dentistry journal
Review
Cantilevers: Multi-Tool in Orthodontic Treatment
Malgorzata Bilinska * , Kasper Dahl Kristensen
Citation: Bilinska, M.; Kristensen,
K.D.; Dalstra, M. Cantilevers:
Multi-Tool in Orthodontic Treatment.
Dent. J. 2022, 10, 135. https://
doi.org/10.3390/dj10070135
Academic Editor: Enrico Spinas
Received: 13 June 2022
Accepted: 15 July 2022
Published: 19 July 2022
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Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Dent. J. 2022, 10, 135. https://doi.org/10.3390/dj10070135
and Michel Dalstra
Section of Orthodontics, Department of Dentistry and Oral Health, Aarhus University, Vennelyst Boulevard 9,
8000 Aarhus, Denmark; kdki@dent.au.dk (K.D.K.); michel.dalstra@dent.au.dk (M.D.)
* Correspondence: m.b.bilinska@gmail.com
Abstract: This review aims to discuss and illustrate various uses of cantilevers to solve multiple
clinical issues and prove their versatility. Cantilevers are commonly used in the segmented arch
technique, and they can be designed to solve various clinical problems with highly predictable results.
Its design and shape can modify the various combinations of vertical and horizontal forces. The
novel trend is to combine cantilevers with skeletal anchorage. Cantilevers offer a very simple and
statically determined force system. The advantage is the control over side effects, which normally
occur on the anchor teeth and the occlusion. The disadvantages include possible side effects on the
anchorage unit, when the anchorage is poorly controlled. The review highlights the clear benefits of
cantilever use in complex corrections of single teeth, segments, and entire arch with a diminished
effect on the dentition, also with the use of skeletal anchorage. With their simple and easily tailored
design, these springs can be called an orthodontic multi-tool.
Keywords: orthodontics; cantilevers; statically determine system; segmented arch technique
1. Introduction
The application of well-defined biomechanical force systems allows to predict and
control the tooth movement, according to the laws of equilibrium. The segmented arch
technique was described by Charles Burstone in 1962 [1] and, in many cases, provides sev-
eral clinical advantages over continuous archwires [2]. Understanding and the application
of basic biomechanics aids to improve the orthodontic appliance efficiency, reduce possible
side effects, and may shorten the overall treatment time. Cantilevers are commonly used
in the segmented arch technique. Their design can solve various clinical problems with
highly predictable results. However, combining cantilevers and straight-wire technique
to move single displaced teeth decrease the risk of displacement of the well-positioned
teeth [3]. As a rule, avoid connecting “the good with the bad”: severely displaced or
impacted teeth with continuous archwire aids to prevent serious side effects. The sys-
tem needs less frequent reactivations due to a low load/deflection rate and long span
among the attachment points [4]. Cantilevers are most commonly made from titanium and
molybdenum alloy (TMA) wire, but can also be made from stainless steel (SS). TMA can
withstand more deflection than SS before permanent deformation occurs. It enables the
creation of cantilevers with simpler designs and in most cases saves time during clinical
procedures. TMA’s stiffness and modulus of elasticity provide a controlled force system
and individualized tooth movement [5]. The cantilever’s design and shape can modify
the various combinations of vertical and horizontal force. The use of a curved cantilever
provides combined retraction and intrusion, while utility-shaped produces protrusive and
intrusive forces [6,7] (Figure 1). In addition, the point of activation influences the force
decay pattern over time [8].
A force system delivered by orthodontic appliances can be either statically determined
or statically indetermined. In a statically determined force system, all forces and moments
can be calculated using the force and moment equilibrium equations and are therefore
https://www.mdpi.com/journal/dentistry
 Dent. J. 2022, 10, 135 2 of 16

predictable. For a statically indetermined force system, little is known from both a quali-
Figure 1. Different cantilever designs (activated). From the left: deep curve, tip back, and utility
tative and quantitative point of view. A cantilever spring is a very simple and statically
arch.
Dent. J. 2022, 10, x FOR PEER REVIEW determined design. A single force is generated on the mesial end of the one-point contact. 2 of 16
On the distal end, there is a reactive force in the opposite direction. These two forces
A aforce
generate couplesystem delivered
that has to by by
be countered orthodontic appliances
a reactive moment can ofbe
for the sake either statically
equilibrium
determined
(Figure 2). or statically indetermined. In a statically determined force system, all force
and moments can be calculated using the force and moment equilibrium equations and
are therefore predictable. For a statically indetermined force system, little is known from
both a qualitative and quantitative point of view. A cantilever spring is a very simple and
statically determined design. A single force is generated on the mesial end of the one
point contact. On the distal end, there is a reactive force in the opposite direction. These
two forces generate a couple that has to be countered by a reactive moment for the sake
Figure 1. Different (Figure
of equilibrium cantilever2).
designs (activated). From the left: deep curve, tip back, and utility arch.
Figure 1. Different cantilever designs (activated). From the left: deep curve, tip back, and utility
arch.

A force system delivered by orthodontic appliances can be either statically

determined or statically indetermined. In a statically determined force system, all forces
and moments can be calculated using the force and moment equilibrium equations and
are therefore predictable. For a statically indetermined force system, little is known from
both a qualitative and quantitative point of view. A cantilever spring is a very simple and
statically determined design. A single force is generated on the mesial end of the one-
point contact.
Figure Onofthe
2. Model distal end,
a statically there force
determined is a system
reactive force
(blue: in the unit
anchorage opposite direction.
with cantilever; These
grey:
Figure
twopoint
forces 2. Model of
generate a(A)a statically
couple determined
thatinhas force system
to beposition,
countered (blue: anchorage unit with cantilever;
the sakegrey
of application). Cantilever a neutral lengthby(d).a(B)
reactive moment
Activated cantileverfor
a single
point of application). (A) Cantilever in a neutral position, length (d). (B) Activated cantilever a singl
of equilibrium
force (F), and a(Figure
force and 2).a moment (M) on the other side (red arrows).
force (F), and a force and a moment (M) on the other side (red arrows).
A cantilever is a universal tool, but it is sometimes overlooked in clinical practice. This
reviewAaims
cantilever is aand
to discuss universal
illustratetool, butuses
various it isofsometimes
cantilevers overlooked in clinical
to solve multiple clinicalpractice
This review aims to discuss and illustrate various uses of cantilevers to solve multiple
issues and prove their versatility.
clinical issues and prove their versatility.
2. Anchorage Considerations
The classicConsiderations
2. Anchorage anchorage unit consists of a segment with an increasing number of
teeth. The anchorage unit can also be reinforced with an intraoral appliance, for example,
The classic
a transpalatal arch.anchorage
The verticalunit consists
extrusive ofcan
force a segment with anbyincreasing
be counteracted number of teeth
the use of high-pull
The anchorage
headgear, unit forces
but occlusal can alsocould bealso
reinforced with anextrusion
partially prevent intraoral [9].appliance, for example,
The novel trend is a
transpalatal
to arch. Thewith
combine cantilevers vertical
skeletal extrusive
anchorage force can be counteracted
(temporary by theTADs,
anchorage devices, use oforhigh-pul
Figure 2. Modelbut
miniscrews).
headgear, ofInaocclusal
statically
the determined
literature,
forces couldforce
various alsosystem
applications
partially (blue:
of anchorage
TAD-anchored
prevent unit with
[9]. cantilever;
one-couple
extrusion The novelgrey:
systems trend i
point
areof application). (A)
described.cantilevers Cantilever
The advantage in a neutral
is skeletal
the control position, length
over side effects, (d). (B) Activated
whichanchorage cantilever
normally occur a single
on the
to combine with anchorage (temporary devices, TADs, o
forceanchor
(F), and a force
teeth and and occlusion.
a moment (M) onTADs the other
doessidenot(red arrows).
miniscrews). In the
the literature,Using various applications reduce the need for biomechanical
of TAD-anchored one-couple system
considerations, but reduces some of the obstacles. It is particularly advantageous when
are described. The advantage is the control over side effects, which normally occur on the
A correction
the cantileverofisa asingle
universal
tooth is tool,
neededbut and
it isthe
sometimes
patient does overlooked
not desire in clinical practice.
comprehensive
anchor teeth and the In occlusion. Using TADs does notthe reduce the need for biomechanica
Thisorthodontic
review aims to discusstheand
treatment. illustrate
treatment various teeth,
of impacted uses of cantilevers
bonding of to solve
fully fixedmultiple
ap-
considerations,
pliance can be but
postponed reduces
until some
the of the
impaction obstacles.
is resolved It
andis particularly
possible advantageous
ankylosis is ruled when
clinical issues and prove their versatility.
the [10].
out correction
When of thea cantilever
single tooth is needed
is directly and the
attached to thepatient
TADs,does it cannotserve
desireas acomprehensiv
direct
orthodontic
anchorage. To treatment.
reduce
2. Anchorage Considerations wire In
play the in treatment
the screw of
head, impacted
the teeth,
cantilever’s the
size bonding
should matchof the
fully fixed
appliance can
dimensions be postponed
of the slot [11]. Asuntil the impaction
an indirect anchorage, is resolved and possible
skeletal anchorage ankylosis
stabilizes the is ruled
The classic
anchorage unit.anchorage
TADs can unit consists
support the of a segment
transpalatal arch with
(TPA) ananchorage
increasingtonumber
prevent of teeth.
side
out [10]. When the cantilever is directly attached to the TADs, it can serve as a direc
Theeffects
anchorage
on theTo unit can
molars also
[11]. Thebe reinforceda with
placement anlineintraoral or appliance, fordentition
example, a
anchorage. reduce wire play in theofscrew TADhead,in with
the parallel to
cantilever’s the
size should match the
transpalatal
minimizesarch. The moments
torquing vertical extrusive
on the screw. force
Whencanthe be TADcounteracted by the use of to
is placed perpendicular high-pull
the
dimensions of the slot [11]. As an indirect anchorage, skeletal anchorage stabilizes the
long axis of the dentition (buccal or palatal cortex), counterclockwise
headgear, but occlusal forces could also partially prevent extrusion [9]. The novel trend is or clockwise torquing
anchorage unit. TADs can support the transpalatal arch (TPA) anchorage to prevent side
momentscantilevers
to combine occur on thewith TAD skeletal
and lead anchorage
to its failure(temporary
[12] (Figure 3). anchorage devices, TADs, or
effects on the molars [11]. The placement of a TAD in line with or parallel to the dentition
miniscrews). In the literature, various applications of TAD-anchored one-couple systems
are described. The advantage is the control over side effects, which normally occur on the
anchor teeth and the occlusion. Using TADs does not reduce the need for biomechanical
considerations, but reduces some of the obstacles. It is particularly advantageous when
the correction of a single tooth is needed and the patient does not desire comprehensive
orthodontic treatment. In the treatment of impacted teeth, the bonding of fully fixed
 Dent. J. 2022, 10, x FOR PEER REVIEW 3 of 16
t. J. 2022, 10, x FOR PEER REVIEW 3 of 16

minimizes torquing moments on the screw. When the TAD is placed perpendicular to the
minimizes torquing moments on the screw. When the TAD is placed perpendicular to the
Dent. J. 2022, 10, 135 long axis of the dentition (buccal or palatal cortex), counterclockwise or clockwise
3 of 16
long axis of the dentition (buccal or palatal cortex), counterclockwise or clockwise
torquing moments occur on the TAD and lead to its failure [12] (Figure 3).
torquing moments occur on the TAD and lead to its failure [12] (Figure 3).

Figure 3. (Left):
FigurePlacement
Figure3.3.(Left):ofPlacement
(Left): aPlacement
TAD in line a with
ofof TAD
a TADorinparallel
line
in line to the
with
with dentition:
or or
parallel to no
parallel torquing
thethe
to moments
dentition: nono
dentition: torquing
torquingmoments
mo-
on the TAD occurs.
onments
the on
TAD (Right)
TADTAD
the occurs. is placed
(Right)
occurs. TAD
(Right) perpendicular
is placed
TAD is placed to the long axis
perpendicular
perpendicular of
thethe
totothe longdentition;
axisofofthethe
axis dentition;
dentition;
counterclockwise or clockwiseor
counterclockwise
counterclockwise torquing
or moments
clockwise
clockwise occurs
torquing
torquing (red: cantilever,
moments
moments occurs green:
occurs(red:
(red: force and
cantilever,
cantilever, moment).
green:
green: force
force andand moment).
moment).

3. Impacted
3.3.Teeth
ImpactedTeeth
Impacted Teeth
The management
The of ectopicofof
The management
management teeth
ectopicrepresents
teethteeth
ectopic one
represents ofone
represents the greatest
of the
onegreatest
of the challenges
greatestinin
challenges orthodon- in
challenges
orthodontics. In In
tics. thethe
treatment
treatment ofofectopic
ectopic canines
canines with
with aastatically
statically determined
determined system, the
system, the cantilever’s
orthodontics. In the treatment of ectopic canines with a statically determined system, the
cantilever’s force
forceline
lineofof action
action cancan
be be adjusted accordingto thetotreatment
the treatment For need. For a impacted
cantilever’s force line of adjusted
action can according
be adjusted accordingneed. a buccally
to the treatment need. For a
buccally impacted canine, the choice would be either to extrude and mesialize/distalize
canine, the choice would be either to extrude and mesialize/distalize the canine, while
buccally impacted canine, the choice would be either to extrude and mesialize/distalize
the canine, while palatally
palatally impactedimpacted need extrusive
need extrusive and pull-force
and buccal buccal pull-force components.
components. In the caseIn of bilateral
the canine, while palatally impacted need extrusive and buccal pull-force components. In
the case of bilateral
impaction, impaction,
tractiontraction can be provided
can be provided simultaneously
simultaneously for bothfor both impacted
impacted teeth [13–15]. The
the The
teeth [13–15]. caseuseof bilateral
of impaction,
lightreduces
forces reducestraction canofbe provided simultaneously for both impacted
use of light forces the riskthe risk complications
of complications and respects
and respects bone
bone biology. The gener-
teeth
biology. Theated [13–15].
generated
force offorceThe use
25–30ofcN of
25–30 light forces
cN extrudes
extrudes reduces
a canineaover canine the
a wide risk of complications
overactivation
a wide activation
range [14,16]. rangeArespects
and bone
cantilever
biology.
[14,16]. A cantilever
should be The generated
should
attached force
be attached of 25–30
to the with
to the canine caninecN extrudes
a with a canine
a single-point
single-point over
contactcontact a
to avoid wide
to avoidactivation
the couple. The range
the couple. The alternative is introducing the compensating toe-in bend when it contact
[14,16]. A
alternative cantilever
is should
introducing the be attached
compensating to the
toe-incanine
bend with
whena single-point
it is attached to to avoid
is the bracket
the
attached to slot couple.
the [4]. The
The slot
bracket alternative
extrusion
[4]. The is
of extrusion introducing
the canineofcan thebecanine the compensating
also achieved
can be alsowith toe-in
a vertical
achieved bend when
tube-supported
with a it is
attached
cantilever
vertical tube-supported tospring,
thecantilever
bracket slot
as described [4].
spring,byThe extrusion
Vijayashree
as described andbyofPai
the canine
[17]. can
andbePai
Supplementary
Vijayashree also achievedwith
anchorage
[17]. with a
vertical
Supplementarydifferent tube-supported
appliance
anchorage withtypes cantilever
or TADs
different spring,
decreases
appliance types as ordescribed
the stress
TADslevels byon
decreases Vijayashree
the stress and
theadjacent teethPai [17].
[18].
levels on theBoth the biomechanics
Supplementary
adjacent teethanchorage
[18]. Bothandthe force
with direction of
different
biomechanics the force
appliance
and canine movement
types or TADs
direction arecanine
of the necessary. the
decreases Poorly
stress
controlled
movementlevels on theorthodontic
are necessary. Poorly teeth
adjacent extrusion
controlled may theleadbiomechanics
orthodontic
[18]. Both toextrusion
the root resorption
may
andlead
forceto ofdirection
adjacent
the root ofteeth
the and
canine
introduced
resorptionmovement
of adjacent teethmoments
are necessary.may
and introduced cause
Poorly unwanted
moments
controlled rotations
mayorthodontic [19].
cause unwanted rotations
extrusion may [19].
lead to the root
resorption of adjacent teeth and introduced moments may cause unwanted rotations [19].
3.1. Buccal Impaction
3.1. Buccal Impaction
A single
3.1.extrusive
A single Buccal extrusive
Impaction
force for theforce for the
eruption of eruption
a buccallyofimpacted
a buccallycanine
impacted canine
can be easilycan be easily
generated with, e.g., a 0.017 00 × 0.02500 TMA cantilever from the auxiliary tube of the first
generated with,Ae.g., a 0.017″
single × 0.025″
extrusive TMA
force for cantilever
the from
eruption ofthe auxiliaryimpacted
a buccally tube of the first can be easily
canine
molar,
molar, attached to attached
the caninetowith
the canine with
a single-point a single-point contact
contact (Figure 4). (Figure 4).
generated with, e.g., a 0.017″ × 0.025″ TMA cantilever from the auxiliary tube of the first
molar, attached to the canine with a single-point contact (Figure 4).

Figure 4. Bilateral canine impaction: (right) buccal and (left) palatal. Right maxillary canine:
traction with 0.017 × 0.02500 TMA cantilever activated for extrusion. Left maxillary canine: can-
tilever is inserted into the auxiliary tube of an upper molar, activated for canine extrusion and
buccal displacement.
 displacement.
Figure 4. Bilateral canine impaction: (right) buccal and (left) palatal. Right maxillary canine
Katiyar
with 0.017et al. described
× 0.025″ TMA the cantilever
cantilever for buccally
activated impacted
for extrusion. canines with
Left maxillary a closi
canine: can
loop, inserted
positionedintomesially to thetube
the auxiliary firstofmolar. Its activation
an upper provides
molar, activated for distal
canineretraction
extrusion ofant
Dent. J. 2022, 10, 135 displacement.
canine, if needed [20] (Figure 5). After the canine is positioned in the arch, a box loop c 4 of 16

be used to produce first- and second-order corrections while continuing the vertical eru
tion [21]. Katiyar et al. described the cantilever for buccally impacted canines with a
loop,Katiyar et al. described
positioned mesiallythetocantilever
the first for buccally
molar. Its impacted canines
activation with adistal
provides closing retractio
loop, positioned mesially to the first molar. Its activation provides distal retraction of the
canine, if needed [20] (Figure 5). After the canine is positioned in the arch, a box l
canine, if needed [20] (Figure 5). After the canine is positioned in the arch, a box loop
be used
can be usedto to
produce
producefirst- andsecond-order
first- and second-order corrections
corrections whilewhile continuing
continuing the vertic
the vertical
tion [21].
eruption [21].

Figure 5. Cantilever with a loop activated for buccally impacted canine extrusion (red: cantileve
green: force and moment).

3.2. Palatal Impaction

Figure 5. Cantilever with a loop activated for buccally impacted canine extrusion (red: cantilever,
Figure 5. Cantilever
The traction of the with
green: force and moment).
a loopimpacted
palatally activated for buccally
canines impacted
includes thecanine
tooth extrusion
eruption(red: cant
out of
palategreen: force and moment).
followed by buccal movement into the final arch position. A cantilever can be
serted3.2.
into theImpaction
Palatal molar buccal auxiliary tube and attached to the canine [14,22,23]. An alt
3.2. The
Palatal Impaction
native option,tractionto avoid occlusal
of the palatallyinterference,
impacted canines is to attach
includesthe thecantilever
tooth eruption to theoutlingual
of sh
of the molar [4,14]. A cantilever could be also inserted into the welded sheet on the ou
the The
palate traction
followed of
by the
buccalpalatally
movement impacted
into the canines
final arch includes
position. Athe tooth
cantilever eruption
can TP
be inserted
palate into theby
followed molar buccal
buccal auxiliary tube
movement into and
the attached
final archto the canine [14,22,23].
position. A cantilever ca
(Figure 5). The described methods do not incorporate anchorage reinforcement. In p
An alternative option, to avoid occlusal interference, is to attach the cantilever to the
longed serted into the molar buccal auxiliary tube andand attached to thewillcanine [14,22,23].if A
lingual sheettraction,
canine of the molarside effects
[4,14]. (molar could
A cantilever tipping intrusion)
be also inserted into the weldedbe observed
sheet t
native
anchorage
on the TPA option,
unit(Figure to
is not5). avoid
well occlusal
Thedesigned. interference,
To reduce
described methods do notside is to attach the
effects,anchorage
incorporate cantilever
a TPA can to the
be employed (F
reinforcement. lingu
of the molar [4,14]. A cantilever could be also
ure 6) [24]. Nakandakari et al. described the canine traction with twoobserved
In prolonged canine traction, side effects (molar tipping inserted
and into
intrusion) the
will welded
be sheet on ot
cantilevers:
if the
(Figure anchorage unit is not well designed. To reduce side effects, a TPA can be employed
welded to the5).TPA, The activated
described for methods
extrusion,do not andincorporate
a second one anchorage
attachedreinforcement.
to the auxilia
(Figure
longed 6) [24].
canine Nakandakari
traction, et al.
side described
effects the
(molar canine traction
tipping andwith two cantilevers:
intrusion) will oneobserve
molarwelded
tube, to activated
the TPA, for buccalformovement
activated extrusion, and [24]. Tepedino
a second et al. described
one attached thebeTPA
to the auxiliary with
anchorage
soldered
molar unit
stainless-steel is not well
tube, activated cantilever, designed.
similar to
for buccal movement To reduce
theTepedino
[24]. side
helical et effects,
torsion a
spring.
al. described TPA
theThecan be employ
TPAdelivered
with for
aure
magnitude 6) depends
soldered [24]. Nakandakari
on the
stainless-steel et al.
amount
cantilever, ofdescribed
similaractivation, thethe
to the helical canine traction
wirespring.
torsion diameter with
and the
The delivered two cantilev
wire
force leng
welded
magnitude
The length ofto thethe
depends TPA,
wire on
can activated
thebeamount
changed for
of extrusion,
activation,
with and diameter
a second
thetheintroduction
wire and
of onethe attached
loops wire length.
[25]. to the a
According
The length
molarettube, of the wire can
activatedfacial be changed
for buccal with
movementthe introduction of
[24]. Tepedino loops [25].
et al. According
described tothe on
TPA
Tepedino al., patients’ divergence and muscular activity
Tepedino et al., patients’ facial divergence and muscular activity have no impact on the
have no impact t
soldered
force force
levellevel stainless-steel
for for
palatally
palatallyimpacted
cantilever, similar
maxillary
impacted maxillary
to
canines
canines
the helical
traction
traction
torsion
[16]. [16].
spring. The deliver
magnitude depends on the amount of activation, the wire diameter and the wire
The length of the wire can be changed with the introduction of loops [25]. Accor
Tepedino et al., patients’ facial divergence and muscular activity have no impac
force level for palatally impacted maxillary canines traction [16].

FigureFigure
6. Traction of a of
6. Traction palatally impacted
a palatally impactedright
rightmaxillary canine. (A)
maxillary canine. (A)Canine
Canineextrusion
extrusion with 0.01
with
0.017 × 0.025 00 TMA cantilever inserted into the welded sheet on TPA, activated for extrusion.
0.025″ TMA cantilever inserted into the welded sheet on TPA, activated for extrusion. (B) Cantile
placed(B)into
Cantilever placed into
the auxiliary tubetheofauxiliary
an upper tube of an upper
molar, molar,for
activated activated
caninefor canine extrusion
extrusion and displa
and buccal
buccal displacement. (C) The canine is aligned
ment. (C) The canine is aligned into its final position. into its final position.

Figure 6. Traction of a palatally impacted right maxillary canine. (A) Canine extrusion wit
TADs can serve as direct and indirect anchorage. Thebault et al. and Heravi et al.
TADs can
0.025″ TMA
described serve
direct as direct
cantilever
impacted and
inserted
canine intoindirect
thewith
traction aanchorage.
welded sheet on
cantilever Thebault
TPA,
attached to twoetTADs.
activated al.
forand
The Heravi
use (B)et
extrusion. C
described
of twodirect
placed impacted
into the
miniscrewsauxiliarycanine
tube
eliminates oftraction
and with
an upper
clockwise molar,a cantilever attached
activatedeffects
counter-clockwise for canine toTADs
twoduring
extrusion
on the TADs. The u
and buccal
ment. (C) The canine is aligned into its final position.

TADs can serve as direct and indirect anchorage. Thebault et al. and Hera
described direct impacted canine traction with a cantilever attached to two TADs.
 Dent. J. 2022, 10, x FOR PEER REVIEW  5 
 

Dent. J. 2022, 10, 135 5 of 16

of two miniscrews eliminates clockwise and counter‐clockwise effects on the TADs du
activation  and  deactivation  and  reduces  the  failure  risk  [10,11].  Annarumma  e
activation and deactivation and reduces the failure risk [10,11]. Annarumma et al. evaluated
evaluated the traction of impacted canines attached to a double miniscrew and cantil
the traction of impacted canines
system  only.  attached
Different  to a double
cantilever  miniscrew
designs  were  and
used cantilever system
to  obtain  only.
canine  extrusion 
Different cantilever designs were used to obtain canine extrusion and distalization, and
distalization, and to improve the torque. Skeletal anchorage allowed the tooth movem to
improve the without 
torque. Skeletal anchorage
stressing  allowed
the  anchorage  the posterior 
of  the  tooth movement, without
teeth.  The  stressing
simplicity  of  the  appro
the anchorage of the posterior teeth. The simplicity of the approach make the segmented
make  the  segmented  method  a  good  alternative  in  the  treatment  of  canine  impac
method a good alternative in the treatment of canine impaction [26].The cantilever can
[26].The cantilever can be also attached both to the anchorage tooth unit and to the T
be also attached both to the anchorage tooth unit and to the TAD, as a multi-attachment
as a multi‐attachment appliance. Insertion in the auxillary tube of a molar aids to red
appliance. Insertion in the auxillary tube of a molar aids to reduce the moment acting
the moment acting on the head of the screw [11]. As an indirect anchorage, the TA
on the head used to stabilize the anchorage unit. The cantilever is attached to the auxiliary tube of
of the screw [11]. As an indirect anchorage, the TAD is used to stabilize the
anchorage unit. The cantilever is attached to the auxiliary tube of the dental unit; the use of
dental unit; the use of skeletal anchorage prevents side effects on the adjacent teeth (Fig
skeletal anchorage prevents side effects on the adjacent teeth (Figure 7).
7). 

 
Figure 7. Panoramic x‐ray shows ectopic tooth 23 in a 16‐year‐old patient with only slight resorp
Figure 7. Panoramic x-ray shows ectopic tooth 23 in a 16-year-old patient with only slight resorp-
tion of 63 (A)of 63 (A) Palatally impacted left maxillary canine. The patient was satisfied with the smile‐est
Palatally impacted left maxillary canine. The patient was satisfied with the smile-
with 
esthetic with the the  diastemas. 
diastemas. Therefore, 
Therefore, a  sectional 
a sectional applianceappliance  was for
was chosen chosen  for  correction 
correction of positionof 
ofposition  o
without changing neither the occlusion or position of the rest of the teeth. (B) Canine extrusion 
23 without changing neither the occlusion or position of the rest of the teeth. (B) Canine extrusion
0.017 × 0.025″ TMA cantilever inserted into the tube of the molar, activated for extrusion and bu
with 0.017 × 0.02500 TMA cantilever inserted into the tube of the molar, activated for extrusion and
displacement. TAD is applied to stabilize indirectly the molar (anchorage unit). (C) The cani
buccal displacement. TAD is applied to stabilize indirectly the molar (anchorage unit). (C) The canine
aligned into its final position. 
is aligned into its final position.

 
Dent. J. 2022, 10, x FOR PEER REVIEW 6 of 16
Dent. J. 2022, 10, 135 6 of 16

When
Whenthe thepalatally
palatallyimpacted
impactedcanine
canineisispositioned
positionedininthe thearch,
arch,torque
torquecorrection
correctionisis
needed in the finishing stage. Gandini et al. described the appliance to correct
needed in the finishing stage. Gandini et al. described the appliance to correct buccolingual buccolin-
gual inclination of teeth, which provide a large buccal root movement
inclination of teeth, which provide a large buccal root movement with minor crown with minor crown
dislo-
dislocation. A 0.017 × 0.025 TMA cantilever is placed into a slot of the canine
cation. A 0.017 × 0.025 TMA cantilever is placed into a slot of the canine bracket bonded to bracket
bonded to the
the palatal palatal surface
or lingual or lingual surface
of the toothofand
theattached
tooth and attached
to the to the bar
transpalatal transpalatal bar
or the lingual
orarch
theas
lingual archofascontact.
one point one point of contact.
Depending on Depending on the of
the initial position initial position
the tooth, theof the tooth,
buccolingual
the buccolingual
inclination inclination
can be correctedcan be corrected
within within
5 to 8 months 5 to 8 months [27].
[27].

4.4.Deep
DeepBite
BiteCorrection
Correction
Thethree-piece
The three-pieceintrusion
intrusionbase
basearch
archconsists
consistsofofanterior
anteriorand
andposterior
posteriorsegments
segmentsand
and
twocantilevers,
two cantilevers,activated
activatedfor
forintrusion
intrusion(Figure
(Figure8).
8).

Three-pieceintrusion
Figure8.8.Three-piece
Figure intrusionarch.
arch.Deep
Deepcurve
curveshape
shapecantilevers
cantileversactivated
activatedforforanterior
anteriorsegment
segment
intrusioncantilevers:
intrusion cantilevers:(Left)
(Left)activated,
activated,before
beforeligation;
ligation;(Right)
(Right)ligated
ligateddistally
distallytotolateral
lateralincisors.
incisors.

ItIthas
hasaalow lowforce–deflection
force–deflectionrate rateusually
usuallyunder
under10 10cN/mm
cN/mmdue duetotothethelarge
largedistance
distance
between the auxiliary tube of the molar and the incisor brackets.
between the auxiliary tube of the molar and the incisor brackets. When the force is applied When the force is applied
at 90 degrees to the occlusal plane, the line of action can pass through
at 90 degrees to the occlusal plane, the line of action can pass through the center of re- the center of resistance
of the incisors.
sistance It is achieved
of the incisors. when the
It is achieved pointthe
when of point
attachment is placediscorrectly
of attachment and no flaring
placed correctly and
of flaring
no the teeth of occurs
the teeth [28]. The [28].
occurs use ofThelight
useconstant
of light forces
constant enables
forcesthe intrusion
enables of teeth with
the intrusion of
minimal side effects on the posterior anchor units. When intrusive
teeth with minimal side effects on the posterior anchor units. When intrusive forces in- forces increase, more
root resorption
crease, more rootoccurs without
resorption changing
occurs without tooth movement
changing rate. Therefore,
tooth movement rate. the force levels
Therefore, the
should be kept as low as possible. The desired magnitude
force levels should be kept as low as possible. The desired magnitude depends on depends on the number of teeth
the
included
number ofin the intruded
teeth included segment and their
in the intruded size. For
segment andthe upper
their arch,
size. Forabout 60 cNarch,
the upper of force for
about
four incisors should be applied to the upper incisors [28]. Van Steenbergen
60 cN of force for four incisors should be applied to the upper incisors [28]. Van Steenber- et al. concluded
thatetmaxillary
gen al. concluded incisors
that could be intruded
maxillary with forces
incisors could of 10 to
be intruded with20 forces
cN peroftooth.
10 to 20 There
cN
wastooth.
per no difference
There was whether 40 or 80
no difference cN was40used,
whether or 80forcNintrusion
was used, rate,
for extrusion
intrusion of buccal
rate, ex-
segments, and change in intermolar width [9]. According to Burstone, the key to anchorage
trusion of buccal segments, and change in intermolar width [9]. According to Burstone,
control is to maintain low-magnitude forces and use a rigid posterior segment, including
the key to anchorage control is to maintain low-magnitude forces and use a rigid posterior
a lingual arch or TPA [28]. The combination of intrusion and incisors retraction is clinically
segment, including a lingual arch or TPA [28]. The combination of intrusion and incisors
desirable when the overbite and overjet are increased as is often the case in perio-ortho
retraction is clinically desirable when the overbite and overjet are increased as is often the
patients. Melsen et al. evaluated the force system delivered by the SS and TMA cantilevers
case in perio-ortho patients. Melsen et al. evaluated the force system delivered by the SS
with an eccentrically placed helix loop. Three-piece intrusion mechanics allow the lateral
and TMA cantilevers with an eccentrically placed helix loop. Three-piece intrusion me-
displacement of the point of force application and the line of action passes closer to the
chanics allow the lateral displacement of the point of force application and the line of ac-
center of resistance [29]. In the case of deep bite and flared incisors, Shroff et al. described
tion passes closer to the center of resistance [29]. In the case of deep bite and flared inci-
a three-piece base arch, used together with Class I elastics, to correct deep bite and retract
sors, Shroff et al. described a three-piece base arch, used together with Class I00elastics, to
the incisors. Bilaterally placed tip back springs, fabricated from 0.017 × 0.025 TMA wire,
correct deep bite and retract the incisors. Bilaterally placed tip back springs, fabricated
were placed to deliver intrusive force [30].
from 0.017 × 0.025″ TMA wire, werethree-piece
The mini-implant-supported placed to deliver
Burstone intrusive force
base arch had[30].
a pronounced effect
The mini-implant-supported three-piece Burstone base
on the intrusion of flared four maxillary incisors with a clinically insignificant arch had a pronounced effectof
amount
on the intrusion of flared four maxillary incisors with a clinically
root resorption. The technique was modified to integrate TADs to overcome the compli- insignificant amount of
root resorption.
cations The technique
of the conventional was modified
anchorage to integrate
protocol. The increasedTADs distal
to overcome
force helpsthe compli-
to avoid
cations of the conventional anchorage protocol. The increased
unscrewing the TADs [31]. Mini plates could also serve as a cantilever attachment distal force helps to avoidfor
unscrewing the TADs
anterior intrusion, [31]. Mini by
as described plates could et
Thebault also
al.serve
[11]. as a cantilever attachment for an-
terior intrusion, as described by Thebault et al. [11].
Dent. J. 2022, 10, x FOR PEER REVIEW 7 of 16
Dent. J. 2022, 10, 135 7 of 16

5. Open Bite
5. Open Bitecases, an anterior open bite can be corrected with dental extrusion. However,
In some
stability in
In some retention
cases, anshould
anterior always be considered.
open bite Kuhlberg
can be corrected with described the system
dental extrusion. with
However,
two cantilevers
stability connected
in retention should to always
the anterior segment and
be considered. anchorage
Kuhlberg unit, which
described workswith
the system op-
posite the three-piece
two cantilevers intrusion
connected to thearch. A passive
anterior segment TPAandwas placed to
anchorage prevent
unit, whichthird-order
works op-
movement of the molars
posite the three-piece [32]. Wilmes
intrusion arch. Aet passive
al. [33] described the open
TPA was placed to bite correction
prevent with
third-order
movement
molar of thewith
intrusion molars [32]. Wilmes
the Mousetrap et al. [33](Figure
appliance described the open
9). Lever arms bite correction
connected to with
two
molar intrusion
mini-implants with the
inserted in Mousetrap
the anteriorappliance
palate are(Figure 9). for
activated Lever arms
molar connected
intrusion. To to two
avoid
mini-implants inserted in the anterior palate are activated for molar intrusion.
tipping of the molars, TPA is placed. When the appliance is deactivated, the distal ends of To avoid
tipping
the leverofarms
the molars, TPA is
are located placed. to
cranially When
the the appliance
molars’ is deactivated,
centers of resistancethe distal
(CR). Theends of
lever
the lever
arms are arms are located
activated cranially todisplacement
with downward the molars’ centers
and a of resistance
constant (CR). The
intrusive lever
force arms
is deliv-
are activated
ered [33]. with downward displacement and a constant intrusive force is delivered [33].

Figure 9.
Figure Mousetrap
9. Mouse trapappliance.
appliance.Lever
Leverarms
armsconnected
connectedto
toTADs,
TADs,activated
activatedfor
formolar
molarintrusion
intrusion(red).
(red).
Transpalatal
Transpalatal arch (green).

Flieger et
Flieger etal.
al.presented
presenteda asimilar
similar appliance
appliance to to Mousetrap.
Mousetrap. TheThe mainmain difference
difference is theis
the placement
placement of two
of two Jet Screws,
Jet Screws, inserted
inserted half
half of theofdistance
the distance
of theofperpendicular
the perpendicular line
line seg-
segment
ment fromfrom
the the
raphe raphe to palatal
to the the palatal
cuspcusp
tip oftipthe
of first
the first bicuspid.
bicuspid. Posterior
Posterior intrusion
intrusion was
was achieved through distally extended cantilevers fabricated out of 16
achieved through distally extended cantilevers fabricated out of 16 × 22 stainless-steel × 22 stainless-steel
wire, connecting
wire, connecting thethe screw
screw withwith maxillary
maxillary molars
molars [34].
[34]. Nojima
Nojima etet al.
al. described
described openopen bite
bite
correction with the use of cantilevers and skeletal anchorage. TADs
correction with the use of cantilevers and skeletal anchorage. TADs were placed in the were placed in the
middle of
middle of the
the palate
palateandandon onthe
thebuccal
buccalalveolar
alveolar bone,
bone, between thethe
between maxillary firstfirst
maxillary molar and
molar
second premolar. Intrusive force was provided with 0.018 × 0.025 00 TMA transpalatal arch
and second premolar. Intrusive force was provided with 0.018 × 0.025″ TMA transpalatal
with with
arch tear drop loops,loops,
tear drop tied to thetobracket
tied slot ofslot
the bracket theofmini-implant and the
the mini-implant andpalatal tubes tubes
the palatal of the
maxillary molars. On the buccal side, intrusion was obtained with a 0.018 × 0.025 00 TMA
of the maxillary molars. On the buccal side, intrusion was obtained with a 0.018 × 0.025″
cantilever
TMA connected
cantilever to theto
connected buccal TAD and
the buccal TADmolar auxiliary
and molar tube [35].
auxiliary tube [35].
6. Intrusion
6. Intrusion
The intrusion of a single tooth can be achieved with statically determined mechan-
The intrusion of a single tooth can be achieved with statically determined mechanics.
ics. According to the literature, 50 percent of the patients with a deep bite have overe-
According to the literature,
rupted mandibular 50 percent
canines [36]. of the
In a finite patients
element withbya Caballero
study deep bite et have
al., overerupted
the effects of
mandibular canines [36]. In a finite element study by Caballero
a cantilever for intrusion were studied. Here, the cantilever was inserted intoet al., the effects
the of a can-
auxiliary
tilever
tube of the molar and placed on the top of the mandibular canine bracket (Figuretube
for intrusion were studied. Here, the cantilever was inserted into the auxiliary 10).
of the molar
Since andapplication
the force placed on the top is
point oflocalized
the mandibular
on the canine bracket
labial side, (Figure 10).amount
a significant Since the
of
force application
labiolingual forcepoint is localized
occurs. However, onthe
theapplication
labial side, of
a significant
a 6-degreeamount
toe-in bendof labiolingual
to prevent
force
buccaloccurs. However,
and lingual crown thetipping
application of a 6-degree
and produce toe-in bend
pure intrusion to prevent
of the buccal
canine was and
shown
lingual crown tipping and produce pure intrusion of the canine was shown to
to be effective [3]. It is advised to attach the cantilever to the occlusal surface of a canine be effective
[3]. It is advised
bracket. to attach
The insertion of athe cantilever
cantilever in atobracket
the occlusal surface an
slot produces of aundesirable
canine bracket.
couple The
at
insertion of a cantilever in a bracket slot produces an undesirable couple
the bracket slot [37]. Force application on the lingual side allows the achievement of almost at the bracket
slot
pure[37]. Force while
intrusion application on the lingual
the bucco-lingual toothside allows the
inclination achievementToe-in
is maintained. of almost
bendpure in-
applied
trusion while the
on a cantilever bucco-lingual
aid to achieve the tooth
pure inclination
intrusion isofmaintained.
a mandibular Toe-in
canine.bendItsapplied on a
angle value
depends on the height of the canine cusp [38]. A similar technique is used for the intrusion
Dent. J. 2022, 10, x FOR PEER REVIEW
cantilever aid to achieve the pure intrusion of a mandibular canine. Its angle va
pends on the height of the canine cusp [38]. A similar technique is used for the in
of the maxillary canine. When an auxiliary molar tube is not available, a cantileve
Dent. J. 2022, 10, 135 cantileverinto
inserted aidthe
to achieve
cross tube theand
pure intrusion
ligated to theof canine
a mandibular
bracket canine. 8Its
[39]. Chandhoke angle va
of 16
e
pends on the height of the canine cusp [38]. A similar technique
scribed a cantilever anchored on two buccal TADs for the correction of an overe is used for the in
of the maxillary
second canine.
molar. canine.
The When an
transpalatal auxiliary
arch molar
controlled the tube is not available,
transverse during thea cantileve
molar in
of the maxillary
inserted into the When
cross tube an auxiliary
and molar
ligated to tube
the is not
canine available,
bracket a cantilever
[39]. can
Chandhoke e
The secondinto
be inserted molar wastube
the cross significantly
and ligatedintruded without
to the canine buccal
bracket tipping [12].
[39]. Chandhoke et al.
scribed a cantilever anchored on two buccal TADs for the correction of an overe
described a cantilever anchored on two buccal TADs for the correction of an overerupted
second molar.
second molar. TheThe transpalatal
transpalatal arch controlled
arch controlled the transverse
the transverse during
during the molar the molar in
intrusion.
The second
The second molar
molar waswas significantly
significantly intrudedintruded without
without buccal buccal
tipping [12]. tipping [12].

Figure 10. Cantilever activated for canine intrusion, placed on the top of the mandibula
bracket (red: cantilever, green: force and moment).

Figure 10. Cantilever activated for canine intrusion, placed on the top of the mandibular canine
Figure
7. Space 10.Closure
Cantilever activated for canine intrusion, placed on the top of the mandibula
bracket (red: cantilever, green: force and moment).
bracket (red: cantilever, green: force and moment).
Choy et al. [40] designed the statically determinate retraction system for sp
7. Space
sure Closure
in extraction therapy. It consists of passive rigid stabilizing units and active re
7. Space Closure
Choy The
et al. anterior
[40] designed
springs. andthebuccal
statically determinateunits
stabilizing retraction
are system
made for of space
rigidclosure
stainless-ste
in extraction
Choy therapy.
et al. [40]It consists
designed of passive
the rigid
staticallystabilizing
determinateunits and active
retraction retraction
system for
reinforced
springs. The
with
anterior
a transpalatal
and buccal
arch. Distal
stabilizing units
extension
are made of
with
rigid
astainless-steel
hook is localized
wire,
onsp
th
sure
rior in extraction
stabilizing therapy. It consists of passive rigid stabilizing units and active re
reinforced with aarch, about arch.
transpalatal six mm superior
Distal to the
extension withcanine
a hookbracket slot.onAthe
is localized single-fo
springs.
tilever
anterior armThe anterior
madearch,
stabilizing and
of 0.017 buccal
about ×six0.025″ stabilizing
TMA alloy
mm superior units are made
wire isbracket
to the canine inserted of rigid
slot. into stainless-ste
the molar tube
A single-force
retraction of the anterior segment (Figure 11). The cantilever springlocalized
reinforced with a transpalatal arch. Distal extension with a hook is on th
cantilever arm made of 0.017 × 0.025 00 TMA alloy wire is inserted into the molar tube
andforthe anter
rior stabilizing
the retraction arch,
of the about
anterior six
segment mm superior
(Figure 11). Theto the canine
cantilever
ment’s extension hook were connected with a ligature. A low load-deflection rat bracket
spring and the slot. A single-fo
anterior
segment’s
tilever armextension
madehook were connected
of 0.017 ×a0.025″ with a ligature.
TMA alloy A low
wire is load-deflection
insertedthe into rate
theofmolar
the tube
cantilever spring
cantilever spring provides
provides a constantconstant
force: atforce: at full
full activation, activation,
the spring delivered spring delivered
163 cN
retraction
with of the anterior segment (Figure 11). The cantilever spring and the anter
with aaload-deflection
load-deflection rate
rate of of 6 cN/mm
6 cN/mm [40]. [40].
ment’s extension hook were connected with a ligature. A low load-deflection rat
cantilever spring provides a constant force: at full activation, the spring delivered
with a load-deflection rate of 6 cN/mm [40].

11.Statically
Figure 11.
Figure determinate
Statically retraction
determinate system for
retraction space closure.
system for spaceCantilever
closure. (red) is activated(red)
Cantilever for is activ
anterior segment retraction (green: line of action).
anterior segment retraction (green: line of action).
8. Occlusal Cant
Figure
8. 11. Statically
Occlusal Cant determinate retraction system for space closure. Cantilever (red) is activ
It is important to set a diagnosis between an incisal cant and an occlusal cant. Incisal
anterior segment retraction (green: line of action).
can beIt corrected
is important to set a diagnosis
with well-controlled, between
determinate an systems,
force incisal cantwhileandthe an occlusal cant
correction
of the occlusal cant is more challenging to treat [41]. In growing
can be corrected with well-controlled, determinate force systems, while the correpatients, the treatment
8. Occlusal
approach mayCantbe the controlled eruption of buccal segments; in adults, often only surgical
the occlusal cant is more challenging to treat [41]. In growing patients, the treatm
correction is
It ismay feasible.
important Deluke
to set aetdiagnosis
al. proposed the treatment
between of lower
an segments;
incisal cantincisal
and cant
an with
occlusal cant
proach
a 0.01700 × 0.025be the controlled
00 TMA eruption
cantilever, attached fromofthebuccal
first molar auxiliaryin adults,
tube to the often
main only s
can be corrected
correction
archwire between
with Deluke
is feasible. well-controlled,
the central
determinate
et al.incisors.
and lateral proposed force
the treatment
Sectioning
systems,
of lower
the main wire
whilethe the corre
allowedincisal cant
the occlusal
unilateral cant
intrusion ofis more
the frontchallenging
segment [41]. to treat
Musilli et [41].
al. In
proposedgrowing
0.017″ × 0.025″ TMA cantilever, attached from the first molar auxiliary tube to tha patients,
cantilever, similarthe
in treatm
proach
shape to amay
archwire be utility
Ricketts
between thethecontrolled eruption
arch with a modification
central and ofofincisors.
lateral buccal segments;
distal hooks attached in
Sectioning adults,
to the
the mainoften
continuous
wireonly s
allow
archwire bilaterally
correction is between
feasible. the second
Deluke et al.premolar
proposed andthe
firsttreatment
molar. Thisof canting
lower spring
incisal cant
unilateral intrusion
produces intrusion on oneof the
side front segment
of the anterior [41]. Musilli
segment et al. on
and extrusion proposed
the other.aSince
cantilever,
0.017″
in × 0.025″
shape TMA cantilever,
to a Ricketts utility archattached from the first
with a modification of molar auxiliary
distal hooks tube tototh
attached t
archwirearchwire
tinuous betweenbilaterally
the centralbetween
and lateral
the incisors. Sectioning
second premolar andthefirst
main wire This
molar. allow
unilateral
spring intrusion
produces of the front
intrusion segment
on one [41].anterior
side of the Musillisegment
et al. proposed a cantilever,
and extrusion on th
in shape to a Ricketts utility arch with a modification of distal hooks
Since it is applied on the continuous arch as an overlay system, the correctionattached to t
Dent. J. 2022, 10, x FOR PEER REVIEW 9 of 16

Dent. J. 2022, 10, 135 9 of 16

achieved without creating steps between the canines and the lateral incisors [42]. Chan-
dhoke et al. described
it is applied the use of arch
on the continuous skeletal anchorage
as an and a cantilever
overlay system, for thecan
the correction correction
be achieved of
a without
mandibular cant with the simultaneous closure of the lateral open
creating steps between the canines and the lateral incisors [42]. Chandhoke et al. bite and transverse
correction.
described In theause
one-couple
of skeletalsystem,
anchorage the and
forcea skewed
cantilever theformandibular
the correction archof in the axial
a mandibular
plane, reducing
cant with the canine overjet
the simultaneous closure andof correcting
the lateral theopen dental
bite andmidline [12]. According
transverse correction.toIn
van Steenbergen
a one-couple and Nanda,
system, the forcein the posterior
skewed occlusal plane
the mandibular archcant, theaxial
in the posterior
plane,segment
reducing
may
the be uprighted
canine overjetwith
andthe cantilever
correcting thehooked to the anterior
dental midline segment. to
[12]. According Expected side ef-
van Steenbergen
fects
andare the extrusion
Nanda, of the buccal
in the posterior occlusal segment and unilateral
plane cant, the posterior intrusion
segment of the
mayanterior seg-
be uprighted
ment. The large tip-back moment on the buccal segment flattens the
with the cantilever hooked to the anterior segment. Expected side effects are the extrusion occlusal plane [43].
of the buccal segment and unilateral intrusion of the anterior segment. The large tip-back
9.moment
Asymmetry, on the Midline Correction
buccal segment flattens the occlusal plane [43].
The correction of the midline discrepancies is important both for aesthetics and to
9. Asymmetry,
achieve functional Midline
occlusion Correction
[44]. According to Nanda et al., the use of a cantilever is ideal
in apical base discrepancies, midline
The correction of the when the discrepancies
aim is to upright is important both forand
tipped incisors aesthetics
change and theirto
achieve
axial functional
inclinations occlusion
[45]. When [44]. According
the midline to Nanda et
discrepancy is al., the use
caused byoftipping
a cantilever
of theis lower
ideal in
apical base
incisors, discrepancies,
simple force applied when the crowns
at the aim is toofupright
the teeth tipped
will incisors
upright and change their
the incisors. axial
In case
inclinations [45]. When the midline discrepancy is caused by
when the bodily movement of incisors is needed, the cantilever shall be attached to thetipping of the lower incisors,
simpleloop,
passive forceextended
applied apically
at the crowns of the teeth
to approximate thewill
centerupright the incisors.
of resistance In caseteeth
of the incisor when
the bodily movement of incisors is needed, the cantilever shall
[32]. Fiorelli et al. proposed the simultaneous treatment of deep bite and midline correc- be attached to the passive
loop,
tion. Theextended apically to
system consisted of approximate
two cantilevers theand
center of resistance
an anterior segment.of the
Oneincisor teethwas
cantilever [32].
Fiorelli et al. proposed the simultaneous treatment of deep bite and
activated for intrusive force delivered to an anterior segment, laterally to the maxillary midline correction. The
system
lateral consisted
incisor. The of two cantilevers
tipping of the segmentand anwasanterior segment.by
counteracted Onethecantilever
horizontal was activated
force pro-
for intrusive force delivered to an anterior segment, laterally
vided by the cantilever on the contralateral side [44]. Mittal et al. designed similar systemto the maxillary lateral
incisor.
for midlineThe tipping of
correction. the segment
Anterior segment was counteracted
with by the horizontal
a vertical extension approximatingforce the
provided
cen-
by the cantilever on the contralateral side [44]. Mittal et al. designed similar system for
ter of resistance is displaced with a 0.017″ × 0.025″ TMA cantilever, bent buccally and tied
midline correction. Anterior segment with a vertical extension approximating the center of
to the loop with an elastomeric chain. When activated, the system produces the force that
resistance is displaced with a 0.01700 × 0.02500 TMA cantilever, bent buccally and tied to the
results in an efficient midline correction through the pure translation of the anterior seg-
loop with an elastomeric chain. When activated, the system produces the force that results
ment [46].
in an efficient midline correction through the pure translation of the anterior segment [46].
The experimental study by Bilinska and Dalstra revealed that different shapes of can-
The experimental study by Bilinska and Dalstra revealed that different shapes of
tilevers produce vertical, but also horizontal forces. The cantilever with a deep curve
cantilevers produce vertical, but also horizontal forces. The cantilever with a deep curve
shape produces retraction and lateral force, and the utility shape protraction and medial
shape produces retraction and lateral force, and the utility shape protraction and medial
force. When the use of different shapes is attached to the sides of the front segment, the
force. When the use of different shapes is attached to the sides of the front segment, the
transversal force may facilitate the midline correction [7] (Figure 12).
transversal force may facilitate the midline correction [7] (Figure 12).

Figure 12. Asymmetric cantilever activation: activation of utility arch (right side of typodont) and
Figure 12. Asymmetric
deep curve cantilever
cantilever (left side of activation: activationintrusion
typodont), resulting of utilityand
arch (right side of anterior
displacement typodont) and
segment
deep curvepink;
(before: cantilever (left side of typodont), resulting intrusion and displacement of anterior seg-
after: blue).
ment (before: pink; after: blue).
10. Molar Uprighting
A classic biomechanical treatment modality for molar uprighting is the segmented
approach. The cantilever inserted into the molar tube is hooked on the anterior teeth
segment and generates extrusion and clockwise rotation on the molar, intrusion on the
anterior teeth. To control the vertical forces, a double cantilever system may be used
 10. Molar Uprighting
A classic biomechanical treatment modality for molar uprighting is the segmented
Dent. J. 2022, 10, 135
approach. The cantilever inserted into the molar tube is hooked on the anterior teeth seg-
10 of 16
ment and generates extrusion and clockwise rotation on the molar, intrusion on the ante-
rior teeth. To control the vertical forces, a double cantilever system may be used (Figure
13). As a13).
(Figure result, we only
As a result, wehave two two
only have opposite moments,
opposite ononthe
moments, themolar
molar and theanterior
and the anterior teeth
segment [47]. [47].
teeth segment

Figure
Figure 13. Double cantilevermechanics.
Double cantilever mechanics. TheThe
redred cantilever,
cantilever, fromfrom the molar
the molar to the to the anterior
anterior teeth, teeth,
generates extrusion,clockwise
generates extrusion, clockwise rotation
rotation onmolar,
on the the molar, and intrusion
and intrusion on the
on the anterior anterior
teeth teeth (red ar-
(red arrows).
rows). In to
In order order to control
control the forces,
the vertical vertical forces, cantilever,
a second a second cantilever,
from a tubefrom
in theaanterior,
tube in isthe anterior, is re-
required.
quired. This
This green green cantilever
cantilever is placed
is placed distally distally
to the molarto theit molar
and andmolar
produces it produces
intrusionmolar
and a intrusion
counter- and a
counter-clockwise
clockwise movementmovement with
with extrusion onextrusion
the anterioron the(green
teeth anterior teethThe
arrows). (green arrows).
resultant The resultant
forces cancel
forces cancel
each other, andeach
twoother, andmoments
opposite two opposite
occur. moments occur.

Uprighting of
Uprighting ofthe
themesially
mesially tipped
tipped molars
molars often differentiates
often between
differentiates successsuccess
between and and
failure in periodontal and restorative treatments [48]. Khouw et al.
failure in periodontal and restorative treatments [48]. Khouw et al. described the helical described the helical
uprighting spring. It is inserted into the molar tube and attached to the continuous wire,
uprighting spring. It is inserted into the molar tube and attached to the continuous wire,
between the canine and premolar. The resultant force is extrusion; a moment with a distal
between the canine and premolar. The resultant force is extrusion; a moment with a distal
direction aids to upright the tooth and lingual crown tipping. The effect on the anchorage
direction
unit should aids
be to upright
taken the tooth andthe
into consideration: lingual
intrusioncrown
and tipping.
lingual tipThe effect
of the on the [48].
premolars anchorage
unit
According to Kojima et al., introducing the bend in the cantilever towards the lingual [48].
should be taken into consideration: the intrusion and lingual tip of the premolars
According to Kojima
direction reduces the et al., introducing
stress on the anchorthe bend
teeth, in thepossibly
which cantilevermaytowards
reduce the theside
lingual di-
effects [49].
rection reduces Ma ettheal.stress
described
on the theanchor
uprighting
teeth,ofwhich
the impacted
possibly second and third
may reduce themolar.
side effects
In the
[49]. Ma first phase,
et al. the impacted
described third molar
the uprighting of was distalized second
the impacted with a three-loop
and thirdspring.
molar.The In the first
phase, the impacted third molar was distalized with a three-loop spring. Thebuccal
second molar was uprighted with the cantilever inserted into the impacted molar second mo-
tube and its free end was hooked onto the main archwire to produce an uprighting force.
lar was uprighted with the cantilever inserted into the impacted molar buccal tube and its
New bone apposition was observed after orthodontic extrusion distally to the adjacent
free end was hooked onto the main archwire to produce an uprighting force. New bone
tooth. The technique could be effective in the separation of third molars from the nerve
apposition
proximity towas observed
provide after orthodontic
safe extraction with the risk extrusion distally
of neurosensory to [50,51].
deficit the adjacent tooth. The
Alessandri
technique could be effective in the separation of third molars
Bonetti et al. presented a disimpaction technique, called “orthodontic extraction” of the from the nerve proximity to
provide
third molarsafewith
extraction withwhich
a cantilever, the risk
wouldof neurosensory deficit [50,51].
facilitate its extraction. Cantilever Alessandri
activated forBonetti et
extrusion
al. presented is connected
a disimpactionto the molar and anchorage
technique, unit. When the
called “orthodontic third molar
extraction” of extrudes,
the third molar
the distance
with between
a cantilever, the roots
which would andfacilitate
the mandibular canal increases.
its extraction. CantileverIts favorable
activated position
for extrusion
for the surgery reduces the risk of nerve damage [52].
is connected to the molar and anchorage unit. When the third molar extrudes, the distance
“Kissing molars” describe a type of tooth impaction with two mandibular molars
between the roots and the mandibular canal increases. Its favorable position for the sur-
severely tipped and impacted with their occlusal surfaces positioned crown-to-crown,
gery reduces the risk of nerve damage [52].
while the roots are pointing in opposite directions. The common treatment protocol is
“Kissing molars”
the extraction of impacted describe
teeth. aThe type of tooth
treatment impaction
approach with two
to upright andmandibular
preserve the molars
severely
molars was described by Barros et al. The protocol included the use of torquedcrown-to-crown,
tipped and impacted with their occlusal surfaces positioned cantilever
while the roots
mechanics, where arethe
pointing
torque arm in opposite
moves the directions. The common
roots in a mesiodistal treatment
direction. The protocol
created is the
extraction
mesiodistalofmoment
impacted teeth.isThe
of force treatment
applied on theapproach
molar roots toofupright and and
the second preserve the molars
produces
an uprighting effect [53]. A long cantilever arm can deliver a relatively
was described by Barros et al. The protocol included the use of torqued cantilever me- low load-deflection
rate and where
chanics, produces thea force
torque system
arm to facilitate
moves therootrootsuprighting [54]. In thedirection.
in a mesiodistal describedThe case,created
a second molar uprighting occurred mainly due to the torque movement, associated mostly
mesiodistal moment of force is applied on the molar roots of the second and produces an
with root repositioning [53].
uprighting effect [53]. A long cantilever arm can deliver a relatively low load-deflection
Dent. J. 2022, 10, 135 11 of 16

Morita et al. discussed two different uprighting mechanics separately applied to the
mesially tipped mandibular first and second molars. For the uprighting of the impacted
and severally tipped first molar, the distal end of the cantilever was twisted to generate the
sufficient uprighting moment. On the mesial end, the cantilever was directly attached to the
TAD to counteract the extrusive force. The second molar was uprighted with a compression
force with two step bends incorporated into a nickel–titanium archwire. The molar was
tipped distally [55]. Chandhoke described the uprighting spring, which was anchored
by TAD for the correction of mesially tipped lower right first and second molars. The
cantilever was stabilized at the TAD, to avoid undesirable moments at the screw and
its failure [12]. Methods on molar uprighting with the use of TADs were described by
Musilli et al. [47]. The molar can be uprighted with a cantilever attached to the TAD in the
retromolar area. The force system clinically produces a moment and an intrusive force on
the molar. In the described approach, no other additional appliances are required. When
the molar is uprighted with a long cantilever attached to the anterior segment, a TAD can
be placed mesially and ligated to the molar to provide a vertical force control. This system
has the advantages of the classic double cantilever approach and is more comfortable for
the patient [47].

11. Dental Transposition

Mechanics for correction of the dental transposition should be planned individually,
reducing the potential risks and side effects. In the transposition of canines and the first pre-
molar, the canine is usually displaced in the mesiobuccal direction between the first and sec-
ond premolars. The first premolar is often tipped distally and displaced in a mesiopalatal
direction [56]. A segmented treatment approach was presented by Laino et al., when tooth
impaction and dental transposition were corrected with the use of different cantilever
configurations [2]. Capelozza Filho et al. presented a case report of the clinical approach to
unilateral tooth transposition of a maxillary canine and first premolar. The first premolar
was displaced in the distal and palatal direction with a 0.019 × 0.02500 TMA cantilever. Fol-
lowing the premolar correction, the maxillary canine was mesialized into its final position
with torque control [57]. Lorente et al. corrected incomplete maxillary canine–first premolar
transposition with a cantilever spring coupled to the auxiliary band tube. The anchorage
unit was reinforced with a TPA. The canine was pulled in a mesial and apical direction. The
aim was to bring the canine to the widest part of the dentoalveolar process to minimize the
amount of periodontal recession [58]. In the case of transposition of the canine and lateral
incisor, the canine was displaced buccally with the cantilever, while the lateral incisor was
mesialized into the right place in the arch. The use of a cantilever with loops provided the
controlled movement of transposed teeth and control of the anchorage unit [59]. Fu et al.
used an innovative cantilever and simplified mechanics to correct an ectopic central incisor
and the transposed canine–lateral incisor without periodontal complications. The cantilever
was attached to a TAD and pulled the impacted tooth canine buccally and distally toward
its normal position. The use of skeletal anchorage provided sufficient anchorage [60].

12. Single Tooth Extrusion

Skeletal anchorage with a cantilever can be also used for a forced eruption for teeth
with subgingival defects, such as root fractures and subgingival cervical caries. Noh and
Park described a system with a TAD and a cantilever, attached to the root of lateral incisor.
An extrusive force was applied along the long tooth axis. In this method, there is no need
to bond brackets to other teeth to correct the target tooth [61] (Figure 14).
 Dent. J. 2022, 10, x FOR PEER REVIEW 12 of 16
Dent. J. 2022, 10, x FOR PEER REVIEW
Dent. J. 2022, 10, 135 12 of 16

Figure 14. Extrusive force (green) applied along the long tooth axis with a cantilever (red) connected
to the TAD (blue).

FigureKumar
Figure Extrusive
14.14. et al.force
Extrusive (green) applied
force (green)
described along the long
applied
the successful tooth the
along
managementaxis with
long
anda tooth
cantilever (red)
axis
prosthetic connected
with a cantilever
rehabilitation of a
to the TAD (blue).
complicated horizontal
to the TAD (blue). root fracture in the mandibular left first premolar and mandibular
lateral incisor.
Kumar et al.When the the
described coronal fragment
successful is extremely
management mobile, rehabilitation
and prosthetic endodontic treatment
of
decoronation,
a complicated and orthodontic
horizontal root extrusion
fracture in the provide
mandibular an easy
left
Kumar et al. described the successful management and prosthetic approach
first premolar for
and functional
mandibular andreha
aes-
thetic rehabilitation.
lateral incisor. When the After root canal
coronal fragmenttreatment, the root
is extremely of the
mobile, incisor was
endodontic extruded with
treatment,
complicated
decoronation,
a 0.017 × 0.025″
horizontal
and orthodontic
TMA cantilever
root fracture
extrusion
attached
in the
provide mandibular
an easy
to the molar andapproach
the root
left
for first premolar
functional
post. and
The extrusion
an
was
lateral
aesthetic incisor. When
followedrehabilitation.
with the crown the coronal
Afterrestoration.
root canal The fragment
treatment,
firstthe isthe
root of
premolar extremely
was incisor mobile,
was extruded
extruded endodon
with
with a helical coiled
a 0.017 × 0.025 00 TMA cantilever attached to the molar and the root post. The extrusion was
decoronation, and orthodontic
0.014 inch NiTi (nickel–titanium) wireextrusion
attached to provide
canine and an easy
molar.approach
The helix wasfor tied
funct
to
followed with the crown restoration. The first premolar was extruded with a helical coiled
thetic rehabilitation.
the hooked end of the post After
withroot canal
ligature wire.treatment,
Both teeth werethe root of theforincisor
stabilized
0.014 inch NiTi (nickel–titanium) wire attached to canine and molar. The helix was tied to
8 weekswas
priore
to prosthetic
athe0.017
hooked rehabilitation
× 0.025″ TMA
end of the post with [62].
cantilever attached
ligature wire. to the
Both teeth weremolar and
stabilized forthe rootprior
8 weeks post. The
to prostheticwith
followed rehabilitation
the crown [62]. restoration. The first premolar was extruded with a
13. Molar Distalization
0.014 inch
13. Molar NiTi (nickel–titanium) wire attached to canine and molar. The he
Distalization
Molar distalization is commonly used for the non-extraction treatment of unilatera
the hooked
or bilateral endII of
Molar distalization
Class the post with
is commonly
malocclusions. used ligature wire.
forskeletal
Direct Bothtreatment
the non-extraction
anchorage teethtowere
helps of stabilized
unilateral
avoid or
anchorage for
loss
bilateral
to Class
prosthetic II malocclusions.
rehabilitation Direct
[62].skeletal anchorage helps to avoid anchorage loss
and unwanted side effects on the dentition. Vilanova et al. described a miniscrew-an-
and unwanted side effects on the dentition. Vilanova et al. described a miniscrew-anchored
chored cantilever. TAD is placed on the buccal side, between the roots of the second pre-
cantilever. TAD is placed on the buccal side, between the roots of the second premolar
molar
13.
and andfirst
Molar
upper upper firstAmolar.
Distalization
molar. 0.014” ASS0.014″ SS cantilever
cantilever is inserted is inserted
into intotube.
the molar the molar
TAD andtube. TAD
the cantilever are connected with a nickel–titanium closed-coil spring with 200 g of force200 g of
and the cantilever are connected with a nickel–titanium closed-coil spring with
Molar 15).
force (Figure
distalization
The appliance
is commonly used for the non-extraction treatmen
(Figure 15). The appliance deliver adeliver a horizontal
horizontal force
force as close asas close as
possible to possible
the CR ofto the CR of
the
or
thebilateral
upper
upper firstClass
first molar molar IIand
malocclusions.
and result result
in in abodily
a distal Direct
distal bodilyskeletal
movement [63]. anchorage
movement [63]. helps to avoid a
and unwanted side effects on the dentition. Vilanova et al. described a m
chored cantilever. TAD is placed on the buccal side, between the roots of th
molar and upper first molar. A 0.014″ SS cantilever is inserted into the mo
and the cantilever are connected with a nickel–titanium closed-coil spring
force (Figure 15). The appliance deliver a horizontal force as close as possib
the upper first molar and result in a distal bodily movement [63].

Figure 15.Unilateral
Figure15. Unilateralmolar
molardistalization withwith
distalization cantilever connected
cantilever to the TAD
connected to thewith
TAD a closed-coil
with a closed-coi
spring (green: force).
spring (green: force).

14. Discussion
14. Discussion
This review article discussed several applications of one-couple systems, both the clas-
This review
sic approach article
and using discussed
skeletal several
anchorage. applications
We highlighted the of one-couple
clear benefits of systems,
cantileversboth the
classic approach and using skeletal anchorage. We highlighted the clear
used in complex corrections of single teeth, segments, and entire arch with a diminished benefits of canti-
leverson
effect used in complex
the dentition. Thecorrections of single
use of skeletal teeth,provides
anchorage segments, and in
benefits entire
termsarch with a dimin-
of anchor-
ished
age effect on the
reinforcement anddentition.
reduces theThe use of skeletal
complexity anchorage
of orthodontic provides
treatment. benefits
Combining in terms of
TADs
with cantilevers
anchorage increase treatment
reinforcement possibilities.
and reduces the complexity of orthodontic treatment. Combin-
Figure
ing TADs15.with
Unilateral molar
cantilevers distalization
increase treatmentwith cantilever connected to the TAD wi
possibilities.
spring (green:
Modern force).
technologies could aid to improve cantilever design and improve the treat-
ment flow. In the last decade, the interest in the field of robotic wire bending and robotic
Dent. J. 2022, 10, 135 13 of 16

Modern technologies could aid to improve cantilever design and improve the treat-
ment flow. In the last decade, the interest in the field of robotic wire bending and robotic
customization of CAD/CAM appliances has increased [64]. To improve the precision,
cantilevers could be designed in the software and bend indirectly by the robots. It could
reduce the chairside time and improve precision. Liu et al. presented a collaboration
between the robot and external bending machine. The method combines task and motion
planning for a robot to curve metal wires into 3D shapes. The described system can bend
different 3D shapes with satisfying performance [65].
In the modern treatment approach, 3D printed appliances are becoming more and
more popular, with regards for printed orthodontic appliances [66]. For the future treat-
ment modalities, cantilevers could be designed in the software and printed, as it is possible
to print beta titanium alloys for biomedical applications [67]. Polymer 3D printing is
a developing technology offering printing low-cost functional parts with diverse capabili-
ties and properties [68]. Orthodontic appliances, such as 3D printed distalizers and various
auxiliaries (e.g., power-arms), can be produced with additive manufacturing with biocom-
patible photopolymers [69]. To introduce this technique, the polymer cantilever should
have similar mechanical properties to TMA alloys. According to Guerrero-Gironés et al.,
the assessment of the biocompatibility of 3D printing and conventional resins revealed no
major differences [70]. Possibility to produce the tooth-shade or transparent cantilevers
would increase aesthetics. In the field of modern technologies in regard to cantilevers
production, there is still a room for further investigation. Nowadays, chairside bending
offers fast and cost-effective treatment approach.

15. Conclusions
With the correct force system and biomechanical understanding, cantilevers generate
a predictable force system to solve the variability of orthodontic problems. With their
simple and easily tailored design, these springs can be called an orthodontic multi-tool.

Author Contributions: Conceptualization, M.B.; methodology M.B., K.D.K. and M.D.; investigation,
M.B. and M.D.; data curation, M.B. and K.D.K.; writing—original draft preparation M.B.; writing—
review and editing, M.B., K.D.K. and M.D. All authors have read and agreed to the published version
of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Written informed consent was obtained from the patients to publish
this paper.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Burstone, C.J. Rationale of the segmented arch. Am. J. Orthod. 1962, 48, 805–822. [CrossRef]
2. Laino, A.; Cacciafesta, V.; Martina, R. Treatment of tooth impaction and transposition with a segmented-arch technique. J. Clin.
Orthod. 2001, 35, 79–86. [PubMed]
3. Caballero, G.M.; Carvalho Filho, O.A.; Hargreaves, B.O.; Brito, H.H.; Magalhaes Junior, P.A.; Oliveira, D.D. Mandibular canine
intrusion with the segmented arch technique: A finite element method study. Am. J. Orthod. Dentofac. Orthop. 2015, 147, 691–697.
[CrossRef] [PubMed]
4. Fischer, T.J.; Ziegler, F.; Lundberg, C. Cantilever mechanics for treatment of impacted canines. J. Clin. Orthod. 2000, 34, 647–650.
5. Gurgel, J.A.; Pinzan-Vercelino, C.R.; Powers, J.M. Mechanical properties of beta-titanium wires. Angle Orthod. 2011, 81, 478–483.
[CrossRef] [PubMed]
6. Dalstra, M.; Melsen, B. Force systems developed by six different cantilever configurations. Clin. Orthod. Res. 1999, 2, 3–9.
[CrossRef] [PubMed]
7. Bilinska, M.; Dalstra, M. The Effect of Symmetric and Asymmetric Loading of Frontal Segment with Two Curved Cantilevers:
An In Vitro Study. Dent. J. 2022, 10, 52. [CrossRef]
Dent. J. 2022, 10, 135 14 of 16

8. Jacob, H.B.; Gonzaga, A.S.; Trinh, B.; Le, E.T.; English, J.D. Effects of stress relaxation in beta-titanium cantilevers used in
orthodontic mechanics. Dent. Press J. Orthod. 2021, 26, e212069. [CrossRef] [PubMed]
9. Van Steenbergen, E.; Burstone, C.J.; Prahl-Andersen, B.; Aartman, I.H. The influence of force magnitude on intrusion of the
maxillary segment. Angle Orthod. 2005, 75, 723–729. [CrossRef]
10. Heravi, F.; Shafaee, H.; Forouzanfar, A.; Zarch, S.H.; Merati, M. The effect of canine disimpaction performed with temporary
anchorage devices (TADs) before comprehensive orthodontic treatment to avoid root resorption of adjacent teeth. Dent. Press J.
Orthod. 2016, 21, 65–72. [CrossRef]
11. Thebault, B.; Dutertre, E. Disimpaction of maxillary canines using temporary bone anchorage and cantilever springs. Int. Orthod.
2015, 13, 61–80. [CrossRef]
12. Chandhoke, T.K.; Nanda, R.; Uribe, F.A. Clinical applications of predictable force systems, part 2: Miniscrew anchorage. J. Clin.
Orthod. 2015, 49, 229–239. [PubMed]
13. Sukh, R.; Singh, G.P.; Tandon, P. Interdisciplinary approach for the management of bilaterally impacted maxillary canines.
Contemp. Clin. Dent. 2014, 5, 539–544. [CrossRef] [PubMed]
14. Yadav, S.; Upadhyay, M.; Uribe, F.; Nanda, R. Mechanics for treatment of impacted and ectopically erupted maxillary canines.
J. Clin. Orthod. 2013, 47, 305–313. [PubMed]
15. Potrubacz, M.I.; Chimenti, C.; Marchione, L.; Tepedino, M. Retrospective evaluation of treatment time and efficiency of a predictable
cantilever system for orthodontic extrusion of impacted maxillary canines. Am. J. Orthod. Dentofac. Orthop. 2018, 154, 55–64.
[CrossRef] [PubMed]
16. Tepedino, M.; Iancu-Potrubacz, M.; Grippaudo, C.; Chimenti, C.; Lagana, G. Does muscular activity related to vertical facial
divergence influence the time needed for orthodontic extrusion of palatally impacted maxillary canines? A retrospective study.
J. Clin. Exp. Dent. 2018, 10, e869–e875. [CrossRef]
17. Vijayashree, U.H.; Pai, V. Canine extrusion with a vertical tube supported cantilever spring. Apos Trends Orthod. 2017, 7, 49–51.
[CrossRef]
18. Zeno, K.G.; El-Mohtar, S.J.; Mustapha, S.; Ghafari, J.G. Finite element analysis of stresses on adjacent teeth during the traction of
palatally impacted canines. Angle Orthod. 2019, 89, 418–425. [CrossRef]
19. Fleming, P.S.; Sharma, P.K.; DiBiase, A.T. How to...mechanically erupt a palatal canine. J. Orthod. 2010, 37, 262–271. [CrossRef]
20. Katiyar, R.; Singh, G.P.; Tandon, P. A cantilever spring for alignment of buccally impacted canines. J. Clin. Orthod. 2012,
46, 354–355.
21. Patel, S.; Cacciafesta, V.; Bosch, C. Alignment of impacted canines with cantilevers and box loops. J. Clin. Orthod. 1999, 33, 82–85.
[PubMed]
22. Paduano, S.; Spagnuolo, G.; Franzese, G.; Pellegrino, G.; Valletta, R.; Cioffi, I. Use of cantilever mechanics for impacted teeth:
Case series. Open Dent. J. 2013, 30, 186–197. [CrossRef] [PubMed]
23. Paduano, S.; Cioffi, I.; Iodice, G.; d’Anto, V.; Riccitiello, F.; Pellegrino, G.; Valletta, R. Correction of multiple canine impactions by
mixed straightwire and cantilever mechanics: A case report. Case Rep. Dent. 2014, 2014, 925019. [CrossRef]
24. Nakandakari, C.; Goncalves, J.R.; Cassano, D.S.; Raveli, T.B.; Bianchi, J.; Raveli, D.B. Orthodontic Traction of Impacted Canine
Using Cantilever. Case Rep. Dent. 2016, 2016, 4386464. [CrossRef] [PubMed]
25. Tepedino, M.; Chimenti, C.; Masedu, F.; Potrubacz, M.I. Predictable method to deliver physiologic force for extrusion of palatally
impacted maxillary canines. Am. J. Orthod. Dentofac. Orthop. 2018, 153, 195–203. [CrossRef]
26. Annarumma, F.; D’Emidio, M.; Rodi, G.; Battista, G.; Papi, G.; Migliorati, M. The effectiveness of miniscrews in the three-
dimensional control of a palatal impacted canine: “Canine Only” approach. Case report. Int. Orthod. 2021, 19, 716–725.
[CrossRef]
27. Gandini, L.G., Jr.; Gandini, M.R.; Amaral, R.M. Continuous torque system with control of the reaction unit. Am. J. Orthod.
Dentofac. Orthop. 2010, 137, 393–395. [CrossRef]
28. Burstone, C. Biomechanics of Deep Overbite Correction. Semin. Orthod. 2001, 7, 26–33. [CrossRef]
29. Melsen, B.; Konstantellos, V.; Lagoudakis, M.; Planert, J. Combined intrusion and retraction generated by cantilevers with helical
coils. J. Orofac. Orthop. 1997, 58, 232–241. [CrossRef]
30. Shroff, B.; Lindauer, S.J.; Burstone, C.J.; Leiss, J.B. 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. [CrossRef]
31. Albelasy, N.F.; Montasser, M.A.; Hafez, A.M.; Abdelnaby, Y.L. Effects on root axes and resorption of simultaneous intrusion and
retraction of maxillary central and lateral incisors using mini-implant supported three-piece burstone base arch: A prospective
observational study. Int. Orthod. 2022, 20, 100595. [CrossRef] [PubMed]
32. Kuhlberg, A. Cantilever Springs: Force System and Clinical Applications. Semin. Orthod. 2001, 7, 150–159. [CrossRef]
33. Wilmes, B.; Vasudavan, S.; Stocker, B.; Willmann, J.H.; Drescher, D. Closure of an open bite using the ‘Mousetrap’ appliance:
A 3-year follow-up. Aust. Orthod. J. 2015, 31, 208–215. [CrossRef] [PubMed]
34. Flieger, S.; Ziebura, T.; Kleinheinz, J.; Wiechmann, D. A simplified approach to true molar intrusion. Head Face Med. 2012, 8, 30.
[CrossRef]
35. Nojima, L.I.; Barreto, B.C.T.; Vargas, E.O.A.; Starling, C.R.; Nojima, M.D.C.G. A clinical approach to managing open-bite
malocclusion associated with severe crowding. Am. J. Orthod. Dentofac. Orthop. 2022, 162, 122–134. [CrossRef]
Dent. J. 2022, 10, 135 15 of 16

36. El-Dawlatly, M.M.; Fayed, M.M.; Mostafa, Y.A. Deep overbite malocclusion: Analysis of the underlying components. Am. J.
Orthod. Dentofac. Orthop. 2012, 142, 473–480. [CrossRef]
37. Burstone, C.R. Deep overbite correction by intrusion. Am. J. Orthod. 1977, 72, 1–22. [CrossRef]
38. Thote, A.M.; Sharma, K.; Uddanwadiker, R.V.; Shrivastava, S. Optimum pure intrusion of a mandibular canine with the segmented
arch in lingual orthodontics. Biomed. Mater. Eng. 2017, 28, 247–256. [CrossRef]
39. Vu, B.T.; Soroushian, S. Single-tooth intrusion with a cross tube and a cantilever spring. J. Clin. Orthod. 2013, 47, 427.
40. Choy, K.; Pae, E.K.; Kim, K.H.; Park, Y.C.; Burstone, C.J. Controlled space closure with a statically determinate retraction system.
Angle Orthod. 2002, 72, 191–198. [CrossRef]
41. Deluke, M.; Uribe, F.; Nanda, R. Correction of a canted lower incisal plane. J. Clin. Orthod. 2006, 40, 555–559. [PubMed]
42. Musilli, M.; Grampone, F.; Melsen, B. A new auxiliary spring for correction of a canted incisal plane. J. Clin. Orthod. 2014,
48, 500–504. [PubMed]
43. van Steenbergen, E.; Nanda, R. Biomechanics of orthodontic correction of dental asymmetries. Am. J. Orthod. Dentofac. Orthop.
1995, 107, 618–624. [CrossRef]
44. Fiorelli, G.; Melsen, B.; Modica, C. Differentiated orthodontic mechanics for dental midline correction. J. Clin. Orthod. 2001,
35, 239–244.
45. Nanda, R.; Margolis, M.J. Treatment strategies for midline discrepancies. Semin. Orthod. 1996, 2, 84–89. [CrossRef]
46. Mittal, T.; Singh, H.; Kapoor, P.; Sharma, P. Dental midline correction using a cantilever spring: A novel approach. Int. J. Orthod.
Rehabil. 2020, 11, 145–149. [CrossRef]
47. Musilli, M.; Marsico, M.; Romanucci, A.; Grampone, F. Molar uprighting with mini screws: Comparison among different systems
and relative biomechanical analysis. Prog. Orthod. 2010, 11, 166–173. [CrossRef]
48. Khouw, F.E.; Norton, L.A. The mechanism of fixed molar uprighting appliances. J. Prosthet. Dent. 1972, 27, 381–389. [CrossRef]
49. Kojima, Y.; Mizuno, T.; Fukui, H. A numerical simulation of tooth movement produced by molar uprighting spring. Am. J. Orthod.
Dentofac. Orthop. 2007, 132, 630–638. [CrossRef]
50. Ma, Z.; Yang, C.; Zhang, S.; Xie, Q.; Shen, Y.; Shen, P. Orthodontic extrusion of horizontally impacted mandibular molars. Int. J.
Clin. Exp. Med. 2014, 7, 3320–3326.
51. Tay, A.B.; Go, W.S. Effect of exposed inferior alveolar neurovascular bundle during surgical removal of impacted lower third
molars. J. Oral. Maxillofac. Surg. 2004, 62, 592–600. [CrossRef]
52. Bonetti, G.A.; Bendandi, M.; Laino, L.; Checchi, V.; Checchi, L. Orthodontic extraction: Riskless extraction of impacted lower third
molars close to the mandibular canal. J. Oral. Maxillofac. Surg. 2007, 65, 2580–2586. [CrossRef]
53. Barros, S.E.; Janson, G.; Chiqueto, K.; Ferreira, E.; Rosing, C. Expanding torque possibilities: A skeletally anchored torqued
cantilever for uprighting “kissing molars”. Am. J. Orthod. Dentofac. Orthop. 2018, 153, 588–598. [CrossRef] [PubMed]
54. Sawicka, M.; Racka-Pilszak, B.; Rosnowska-Mazurkiewicz, A. Uprighting partially impacted permanent second molars. Angle
Orthod. 2007, 77, 148–154. [CrossRef] [PubMed]
55. Morita, Y.; Koga, Y.; Nguyen, T.A.; Yoshida, N. Biomechanical considerations for uprighting impacted mandibular molars. Korean
J. Orthod. 2020, 50, 268–277. [CrossRef]
56. Allen, W.A. Bilateral transposition of teeth in two brothers. Br. Dent. J. 1967, 123, 439–440.
57. Filho, L.C.; Mde, A.C.; An, T.L.; Bertoz, F.A. Maxillary canine—First premolar transposition. Angle Orthod. 2007, 77, 167–175.
[CrossRef]
58. Lorente, C.; Lorente, P.; Perez-Vela, M.; Esquinas, C.; Lorente, T. Orthodontic management of a complete and an incomplete
maxillary canine-first premolar transposition. Angle Orthod. 2020, 90, 457–466. [CrossRef] [PubMed]
59. Gebert, T.J.; Palma, V.C.; Borges, A.H.; Volpato, L.E. Dental transposition of canine and lateral incisor and impacted central incisor
treatment: A case report. Dent. Press J. Orthod. 2014, 19, 106–112. [CrossRef] [PubMed]
60. Fu, P.S.; Wang, J.C.; Wu, Y.M.; Huang, T.K.; Chen, W.C.; Tseng, Y.C.; Tseng, C.H.; Hung, C.C. Unilaterally impacted maxillary
central incisor and canine with ipsilateral transposed canine-lateral incisor. Angle Orthod. 2013, 83, 920–926. [CrossRef]
61. Noh, H.K.; Park, H.S. An efficient and noncompliant method for forced eruption with microimplants that is bracket free, and its
long-term stability. J. Am. Dent. Assoc. 2019, 150, 369–377. [CrossRef] [PubMed]
62. Kumar, G.; Verma, N.; Parashar, S. Management of Subgingival Root Fracture with Decoronation and Orthodontic Extrusion in
Mandibular Dentition: A Report of Two Cases. Contemp. Clin. Dent. 2019, 10, 554–557. [CrossRef] [PubMed]
63. Vilanova, L.; Henriques, J.F.C.; Patel, M.P.; Da Costa Grec, R.H.; Aliaga-Del Castillo, A. The Miniscrew-Anchored Cantilever:
A Simple Molar Distalizer. J. Clin. Orthod. 2020, 54, 773–774.
64. Adel, S.; Zaher, A.; El Harouni, N.; Venugopal, A.; Premjani, P.; Vaid, N. Robotic Applications in Orthodontics: Changing the Face
of Contemporary Clinical Care. Biomed. Res. Int. 2021, 2021, 9954615. [CrossRef] [PubMed]
65. Liu, R.; Wan, W.; Isomura, E.T.; Harada, K. Metal wire manipulation planning for 3D curving—How a low payload robot can use
a bending machine to bend stiff metal wire. arXiv 2022, arXiv:2203.04024. [CrossRef]
66. van der Meer, W.J.; Vissink, A.; Ren, Y. Full 3-dimensional digital workflow for multicomponent dental appliances: A proof of
concept. J. Am. Dent. Assoc. 2016, 147, 288–291. [CrossRef]
67. Pellizzari, M.; Jam, A.; Tschon, M.; Fini, M.; Lora, C.; Benedetti, M. A 3D-Printed Ultra-Low Young’s Modulus β-Ti Alloy for
Biomedical Applications. Materials 2020, 13, 2792. [CrossRef]
Dent. J. 2022, 10, 135 16 of 16

68. Arefin, A.M.E.; Khatri, N.R.; Kulkarni, N.; Egan, P.F. Polymer 3D Printing Review: Materials, Process, and Design Strategies for
Medical Applications. Polymers 2021, 13, 1499. [CrossRef]
69. Thurzo, A.; Urbanová, W.; Novák, B.; Waczulíková, I.; Varga, I. Utilization of a 3D Printed Orthodontic Distalizer for Tooth-Borne
Hybrid Treatment in Class II Unilateral Malocclusions. Materials 2022, 15, 1740. [CrossRef]
70. Guerrero-Gironés, J.; López-García, S.; Pecci-Lloret, M.R.; Pecci-Lloret, M.P.; Lozano, F.J.R.; García-Bernal, D. In vitro biocompati-
bility testing of 3D printing and conventional resins for occlusal devices: Biocompatibility of 3D printing and conventional resins.
J. Dent. 2022, 123, 104163. [CrossRef]