) Copy-
right © 2001 by W.B. Saunders Company

A lign Technology, Inc. developed the Invis-

align appliance for orthodontic tooth
movement in the USA in 1998. This appliance
was the first orthodontic treatment method to
be based solely on three-dimensional (3D) digi-
tal technology. Through the use of computer
programs that can manipulate 3D images of in-
dividual malocclusions, a series of algorithmic
stages is produced which move the teeth in a
series of precise movements (0.15-0.25mm), or
stages. Stereolithographic models are then con-
From the Department of Orthodontics, School of Dentistry, Uni-
versity of the Pacific, San Francisco, CA.
Supported by a grant from Align Technology, Inc., Santa Clara,
CA. Dr. Boyd has a financial interest in Align Technology, Inc.
Address correspondence to Robert L. Boyd, DDS, MEd, Depart-
ment of Orthodontics, School of Dentistry, University of the Pacific,
2155 Webster Street, Room 130, San Francisco, CA 94115.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0704-0008$35.00/0
doi:10.1053/sodo.2001.25414
structed for each stage. Clear overlay appliances
of 0.030-inch thickness are each worn sequen-
tially by the patient for between 1 to approxi-
mately 2 weeks. Because this appliance is clear
and removable, it provides an esthetic and hy-
gienic appliance to correct malocclusion.
The concept of moving teeth as a series of
planned, individual stages through the use of
set-up models and elastic appliances was first
described by Kesling in 19451 and later by
Ponitz,2 McNamara et al,3 Sheridan et al,4 Rin-
chuse and Rinchuse,5 and Lindauer and Shoff.6
The major limitation of these described meth-
ods is that only relatively small magnitudes of
change are possible because of the technical
difficulty of evenly dividing larger overall move-
ment into small, precise stages manually.
The first university-based clinical study of the
Invisalign appliance recently reported successful
clinical results of subjects with varying degrees of
mild to moderate malocclusion severity includ-

274 Seminars in Orthodontics, Vol 7, No 4 (December), 2001: pp 274-293

<<    
     Article
      >>
Treatment of Complex Malocclusions With the Invisalign Appliance
ing cases of 3 to 6 mm crowding and 3 to 6 mm
of space closure.7 This report contains treatment
results for subjects in that study with more com-
plex malocclusions, including extractions. Two
additional university clinical studies investigat-
ing treatment of complex malocclusions with
this appliance are currently underway at the Uni-
versities of Florida and Washington.
Treatment Procedures
Case Acceptance
Based on our results thus far, treatment out-
come is highly dependent on clinician experi-
ence, as well as specific case selection. Because
certain tooth movements are more predictable
than others with this technique, case selection is
at present ultimately determined by the manu-
facturer, Align Technology, Inc. (Santa Clara,
CA).
Computerization of Treatment
Once a diagnosis has been made by the clini-
cian, polyvinylsiloxane (PVS) impressions are
made of the arches. It is imperative that this
impression is accurate and stable, as it is the
basis for the 3D dental arch image that is
scanned into the computer. The impression, a
wax bite, radiographs, photographs and treat-
ment plan are then sent to the manufacturer.
After the clinician's treatment-plan has been
computerized, the program may be accessed via
the Internet for either acceptance or alteration
by the clinician, to this virtual treatment (re-
ferred to as ClinCheck). Any modifications to
the plan are reviewed by an Align staff orthodon-
tist and are available on-line at the manufactur-
er's web-site for final approval. A specific file is
maintained on the website for all patients each
individual clinician has treatment-planned.
Manufacture of Appliances
Once treatment is approved by the clinician, it is
sequenced into a series of evenly divided, 0.15 to
0.25 mm movements. This threshold of move-
ment is an important aspect in the development
of this appliance because it reflects the maxi-
mum amount of activation possible, given the
virtual tooth position, modulus of elasticity of
the appliance material and thickness. Sterolitho-
Home | TOC |          
Index
275
graphic, resin models are then constructed for
each arch, and for each stage of treatment. The
clear, 0.030-inch thickness, overlay appliances or
"aligners" are subsequently made for each resin
model.
One advantage of this appliance system is that
the virtual treatment sequence presents an op-
portunity to the clinician and the patient for
evaluation of the proposed post-treatment occlu-
sion on-screen, before treatment commences.
Proposed treatments can be evaluated by thor-
ough examination of the entire sequence of
tooth movement, from many visual perspectives.
Final agreement of this virtual treatment is the
most important step for the clinician because
once approved, the only way to modify the treat-
ment-plan is to generate a new computer plan.
The virtual treatment plan also provides a
powerful communication tool between the clini-
cian and patient. Patients can see their own
treatment on the computer at the exact stage
they are at as well as visualize the final result and
all the steps in between. Patients may also have a
copy made of their virtual treatment file, to re-
view their own treatment sequence as their treat-
ment progresses.
Treatment Progress
The initial treatment visit involves inserting the
first appliance of the series and carefully check-
ing to be sure the appliances are fully seated
(Fig 1). Some patients require attachments to
their teeth to facilitate certain movements such
as extrusion, extraction space closure or rotation
of lower premolars. These attachments are ap-
plied using a clear, 0.015- to 0.020-inch thick
template and posterior composite restorative
material, cured with light activation in a method
similar to indirect bonding (Fig 2). Appliances
are commonly worn for 7 to 14 days, with
progress being patient and movement specific.
Patient visits are similar to orthodontic visits with
other types of appliances and include evaluation
of the occlusion and treatment progress. The
actual clinical movement of the teeth should be
compared periodically with the specific com-
puter stage to ensure that they match.
After the final appliances are worn, the clini-
cian may determine whether additional stages of
treatment are required. If the last appliance fits
well, the addition of stages requires no rescan-
<<    
     Article
      >> Home | TOC |          
Index

276 Boyd and Vlaskalic

Figure 1. Frontal intraoral view of a patient showing
a fully seated appliance. Note that there is a slight
space between the upper left lateral incisor, the upper
right canine, and the appliance. These spaces are
present because the incisal edges had been reduced
with a bur after PVS impressions were taken. This
could lead to less effective tooth movement for these
teeth due to a less than complete fit of the appliance.
Significant changes in crown form from stripping,
restoration or contouring should always be done
whenever possible before the PVS impressions.
ning. However, if the patient's teeth do not fit
the appliance, or if the teeth do not simulate the
final computer stage, a new PVS impression will
be necessary for rescanning.
Figure 3. An appliance showing a lack of seating as
evidenced by space between the appliance and the
upper central incisors. Extrusion was planned into the
virtual computer plan for these teeth, but the teeth
did not extrude because attachments were not placed
on these teeth to allow the appliance to engage the
undercut area of the attachment.
Compliance
Compliance has been excellent in most cases.
This may be due to our case selection of moti-
vated, adult patients, or due to the formation of
a slight posterior open bite in the first few weeks
of wear. The open bite is caused by slight poste-

Figure 2. Intraoral views of patient who will have four premolars extracted because of crowding and protrusion
(A). The patient at pretreatment (B), at 10 months of active treatment (C), and after 15 months treatment (D).
Attachments to the upper canine and second premolar have been bonded with composite restorative material.
Panel C illustrates patient with the appliance in place showing that the appliance encircles or engages the
attachment. These attachments provide a method for controlling tooth movement by keeping the appliance in
place so that the tooth movement does not unseat the appliance and to hold the tooth upright for extraction
space closure. Note that on the day of delivery of the appliance, in this case, that it is not fully seated on the
second premolar attachment. It is important to tell the patient not to progress to the next appliance until the
appliance completely covers the tooth.
<<    
     Article
      >>
Treatment of Complex Malocclusions With the Invisalign Appliance
rior tooth intrusion due to the thickness of the
appliance increasing vertical dimension (ap-
proximately 0.06 inch). Patients generally prefer
the occlusal pattern of the more even contacts
between their teeth when the appliances are in
place, rather than the heavier anterior contact
when the appliances are removed.
An early finding was that patients who pro-
gressed too quickly (usually less than 1 week per
appliance), may present with appliances that did
not fit the teeth for the indicated stage of treat-
ment (Fig 3). Thus it is important that clinicians
monitor patients carefully, especially during the
first four to five stages, and not dispense more
than two appliances at each of the first two visits.
Patients should be warned of the risks of pro-
gressing too quickly, which may cause the appli-
ances to not fit properly and lead to increased
laboratory costs and time delays.
Discomfort and Speech Effects
Subjective evaluation of patient discomfort dur-
ing treatment has demonstrated generally less
discomfort than seen with traditional fixed ap-
pliances. This is most likely because the magni-
tude of the tooth movements are only 0.2 mm,
on average. In addition, speech problems have
rarely been a problem, particularly after the first
week of treatment.
Problems During Treatment
Any discrepancy between the actual clinical ap-
pearance of the occlusion and the virtual treat-
ment sequence program indicates that treat-
ment should be fully reviewed. Possible reasons
for this discrepancy are that the patient has lost,
or is not wearing their appliances for a sufficient
time (at least 20 hours per day), or that the
appliances have not been fully seated. This can
usually be corrected by remaining in a specific
appliance for more than 20 hours per day for 2
weeks or more to allow the appliance to recap-
ture tooth position.
For maximum treatment efficiency, it should
be stressed to patients at the outset that if they
lose an appliance, they should progress to the
next stage if that stage seats fully, or return to
the previous stage. For this reason, appliances
should not be discarded until the patients are at
least two stages ahead. If the patient's occlusion
cannot be recaptured by an appliance, it may be
Home | TOC |          
Index
277
useful to use the computer program to identify
which stage visually matches the clinical appear-
ance most closely, and return to that particular
stage. If this fails, the patient should be placed in
clear, overlay retainers and another PVS impres-
sion taken for rescanning, with a new treatment
plan devised.
If bonded attachments are lost during treat-
ment, this may hinder treatment progress. Pa-
tients should be informed to report this as soon
as possible to have them replaced. If successive
appliances are worn before the attachment is
replaced, the position of the attachment on the
tooth surface is altered and mechanical advan-
tage is lost.
If the appliances are fully seated and the final
result is not ideal, it may be attributed to two
possibilities. The first is that a tooth position
discrepancy between the desired occlusal result
and the plan that was approved by the clinician
exists. Scrutiny of the initial virtual treatment
plan reduces this problem. The second is that
the magnitude of small tooth movements may lie
below the activation range of the appliance ma-
terial, so that final tooth position is not ex-
pressed. For these reasons, overcorrections of
certain movements such as rotations, torque and
bite opening should be incorporated into the
occlusal goals before final approval of the virtual
plan of treatment. Patients who have complex
malocclusions should understand that it may be
necessary to place fixed appliances for several
months either before or after use of this appli-
ance, to fulfill treatment goals.
To date, 3 patients of the 40 enrolled in this
feasibility study have required fixed appliances
to complete treatment. Further clinical study
will help to reveal the true limits of this appli-
ance, with regard to particular tooth movement
ability. This information should assist decisions
regarding the particular categories of malocclu-
sion that may be treated more efficiently with
combined use of this appliance with fixed appli-
ances.
Tooth Movement
The biomechanics involved with this appliance
have not been reported in the literature. They
differ from those described for traditional fixed
appliances because of the greater surface area of
force application to the tooth. Bodily tooth
<<    
     Article
      >>
278 Boyd and Vlaskalic
movement is possible, particularly if the entire
crown is tightly held with no space between the
appliance and the tooth. The activation in the
appliance can then move the tooth bodily be-
cause the tooth is a rigid body, and at least two
points of contact are in play. However, for the
appliance to fit tightly, it may be necessary to
add attachments. The forces involved for the
0.02 mm activations are most likely of a light,
continuous nature due to the elastic properties
of the appliance and the small magnitude of
individual activation at each stage. The effects
of tooth movement can only be described clin-
ically at this point because of the lack of scien-
tific data on biomechanical principles involved
with tooth movement created by this appliance.
Examples of various types of treatment are pre-
sented.
Treatment of Crowding
Buccal expansion, in the range of 2 to 4 mm, can
be achieved with this appliance to provide space
for crowded anterior teeth or to change arch
form (Figs 4, 5). It is likely that this expansion is
largely of a tipping nature, however, if bodily
expansion is required, this may be specified
(usually as an overcorrection) as the goal for
treatment into the computer plan initially.
This appliance, as is true of most removable
appliances, is relatively efficient at tipping move-
ments. Patients who usually progress most rap-
idly are those that have required primarily tip-
ping of their crowns. Anterior tooth alignment
achieved by proclining of anterior teeth (Fig 4)
is predictably accomplished, provided appropri-
ate overcorrection is done for accompanying
rotations or overbite corrections.
Treatment of crowding with premolar extrac-
tion is shown in Figure 6, where the upper left
canine was initially positioned labially which re-
sponded well to first premolar extraction and
primarily a tipping movement of the canine
crown back into the arch. Usually attachments
are required for extraction treatment in order to
bodily move teeth into the extraction space.
Deep Overbite Correction
Correction of deep overbite is one of the most
predictable movements possible with this appli-
ance, provided attachments are placed for reten-
tion. Figure 7A shows a 33-year-old man who had
Home | TOC |          
Index
orthodontic treatment for a Class II Division 2,
deep overbite with crowding of incisors. He had
previous orthodontic treatment as an adolescent
with extraction of four first premolars. Orth-
odontic treatment was performed due to his
chief complaint of continued tooth movement
since he had stopped wearing his retainers. Be-
cause of severe lingual inclination of the maxil-
lary incisor crowns, labial movement was neces-
sary. Treatment with this appliance corrected
the incisor crowding and also decreased the
overbite by more than 4 mm. The cephalometric
superimpositions show this correction was
achieved primarily through labial tipping and
intrusion of anterior teeth. Comparison of pre-
treatment and posttreatment panoramic radio-
graphs showed no signs of root resorption or
root malalignment.
Another example of intrusion is demon-
strated by the posterior teeth which usually in-
trude in the first 3 months of treatment because
of the double layer of material (total thickness
0.06 inch) between the posterior teeth. This ex-
ample of intrusion is easily corrected at the end
of treatment by cutting away the appliance ma-
terial distal to the premolars (Fig 8) and allow-
ing re-eruption to occur, typically within 2 to 4
weeks.
Molar Distalization
One of the most interesting possibilities for
treatment with this appliance is the ability to
distalize molars, followed by premolars and ca-
nines, with the anchorage segment involving re-
maining teeth. Figure 8 shows a patient with
Class II Division 2, deep overbite with moderate
upper and mild lower arch crowding. She was
initially presented a treatment plan of upper
premolar extraction treatment with fixed appli-
ances. However, because she did not want ex-
traction treatment, a treatment plan with this
appliance was selected which involved distaliza-
tion of maxillary molars, followed by premolars
and canines, which provided space to align the
incisors. (Fig 8) shows the progressive move-
ments of first molars distally, as evidenced by
spaces opening mesial to the teeth and that the
distance increased from the palatal rugae by
more than 3 mm. Cephalometric superimposi-
tion corroborates that bilateral distal movement
of the maxillary posterior teeth was accom-
<<    
     Article
      >> Home | TOC |          
Index

Treatment of Complex Malocclusions With the Invisalign Appliance 279

Figure 4. Shows a crowded

maxillary arch that was
treated with labial tipping
of upper and lower anterior
teeth and incisor rotation.
Note that the rotations
were not fully corrected
(see arrows). Overcorrec-
tion of the virtual treatment
for this type of treatment is
necessary to completely
correct rotated incisors.

Figure 5. Shows a crowded

maxillary arch (A) that was
treated by premolar expan-
sion and incisor rotations
(B). Treatment time was 8
months.

Figure 6. Shows the pre-

(A) and posttreatment (B)
facial and intraoral views of
a 31-year-old woman with
an ectopic maxillary left ca-
nine that is tipped labially.
Treatment involved extrac-
tion of the maxillary left
first premolar and primar-
ily a distal tipping move-
ment of the canine. No at-
tachments were required as
the movement did not re-
quire bodily tooth move-
ment.
<<    
     Article
      >> Home | TOC |          
Index

280 Boyd and Vlaskalic

Figure 6. (cont'd) No at-

tachments were required as
the movement did not re-
quire bodily tooth move-
ment.

Figure 7. Pre- and post-

treatment intraoral views of
a 33-year-old male patient
with a Class II, Division 2
deep overbite, lingually in-
clined incisors and anterior
crowding. This patient's
chief complaint was that his
previous orthodontic treat-
ment as an adolescent had
been gradually "shifting"
since he had stopped wear-
ing retainers (A). Post-treat-
ment intraoral views and
cephalometric superimpo-
sitions showed correction
of the deep overbite and
correction of the lingually
inclined incisors (B-D). Ide-
ally, additional over correc-
tion of the upper incisor
long axis should have been
achieved.
<<    
     Article
      >> Home | TOC |          
Index

Treatment of Complex Malocclusions With the Invisalign Appliance 281

Figure 7. (cont'd)

Figure 8. Show pre-, and post-treatment facial views of a 24-year old woman with a Class II, Division 2, deep
overbite and upper moderate and lower mild crowding (A-B). Show pre-, 8 months, post-, and one year
post-treatment. The midlines were corrected at the end of active treatment of 13 months by placing light elastics
from the bottom on the upper right canine areas to the molar area of the lower left side (C-E). Shows when
treatment was complete, the appliances were cut distal to the premolars to allow the molars to erupt into full
occlusion (F). Cephalometric superimposition showed movement of molars distally, intrusion of upper and
lower incisors, and 4 mm of overbite correction. Cephalometric superimpositions at one year post-treatment
showed good stability of this result with no opening of the mandibular plane angle (I). Shows the distance from
the rugae that the posterior teeth were distalized (G). Shows the lower occlusal views (H).
<<    
     Article
      >> Home | TOC |          
Index

Figure 8. (cont'd)
<<    
     Article
      >> Home | TOC |          
Index

Figure 8. (cont'd)
<<    
     Article
      >> Home | TOC |          
Index

Figure 8. (cont'd)
<<    
     Article
      >> Home | TOC |          
Index

Treatment of Complex Malocclusions With the Invisalign Appliance 285

plished. Slight intrusion of the maxillary inci-
sors, bite opening and proclination of incisors
was also noted in the super-imposition. No open-
ing of the mandibular plane was evident at post-
treatment or 1 year later. Comparison of the
pretreatment and posttreatment panoramic ra-
diograph did not reveal any increased tipping of
molars after this distal movement or root resorp-
tion (Fig 8).
Premolar Extraction
Early results with this appliance caused teeth
to tip into extraction spaces, especially if there
were short clinical crowns and more than 2
mm of mesial movement of posterior teeth
required. However, the use of 5-mm long, rect-
angular, vertical attachments corrected this
limitation (Fig 2). Due to the success of molar
distalization in a limited number of patients,
end on anterior-posterior relationships of the
buccal segments would be treated with this
approach in less treatment time than for an
extraction approach. Further study is needed
to determine if these movements can predict-
ably achieve bodily distalization while main-
taining anterior tooth position.
Mandibular Incisor Extraction
Mandibular incisor extraction cases have shown
acceptable results and have been part of the
manufacturer's acceptance protocol for more
than 2 years. Attachments are usually used to
control any tipping movements (Fig 9).
Ectopically Positioned Teeth
Another difficult type of tooth movement to
achieve with this appliance initially was in the
movement of severely, ectopically positioned
teeth. The use of more flexible materials and
extension of material further gingivally was
necessary to complete this type of treatment
(Fig 9). Ectopically positioned teeth beyond
the degree of this lower right second premolar
should be corrected first, at lease partially,
with fixed appliances.
Rotation
Rotation of teeth with rounded anatomy, such as
lower premolars, has been challenging to ac-
complish with this appliance. The addition of
attachments on the labial or lingual surfaces (or
both) is required for these teeth to be rotated
(Fig 10). Rotated molars may also be treated in
this manner. If the rotation is more than 45°
(Fig 11), fixed appliances may be employed ini-
tially to reduce the magnitude of the rotation or
used after other movements are completed with
this appliance. Incisors usually rotate more easily
with this appliance with no need for attach-
ments. Canines, however, are more difficult to
rotate and may require attachments.
Extrusion
Extrusion has proven to be one of the most
difficult movements to achieve with this appli-
ance. Bonded attachments are necessary to assist
movement by securing an undercut area. Figure
12 shows a case where incisor extrusion has been
achieved with the use of attachments.
Open Bite Treatment
One of the most successful types of treatment,
with this appliance has been in the correction of
mild to moderate open bite malocclusion. For the
patient in (Fig 13), cephalometric superimposi-
tions showed that the bite closed even though
there were no computer programmed extrusive
movements on the anterior teeth. The superim-
postions showed intrusion of the molars with
counter clockwise rotation of the mandible. Al-
though further study is required to determine

Figure 9. Pre-, 8 months, 14 months, and posttreatment facial and intraoral views of a 24-year-old male with Class
III, bimaxillary protrusion, moderate lower arch crowding, deep overbite, and an ectopically positioned lower
right second premolar (A-F). Because the lower right molars had drifted mesially (most likely from the early loss
of a primary second molar), and mandibular excess tooth mass was present, a decision was made to remove the
lower right labially positioned central incisor and distalize the right mandibular molars slightly. Fourteen months
of active treatment showed significant bite opening and space for the ectopically positioned lower right second
premolar. To bring in the ectoptically positioned second premolar, it was necessary to extend the appliance
material further gingivally and use more resilient material to completely cover this tooth (F).
<<    
     Article
      >> Home | TOC |          
Index

286 Boyd and Vlaskalic

Figure 9. (cont'd)

Figure 10. Shows the use of small, bonded attachments to allow the appliance to engage rotated lower premolars
(see arrows). These attachments were necessary because these teeth are rounded in contour which makes the
application offeree difficult.
<<    
     Article
      >> Home | TOC |          
Index

Figure 11. A 24-year-old

male with a Class III maloc-
clusion with moderate lower
arch crowding and good fa-
cial balance (A-F). A deci-
sion was made to extract the
lower right central incisor
and introduce dental com-
pensations to mask the mild
skeletal problem. Unfortu-
nately, the severely rotated
lower left second premolar
could not be successfully
rotated with this appliance.
Fixed appliances were placed
at 9 months on the patient to
complete treatment (C-D)
(Please see page 288 for 11B).
<<    
     Article
      >>
288 Boyd and Vlaskalic
Figure 11. (cont'd)
the exact nature of this effect, the results thus far
are promising for cases with an increased verti-
cal jaw relationship and open bite.
Periodontal Implications
Subjects within this study who had good oral
hygiene standards appeared to continue to
maintain that level during treatment. Investiga-
tion is necessary to determine exactly how well
patients' periodontal health is maintained dur-
ing treatment when compared with fixed appli-
ances. A strong motivating factor for many pa-
tients to have excellent oral hygiene during
treatment is to prevent build up of plaque on the
Figure 14. This 23-year-old patient had generalized severe bone loss. Six months of orthodontic treatment with
smaller magnitudes of tooth movements showed excellent progress. At the 3- and 6-month periodontal main-
tenance visits there were no increases in pocket depth or bleeding on probing noted (A-C).
Home | TOC |          
Index
inside of their appliances, thus avoiding unpleas-
ant odor and slight discoloration of the appli-
ance. As plaque accumulates inside the appli-
ance, it becomes more opaque, and therefore
less esthetic.
To determine if the lower plaque level associ-
ated with this appliance would be advantageous for
patients who were susceptible to periodontal dis-
ease, several young adult patients who had previ-
ous treatment for periodontal disease with signifi-
cant bone loss were treated with this appliance.
Usually younger patients who have significant
bone loss are considered at greater risk for future
periodontal breakdown with fixed appliances.8
Figure 14 shows a 23-year-old woman who had
severe, generalized bone loss, and who was treated
with this appliance. Evaluation at 3-month and
6-month periodontal maintenance visits revealed
no additional increase in pocket depth or signs of
inflammation. The anterior crowns were initially
reduced in height to decrease the crown to root
ratio and to reduce mobility. The anterior
crowns were also initially reduced in width to
decrease the presence of dark triangles be-
tween the teeth after incisor alignment. The
upper right molars were distalized to provide a
Class I buccal occlusion and space to relieve
upper anterior crowding.
Examination of intraoral radiographs during
and after treatment of study patients showed no
signs of root resorption in any of the patients. A
controlled clinical study that uses standardized
periapical radiographs9"11 will be needed to de-
termine the extent of root resorption with this
appliance.
<<    
     Article
      >> Home | TOC |          
Index

Treatment of Complex Malocdusions With the Invisalign Appliance 289

Figure 11. (cont'd)

Figure 12. Show pre and

postextrusion of anterior
teeth with attachments
placed at the gingival third
for a purchase point.

Figure 14. (cont'd)

All patients had routine dental care com-
pleted before starting orthodontic treatment
and were requested to visit their general dentist
at regular 6-month intervals during treatment.
This was important because if a large restoration
was needed during treatment, the appliances
would potentially not fit and a new set of PVS
impressions would be needed. No patients de-
veloped any areas of decalcification during the
treatment.
<<    
     Article
      >> Home | TOC |          
Index

Figure 13. This 32-year-old female had a Class II Division 1 malocclusion with and increased vertical jaw relation-
ship (long-face syndrome) (A). Panel B shows that this appliance intruded the molars which allowed the
mandible to rotate counter clockwise. Cephalometric superimpositions showed that incisors were retracted into
extraction spaces with some extrusion from these tipping movements (C).
<<    
     Article
      >> Home | TOC |          
Index

Figure 14. (cont'd)

Pre Post

Figure 15. Pre and postbleaching views of a 54-year-old male who used his first appliance to bleach his teeth over
five daily, 1-hour sessions with a zero clearance 18% type of carbonide peroxide, viscous gel bleaching agent.
<<    
     Article
      >>
292 Boyd and Vlaskalic
Retention and Stability
At present, retention protocol with this appliance
is similar to that used with other types of appli-
ances. Usually, the final appliance or a thicker
version (0.04 inch) of it is worn full-time for 6
months, followed by nighttime wear indefinitely.
As with any orthodontic appliance, additional re-
search is required to determine whether alternate
protocols are superior in terms of post-treatment
stability. Stability has not been studied, as this ap-
pliance has only recently been introduced.
Advantages
The greatest advantage of this appliance com-
pared to fixed orthodontic appliances is the im-
proved esthetics and ability to remove the appli-
ance. For these reasons, patients to whom
appearance and public speaking are a priority
are good candidates for its use.
Once tooth movement has begun, treatment
time with this appliance is usually equivalent to
traditional fixed appliances. However, this as-
pect of treatment requires further investigation.
Another advantage is that teeth can be
bleached with the appliance at the beginning of,
and during treatment (Fig 15).
The current popularity of "esthetic restorative
dentistry" in which otherwise healthy but rotated
teeth may be prepared for porcelain veneers
may be reduced by dentists informing their pa-
tients that there is an esthetic alternative to fixed
appliances which may be less costly and damag-
ing to the teeth.
Limitations
All permanent teeth should be fully erupted for
treatment using this appliance, as it is difficult to
achieve retention of the appliance on short clin-
ical crowns. The treatment procedures do not
allow for continued eruption of teeth, or signif-
icant dental arch changes during growth that
may occur during the mixed dentition phase.
There is currently no capability to incorporate
basal orthopedic change with this appliance sys-
tem, thus restricting it to malocclusions requir-
ing purely dental movement.
A benefit of the removable nature of the ap-
pliance is that routine dental care in terms of
routine examinations and prophylasix may con-
Home | TOC |          
Index
tinue unimpaired. However, due to the fact that
the surface anatomy of the teeth cannot un-
dergo change during treatment, major restor-
ative work should be performed before the com-
mencement of treatment.
Unlike fixed or other types of removable appli-
ances, the treatment plan cannot be changed once
the appliance series has begun. If change in treat-
ment goals is desired, the current series may be
completed and a new plan and appliances made,
or the current series may be stopped. Either sce-
nario, however, will lead to increased cost for treat-
ment and increased treatment time.
Currently, only crown position is displayed on
the computer program. Because the clinical ap-
pearance of crown inclination is not always pre-
dictive of root inclination, the potential exists
for a virtual treatment to be approved, in which
crown position appears optimal but root posi-
tion is not ideal. However, upcoming advances
in the design of patient imaging and software
programs make it possible to include virtual
roots onto the software application.
Recently the ability to record an eccentric jaw
position (centric occlusion not coincident with
centric relation) has been made possible by hav-
ing the clinician provide a wax bite that records
this discrepancy. The technician then sets the
models in the computer to this bite relationship.
Sending mounted models to the lab is an even
more effective way to provide this information
for the technician. The computer software also
has the ability to have the rotational path of
closure programmed into the virtual plan which
is determined from the mounted models and
lateral cephalometric radiograph.
Another limitation of the current appliance is
the inability to integrate hard and soft tissues of
the head into the computer treatment. Thus, the
clinician has no direct indication of where teeth
are in relation to basal bone or in relation to the
lips or other soft tissues of the head. In a previ-
ous article in this journal by Baumrind, Boyd
and Curry, a prototype for a 3D system that
positions the scanned in 3D surface map of the
teeth used for this appliance in real space with
frontal and lateral stereo cephalometric radio-
graphs is described. This system also places a 3D
surface map of the face in its exact relationship
to the skeletal structures by overlaying the face
on radiopaque markers seen in both the 3D-face
map and the stereo x-rays. With a volumetrically
<<    
     Article
      >>
Treatment of Complex Malocclusions With the Invisalign Appliance
correct 3D digital model of the hard tissues of
the head which is now available (the Newtorn),12
it will be possible to include all of the skeletal
structures of the head into this system. With this
"virtual patient" 3D diagnostic system the clini-
cian will be able to overcome the shortcomings
of the present software which has only the
crowns of the teeth available to the clinician.
Generally, the cost to patients is greater for
this appliance than fixed appliances. This is due
to the cost of the technology used to scan in
models and to develop a virtual treatment, in
addition to manufacturing, packaging, and ship-
ping costs for as many as 40 to 80 appliances.
However, doctor and chair time, instrument and
sterilization costs are significantly lower when
compared with other esthetic orthodontic op-
tions, such as clear or lingual appliances.
Summary
A new system for orthodontic tooth movement
using established methods for minor correction
to achieve greater magnitudes of correction has
been introduced. The system has been tested in
university clinical trials and is now available to
the public. The major advantage of the system is
the esthetic, hygienic, low discomfort and re-
movable nature of the appliance.
There are currently limitations to this appli-
ance in terms of case selection, increased cost,
experience required for computer treatment
planning, difficulty obtaining certain tooth move-
ments, and the lack of potential in cases involving
mixed dentition or impacted teeth. However, as
the number of clinicians using this appliance in-
creases, more information will be available for cli-
nicians and researchers to further evaluate the
risks and benefits of this system for their patients.
Because clinical judgement of the relative
crown inclination in relation to adjacent teeth is
required to use this appliance, having only the
crowns of the teeth currently available for viewing
limits the accuracy of this appliance. Other soft
and hard tissue landmarks should also be consid-
ered throughout the planning and treatment pro-
cess. Thus the clinician must have an in-depth
Home | TOC |          
Index
293
understanding of the biomechanics, biology, peri-
odontal concerns, and optimal therapeutic occlu-
sion achieved during orthodontic treatment to
successfully plan and use this appliance.
A great help in the future will be to use one of
the emerging intraoral scanning devices to re-
place the PVS impressions and to record treat-
ment changes or modifications immediately in a
digital format.13 Adding the other 3D compart-
ments (skeletal, facial, jaw movement and ani-
mation to the current surface map of the teeth)
will greatly enhance the diagnostic and treat-
ment capabilities of this new appliance.
References
1. Kesling HD. The philosophy of the tooth positioning
appliance. Am J Orthod 1945;31:297-304.
2. Ponitz RJ. Invisible retainers. Am J Orthod 1971;59:266-
272.
3. McNamara JA, Kramer KL, Juenker JP. Invisible retain-
ers. J Glin Orthod 1985;19:570-578.
4. Sheridan JJ, Ledoux W, McMinn R. Essix retainers: Fab-
rication and supervision for permanent retention. J Glin
Orthod 1993;27:37-45.
5. Rinchuse DJ, Rinchuse DJ. Active tooth movement with
essix based appliances. J Glin Orthod 1997;31:109-112.
6. Lindauer SJ, Shoff RC. Comparison of Essix and Hawley
retainers. J Glin Orthod 1998;32:95-97.
7. Boyd RL, Miller RJ, Vlaskalic V. The Invisalign system in
adult orthodontics: mild crowding and space closure.
J Glin Orthod 2000;34:203-213.
8. Boyd RL, Leggott P, Quinn R, et al. Periodontal impli-
cations of orthodontic treatment in adults with reduced
or normal periodontal tissues versus adolescents. Am J
Orthod 1989;96:191-98.
9. Baumrind S, Boyd RL, Korn EL. Investigating the corre-
lates of aprical root resportion, vol 31, in McNamara JA
(ed): Orthodontic Treatment: Management of Unfavor-
able Sequelae. Ann Arbor, MI, The University of Michi-
gan, Center for Human Growth and Development,
Craniofacial Growth Series, 1996.
10. Baumrind S, Korn EL, Boyd RL. Apical root resportion
in orthodontically treated adults. Am J Orthod Dentofac
Orthop 1996;! 10:311-320.
11. Vlaskalic V, Boyd, RL, Baumrind S. Etiology and se-
quelae of root resorption. Sem Orthod 1998;4:124-131.
12. Mozzo P, Procacci G, Tacconi A, et al. A new volumetric CT
machine for dental imaging based on the cone-beam tech-
nique: preliminary results. Eur Radiol 1998;8:1558-1564.
13. Sachdeva R. A total orthodontic care solution enabled by
breakthrough technology. J Glin Orthod 2000;34:223-
323.
<<    
     Article
      >> Home | TOC |          
Index

Internet Sites
The following list of sites may be of general interest to the reader. Other links pertaining to specific
subjects are supplied among the References of several papers.

Institutions:
American Association of Orthodontics (AAO): www.aaortho.org
Case Western Reserve University School of Dentistry: www.cwru.edu/dental/casewebsite
Craniofacial Research Instrumentation Laboratory/UOP: www.cril.org
National Institutes of Health (NIH Image): rsb.info.nih.gov/nih-image
Temple University School of Dentistry: www.temple.edu/dentistry
University of the Pacific School of Dentistry: www.uop.edu/dental
University of Southern California School of Dentistry: www.usc.edu/hsc/dental

Commercial Sites:
3DMetrics: www.3dmetrics.com
Acuscape: www.acuscape.com
Align Technology: www.aligntech.com
Cadent, Inc. (OrthoCad): www.orthocad.com
Gendex Corporation: www.gendexxray.com
GeoDigm Corporation (Emodel Digital Orthodontics Model): www.dentalmodels.com
NewTom: www.zerobase-usa.com
Minolta Corp. (Vivid 700): www.minolta3d.com
OraMetrix: www.orametrix.com

294 Seminars in Orthodontics, Vol 7, No 4 (December), 2001: p 294

<<    
     Article
      >> Home | TOC |          
Index

ESTATE PLANNING/PLANNED GIVING

Estate Planning: The AAO Foundation offers information
on estate planning to AAO members and their advisors
on a complimentary basis and at no obligation.

Planned Giving: Those individuals who are contemplating

a gift to the AAO Foundation through their estates
are asked to contact the AAOF before proceeding.
Please call 800-424-2841, Ex. 246.

Please remember the AAO Foundation in your estate planning.

Seminars in Orthodontics, Vol 7, No 4 (December), 2001: p 295 295

<<    
     Article
      >> Home | TOC |          
Index

Author Index
Alexander, C.D., 80 Curry, S., 258 Marcotte, M.R., 191
Alexander, C.M., 67 Min, K.-J., 233
Alexander, J.M., 80 Dean, D., 233 Miyajima, K., 169
Alexander, R.G., 59, 62
Asai, Y., 107 Haitom, T., 132 Nevant, C., 117
Han, S., 233 Nikolai, R.J., 182
Bagden, M.A., 74 Hans, M.G., 233
Baumrind, S., 222, 223, 258 Horton-Reuland, S.J., 117 Palomo, J.M., 233
Beers, A., 258 Preston, C.B., 90
Benedetti, R., 85 Isaacson, R.J., 34, 207 Priebe, D.N., 42
Boley, J.C., 100
Boyd, R.L., 222, 258, 274 Jureyda, O., 90 Redmond, W.R., 266
Braun, S., 139, 180, 215
Britto, A.D., 207 Kanomi, R., 169 Sadowsky, P.L., 221
Broadbent, B.H., 233 Kuhlberg, A.J., 42, 150 Shroff, B., 16, 50
Bumann, A., 251 Siatkowski, R.E., 141
Burstone, C.J., 26 Legan, H.L., 160 Sinha, P.K., 169
Buschang, P.H., 117 Legier, L., 117
Lertpitayakun, P., 169 Takagi, S., 107
Cakirer, B., 233 Lindauer, SJ., l, 16, 34, 207 Tuncay, O.G., 244
Carcara, S., 90
Carlson, S., 258 Mah, J., 251 Vlaskalic, V., 274

Subject Index
Alexander Discipline Alexander Discipline (Continued)
appliance design and construction for, 74-79 patient character development in, 67-73
arch consolidation in, 64 planning in, 62-63
arch form design in, 64 principles of, 62-66
auxiliary appliances in, 63-64 rapid palatal expansion in, 112
brackets in. See Brackets, in Alexander Disci- results of, 59-60
pline retention phase of, 65, 132-137
in Class III malocclusion, 107-116 simplicity in, 62
chin cap in, 111 skeletal discrepancy correction in, face bow
elastics in, 111-112 for, 80-84
lip bumper in, 112 stability goals in, 63
curve of Spee and symmetry in, 64-65
vs. relapse in, 64, 90-99 tooth size vs. arch length correction in
vertical deficiency control and, 86-87 extraction in, 100-106
effort equals results in, 62 lip bumper in, 117-131
extraction cases in, 65, 100-106 nonextraction approach to, 117-131
brackets for, 78 unique aspects of, 59
for vertical deficiency control, 85 vertical deficiency correction in, 85-89
face mask therapy in, 110-112 Alignment, straight wires in, 16-25
finishing in, 64, 65, 132-137 popularity of, 17-18
general plan for, 65-66 side effects of, 18-24
goals of, 62, 132 Anchorage control, biomechanics of, 42-49
importance of details in, 62 biologic considerations in, 46-47
nonextraction cases in, 65 differential moment use in, 47-48

296 Seminars in Orthodontics, Vol 7, No 4 (December), 2001: pp 296-303

<<    
     Article
      >>
Subject Index
Anchorage control, biomechanics of, 42-49
(Continued)
in en masse space closure, 141-149
history of, 42-43
in segmented arch technique. See Segmented
arch technique
techniques for, 43-46
Animation, motion, in three-dimensional imag-
ing, 244-250
Appliances
in Alexander Discipline, 74-79
advantages of, 75-76
angulation in, 78
bracket selection for, 76-77
for deep-bite, 78
evolution of, 74-75
for extraction cases, 78
mesiodistal bracket position for, 78
for open-bite, 78
specifications of, 77-78
biomechanics of
in activation
for en masse space closure, 141-149
force systems, 8-12, 207-214
three-dimensional, 210-214
tooth movement in, 12-14
two-dimensional, 208-210
in application, 2-8
for deep overbite correction
incisor intrusion, 27-32
posterior segment extrusion, 32-33
design of, biomechanics in, 13-14
expansion, for transverse distraction osteo-
genesis, 163-164
Invisalign, 274-293
maxillary intraoral, face mask therapy with,
169-179
one-couple (statically determinate), 9-10
for segmented arch technique, 193-195
two-couple (statically indeterminate), 10-12
Arches and arch wires
in Alexander Discipline
consolidation of, 64
coordination of, 87
design of, 64
finishing, 64, 65
length of, vs. tooth size
extraction in, 100-106
nonextraction approaches to, 117-131
mandibular, development of, 87
maxillary, development of, 86
Home | TOC |          
Index
297
Arches and arch wires (Continued)
for canine retraction, biomechanics of, 182-
190
continuous, for root correction, 50-51
for en masse space closure, 141-149
extrusion, for anterior open bite closing, 3441
intrusion, in deep overbite correction, 27-32
rectangular, incisor torqued brackets with, for
leveling of curve of Spee, 215-220
segmented technique for. See Segmented arch
technique
Banding and bonding, in Alexander Discipline,
77
character development during, 69-70
Bicuspids, retraction of, in segmented arch tech-
nique, 196-199
Biomechanics
of anchorage control, 141-149
of anterior open bite closing, 34-41
of appliance activations, 207-214
for en masse space closure, 141-149
force predictions, 8-12
tooth movement prediction, 12-14
basics of, 2-15
of canine retraction with arch wire guidance,
182-190
of cantilever springs, 150-159
of deep overbite correction, 26-33
of face mask with maxillary intraoral appli-
ance, 169-179
of leveling and aligning, 16-25
with rectangular arch wires and torqued in-
cisor brackets, 215-220
of maxillary protraction therapy, 180-181
of root correction, 50-58
of segmented arch technique, 191-206
of space closure and anchorage control, 42-49
of tooth movement, 2-8, 12-14
of transverse distraction osteogenesis, 160-168
Bite plate
for deep overbite correction, 32-33
for vertical deficiency control, in Alexander
Discipline, 87
Brackets
in Alexander Discipline, 63, 64
advantages of, 75-76
angulation of, 78
for deep-bite, 78
in extraction, 78
height of, 77-78, 86
Lang, 77
<<    
     Article
      >> Home | TOC |          
Index

298 Subject Index

Brackets (Continued) Character development, in Alexander Discipline,

Lewis, 77 67-73 (Continued)
lower first molar, 76 in first visit, 68-69
lower incisor, 76 Individual Responsibility Agreement in, 69, 71
mesiodistal position of, 78 methodology for, 69
molar bands for, 77 opportunities for, 67-68
for open-bite, 78 problems with, 71-72
rotational control of, 75 separation agreement in, 69
selection of, 75-77 in temporary setbacks, 71
space between, 75 Chin cap, in Class III malocclusion, in Alex-
torque of, 75-76 ander Discipline, 111
twin, 76 Cleft lip and/or palate, presurgical treatment of,
torqued, on incisors, with rectangular arch cantilever springs for, 153
wires, for leveling of curve of Spec, 215- Clinical biomechanics. See Biomechanics
220 Communication, in digital age, 270-273
Broadbent cephalometer, 225-226 Compliance, with Invisalign appliance, 276-277
Buccal-lingual axial inclination, correction of, Computed tomography, in craniofacial map-
cantilever springs for, 155-157 ping, 226, 253-255
Buccal segment, retraction of, in segmented cone beam, 254-255
arch technique, 203-204 tuned aperture, 254
Couples, in appliance systems, 4-5
Calibration, in three-dimensional craniofacial map- Craniofacial mapping, three-dimensional. See
ping, 228, 259-261 Three-dimensional craniofacial map-
Camera, intraoral, for three-dimensional imag- ping
ing, 255 Craniofacial Research Instrumentation Labora-
Canines, retraction of, with arch wires, biome- tory, mapping system of, 258-265
chanics of, 182-190 calibration of, 259-261
Cantilever springs creation of, 258-259
biomechanics of, 150-159 data acquisition in, 261-264
design and, 150-151 viewing of, 263-264
fabrication of, 157 Cross-bite, anterior, treatment of, face mask with
first-order, 151-153 maxillary intraoral appliance for, 169-
second-order, 153-155 179
in side effects, 158 Crowding
third-order, 155-157 in Alexander Discipline
for incisor intrusion, in deep overbite correc- extraction in, 100-106
tion, 31 nonextraction approaches to, 117-131
Case Western Reserve Method, for three-dimen- Invisalign appliance for, 278-280
sional imaging, 233-243 Crown movement, biomechanics of, 6-7
digital vs. analog, 234 Curve of Spee, leveling of
grayscale resolution in, 234-235 in Alexander Discipline, 64
image resolution in, 234 vs. relapse in, 90-99
need for, 235-236 vertical deficiency control and, 86-87
spatial resolution in, 234-235 rectangular arch wires for, with torqued inci-
Centers of rotation, in appliance systems, 5-6 sor brackets, 215-220
Cephalometry, in therapy with face mask and segmented arch technique for, 195-196
maxillary intraoral appliance, 169-179 Cuspid retraction, in segmented arch technique,
Character development, in Alexander Discipline, 196-199
67-73
in banding and bonding appointment, 69-70 Deep bite, correction of, in Alexander Disci-
brace removal celebration in, 72-73 pline, 78
Certificate of Achievement in, 72-73 Dental imaging, three-dimensional, 237-238, 255
<<    
     Article
      >> Home | TOC |          
Index

Subject Index 299

Destructive scanning, in three-dimensional cranio- Face bow (Continued)

facial mapping, 229 high-pull, 80-81
Distalization, molar, Invisalign appliance for, history of, 80
278, 281-285 innerbow of, 81-83
Distraction osteogenesis, transverse, 160-168 key principles of, 84
diagnosis for, 161 research on, 83-84
distraction stage of, 164-166 three-dimensional effects of, 80-82
expansion appliance placement in, 163-164 treatment time with, 83
indications for, 160 for maxillary protraction, 180-181
orthodontics after, 166-168 Face mask therapy
orthodontics before, 161-163 in Class III malocclusion, in Alexander Disci-
planning of, 161 pline, 110-112
Documentation. See Records maxillary intraoral appliance therapy with,
169-179
Ectopic teeth, movement of, Invisalign appli- Finishing
ance for, 285-286 in Alexander Discipline, 64, 65, 132-137
Elastics in segmented arch technique, 205-206
in Alexander Discipline, 87-88 Forces
in Class III malocclusion, in Alexander Disci- in appliance systems, 2-3
pline, 111-112 in activations, 8-12, 207-214
Equilibrium, static, in appliance activations, 8-9 equal and opposite, 9
Equivalent force systems, in appliance systems, equivalent, 5
4-5 in cantilever springs, 150-159
Expansion appliances, for transverse distraction in straight wire systems, 17-18
osteogenesis, 163-164
Extraction Grayscale resolution, in three-dimensional imag-
in Alexander Discipline, 65, 100-106 ing, 234-235
brackets for, 78 Grid projection techniques, in three-dimen-
for vertical deficiency control, 85 sional imaging, for motion animation,
of bicuspids, in segmented arch technique, 245
200, 202-203
of premolars, for Invisalign appliance treat- Head, three-dimensional mapping of. See Three-
ment, 285 dimensional craniofacial mapping
space closure and anchorage control after, Headgear. See Face bow
biomechanics of, 42-49
Extrusion and extrusion arches Image resolution, in three-dimensional imaging,
for anterior open bite closing, 34-41 234
incisor action in, 39-40 Incisor(s)
molar action in, 36-37 action at, in anterior open bite closing, 39-40
principles of, 34-36 intrusion of, in deep overbite correction, bio-
retention in, 41 mechanics of, 27-32
timing of, 37-39 mandibular, extraction of, for Invisalign appli-
wire for, 40-41 ance treatment, 285
cantilever springs for, 154-155 movement of, cantilever springs for, 151-153
for deep overbite correction, 32-33 roots of, correction of, 52
Invisalign appliance for, 285, 289 torqued brackets on, with rectangular arch
wires, for leveling of curve of Spee, 215-
Face bow 220
in Alexander Discipline, 80-84 Individual Responsibility Agreement, in Alex-
adjustment of, 83 ander Discipline, 69, 71
advantages of, 82 Intrusion
cervical, 80 cantilever springs for, 153-155
<<    
     Article
      >> Home | TOC |          
Index

300 Subject Index

Intrusion (Continued) Magnetic resonance imaging, in craniofacial map

correction of, Invisalign appliance for, 278
of incisors, in deep overbite correction, bio-
mechanics of, 27-32
Intrusion arch, biomechanics of, 210-211, 213-
214
Invisalign appliance, 274-293
advantages of, 292
development of, 274
limitations of, 292-293
periodontal implications of, 291-292
retention with, 292
special attachments with, 275-276
stability with, 292
tooth movement with, 277-291
in crowding, 278-280
in deep overbite, 278, 280-281
in ectopically positioned teeth, 285-286
in extrusion, 285, 289
after mandibular incisor extraction, 285
molar distalization, 278, 281-285
in open bite, 285, 289-290
after premolar extraction, 285
rotation, 285, 287-288
treatment procedures with, 274-277
appliance manufacture for, 275
case acceptance in, 275
compliance in, 276-277
computerization of, 275
discomfort in, 277
plan for, 275
problems in, 277
progress with, 275-276
speech effects with, 277
Lang brackets, in Alexander Discipline, 77
Lasers, in three-dimensional imaging, 228-229
facial, 253
for motion animation, 247-249
Leveling and alignment, straight wires in, 16-25
popularity of, 17-18
side effects of, 18-24
Lewis brackets, in Alexander Discipline, 77
Light, structured, in three-dimensional imaging,
229, 253
for motion animation, 245-247
Lip, cleft, presurgical treatment of, cantilever
springs for, 153
Lip bumper, in Alexander Discipline
in Class III malocclusion, 112
in tooth size arch vs. arch length discrepan-
cies, 117-131
ping, 226
Malocclusion
Class III, treatment of
in Alexander Discipline, 107-116
case studies of, 112-116
diagnosis in, 107
planning in, 107
timing of, 107-112
face mask with maxillary intraoral appliance
for, 169-179
Invisalign appliance for, 274-293
Mandible
motion of, ultrasonic capture of, 255
transverse distraction osteogenesis of, biome-
chanics of, 160-168
Mandibular incisors, extraction of, for Invisalign
appliance treatment, 285
Mandibular retainer, in Alexander Discipline,
136-137
Mapping, craniofacial, three-dimensional. See
Three-dimensional craniofacial mapping
Mask, face. See Face mask therapy
Maxilla
intraoral appliance in, with face mask therapy.
See Face mask therapy
protraction of, treatment of, biomechanics of,
180-181
Maxillary retainer, in Alexander Discipline, 135-
136
Mechanics. See Biomechanics
Midline correction, cantilever springs for, 151-
152
Mini-Wick Discipline, 74-75
Molar(s)
action at, in anterior open bite closing, 36-37
bands on, in Alexander Discipline, 77
distalization of, Invisalign appliance for, 278,
281-285
Moment(s), in appliance systems, 3-4
differential, for anchorage control, 47-48
Moment-to-force ratios, in appliance systems, 5-6
in space closure and anchorage control, 43-46
Motion animation, in three-dimensional imag-
ing, 244-250
background of, 244-245
future of, 249-250
grid projection techniques, 245
laser scanner in, 247-249
structured light in, 245-247
Nonextraction cases, in Alexander Discipline, 65
<<    
     Article
      >> Home | TOC |          
Index

Subject Index 301

Open bite Protraction, maxillary, treatment of, biomechan-

anterior, extrusion arch for, 34-41
incisor action in, 39-40
molar action in, 36-37
principles of, 34-36
retention in, 41
timing of, 37-39
wire for, 40-41
correction of, in Alexander Discipline, 78
Invisalign appliance for, 281, 285, 289
Opus Loop, for en masse space closure, 141-149
anterior root stress in, 148-149
description of, 141-142
disadvantages of, 146
maximum anchorage in, 142, 145-146
minimal anchorage in, 142, 145
moderate anchorage in, 142, 144-145
tooth movement in, 143-146
OrthoCad software system, for three-dimen-
sional representations, 267-270
diagnostic use of, 268-270
downloading utility of, 268
vs. plaster casts, 267
storage utility of, 270
Osteogenesis, distraction, transverse, biome-
chanics of, 160-168
Osteologic curve, in tooth movement, for en
masse space closure, 143-144
Osteotomy, for transverse distraction osteogene-
sis, 163-164
Overbite, deep, correction of
biomechanics of, 26-33
Invisalign appliance for, 278, 280
Palate
cleft, presurgical treatment of, cantilever
springs for, 153
rapid expansion of, in Alexander Discipline,
112
Patient records. See Records
Periodental health, with Invisalign appliance,
291-292
Periodontal ligament, stress on, tooth move-
ment in, 143-147
Posterior segments, extrusion of, in deep over-
bite correction, biomechanics of, 32-33
Practice management, digital, 266-273
communication in, 270-273
three-dimensional system for, 267-270
Premolars, extraction of, for Invisalign appli-
ance treatment, 285
ics of, 180-181
Psychologic issues, in Alexander Discipline,
67-73
Records, three-dimensional, 266-273
electronic transmission of, 270-273
with Invisalign appliance, 275
technology for, 251-257
anatomic reconstructions, 254
computed tomography, 253-255
current status of, 252-253
dental, 255
facial, 253
history of, 251-252
laser scanners, 253
OrthoCad software system, 267-270
skeletal, 253-255
structure light, 253
tomosynthesis, 254
ultrasonic motion capture, 255
Rectangular arch wires, incisor torqued brackets
with, for leveling of curve of Spee, 215-
220
Retention
in Alexander Discipline, 65, 88, 132-137
appointments during, 137
countdown to, four appointments for, 133-
135
criteria for, 132-133
instructions for, 137
mandibular retainer in, 136-137
maxillary retainer in, 135-136
in anterior open bite closing, 41
with Invisalign appliance, 292
Retraction
buccal segment, in segmented arch tech-
nique, 203-204
canine, with arch wires, biomechanics of, 182-
190
cuspid, in segmented arch technique, 196-199
root, in segmented arch technique, 201-202
Roots
correction of, 50-58
anterior root springs for, 211-212, 214
cantilever springs for, 155-157
case studies of, 53-56
in continuous arch wire system, 50-51
diagnosis for, 51-52
incisor, 52
movement of, biomechanics of, 7-8
<<    
     Article
      >>
302 Subject Index
Roots (Continued)
retraction of, in segmented arch technique,
201-202
Rotation
centers of, in appliance systems, 5-6
control of, in Alexander Discipline, 75
Invisalign appliance for, 285, 287-288
pure, biomechanics of, 8
Sagittal dimension, modification of, in Alex-
ander Discipline, 80
Segmented arch technique, 191-206
appliance for, 193-195
finishing stage of, 205-206
with Group A anchorage, 199-202
with Group B anchorage, 202-203
with Group C anchorage, 203-205
initial treatment stage of, 195-198
intermediate treatment stage of, 198-199
overview of, 191-193
steel anterior stabilization segment in, 195
Separation agreement, in Alexander Discipline,
69
Skeletal discrepancies, face bow for, in Alex-
ander Discipline, 80-84
Soft tissue images, for three-dimensional imag-
ing, 237-238
Space closure and anchorage control, biome-
chanics of, 42-49
biologic considerations in, 46-47
differential moment use in, 47-48
in en masse space closure, 141-149
history of, 42-43
techniques for, 43-46
Spatial resolution, in three-dimensional imag-
ing, 234-235
Speech, with Invisalign appliance, 277
Springs
in anchorage control, 47-48
anterior root, biomechanics of, 211-212, 214
cantilever
biomechanics of, 150-159
for incisor intrusion, in deep overbite cor-
rection, 31
titanium T-loop retraction, in segmented arch
technique, 200-205
Stability, in Alexander Discipline, in vertical di-
mension control, 88
Static equilibrium, in appliance activations, 8-9
Stereophotogrammetry, 226
Straight wires, for leveling and alignment, 16-25
popularity of, 17-18
Home | TOC |          
Index
Straight wires, for leveling and alignment, 16-25
(Continued)
side effects of, 18-24
Stress, on periodontal ligament, tooth move-
ment in, 143-147
Structured light methods, in three-dimensional
imaging, 229, 253
for motion animation, 245-247
Symmetry, in Alexander Discipline, 64-65
T-loop retraction springs, in segmented arch
technique, 200-205
Teeth
leveling and alignment of, straight wires in,
16-25
movement of. See Tooth movement
size of, vs. arch length
extraction in, in Alexander Discipline, 100-
106
nonextraction approach to, in Alexander
Discipline, 117-131
three-dimensional imaging of, 255
Tele-orthodontics, 231
Three-dimensional craniofacial mapping, 223-
232
calibration requirements in, 228
case studies of, 239-242
Case Western Reserve University method, 233-
243
for complex malocclusions with Invisalign ap-
pliance, 274-293
Craniofacial Research Instrumentation Labo-
ratory system for, 223-232
digital vs. analog, 234
future of, 230-231
grayscale resolutions in, 234-235
historical antecedents of, 225-226
image resolution in, 234
measurement principles in, 226-228
merging of, 229-230, 238-239
motion animation in, 244-250
need for, 223-224, 235-236
orthogonal measurement in, 227
in outcomes assessment, future of, 242-243
paradigm shift related to, 266-273
for patient record, 251-257, 266-273
as paradigm shift, 266-273
technology for, 251-257
quantitative measurement in, 228-229
soft tissue images in, 237-238
spatial resolutions in, 234-235
study cast images in, 238
<<    
     Article
      >> Home | TOC |          
Index

Subject Index 303

Three-dimensional craniofacial mapping, 223- Transverse dimension, modification of (Continued)

232 (Continued) distraction osteogenesis in, biomechanics of,
tie points in, 229-230 160-168
triangulation measurement in, 227 Tuned aperture computed tomography, in
two-dimensional records used in, 236 three-dimensional imaging, 254
vs. two-dimensional superimposition, 239-242 Twin brackets, in Alexander Discipline, 76
Tipping
of anterior segment, in segmented arch tech- Ultrasonic motion capture system, for mandibu-
nique, 201 lar motion, 255
biomechanics of, 6
in space closure and anchorage control, 46-47 Vari-Simplex Discipline, 74-75
Titanium T-loop retraction springs, in seg- Vertical dimension control, in Alexander Disci-
mented arch technique, 200-205 pline, 80-81, 85-89
Tomosynthesis, in three-dimensional imaging, arch coordination in, 87
254 bite plate in, 87
Tooth movement curve of Spee in, 86-87
crown, biomechanics of, 6-7 elastics in, 87-88
in en masse space closure, with Opus Loop, mandibular arch development in, 87
143-146 maxillary arch development in, 86
with Invisalign appliance, 274-293 maxillary bracket height in, 86
prediction of, in appliance activation, 2-8, principles of, 85-88
12-14 retention in, 88
root, biomechanics of, 7-8 stability in, 88
Torque
in Alexander Discipline, 75-76 Wires. See also Arch wires
on incisor brackets, with rectangular arch straight, for leveling and alignment, 16-25
wires, for leveling of curve of Spee, 215- popularity of, 17-18
220 side effects of, 18-24
Translation, pure, biomechanics of, 7 two-dimensional force systems of, 208-210
Transverse dimension, modification of
in Alexander Discipline, 81-82 X-ray system, for three-dimensional craniofacial
cantilever springs for, 152-153 mapping, 258-265
<<    
     Article
      >> Home | TOC |          
Index

Mosby
M Harcourt Health Sciences

ON THE INTERNE!!

ISSN 1079-2104

No other journal brings you

Inside U.S.A.
such complete coverage
Individuals $141.00
Institutions $307.00 Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics
Students/Residents* $ 69.00 offers comprehensive coverage of diagnostic methods, pathologic problems and
Outside U.S.A. medical-surgical treatments as they relate to developments in five branches of
Individuals $170.00 dentistry. It is the only major dental publication that gives readers such a prac-
Institutions $336.00 tical and complete overview.
Students/Residents* $ 98.00
*Please supply, on institution letterhead, your An aggressive editorial policy has enabled Oral Surgery, Oral Medicine, Oral
name, dates of internship/residency, and signature
of program director. Orders will be billed at the Pathology, Oral Radiology, and Endodontics to keep pace with changing trends
individual rate until proof of status is received.
Airmail rates are available upon request.
and developments in dentistry. Attuned to the needs of today's practitioners,
the journal features:
§SUBSCRIPTION PRICES INCLUDE
ACCESS TO FULL TEXT ONLINE. • monthly editorials by the journal's section editors that address the
most important current issues in each branch of dentistry
To order, call toll-free:
• review papers that bring you state-of-the-art information and serve
1-800-654-2452 as a ready reference
Outside U.S.A. and Canada: • Clinicopathologic Conference (CPC) articles that challenge you to
1-407-345-4000
test and improve your clinical diagnostic skills
Fax:
1-407-363-9661 Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics
E-mail: is recommended for initial purchase in the Brandon-Hill study, Selected List of
periodical.service@mosby.com
Books and journals f or the Small Medical Library (1999/2000 Edition). Start your
Visit:
www.mosby.com/tripleo
subscription to the journal today!

Or contact: SPECIAL OFFER FOR SUBSCRIBERS!

M Mosby
Customer Subscription Services
As part of your subscription to Oral Surgery, Oral Medicine, Oral Pathology, Oral
Radiology, and Endodontics, you'll receive FREE access to the online version of
the journal. You'll have instant access to the full text of each issue as it publishes.
6277 Sea Harbor Drive
Orlando, FL One click of the mouse allows you to search and easily pinpoint information by
32887-4800 U.S.A. abstract, title or author. In addition, you'll have access to PubMed (MEDLINE)
©2001 Mosby. Prices subject to reference links. This offer is available only to journal subscribers, so don't delay!
change without notice. Add the
applicable sales tax f or your area. Visit www.mosby.com/tripleo today for full details!
<<    
     Article
      >> Home | TOC |          
Index

W.B. SAUNDERS

URNALS CamPMslm

ANESTHESIOLOGY American Journal of Kidney Diseases—The Official Journal RADIOLOGY

Journal of Cardiothoracic and Vascular Anesthesia
Journal of Pain—Official Journal of the American Pain Society
Regional Anesthesia and Pain Medicine
and Latin American Societies of RegionalAnesthesia
Seminars in Anesthesia
Seminars in Cardiothoracic and Vascular Anesthesia
Techniques in Regional Anesthesia and Pain Management
CARDIOVASCULAR DISEASES
Progress in Cardiovascular Diseases
CRITICAL CARE MEDICINE
Journal of Critical Care
DENTISTRY
Journal of Oral and Maxillofacial Surgery—Official Journal of
the American Association of Oral ana Maxillofacial Surgeons
Journal of Prosthodontics—Official Journal of The American
College of Prosthodontists
Seminars in Orthodontics
DERMATOLOGY
American Journal of Contact Dermatitis—The Official Journal
of the American Contact Dermatitis Society
Seminars in Cutaneous Medicine and Surgery
EMERGENCY MEDICINE
American Journal of Emergency Medicine
Clinical Pediatric Emergency Medicine
ENDOCRINOLOGY
Metabolism—Clinical and Experimental
GASTROENTEROLOGY/HEPATOLOGY
Clinical Perspectives in Gastroenterology—The Official Clinical
Gastroenterology— Official Journal of the American
Hepatologf—OfficialJournal of the American Association for
the Study of Liver Diseases
Liver Transplantation^» Official Publication of the American
Seminars in Gastrointestinal Disease
Techniques in Gastrointestinal Endoscopy
HEMATOLOGY/ONCOLOGY
Seminars in Hematology
Seminars in Oncology
Seminars in Radiation Oncology
Transfusion Medicine Reviews
INFECTIOUS DISEASES
Seminars in Infection Control
Seminars in Pediatric Infectious Diseases
Seminars in Respiratory Infections
MEDICAL TRANSCRIPTION
The Latest Word
NEONATAL/PERINATAL MEDICINE
Newborn and Infant Nursing Reviews
Seminars in Perinatology
NEPHROLOGY
Advances in Renal Replacement Therapy—A Journal of
©2001 W.B. SAUNDERS
Journal of Digital Imaging—The Official Journal of the Society
Journal of Renal Nutrition—The Official Journal of The Council for Computer Applications in Radiology
on Renal Nutrition of the National Kidney Foundation Seminars in Breast Disease
Seminars in Nephrology Seminars in Nuclear Medicine
Seminars in Radiologie Technology
NEUROLOGY Seminars in Roentgenology
Journal of Pain—Official Journal of the American Pain Society Seminars in Ultrasound, CT and MRI
Journal of Stroke and Cerebrovascular Diseases—Official Journal Techniques in Vascular and Interventional Radiology
of the National Stroke Association and theJapan Stroke Society
Seminars in Cerebrovascular Diseases and Stroke RHEUMATOLOGY
Seminars in Pediatric Neurology Seminars in Arthritis and Rheumatism
NURSING SURGERY
Applied Nursing Research Journal of Pediatric Surgery—Official Journal of the Section on
Archives of Psychiatric Nursing—Official Journal of the SERPN
Division, International Society of Psychiatric-Mental Health Nurses
Journal of Pediatric Nursing—Nursing Care of Children and Families Canadian Association ofPaediatric Surgeons and Pacific
Journal of Pediatric Oncology Nursing—Official Journal of the
Association of Pediatric Oncology Nurses Operative Techniques in General Surgery
Journal of PeriAnesthesia Nursing—Official Journal of the American Operative Techniques in Gynecologic Surgery
Society of PeriAnesthesia Nurses Operative Techniques in Neurosurgery
Journal of Professional Nursing—Official Journal of the American Operative Techniques in Plastic and Reconstructive Surgery
Association of Colleges of Nursing Operative Techniques in Thoracic and Cardiovascular Surgery—
Nurse Practitioner Forum An Official Publication of The American Association for
Pain Management Nursing—Official Journal of the American Society Thoracic Surgery
Seminars in Colon and Rectal Surgery
PeriAnesthesia and Ambulatory Surgery Nursing Update—Official Seminars in Laparoscopic Surgery
Publication of the American Society of PeriAnesthesia Nurses Seminars in Pediatric Surgery
Seminars for Nurse Managers Seminars in Spine Surgery
Seminars in Oncology Nursing Seminars in Thoracic and Cardiovascular Surgery—4« Official
Seminars in Perioperative Nursing Publication of The American Association for Thoracic Surgery
Seminars in Thoracic and Cardiovascular Surgery: Pediatric Cardiac
OBSTETRICS AND GYNECOLOGY Surgery Annual—An Official Publication of The American
Clinical Journal of Women's Health Association for Thoracic Surgery
Operative Techniques in Gynecologic Surgery Seminars in Urologie Oncology
ORTHOPEDICS Seminars in Vascular Surgery
Arthroscopy: The Journal of Arthroscopic and Related Surgery— TRANSPLANTATION
Liver Transplantation—4» Official Publication of the American
and the International Society of Arthroscopy, Knee Surgery, and
Orthopaedic Sports Medicine
Journal of the American Society for Surgery of the Hand—An Official Transplantation Reviews
Journal of the American Society for Surgery of the Hand
Journal of Hand Surgery—An Official Journal of the American UROLOGY
Society for Surgery of the Hand Seminars in Urologie Oncology
Operative Techniques in Orthopaedics
Operative Techniques in Sports Medicine VETERINARY MEDICINE
Seminars in Arthroplasty Advances in Small Animal Medicine and Surgery
Seminars in Spine Surgery Clinical Techniques in Small Animal Practice
Seminars in Avian and Exotic Pet Medicine
OTORHINOLARYNGOLOGY Veterinary Surgery—fee Official Journal of The American
American Journal of Otolaryngology
Operative Techniques in Otolaryngology—Head and Neck Surgery of Veterinary Surgeons
PATHOLOGY For more information about these journals,
Annals of Diagnostic Pathology
Human Pathology please contact:
Seminars in Diagnostic Pathology Periodicals Marketing
PHYSICAL MEDICINE WJB* SAUNDERS
Archives of Physical Medicine and Rehabilitation—Official Journal Harcourt Health Sciences
of the American Congress of Rehabilitation Medicine and the
The Curtis Center
Independence Square West
PSYCHIATRY Philadelphia, PA 19106-3399
Comprehensive Psychiatry—Official Journal of the American
Psychopathological Association
Phone (215) 238-5614
Seminars in Clinical Neuropsychiatry Or visit our homepage at:
www.wbsaunders.com